[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
EXAMINING THE PROGRESS OF SUICIDE
PREVENTION OUTREACH EFFORTS AT THE
U.S. DEPARTMENT OF VETERANS AFFAIRS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JULY 14, 2010
__________
Serial No. 111-91
__________
Printed for the use of the Committee on Veterans' Affairs
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58-058 WASHINGTON : 2010
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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
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
Subcommittee on Oversight and Investigations
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio DAVID P. ROE, Tennessee, Ranking
TIMOTHY J. WALZ, Minnesota CLIFF STEARNS, Florida
JOHN H. ADLER, New Jersey BRIAN P. BILBRAY, California
JOHN J. HALL, New York
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
__________
July 14, 2010
Page
Examining the Progress of Suicide Prevention Outreach Efforts at
the U.S. Department of Veterans Affairs........................ 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 50
Hon. David P. Roe, Ranking Republican Member..................... 3
Prepared statement of Congressman Roe........................ 51
Hon. Timothy J. Walz............................................. 4
Hon. John H. Adler............................................... 4
Hon. Rush D. Holt................................................ 7
WITNESSES
U.S. Department of Defense, Colonel Robert W. Saum, USA,
Director, Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury.............................. 31
Prepared statement of Colonel Saum........................... 64
U.S. Department of Veterans Affairs, Robert Jesse, M.D., Ph.D.,
Principal Deputy Under Secretary for Health, Veterans Health
Administration................................................. 32
Prepared statement of Dr. Jesse.............................. 67
______
American Legion, Jacob B. Gadd, Deputy Director, Veterans Affairs
and Rehabilitation Commission.................................. 19
Prepared statement of Mr. Gadd............................... 58
Bean, Linda, Milltown, NJ........................................ 7
Prepared statement of Ms. Bean............................... 53
Cintron, Warrant Officer Melvin, USA (Ret.), Manassas, VA........ 5
Prepared statement of Warrant Officer Cintron................ 51
Iraq and Afghanistan Veterans of America, Timothy S. Embree,
Legislative Associate.......................................... 17
Prepared statement of Mr. Embree............................. 54
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Executive
Director, Veterans Health Council.............................. 21
Prepared statement of Dr. Berger............................. 61
SUBMISSIONS FOR THE RECORD
American Foundation for Suicide Prevention, Paula Clayton, M.D.,
Medical Director, statement.................................... 72
Coleman, Penny, Rosendale, NY, Author, Flashback: Posttraumatic
Stress Disorder, Suicide, and the Lessons of War, statement.... 74
Oregon Partnership, Portland, OR, statement...................... 81
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, to Hon. Robert M. Gates, Secretary, U.S.
Department of Defense, letter dated July 28, 2010, and DoD
responses.................................................. 82
Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, to Hon. Eric K. Shinseki, Secretary, U.S.
Department of Veterans Affairs, letter dated July 28, 2010,
and VA responses........................................... 86
EXAMINING THE PROGRESS OF SUICIDE
PREVENTION OUTREACH EFFORTS AT THE U.S. DEPARTMENT OF VETERANS AFFAIRS
----------
WEDNESDAY, JULY 14, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Walz, Adler, Hall, and
Roe.
Also present: Representative Holt.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Good morning and welcome to the hearing on
Examining the Progress of Suicide Prevention Outreach Efforts
at the U.S. Department of Veterans Affairs (VA) for July 14,
2010.
The Committee on Veterans' Affairs' Subcommittee on
Oversight and Investigations will now come to order. I ask
unanimous consent that all Members have 5 legislative days to
revise and extend their remarks and that statements may be
entered into the record. I also ask unanimous consent that the
statements of Dr. Paula Clayton of the American Foundation for
Suicide Prevention and Penny Coleman from New York be entered
into the record. Hearing no objection, so ordered.
I appreciate everyone being here today and for your
interest and concerns on the progress of suicide prevention
outreach efforts.
Before we begin, I want to acknowledge a positive step that
the VA has taken recently to help veterans suffering from post-
traumatic stress disorder, or PTSD. The VA recently announced
it is easing the evidentiary hurdle that veterans must clear to
receive treatment for PTSD. This is a step in the right
direction. I am glad they are doing it. However, to be truly
effective in reaching all veterans who need help, not just
those who are already showing up at the VA and asking for it,
the VA also needs an effective outreach strategy.
We have 23 million veterans in this country, only 8 million
of which are enrolled to receive care at the VA. The VA has an
obligation to the 15 million who are not enrolled for care, not
just the 8 million who are already enrolled. If these other
veterans have PTSD or are at risk for suicide, the VA has an
obligation to reach out to them as well and let them know where
they can turn for help.
Last year upwards of 30,000 people took their lives by
suicide in the United States. Twenty percent of these deaths
were veterans. Each day, an estimated 18 veterans commit
suicide. By the time this hearing concludes between one and two
veterans will have killed themselves. These statistics are
startling.
As you know, many of our newest generation of veterans, as
well as those who served previously, bear wounds that cannot be
seen and are hard to diagnose. Proactively bringing the VA to
them as opposed to waiting for veterans to find the VA is a
critical part of delivering the care they have earned in
exchange for their brave service. No veteran should ever feel
that they are alone.
As Chairman of this Subcommittee, I have repeatedly called
upon the VA to increase outreach to veterans who need mental
health services and are at risk of suicide, and Members on both
sides of the aisle have urged the same.
In 2008, the VA finally reversed its longstanding self-
imposed ban on television advertising and launched a nationwide
public awareness campaign to inform veterans and their families
about where they can turn for help. As part of this campaign,
the VA produced a public service announcement featuring Gary
Sinise and distributed it to 222 stations around the country,
aired it more than 17,000 times. The VA also placed printed ads
on buses and subway trains.
According to the VA's own statistics, the effort proved
successful. As of April 2010, the VA had reported nearly 7,000
rescues of actively suicidal veterans which were attributed to
seeing ads, PSAs (public service announcements), or promotional
products. Additionally, referrals to VA mental health services
increased.
However, despite the success late last year, the public
service announcements stopped airing. I don't understand this.
If anything, it seems to me we need to be increasing outreach
to veterans at risk for suicide, not stopping it. It is my
understanding that VA is planning to produce a new public
service announcement, which will be ready by the end of this
year.
However, the question remains, why did the VA stop running
the first public service announcements while they worked on the
second one? How does this help veterans to go dark for more
than a year?
While I commend the additional expansion in outreach that
has grown in the way of brochures and other useful steps, I do
not think the VA should suspend, even temporarily, outreach
efforts like the public service announcements that have proven
so successful. It is also imperative for the VA to utilize and
adapt to technology, including the use of Facebook and Twitter,
to reach the latest generation of veterans. Doing so I believe
will help transform VA into a 21st Century organization and,
most importantly, save lives.
Today, the Subcommittee is assessing the suicide prevention
outreach program on national implementation and achievements.
We have a wide range of testimony that will be presented today,
and I look forward to hearing all that will be said on this
vitally important issue. We appreciate our panelists'
dedication to the formulation of a more comprehensive and
targeted suicide prevention outreach program. These struggling
veterans deserve our help. We must continue to work on breaking
the stigma associated with asking for help. We cannot wait for
veterans to go to the VA. The VA needs to go to them.
Additionally, we must work in a bipartisan way to ensure the VA
delivers the resources our veterans have earned.
Before I recognize the Ranking Republican Member for his
remarks, I would like to swear in our witnesses. I ask that all
witnesses stand and raise their right hand, from all three
panels.
[Witnesses sworn.]
Mr. Mitchell. I now recognize Dr. Roe for opening remarks.
[The prepared statement of Chairman Mitchell appears on p.
50.]
OPENING STATEMENT OF HON. DAVID P. ROE
Mr. Roe. Thank you, Mr. Chairman. I appreciate your calling
this hearing today to review what the VA has done in the area
of outreach to veterans in our communities who are feeling
vulnerable and uncertain of their future.
I cannot imagine what goes through the mind of someone
seeking to end their life, but we must do anything we can to
ease their pain and to help them through this crisis that they
find themselves in so that they can move forward and heal the
wounds from which they are suffering.
Public Law 110-110 was signed on November 5, 2007, by
President Bush. This law, as part of the comprehensive program
of suicide prevention among veterans, provided that the
Secretary may develop a program for a toll-free hotline for
veterans available and staffed by appropriately trained mental
health personnel at all times and also designated that the
Secretary would provide outreach programs for veterans and
their families.
As part of this outreach, the VA contracted with the
PlowShare Group, Inc., to distribute, promote, and monitor a
public service announcement featuring actor Gary Sinise, who
played Lieutenant Dan in the movie Forrest Gump and also
performs with the Lieutenant Dan Band. This moving PSA, which
can still be found on YouTube, encourages veterans to contact
the toll-free national suicide hotline in an emotional crisis.
According to PlowShare, their work on this campaign was
successful as they were able to generate nearly $4 million in
donated media and the suicide hotline saw an increase in
activity during the campaign, as the Chairman mentioned.
The VA also piloted outreach advertising right here in the
metro area of Washington, DC, driving around the city and on
the metro bus system, and signs could be seen in various
locations promoting the hotline to veterans.
What I look forward to learning in the hearing today is the
following: Have we seen a reduction in the number of veteran
suicides since the inception of PSAs, whether the plan is there
to continue the PSAs now that the contract for the previous PSA
has expired, and how has the national suicide hotline helped in
the reduction of veteran suicides, and where do we go from
here?
I am pleased that the witnesses from our veteran community
are here today as well as the VA so that we can hear from
everyone how useful the previous PSAs were and what other kinds
of outreach efforts need to be made to reach not just our older
veteran population, but our new veterans coming out of Iraq and
Afghanistan, and how the VA is using new media to get
information out to our new set of veterans who may not be aware
of all the services that the Department provides. We need to
review and evaluate the successes of outreach efforts on an
ongoing basis and see where they can be improved and enhanced
as well as how frequently they are being broadcast to the
general public.
And again, Mr. Chairman, I thank you for holding this
hearing and I yield back my time.
[The prepared statement of Congressman Roe appears on p.
51.]
Mr. Mitchell. Mr. Walz.
OPENING STATEMENT OF HON. TIMOTHY J. WALZ
Mr. Walz. Well thank you, Chairman and Ranking Member Roe,
and I appreciate your continued commitment to providing the
oversight and responsibility that this Subcommittee has. I
thank all of you for being here today. But I know no one in
this room needs to be reminded, but I said here looking at the
picture of Sergeant Coleman Bean and his mother who is going to
speak to us in just a moment, this is the face of why we are
here. There is no higher calling that we do here in the
protection of these warriors that are willing to go and protect
our freedoms, and I think that obligation and that
responsibility is very apparent on everyone here that this is a
zero sum game. One Coleman Bean is too many, and we need to get
this right.
I am very encouraged to see we have in this room, and it is
something many of you have heard me talk about often, we have
U.S. Department of Defense (DoD) here, we have VA here, we have
veterans service organizations (VSOs) here, we have the private
sector here, we have the Congressional oversight here. We are
starting to understand that this is a very complex project. It
is going to have to be multidisciplinary across all these
agencies, we have to get seamless transition right. We have to
bring to bear on this problem all the resources this Nation can
have. It is a moral responsibility, and it is a national
security responsibility.
A mother lost this beautiful young man. We as a society
lost one of our best and brightest. The world is weaker and
worse for this, and we can do something about it.
So I am encouraged that we are here. I am, like many of
you, searching for ways we can do this better, but the
commitment amongst all of you here, I know, is unwavering. And
I am personally very appreciative of it. And when we get to
that zero sum, that has to be our goal. We may never get there,
but we have an obligation to try. So thank you, Mr. Chairman,
and I yield back I look forward to hearing from our witnesses.
Mr. Mitchell. Thank you. Mr. Adler.
OPENING STATEMENT OF HON. JOHN H. ADLER
Mr. Adler. Thank you, Mr. Chairman. I share your comments,
those of Dr. Roe and Sergeant Walz. I want to particularly
direct my attention with gratitude to Linda Bean of New Jersey,
my State. It would have been enough just to let your son serve
in the military and serve two tours in Iraq, serve our country
valiantly, heroically, and to have lost him is a loss you can't
ever get back. You could then go away and not talk out, but
instead, Ms. Bean, you choose to keep your son's memory alive
by helping other people, by reaching out to other folks
returning from Afghanistan, from Iraq and from missions around
the world to keep us safe here at home, and that is an ongoing
patriotism consistent with your love for your own son and his
own patriotism. So I am grateful to you, to all the experts,
the DoD, VSOs, private sectors, as Sergeant Walz said, but
particularly Ms. Bean you take the time to share with us your
own experience, Coleman's experience so that we can learn from
it and avoid recurrences.
Thank you. I yield back.
Mr. Mitchell. At this time I would like to welcome panel
one to the witness table.
And joining us on our first panel is retired Warrant
Officer Mel Citron, a Gulf War and Operation Iraqi Freedom
(OIF) veteran from Woodbridge, Virginia, and Mrs. Linda Bean, a
mother of an OIF veteran from Milltown, New Jersey. If both of
you would please come and sit at the table.
I ask that all witnesses stay within 5 minutes of their
opening remarks. Your complete statements will be made part of
the public record.
Mr. Citron, you are recognized for 5 minutes.
STATEMENTS OF WARRANT OFFICER MELVIN CINTRON, USA (RET.),
MANASSAS, VA (GULF WAR VETERAN AND OIF VETERAN); AND LINDA
BEAN, MILLTOWN, NJ (MOTHER OF OIF VETERAN)
STATEMENT OF WARRANT OFFICER MELVIN CINTRON, USA (RET.)
Mr. Cintron. Thank you. Mr. Chairman, distinguished Members
of the Committee on Veterans' Affairs. My name is Melvin
Cintron. I was a flight medic conducting forward area medical
evacuation in support of U.S. and enemy wounded personnel,
civilian, military and enemy prisoners of war.
I am also a veteran of Iraq Freedom War on Terrorism. I am
extremely proud of my service to our country. I have been
submitted for Combat Air Medal in Desert Storm and the Army
Bronze Star Medal, which I did receive for my services in this
last tour as an aviation maintenance officer.
I have no regrets for answering the call and would proudly
do so again, despite the fact that it came at a great cost to
me and my family financially, physically, socially and
mentally.
However, I am often ashamed to enter the VA for help,
having seen so many of my fellow soldiers that have paid an
even much higher price for their service. I am here today in
hopes that my testimony will help improve the support for them.
I would like to make clear that I personally know that the
VA has many caring and committed professionals. My testimony is
reflective of the system, not of the dedicated and committed
personnel of the Veterans Administration.
When I entered the VA medical center, I see a poster
saying, it takes the courage of a warrior to ask for help. But
the poster should read, it takes the courage of a warrior to
ask for help from the VA.
There are numerous examples of failures our veterans
encounter when seeking help from the VA. But this Committee is
seeking specific input on the VA's suicide prevention efforts
and hotline.
Make no mistake, I consider myself extremely blessed. I
have the ability to provide for my loved ones, two arms to hug
my children, full sight to see my family, two legs which led me
here to testify, not for my own need, but as stated, in hopes
that in some way I can contribute to providing better support
for others who may not be as blessed.
Their need for timely help from the VA should never be
compromised. I feel strongly that the VA suicide prevention
efforts and hotline are not working since it is too much of a
last alternative with little else in between before getting
there.
Have you heard the recording when veterans call the VA?
Either you don't have enough of a problem and you can wait,
sometimes for weeks for an appointment, or you're suicidal.
Distinguished ladies and gentlemen, I believe that there is
a large void that exists between the no problem type strategy
and the suicidal stigma strategy. Not having that void filled
with intermediate prevention tools and mitigation strategies
will only continue to fuel the need for the forensic type
strategy of concentrating only on the suicidal hotline. I could
easily be wrong, but I believe that by the time a veteran is
desperate enough to call the suicide hotline, it may already be
too late.
In my 19 years since coming back from Desert Storm, and my
5 years coming back from Iraq, I have met many veterans who
have broken down while talking to me about their experiences,
experiences they held for a long time. I have asked them, why
don't you go to the VA for help, knowing the answer. I have
advised them to call the VA, but they don't, because they are
not suicidal and do not want to risk that label for fear of the
effect on their jobs, their family, or social circles.
I have interacted with the VA regularly for many years, and
I am aware of the suicide prevention hotline. However, I do not
know of a readily or easily accessible intermediate or
nonsuicide hotline. I apologize for my ignorance if such a
system does exist. But if it does, and so many don't know of
it, then the system obviously needs better marketing,
promotion, and outreach, or at least as much as is done with
the suicide hotline.
Instead of just suicide hotline, we should provide support
long before a veteran considers suicide. Veterans need and
deserve a system of continuing support, a dignified program
that addresses basic needs of a soldier to talk without the
stigma or label of being considered a suicidal risk.
Please help our veterans ask for help in dignity, not in
fear, apprehension or labeling. Thank you very much.
[The prepared statement of Warrant Officer Cintron appears
on p. 51.]
Mr. Mitchell. Thank you. At the time I would like to
introduce Congressman Holt. You are recognized to introduce Ms.
Bean.
OPENING STATEMENT OF RUSH D. HOLT
Mr. Holt. Chairman Mitchell, Ranking Member Roe, and
Members of the Subcommittee, thank you very much for holding
this hearing and for allowing me the courtesy and giving me the
honor of introducing my remarkable constituent, Linda Bean of
East Brunswick, New Jersey. Linda and her husband Greg are
accomplished communications professionals who have lived in
central New Jersey for many years. For nearly 2 years now,
Linda and Greg have waged a battle openly and courageously to
prevent other military families from suffering the kind of loss
that they endured when their son, Coleman, tragically took his
own life in September 2008 after serving two grueling tours in
Iraq. This is Linda's story to tell, and I ask you to give her
your full attention.
I was astounded to learn that servicemembers who are in the
Individual Ready Reserve (IRR), as Coleman was, do not receive
the kind of suicide outreach protection they need and deserve.
As the Bean family and I discovered, our current suicide
prevention efforts simply do not encompass these reservists and
a number of others.
I have sent a letter to Secretaries Gates and Shinseki
asking that to the extent possible under law they implement the
kind of Individual Ready Reserve suicide prevention program
that I have advocated and which is included in the House
version of the Fiscal Year 2011 National Defense Authorization
Act. The very least we can do for the veterans of Iraq and
Afghanistan who are still in the Reserve rolls but not in units
is ensure that someone from the DoD or VA checks in with them
periodically over the course of a year. If we can afford to
send them to war, we can certainly afford a few regular phone
calls to make sure that they are doing okay, that they are
readjusting to civilian life and, if necessary, that they get
the help quickly that they need when they need it, not after it
is too late.
I ask for the Subcommittee's support in this effort and I
now ask you to turn your attention to someone who can speak far
more eloquently than I can about the need for action, Linda
Bean.
Mr. Mitchell. Thank you, Mr. Holt. Ms. Bean, you are
recognized for 5 minutes.
STATEMENT OF LINDA BEAN
Ms. Bean. Mr. Chairman and Members of the Subcommittee,
thank you for allowing me to appear before you today.
Representative Holt, thank you for all your support to my
family and for me and for your leadership on this issue.
I testify today because my son, Sergeant Coleman Bean, 25,
a veteran of two tours of duty in Iraq, shot and killed himself
on September 6, 2008.
I am so grateful for this opportunity.
Coleman was an amazing man, and he was a proud soldier. I
owe a duty to my son, and I owe a debt to the men with whom
Coleman served.
It is my hope that the observations drawn from a shared
experience of loss will be useful to you as you oversee the
development and the implementation of suicide prevention
strategies for the VA.
First, I would encourage you to accept some facts. Men and
women come home from service to towns and cities and families
that are far removed from a VA hospital or a Vet Center. Many
veterans who are at risk for suicide would never call
themselves suicidal. And some veterans, as I think you well
know, either will not or cannot use VA services.
I believe it is crucial for the VA to assume immediately,
identify and publicize civilian counseling alternatives,
including the Soldier's Project, GiveAnHour and the National
Veterans Foundation; partner with civilian organizations to
assure that all vets have the immediate access to the widest
possible range of mental health care; and encourage media
outlets in your district to publicize local information on
mental health resources for veterans.
Second, I believe it is critical to implement a simple,
straightforward public information campaign that is geared
specifically to veterans' families and their friends. It may
fall to a grandmother or a best friend or a favorite neighbor
to seek out help for a veteran who is in trouble. Make
information on available services easy to find, easy to
understand, and publish that information broadly. The suicide
hotline number, as you have already heard, is not enough.
Finally, I would encourage you to help veterans help each
other. The VA is confronting PTSD and suicide with new programs
and new research, and that is all good and important work. But
that has not always been the case. And there are plenty of
veterans who will tell you that they have had to scrap and
fight for every service they have received from the VA.
In addition to the official patient advocacy complaint
resolution program, please establish a separate body, one made
up of your most feisty and tenacious veterans, to help ensure
that no one gives up because it was too hard or because it took
too long to get the service that they needed.
My son joined the Army when he was 18 on September 5, 2001.
The terrifying tragedy of September 11 confirmed for my son the
rightness of that commitment. When he came home on his first
leave, he took a pair of socks, lovingly folded by his mother,
and he unfolded them and refolded them to Army specifications.
It was his intention, he said, to be a perfect soldier.
In the days following Coleman's death, our family had the
humbling experience of meeting with the men with whom Coleman
had served. They traveled from all over the country to be with
us and to be with each other, and it was clear to us then that
many of these men were carrying their own devastating burdens.
In the days after Coleman's service, I spent hours on the
telephone trying to identify for some of these young men
services that would assist them as well, and I reached out
first to the VA hospitals in the States where those young men
lived. I have to tell you my inquiries netted some mixed
results.
A VA representative in Texas was horrified when I described
for him my fear for our young veterans. And he said, Ms. Bean,
just tell me where he is, I will get in my car, I will go there
right now. Just tell me where he is and I will go to him.
By contrast, a man in Maryland told me, if they don't walk
through the door, we can't help them.
Now, I know that is not correct. Of course we can help
them. And it is our duty to figure out how, not theirs.
Thank you.
[The prepared statement of Ms. Bean appears on p. 53.]
Mr. Mitchell. Thank you. Ms. Bean, I am very sorry for your
loss.
Ms. Bean. Thank you.
Mr. Mitchell. And I want to thank you for your son's
service.
Ms. Bean. Thank you Mr. Chairman.
Mr. Mitchell. In your testimony you described how you would
like to see the VA identify and describe, identify and
publicize civilian counseling alternatives.
How do you think the VA should go about this?
Ms. Bean. There are a number of established organizations,
most of them have developed since 2003, that use the services
of civilian therapists in local communities to help augment
whatever services the VA has available. The services are
confidential, they are free of charge, they help veterans and
they help the families, and I suspect if the VA posted a notice
saying we would be interested in hearing what you do they would
come to the VA. I am not sure the VA is going to have to look
that hard to find community-based organizations that want to
help soldiers.
In our own State of New Jersey, there is a hotline for
veterans staffed by veterans that developed out of the events
of September 11, a similar program, Cop to Cop. I know that
there are vet to vet programs in a number of States and if
somebody wanted to throw out the welcome mat and say tell us
what you do, I know those people would come to you. But if you
need a list of resources, Mr. Chairman, I have a list and I
would be happy to provide that to your office.
Mr. Mitchell. Thank you. Also from your testimony it is
clear that you continue to be in contact with other veterans
and their families as they try to navigate the government
bureaucracy in search for help.
Can you tell the VA on how to make information easier and
more accessible to veterans and their families?
Ms. Bean. Veterans who are already in the system know how
to navigate the VA Web site and they understand the jargon and
they know how to get from point A to point B. But it isn't
always the veteran who is going to be looking for the services.
So somewhere within that dense content on both the DoD and the
VA Web sites, there needs to be, and I think I said, a welcome
mat. There needs to be a notice that says, if you know a
veteran in trouble, if you have questions, if you think someone
is suffering PTSD, click here, and make those resources easy to
read and easy to understand.
It is daunting to go through the VA Web site in search of
help.
Mr. Mitchell. Mr. Cintron, in your testimony you say that
the VA's suicide prevention hotline and suicide prevention
efforts aren't working.
Can you please elaborate on why you think that?
Mr. Cintron. Yes, sir. I believe, Mr. Chairman, that--and I
am an aviation safety professional. I have a responsibility for
safety. The things that we try to do is never go to an accident
site but rather prevent the accident from happening. But the
suicide hotline the way it is, and you are either don't have a
problem serious enough to consider and you can wait and make a
appointment 3, 4 weeks down the road, or you are suicidal.
There is no intervention in between. There is no prevention.
There is no strategy there to say how do we keep our soldiers
and our veterans from getting to that stage.
I am very glad that the hotline is there. Please don't
misunderstand. I think it is needed. However, by not having
something in the program that allows somebody to just talk or
just keep them from going to the next level, because they don't
have an outlet, that now they will get there, and by the time
they reach the suicide hotline it is too late. We could have
prevented them from even getting there.
The numbers that you stated today are stunning to me, both
in the soldiers that we are losing, the veterans that we are
losing, and in the good way, the ones that we are preventing.
But I say we could prevent so many more if there was a
prevention strategy of keeping them from getting to a suicide
hotline.
One of the things that I would like to say, Mr. Chairman,
is that programs such as are out there for our folks to
interact with, are critical. But it also has to be part of the
military's program. And I will share this example with you.
When I came out of Iraq the second time around, we were in Fort
Dix being outprocessed. As we are being given all our out
briefings, a sergeant steps up and says who here needs to talk
to somebody for anything you have seen or done? And nobody
raised their hand. Nobody said here. He said okay, if you want
to do it confidentially, we will have a board, a tablet that
you can sign up on. The day before we left Fort Dix, same
sergeant stood in an auditorium with that board and read those
names and said, do you still need to talk to somebody?
I was one of those soldiers. I did not need to talk to
somebody at that time.
So there has to be an interlacing, collaborative effort to
also get the services involved in having peer-to-peer training
in identifying, you know we have the buddy system, we have the
life saver program for a soldier that doesn't have to be a
trained medic to be able to provide that first aid lifesaving
technique. They have that. We can have the same thing, but we
are talking about saving a soldier's mind and saving their
life.
Mr. Mitchell. Thank you.
Dr. Roe.
Mr. Roe. Thank you all for being here, and Ms. Bean,
especially you. I have a unique perspective being a veteran and
being a physician to have worked with these types of issues
during my medical career and I can't tell you how courageous it
is and how much I appreciate you being here and sharing your
testimony.
Ms. Bean. Thank you.
Mr. Roe. I think you and actors like Gary Sinise who have
stepped up and done an incredible job have more credibility
than anyone, and I want you to comment certainly on some of the
PSAs. It brings back to me breast cancer awareness, how we used
public service announcements to raise awareness among women,
and I think that has done a great deal in decreasing the
incidence of breast cancer. And I think the VA, if we talked
about suicide or talked about suicide ideation, that somehow we
would increase the incidence. I think it does just the
opposite.
And I wanted to hear your comments and both of you, Mr.
Cintron also, on how you believe that just making people aware
and then having some place to go, and I could not agree more
with you, having that in between is very important because I as
a physician had patients who said, you couldn't determine from
even sitting down in a fairly long conversation whether they
really were suicidal. And it is not easy. This is a very
difficult diagnosis to make.
So I will be quiet. I want to hear what Ms. Bean has to say
about that.
Ms. Bean. I think that there are families like mine who
have experienced the homecoming of a much loved child who is
now out of harm's way and you are so grateful that they are
back with you that you may overlook the fact that they are
drinking too much or that they are irritated or that they
insist on being isolated. And you are not empowered, as a
mother or a sister or a wife, to go to the VA and say, my
veteran is in trouble.
I don't even know that I would have known how to do that.
I think, in the way that Mr. Cintron described, we need to
make sure that people understand there are places to go before
you hit the suicide hotline. There are veterans who are not,
who may in the end be alone in a room with a gun to their heads
but the day before would not describe themselves to you as
suicidal.
So I guess I would go back to my very strong feeling that
as part of that, in addition to the messaging, we need to make
sure that there are community-based programs that are easily
accessible, and we need to make sure that the information that
the VA has is geared to families and friends in a friendly and
accessible way, made easily available so people can find it,
and that the VA is willing to say, look, if you won't come
here, that is okay, we will help you find help somewhere else.
Is that what you were looking, the answer?
Mr. Roe. The public service announcements, I think you and
the public service announcement in New Jersey would be an
incredible statement for people.
Ms. Bean. I guess if you are saying, are there other kinds
of public service announcements that would be workable.
Mr. Roe. Yes.
Ms. Bean. I think it would be the public service
announcement that said, you know, you're home, you're drinking
too much, you're fighting with your wife, you can't get along
with your boss, you need help.
That is a message that resonates with people who are in
that position. The message that says you are home and you are
suicidal, not so much.
Mr. Roe. I agree. I agree.
Mr. Cintron.
Mr. Cintron. Yes, sir. I agree. I think there has to be
peer counseling both on the family side and on the soldier
side. I once read in a magazine that had a copy, had a picture
of a wall that was used as a firing squad wall, and in it, it
said, you have never lived until you have almost died. For
those who fight for it, life has a flavor to protect it we will
never know. For the veterans, it also has a price for that
flavor. They cannot just go to a family member and talk about
what that family member would never know. They cannot just go
and talk to anyone.
So even that, in itself, is something that also needs to be
addressed so that they feel that a mother is not nagging when
they say, hey, I think you're drinking too much or a wife isn't
nagging. So those are awareness things that also need to be out
there.
I think there are so many good outreach programs that can
be done. You have groups here that you must interact with and
reach those folks that can be reached. The other thing that I
would ask is that consider the unreached soldier, the person
that doesn't go to the VA, the person that doesn't go to AVA,
the person that doesn't think they need help. And all it takes
is a simple outreach from someone saying, hey, let's talk about
what you did.
Mr. Roe. I think your comment, Mr. Chairman, and then I
will yield back, your comment about when you had the sergeant
stand up is at least a move further than when I ETSed 36 years
ago when nobody did and I am a Vietnam era veteran and served
overseas, and we are doing better, and I think we have to do a
lot better. But I know that then there was no outreach or
anything, and that has steadily improved because of people like
yourself being willing to stand up and saying something needs
to be done. I thank you for doing that, and I yield back my
time.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Thank you and, Ms. Bean, again I echo the
comments of my colleagues and thank you again for being here,
Mr. Cintron, and thank you both. You are making a difference
and you are continuing your service. And I truly appreciate
that.
I would also mention what Dr. Roe said, it may be a little
bit of a move forward, but as a senior NCO myself I am just
appalled by that. I think it goes to a deeper cultural issue.
It is mental health parity in this Nation and how we view
mental health issues. I think the good news is, and I would
like to say a deep heartfelt thank you to my colleague from New
York, Mr. Hall, on Monday when we got the notice from the VA on
the issue of PTSD in trying to make this easier for folks, this
is a huge step forward on the issue we are talking about today.
I think we are starting to attack this from multiple
perspectives. Monday was a very gratifying day for me because
of that ruling coming down and I was in Hennepin County in
Minneapolis where we established our State's first vets' court,
which we all know is a way we start to see these things, a
progression, exactly what you are all talking about is stop it
before we get to that point, stop it before it escalates from
driving on the wrong side of the road, drinking and driving,
domestic violence down the road to these types of things. So I
appreciate obviously because of your experience and
unfortunately in your case, Ms. Bean, your personal experience.
You are incredibly insightful on what needs to happen and I
think we are starting to see that happen. I want to hit on one
thing with you, Ms. Bean, and I know Mr. Holt just left but he
mentioned and you explained a little of your concern with the
IRR, and dropping back, I understand your son was on active
service his first tour, then he was called back through the IRR
on the second one. I am concerned with this as a former
National Guardsman and coming from a State where we have put a
lot of time and thought in the beyond the yellow ribbon
campaign on when these folks come back, of how we capture them
in that seamless transition in that care. What did you see in
your experience where there was a drop-off, both of you, as you
see this, is it fair for me to say that it is, and Ms. Bean,
you mentioned it about your view in Texas versus Maryland,
those types of things. Do you think we are not capturing it as
a whole and that it is spotty across the country as you come
back on how that care is?
I would like each you to take a stab at that because we
have talked about this, of nationalizing this beyond the yellow
ribbon campaign, to make sure that no matter where you go into
service or how you go in either active service or IRR, you are
still going to have that support net. So if you have a comment
on that of how that affected you.
Ms. Bean. Coleman's first tour of duty was with the 173rd,
and when they returned from Iraq to Vicenza, Italy, they had
mental health musters on a regular basis. They were on a base.
They were together. They had each other. They had shared the
same sort of experiences, and they had that opportunity to talk
things through.
He was home for I think almost 18 months, recalled to duty
through the Individual Ready Reserve, and he was assigned to a
unit of the Maryland National Guard. When they came back out of
Iraq, the Maryland National Guard went home to Frederick,
Maryland. Coleman came home to New Jersey. I know that they had
regular musters in Frederick, mental health musters, health
musters, weapons checks, all the kinds of things that you would
do to keep a unit running. Mental health was a part of that.
Coleman participated in none of that.
And I know that when the men from that National Guard unit
came to Coleman's service and we talked later, they were
heartbroken. They didn't know. And they didn't know how they
could have known how to reach out. There wasn't, for them, for
the leadership of that unit, there wasn't a way for that
leadership to reach these men who served under their flag but
lived in a different State.
And I would say to you, Mr. Walz, it is very, very hard to
get numbers of soldiers in that circumstance. I don't think we
have a clear number of how many IRR soldiers or how many
individual augmentees may be at risk for suicide. But I think
the numbers are big. And I think it is a shame that if a man
from Wyoming serves with the National Guard from California, he
should get the same help those boys get.
Mr. Walz. You are absolutely right.
Mr. Chairman, I would suggest and I think Ms. Bean has hit
on something that has troubled me for quite some time is how we
disaggregate that data and find that out. We see this also with
active forces coming back in ones and twos to our States. I
have to be honest that I see that in Minnesota. You are far
better off to go with a National Guard unit from Minnesota and
be part of that community than you are not to. And I bet, I am
willing to, anecdotal, but I bet if we disaggregate that I bet
you we are seeing better prevention measures amongst that and
that would be something that would be very interesting to know.
Mr. Cintron, before my time is up, any comments?
Mr. Cintron. Yes, sir. I am your poster child also because
I was in the IRR, and after 6 years of not being in uniform I
got a letter in the mail saying that I have been called up. I
served my country proudly. And I was put in with a National
Guard unit from Maryland and New Hampshire and sent to Iraq as
an IRR soldier.
When I came back, I didn't have any of that support that
they had. Nobody reached out or said, hey, you are part of this
unit, you did this, you did that, no, nobody did.
Mr. Walz. Did you get a call from a first sergeant or
anything?
Mr. Cintron. No, I did not, sir. No, I did not, and so if
you are part, at least my personal experience, being the IRR,
having been called back, having served, you are done, we are
done with you, you are not part of the unit. So you don't get
this, you are not part of that unit.
I will even share you with an issue coming back, one of the
programs was, which I think would have been an excellent
program if it continued, was that when the soldiers came back
you could actually go with your family to a retreat, to a
retreat, you could go with your family. After 19 months and
countless phone calls because I was not attached to a unit, and
I could not get a first sergeant to approve this or a commander
to approve that because I am not attached to a unit, my wife,
who is extremely patient, we gave up after 19 months of the
bureaucracy because we were not part of a unit.
Mr. Walz. I know I have gone over my time but I want to hit
on this. This is something I brought up back home often on
this. They will not cut you travel orders, they will not pay
for you to come back. These soldiers would come back if we were
paying for them to come back, get them a hotel room, let then
attend the 30, 60, 90, 120-day out processings on these
retreats. This has been an ongoing problem.
I think it comes back to, and I will leave it at this, very
frustrating on this. People like these two folks here and
others have been talking about this for a long time. We know
this is an issue and now we just need to address it. So I thank
you both.
Mr. Mitchell. Thank you.
Mr. Adler.
Mr. Adler. Mr. Chairman, thank you. I want to follow up on
what Mr. Walz was saying. I am very grateful for the two of you
to make this so real for me. I think that the panelists and at
least for me to give me some takeaways so that I can go do
things starting today.
Mr. Cintron, you mentioned Fort Dix. I have the privilege
of representing Fort Dix. I plan to call the base commander
today, not to find out who the sergeant was a few years ago who
was a little insensitive with respect to you and some other
folks, but maybe to alert her so she can alert the various
folks, people who are deploying and returning that show
sensitivity for individual needs and on a discreet,
confidential basis because folks aren't going to raise their
hands in a big crowd and say I need help with something.
Ms. Bean, thank you for being a New Jersey person. We have
fantastic yellow ribbon clubs throughout New Jersey, certainly
at least in my area. Every soldier, sailor, Marine, Coast
Guardsman, Navy person who returns from overseas from anywhere
has a welcome home party. That is great. But maybe some of
these organizations could also followup people afterwards 30
days, 60 days, 90 days, if somehow they are falling through the
cracks governmentally, there are lots of very caring people who
really want to celebrate the human being, not just somebody
that wore a uniform and went overseas but the actual human
being that did this mission for America. And I think some of
those folks would be very willing to schedule followups so it
is not just one parade and then forgotten but actually treating
each person holistically, even episodically, the way Tim said
first sergeants might want to call. There are volunteers who
would be just as committed in terms of helping individuals.
So I thank you for at least giving me ideas of what I can
do in New Jersey to help avoid Coleman Bean's situation for the
next tier that comes back from overseas.
And I thank both of you.
Mr. Mitchell. Mr. Hall?
Mr. Hall. Thank you, Chairman Mitchell and Ranking Member
Roe, and thank you to our witnesses for graciously appearing
and testifying before us today.
I will submit a statement for the record.
[No statement was submitted.]
But I would just like to ask Ms. Bean, first of all to
thank you for your strength and clarity, appearing and speaking
before us. I know how difficult that is but I think I can
imagine how difficult that must be to speak about your son and
I commend you for being willing to put that aside to help other
veterans and their families. It has been obvious to many of us
that when a person joins the military they should also be
automatically enrolled in the VA and members of the Armed
Forces and their families should have access to information or
education about assimilating back into civilian life, into
their families, into their communities before, during and after
deployment.
One of the problems, as I see it, is that the Veterans'
Affairs Committee has one piece of jurisdiction, the Armed
Services Committee has another one, on the Executive side the
DoD has one piece and then the VA has another piece, and there
is not that overlap and that seamless transition that we have
talked about in so many ways, not just medical records, but
mental health followup.
So perhaps, Ms. Bean, you can start a little bit about what
kind of information or resources were available to you and to
your son before he took his life and what kind of outreach was
there. And you have told us a little about what you would like
to see available, but was there anything of substance?
Ms. Bean. We have a strong VA system in New Jersey. When
Coleman came home from his second tour of duty, VA services
were certainly available to him. Mental health care is at a
premium, and it is difficult to get an appointment in a timely
fashion.
I don't know when or how Coleman called the VA to seek out
mental health assistance, but it is something that we learned
of only after Coleman had died.
I didn't know, and this is a gap in my own understanding as
much as anything else, I didn't know what else was available. I
didn't go looking for something else to be available. And it
wasn't until Coleman had died that I learned that there were
many other programs that could have been available.
I keep going back to the idea that our local newspapers run
Little League box scores, we run the Butterball Turkey hotline
on Thanksgiving, we put out notices about bowling leagues. I
think our local newspapers and radio stations could run a
little box of resources; if you are a vet, if you are a
soldier, if you are family, you can go to these places for
help, and that list could include the VA hospitals and the Vet
Centers, but it needs to go beyond that to include civilian
resources, localized civilian resources.
And I am not sure I am answering your question.
Mr. Hall. That is helpful. Thank you.
Mr. Cintron, would you discuss the kinds of prevention that
might help a veteran from reaching the point where they take
their own life? We have heard about how Coleman and other
veterans had not exhibited or used the word ``suicide'' and had
not exhibited those tendencies until it is too late. And so
what kind of outreach would you suggest could reach a veteran
before they get to that point?
Mr. Cintron. I think there are a few outreach efforts that
can be done. But the first effort has to be to have the people
to reach out to, and that can reach out to the folks, and they
have to have some minimal training, not a lot. All it takes
oftentimes, and like I said, I have encountered many veterans
and for some reason they start talking to me and share their
experience, and it is like, wow, you don't know that weight
that was on me. And it just lingers with them and all they
wanted to do was get it out at least once with someone that can
understand, not to judge, but just to listen to them. That is
what is needed.
Those outreaches, I think when you get with some of the
groups that are available to us, if there is a combined effort
with the groups, find the synergy with them and with the
governmental organization, so that we all own part of the
solution. It is not just the VA solution, it is not just the
DoD solution, it is not just the solution of any individual
program. It is a combined solution. We all own part of it.
So the outreach would be obviously training and identifying
personnel who are willing to take a call at anybody. I give my
phone to friends and to veterans that I meet and I say hey, if
you ever have an issue give me a call, and I have actually
received calls in the middle of the night. Man, I can't sleep
tonight, I was just thinking about this, and we talked through,
and we are done. But having that available, that outreach, the
ability to call somebody, and it doesn't have to be somebody
that they really know but somebody that knows what it is they
are going through.
Mr. Hall. Thank you. I know I am over my time, but I would
just mention that this Committee has--the full Veterans'
Affairs Committee on the House side has voted to give funding
not just for PSAs, as Ranking Member Roe mentioned, but for
paid advertising and Iraq and Afghanistan Veterans of America
(IAVA), who we will hear from shortly, partnered with the Ad
Council in one effort to put together an ad that is more
powerful than the average PSA. Public service announcements run
in the middle of the night usually because that is when the
time is cheapest and the TV station will give it up to do their
public service, whereas what we really need I believe is
advertising during the Super Bowl, during American Idol, during
the highest rated shows during prime time where the half hour--
I mean the 30-second spot or the 1-minute spot costs the most
money. But we are willing to do that, to advertise be all that
you can be or the few, the proud, the Marines, you know the
lightning bolt coming down into the sword. So if we want to
attract and recruit people to go into the armed services and go
fight for our country we will spend the money for prime time
advertising, but when it comes time to help them find the
resources they need to stay healthy after they come home, we
want to do it on the cheap and just do it at 3:00 in the
morning on a PSA, and I think that needs to change to something
we in Congress should fund so that the outreach is just as
strong afterwards as it is before they were recruited.
I yield back.
Mr. Mitchell. Thank you.
And again, Ms. Bean, I am very sorry for your loss and I
want to thank you for your son's service and for you being here
today.
Mr. Cintron, same with you, thank you for your service and
I think you have both done a terrific job today to help further
try to solve this big problem. So thank you very much.
Mr. Cintron. Thank you, Mr. Chairman and Members of the
Committee.
Mr. Mitchell. At this time, I would like to welcome Panel
two to the witness table.
For our second panel we will hear from Tim Embree,
Legislative Associate for the Iraq and Afghanistan Veterans of
America; Jacob Gadd, Deputy Director for Veterans Affairs and
Rehabilitation Commission of the American Legion; and Dr.
Thomas Berger, Executive Director of the Veterans Health
Council for Vietnam Veterans of America (VVA).
And like the other panelists, I ask that you please keep
your comments to 5 minutes. Your complete statement will be
entered into the record.
I would first like to recognize Mr. Embree for 5 minutes.
STATEMENTS OF TIMOTHY S. EMBREE, LEGISLATIVE ASSOCIATE, IRAQ
AND AFGHANISTAN VETERANS OF AMERICA; JACOB B. GADD, DEPUTY
DIRECTOR, VETERANS AFFAIRS AND REHABILITATION COMMISSION,
AMERICAN LEGION; AND THOMAS J. BERGER, PH.D., EXECUTIVE
DIRECTOR, VETERANS HEALTH COUNCIL, VIETNAM VETERANS OF AMERICA
STATEMENT OF TIMOTHY S. EMBREE
Mr. Embree. Thank you, sir.
Mr. Chairman, Ranking Member, and Members of the
Subcommittee, on behalf of Iraq and Afghanistan Veterans of
America's 180,000 members and supporters, I would like to thank
you for inviting us to testify before your Subcommittee.
My name is Tim Embree. I am from St. Louis, Missouri, and I
served two tours in Iraq with the United States Marine Corps
Reserves. Veteran suicide is an issue that resonates with all
of our members, and we are grateful that you are holding this
hearing today. This issue is of particular importance to me
because I lost one of my Marines to suicide in 2005.
Last year, more U.S. servicemembers died by their own hands
than in combat in Afghanistan. Most Iraq and Afghanistan
Veterans of America, or veterans, know a fellow warfighter who
has taken their own life since coming home.
As the suicide rate of our servicemembers and veterans
continues to increase without any signs of abating, we must
acknowledge that suicide is only one piece of the mental health
epidemic plaguing our returning warfighters. Left untreated,
mental health problems can and do lead to substance abuse,
homelessness, and suicide.
For a veteran considering suicide, the act of reaching out
to those close to them can often seem overwhelming. The act of
a simple anonymous call to the VA's National Suicide Prevention
Lifeline might be enough to save the life of a veteran who is
struggling, feeling alone, and hopeless. IAVA proudly supported
the Joshua Omvig Veteran Suicide Prevention Act, which
established this important hotline, and we are encouraged to
see some of the new programs the VA has implemented to help
returning veterans.
The heavy stigma associated with mental health care stops
many servicemembers and veterans from seeking treatment. More
than half the soldiers and Marines in Iraq who tested positive
for psychological injury reported concerns that they would be
seen as weak by their fellow servicemembers.
To end the suicide epidemic and forever eliminate the
stigma associated with combat stress, the VA and DoD must
declare war on this problem and must launch a nationwide
campaign to combat stigma and promote the use of DoD and VA
services, such as the Vet Centers and the National Suicide
Prevention Lifeline. This campaign must be well funded,
research tested, and able to integrate key stakeholders such as
veteran service organizations and community-based nonprofits.
Through our own historic public service announcement with
the Ad Council and the help of some of the world's best
advertising firms, IAVA has learned a lot about stigma busting
and veteran outreach campaigns. Millions of Americans continue
to see our uncomplicated, yet iconic PSAs, such as the one
featuring two young veterans shaking hands on an empty New York
street. These TV ads are just one component of this ground-
breaking campaign. They are complemented by billboards, radio
commercials, and Web ads, which have blanketed the country and
touched countless Americans.
This cutting-edge campaign directs veterans to an exclusive
online community, communityofveterans.org. This exclusive
community shows our Nation's new veterans that we have your
back.
Once inside a community of veterans, these vets are
directed to a wide range of mental health, employment and
educational resources operated by private, nonprofits, and the
Department of Veterans Affairs. This campaign is an example of
the innovation coming out of the VSO and nonprofit communities,
which the VA should treat as an asset. Innovative, aggressive
outreach programs like this should become part of the new VA
culture and they can fuel inject outreach efforts. IAVA is
learning what works, and we want to share our knowledge.
Additionally, IAVA supports creative solutions for rural
veterans. We support contracting at the local community mental
health clinics and extending grants to groups that provide
programs such as peer-to-peer counseling. Veterans must be able
to receive mental health care near their personal support
system, whether that system is in New York City or Peerless,
Montana.
Our veterans are facing a mental health epidemic. Unless we
address the overall issue of mental health stigma, we will
never be able to stem the growing tide of suicides. The VA and
DoD have created many programs that are extremely effective in
helping servicemembers and veterans who are hurting, but great
programs are worthless if servicemembers and veterans don't
know they exist, cannot access them, or are ashamed to use
them.
IAVA is proud to speak on behalf of the thousands of
veterans coming home every day. We will continue to work
tirelessly so veterans know we have their back. Thank you for
your time today, and I look forward to answer any questions you
may have.
[The prepared statement of Mr. Embree appears on p. 54.]
Mr. Mitchell. Thank you.
Mr. Gadd.
STATEMENT OF JACOB B. GADD
Mr. Gadd. Mr. Chairman and Members of the Subcommittee,
thank you for this opportunity to submit the American Legion's
views on the progress of suicide prevention efforts to the
Subcommittee today.
Suicide among servicemembers and veterans has always been a
concern. It is the position of the American Legion that one
suicide is too many. The tragic and ultimate result of failing
to take care of our Nation's veterans' mental health illnesses
is suicide.
Turning first to VA's efforts in recent years with mental
health care, the American Legion has consistently lobbied for
budgetary increases and program improvements to VA's mental
health programs. Despite the increased funding, the number of
servicemembers and veterans with PTSD and traumatic brain
injury (TBI) continues to grow. VA has seen more mental health
patients with fewer resources and staff.
Of the 30,000 suicides reported among the general
population every year, VA reports 20 percent of those suicides
are veterans. In a recent AP article, it was cited that there
have been more suicides than servicemembers killed in
Afghanistan.
In regards to suicide prevention outreach efforts, VA
founded the National Suicide Prevention Hotline where veterans
are assisted by a dedicated call center in Canandaigua, New
York. VA also hired local suicide prevention coordinators at
all 153 VA medical centers. One of the primary responsibilities
of the local suicide prevention coordinators is to track and
monitor veterans who are placed on high risk of suicide. A
safety plan for that individual veteran is created to ensure
they are not allowed to fall through the cracks.
In 2009, VA also instituted an online chat center for
veterans to further reach those veterans who utilize online
communications. And as was mentioned earlier, VA has also
targeted outreach campaigns, which has included billboards,
signage on buses, and PSAs to encourage veterans to contact VA
for assistance.
The American Legion has been at the forefront of helping to
prevent military and veteran suicides in the community. Last
year during our national convention, we adopted Resolution 51,
the American Legion's Policy on Suicide Prevention and
Outreach. And Dr. Janet Kemp, who is with us today, also
provided training to our VA and our commission members. And
then after the training, American Legion State, district and
post volunteers have established programs to refer veterans in
distress with the suicide prevention hotline.
Also, in December, 2009, the American Legion took the lead
in creating the Suicide Prevention Assistant Volunteer
Coordinator position description under the auspices of VA's
Voluntary Service Office.
Despite the recent suicide prevention efforts, more still
needs to be done as the number of suicides continues to grow,
and as we all know, the challenges still exist. The American
Legion's System Worth Saving program conducts site visits to VA
medical center facilities annually, including this year going
to Canandaigua, New York to report firsthand on some of the
progress that is being made.
One of the first problems we wanted to discuss was
recruiting psychologists. The VA has a goal to recruit from
their current level of 3,000 psychologists to 10,000 to meet
the demands for mental health services.
Second, the budget. The American Legion applauded Congress
for passing advanced appropriations, but delays still persist
within VA itself in allocating budget funds from VA's Central
Office to the Veteran Integrated Service Networks, and down,
finally, to the VA medical center. So the American Legion
continues to advocate for additional funding to meet the demand
for mental health care and urges Congress to provide oversight
that those mental health dollars are being used to their full
intent.
Additionally, the issue of a lack of interoperable medical
records between DoD and the VA, which is currently being
addressed by the lifetime virtual electronic medical record,
still exists. In addition, the American Legion recommends VA
take the lead in developing a joint database with DoD, the
National Center for Health Statistics, and the Centers for
Disease Control to track suicide trends nationally, and have
the numbers for the military as well as for veteran suicides.
The American Legion continues to be concerned about the
delivery of health care to rural veterans. No matter where a
veteran chooses to live, VA must continue to expand and bring
needed medical services to the highly rural veteran population
through telehealth, virtual reality exposure therapy, and
online technologies.
The American Legion has seven recommendations to improve
suicide prevention efforts: First, that Congress exercise
oversight on VA and DoD programs to ensure maximum efficiency
and compliance.
Second, Congress should appropriate additional funding for
mental health research and a standardized DoD and VA screening
diagnosis and treatment protocols.
Third, DoD and VA expedite development of a joint medical
record to better track and flag veterans with mental health
illnesses.
Four, that Congress allocate separate mental health funding
for VA's recruitment and retention incentives for behavior
health specialists.
The rest of my recommendations are included in the written
testimony.
In conclusion, Mr. Chairman, VA has increased its efforts
in support for suicide prevention but must continue to work
with veteran service organizations, such as the American
Legion, to improve outreach. The American Legion is committed
to working with DoD and VA in providing assistance to increase
involvement.
Thank you for allowing me to submit testimony today.
[The prepared statement of Mr. Gadd appears on p. 58.]
Mr. Mitchell. Thank you.
Mr. Berger.
STATEMENT OF THOMAS J. BERGER, PH.D.
Dr. Berger. Chairman Mitchell, Ranking Member Roe, and
distinguished Members of the Subcommittee on Oversight and
Investigations, Vietnam Veterans of America thanks you for the
opportunity to present our views on examining the progress of
suicide prevention outreach efforts at the VA. We also want to
thank you for your overall concern about the mental health care
of our troops and veterans.
Suicide is most often the result of unrecognized and
untreated mental health injury, including depression, post-
traumatic stress disorder, and traumatic brain injury. Those
are three of the most common mental health injuries and
conditions that can lead to suicide, and these three conditions
in particular are medical conditions that can be life
threatening.
In more than 120 studies of a series of completed suicides,
according to our colleagues at the American Foundation for
Suicide Prevention, at least 90 percent of the individuals
involved were suffering from a mental illness at the time of
their death. The most important interventions are recognizing
and treating those underlying illnesses, such as depression,
alcohol and substance abuse, post-traumatic stress, and
traumatic brain injury.
Many veterans, and obviously active military people, resist
seeking help because of the stigma associated with mental
illness or they are unaware of the warning signs and treatment
options. These barriers must be identified and overcome.
But I think we need to also put this hearing or the call
for this hearing in the proper historical context, and that is,
in May 2008, then Secretary of the VA, General Peake, chartered
the Blue Ribbon Work Group on Suicide Prevention in the Veteran
Population. Its function was to provide advice and consultation
to him on various matters relating to research, education and
programs, as well as improvements relevant to the prevention of
suicide in the veteran population. Subsequently, on September
16, 2008, the House Veterans Subcommittee on Health held an
oversight hearing on the VA's suicide hotline. As part of the
press release for this hearing, VA announced that Secretary
Peake had received recommendations from this Blue Ribbon Panel,
eight recommendations and findings, as well as a series of 14
other elements. While all those recommendations and findings
are contained in my written report, I will just read to you
panel finding number six:
``Efforts to improve accurate media coverage and
disseminate universal messages to shift normative behaviors to
reduce population suicide risk are not being fully pursued.''
Now, suicide prevention of course starts with leadership,
but it has been almost 2 years now since the Blue Ribbon Work
Group finished its work and we have yet to see any formal
action plan that addresses each of the group's findings and
recommendations in a comprehensive, prioritized fashion. In
fact, no one outside a select group of bureaucrats at the
Veterans Health Administration (VHA) has probably ever seen
this complete report, which of course was funded with taxpayer
dollars.
This Committee must ensure that our veterans and their
families are given access to the resources and programs
necessary to stem the tide of suicide. We have heard of some
attempts to do that. Where is the plan, the overall plan to do
it? The first step in the process is knowing what has been
recommended by the best medical scientists the VA could
assemble to study the problem, and that is the report I
referenced earlier. What is being done to implement those
recommendations and address the findings of those experts?
Once again, on behalf of VVA, I thank you for your
leadership in holding this hearing on this topic, and I also
thank you for the opportunity speak to this issue directly. I
will be glad to answer any questions later on.
[The prepared statement of Dr. Berger appears on p. 61.]
Mr. Mitchell. Thank you, Dr. Berger.
Mr. Embree, I am very impressed by the PSA campaign that
the IAVA ran with the Ad Council. You did this on a fraction of
the budget that the VA has, and you clearly saw a vision and
wanted to air it. Why do you think the VA has such a hard time
recreating what the IAVA has done?
Mr. Embree. Sir, thank you for the question. I think one of
the major problems is that we understand that vets help vets.
Young vets coming back from Iraq and Afghanistan right now can
speak to each other. If you are a first sergeant that served in
Iraq, you can talk to a PFC that served in Iraq because you
have a lot of the same experiences, you understand what is
going on. Vets help vets, and we can talk to each other. And we
understand that feeling, like in our first PSA, of that young
soldier walking to the airport felt alone; in fact, that is the
title of the commercial, it is called ``Alone.'' Because a lot
of us vets have come back, we know that feeling, we remember
that feeling very strongly, that first time when you are
sitting there in a crowd and you feel like it is just you. We
can speak to that. And we also understand what it is like when
another veteran comes up and shakes your hand or just talks to
you, how all of a sudden the world comes alive again, you feel
part again, you feel part of something bigger.
I think the VA for too long has been dealing with issues
that have affected past generations, and they haven't
recognized that those issues are affecting this new generation
of veterans just in different ways and we are dealing with them
in different ways.
So I think that the VA is treating some of the old problems
and not recognizing that those are the same problems just in
different forms now. So I think the VA needs to reach out to
the veteran service organizations, such as Afghanistan and Iraq
Veterans of America, Student Veterans of America, and some of
the other larger veterans service organizations to talk to the
newer vets and to find out what is affecting us.
Because I remember when I saw the VA PSA, it was about 2:00
in the morning, I think it was actually one of those nights
when I couldn't sleep because I came from a deployment and I
had no idea what was going on. There was a bunch of World War
II memorabilia around, and Lieutenant Dan from Vietnam with
Forrest Gump was talking to me. That didn't speak to me, it
didn't make any sense to me. But when I see two young veterans
walking up to each other and shaking hands and the world coming
back to life, that made sense to me, that hit me, I understood
what was going on with those guys.
Mr. Mitchell. The IAVA has secured $50 million in donated
media, reaching millions of veterans and their families. What
lessons learned can the VA gain from your experiences in
creating a new energy and new support? Maybe you just mentioned
it.
Mr. Embree. Yes, sir. But also I think it means they need
to work with a lot of these cutting-edge firms, some of these
advertising firms that their job is to market products to
people, to help you understand how to talk to the families, how
to get mom to see a commercial or to see an ad at a bus stop or
on Facebook and then go and talk to their son or daughter who
may be dealing with these issues, or the wife or husband of a
soldier or Marine or airman or sailor.
So I think it has to be more than just we put ads on a bus.
I mean, if you have seen the VA ad on a bus, it is very hard to
read; it is a lot of words, and unfortunately buses are mobile,
so trying to read the small print is very hard to catch.
So I think that the need to listen to the private side and
also the nonprofit world and find out what works, how do you
get to your customers, how do you get to your members?
Mr. Mitchell. And one last one to you, Mr. Embree: What
actions can the DoD do to facilitate the VA's mission to
prevent suicide?
Mr. Embree. Yes, sir. With the DoD, I think it is an even
larger issue. I think they need to help with the stigma
campaign, but I think they also need to implement training for
your junior officers and your young noncommissioned officers.
The way I like to explain it is, if you are a young Marine and
you roll your ankle on a run, you come back to the squad bay,
you don't just keep walking around on a swollen ankle, you go
to the doc, you go to the corpsman and you say, hey, doc,
something is wrong with my ankle, I need to figure out how to
get better, how to get back in the fight. It needs to be the
same thing with mental health injuries. We need to make sure
that that platoon sergeant or that corporal as a squad leader
or that platoon commander can recognize these injuries and say,
hey, private so and so, it looks like something is going on
with you, we need to go get you treatment so you can get better
and make our fighting force stronger, so you can come back in
the fight, get back to the platoon.
So we need to teach our young leaders in the military how
to recognize these injuries and treat them before they get too
far.
Mr. Mitchell. And one last question I have with what little
time I have, Dr. Berger: What suggestions do you have on how
the VA can best provide the outreach to at-risk veterans?
Dr. Berger. Thank you, sir, it is a good question.
Certainly the suggestions that have been made by everyone who
has already been here at the table, but I do believe that any
kind of comprehensive plan, as was hinted at by Representative
Roe, is a plan. There has got to be parts that involve
Facebook, the new communication technology. There has got to be
parts of it that are messages on our transportation system. The
list goes on. Let's see a plan so we don't have gaps in the
message getting out there.
Furthermore, it has to be tailored to the various segments
of our population. As you know, Vietnam veterans comprise the
largest cohort of American veterans, and we still have, as I am
sure Dr. Kemp can provide statistics, a significant number of
Vietnam vets taking their own lives. We must not forget about
them as well.
Thank you.
Mr. Mitchell. Thank you very much.
Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman.
Just a couple of things. And then to all of you, for me,
what I have had problems getting my hands--this is a huge
problem when you are talking about thousands of people. As a
doctor, you try to identify the person that would be at risk,
and it is very hard in this situation to do. I have looked at
it, and we have two issues, I think. We have active-duty
veterans who are taking their lives and we have a much larger
number of veterans who are taking their lives. So we have two
separate issues. And when I started thinking about this, I read
all this testimony, and it looks like we need to look at is
there a trend here? How old is the veteran? Are they homeless?
Do they have a job? Do they have family members? You can do
that and get that information and look and see which one of
those specific groups--and Dr. Berger, I know you are well
aware of this--that you can identify. I thought about how many
of them are unemployed? Are they Vietnam-era veterans? My
personally, in the last few months, in my own district, in my
own hometown, a patient of mine's husband committed suicide who
is a Vietnam veteran. And there was an attempt by somebody I
know extremely well just in the last 2 weeks, it was
unsuccessful, thank goodness, and didn't commit suicide and now
has a chance to get help and hopefully turn his or her life
around.
Mr. Embree, your point was an incredible point you made.
Both of those ads made a difference to me because I have the
idea of looking at it both of not being welcomed home and of
also being welcomed home. So I saw a different view of it than
you did, and you can only see it through the experience you
have had. But I can tell you that Dr. Berger will tell you in a
Vietnam-era veteran, both of those ads hit home.
I want to know how we use, because I think the younger
generation--I mean, how the Chairman and I Twitter is we shake
hands, that is our Twitter. But Facebook and Twitter and the
new media, how do you see that helping? I think it can be
tremendous because you have access to someone in California or
New York or around the world, a friend, with the new media.
Could you comment on that?
Mr. Embree. Yes, sir. And thank you for asking about this.
This is something that our organization, IAVA, takes very
seriously because we recognize that our members are all over
the country. One of the biggest successes of
communityofveterans.org has been because a veteran in Tennessee
can talk to a veteran in Florida securely, knowing they are
both vets. They can talk about what is going on and what they
are experiencing, and also those hundreds of miles go away and
they help each other deal with these issues.
But I think one of the biggest problems is the VA is making
steps, they are trying to use Facebook, they are trying to use
Twitter, but they are using it as press releases, saying this
is great, this is what we have done, and it is very regimented.
But the vets want to hear more about what is going on. It needs
to be a breathing organization they feel bought into. So when
they are sending out tweets or Facebook updates, it needs to be
stuff that is not just, hey, this new hospital has 20 new
doctors because that doesn't make any sense to the vet, they
are like, okay, that is great. But if one of the folks that
runs the program tells a little bit about their life and about
dealing with these programs and about their ideas and what they
would like to do, it gives a face to the VA. I think that is
what is so important. Folks want to know a little bit more;
they don't just want press releases.
Mr. Roe. Let me give you an example of what one local
sheriff in my district does, small county, mountain county,
Unicoi County, Tennessee, Sheriff Harris has his officers call
130 people, elderly people who live alone every day to check on
them and see how they are doing. Every single day they get a
phone call. If they have a medical problem, they call the next
morning and say, how are you getting along, did you have a good
night? And they listen for that. I am wondering when our
veterans--because we had a group, the 278s, just got home to
Greenville, Tennessee, Friday night. I was out, they got home
at 8:00 at night. And my question is, how hard would that be?
It doesn't take, no offense, a Ph.D. to talk to someone, how
are you getting along, are you having a tough day? I wonder if
we can't do that, especially for our veterans that are in rural
areas or anywhere. And I see this new media as being a real
resource to do that, just pick this up right here and get on
it, and it doesn't take you 30 seconds to do it. That may be a
lifeline to somebody. If they are having a tough day, they can
get pointed in the right direction if they know what direction
to go in.
Dr. Berger, one other thing, and I want to know before my
time runs out, this data that I mentioned here, has that been
done with this Blue Ribbon Panel? Is there a way I can sit down
and look at that and say, when I am talking to someone, and
look at their experiences, are they 20 years old within a
combat unit? Did they go through Fallujah? What experience did
they have? Is that data out there?
Dr. Berger. There are data contained in the final report--
at least the copy of it that I have--and I would be glad to
share that with you and you will have to look at it.
I would like to comment on what you said just a few minutes
ago about looking at the veterans audience out there because
what you said hinted at what suicide really is, and that is,
suicide is a process where you lose hope. There are proximal
events, whether it be a bad marriage, a drinking bout, some
other kind of situation, losing a job, what have you, that may
push the individual over the edge, but it is a process that 99
percent of the time people are thinking about as they lose
hope. The point being that in the campaign, it needs to bring
these elements in. It is not just taking your life, that is the
ultimate, but what impact does losing your job when you can't
get a mental health service, when your wife says, all right, go
to the substance abuse clinic or I am taking the kids and
leaving. It has to be thought out so that is addressed in the
campaign.
Thank you, sir.
Mr. Roe. Thank you. I yield back.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Well, thank you. I thank all of you for your
great advice. You have all been great partners and great
resources to help us get this right.
I keep coming back to this, and I think our first panel
made this very clear. We have to get to the front end of this
instead of chasing our tails on the back end forever. I come at
this from an education perspective. I am a teacher, and it just
drives me nuts. We talk about closing the achievement gap.
Every piece of research shows that by the time these kids get
to be 18 it is virtually impossible to close the achievement
gap. So we spend billions of dollars, tons of things, we don't
get it done. We know that if we attack them between preschool,
age two to five, our success rates are much greater.
This still comes back to the seamless transition. We are
not going to get this right until it is all part of the same
thing, until that culture changes, Tim, as you said amongst
that, until we group all our veterans together and we
understand that once they get in there.
My question to each of you is somewhat subjective, but I
trust your opinions on this, you get this. Are we getting any
closer? Is the virtual lifetime record moving us there? Are we
getting any closer on seamless transition?
Tom, do you want to take it first and then we will just
work our way down.
Dr. Berger. Seamless transition. We need to change that to
something that really better represents what we are trying to
do.
I think there have been very good efforts made, but again,
as you can hear, they are disjointed, the right hand doesn't
necessarily know what the left hand is doing.
Mr. Walz. It is not for lack of good intention.
Dr. Berger. It is certainly great intentions, but let's get
all the parties together and sit down and say, okay. And then
ask, ask our veterans, the ones who are coming out, what do you
need? What I need is not the same thing that Tim needs or that
Mr. Gadd needs. It has to be individualized as well, in my
opinion. And certainly we heard earlier about the retreat kind
of approach. Certainly that should be considered as well, where
you can bring all these elements together in a nonthreatening
kind of situation.
When my colonel walked in and said you are not going to
commit suicide, that is a lot different than me sitting down
with Tim and saying, you know, I have some things I need to
talk about, buddy, can you help me?
Mr. Gadd. Thank you for the question.
Does the American Legion believe it is moving fast enough?
We do not. They have been talking about this for several years,
we just want them to make it happen. The AHLTA system and the
VistA system, the architecture is very complex, but they have
teams working on it and it is just not moving quick enough. We
are here today talking about suicide and veterans falling
through the cracks, and that is a byproduct of the system not
being designed too effectively, once that servicemember goes in
the first day of active duty, tracking him until he comes back
to his community and returns from the service.
But also, I just wanted to point out too, VA did make some
strides with the TBI screening and how if you go in for a
podiatry appointment, something completely unrelated, they will
ask you about the TBI screening, they have that questionnaire.
There is nothing of that sort for mental health, and there
should be. They have integrated mental health into primary care
in the hospitals and in the clinics, but the American Legion
would like to see more tracking there.
Thank you.
Mr. Embree. Yes, sir. There are a lot of different programs
going on. I think one thing that is extremely important is
there must be more VA contact. There is actually a model
already out there, and it is your average college university
alumni association. Everyone knows when you are a freshman and
you get that first intro to college, there is a rep from your
alumni association to meet you, to tell you about all the
events going on campus, and then they are going to contact you
throughout your whole 4 years--or in some people's case, 5 or 6
years.
Mr. Walz. And then the rest of your life for donations.
They will be there.
Mr. Embree. Exactly, sir. And that is the thing, they make
those touches, they make those touches while you are there so
you become bought in, you become part of that alumni
association. And in that way, throughout the rest of your life
they stay in contact with you. The VA needs to be the DoD's
alumni association. They need to make that contact when you
come into the fleet, when you are that young lance corporal or
PFC or young sailor or a young soldier or airman, they need to
make that contact with you. And they need to keep making that
contact with you and your family throughout your time in
uniform. So when you leave, it is that actual simple transition
into the VA because you already understand everything they do,
you already understand the programs that are available.
Mr. Walz. Well, thank you. And I couldn't agree more with
all of you. I think that is absolutely the key to this. The
systemic change to help us prevent suicides, that is what we
are trying to get at. So I yield back.
Mr. Mitchell. Thank you.
Mr. Hall.
Mr. Hall. Thank you, Mr. Chairman.
Earlier this week, as Mr. Walz referred to, the VA
announced a new rule change which went into effect yesterday
morning which gives veterans who served in a combat zone,
servicemen or women, a presumed service-connection for PTSD and
removes the necessity of proving a particular incident that was
the trigger of that trauma. This Committee, the full VA
Committee, voted unanimously for legislation that basically did
the same thing. It was on its way to the floor when the
President and the Secretary, General Shinseki, moved in and did
a rule change to basically accomplish that piece of it.
What impact do you see this as having on veterans being
willing to come forward and seek treatment for possible mental
injuries before they reach the point where they could harm
themselves or others? And how best can the knowledge of this
rule change be spread far and wide in the veterans community so
that those who are afraid of rejection or afraid of stigma can
have less of that fear and take advantage of this new
opportunity?
Tim, do you want to start that?
Mr. Embree. Yes, sir. I think with the new rules for PTSD,
what it does is it makes it easier for the veterans to get the
care that they need. There are very good counselors within the
VA system and there are very good doctors that have very
effective treatment to help these folks, but unfortunately the
process was so long before with the old rule, it was very hard.
Say if you were a female veteran who had served in a forward
operating base in al Anbar Province in Iraq and you got
mortared on a regular basis, or you served as a machine gunner
on multiple convoys, but you walked into a VA system that
didn't understand that women are in combat and you had to sit
there and prove these horrible things that happened to you and
relive it every time you are trying to prove your case, that
was awful. It was very unfair to the former servicemembers.
Something now that the rules have changed and we are making it
easier for folks to get to that care. That has been a major
step forward and we are very pleased to see that. We think a
lot more servicemembers and veterans are going to be able to
get the care they need because they are not going to have to go
through that 6-month, 9-month process to say, yes, I got blown
up, or, yes, I was shot at, or, yes, I watched my buddy die
right in front of me, be it man or woman in uniform. This
eliminates one more barrier for those folks seeking treatment.
Mr. Gadd. Yes, sir. The American Legion is supportive of
any law that can be relaxed such as that to make the process
simpler. Our veterans come home and have to fight another war
to get their benefits. Our 1,400 accredited service officers
help them with the claims, and this will make it a lot easier
for the veteran. We hope to see more of them file for their
benefits and use their 5 years of free care at the VA and
knowing about this.
So thank you.
Dr. Berger. Good question. VVA certainly agrees with that.
And as you may remember, Congressman, we strongly supported the
initiative. The one area where we have some difficulties is the
VA's requirement that it only be a VA clinician, meaning a
psychiatrist, psychologist or clinical social worker's
diagnosis that is acceptable. We find that rather difficult. It
does impose a burden on people who live far away from a VA
facility. And let's suppose that there were no VA in Topeka,
Kansas, you mean the VA is going to turn down the opinion of a
psychiatrist from Menninger Clinic who has been practicing for
30 years? That is going to be a problem. That is going to be a
problem. And it could create some backlogs in terms of
complaints down the road. But overall, as has been indicated by
my colleagues here, it certainly will ease the process.
Mr. Hall. I would agree with that. And I think in my
written comments last fall to the VA on the proposed rule was
that they include private psychiatrists and psychologists'
diagnoses equal to VA docs. But at any rate, this is,
nonetheless, I think a big step forward.
I wanted to ask, in your own experience, and as a matter of
what you would suggest, how active duty or soldiers who are
going through basic training who are entering the military
could be prepared for this? The reason I ask is because West
Point, which is in my district and where my nephew just
graduated a few weeks ago, had a year and a half ago a spate, a
rash of suicide attempts, half of them unsuccessful I am happy
to say. But the stress and the manifestation of this caused a
stand down and a teach-in and a buddy system all in an academy
predeployment.
So the question is, should this not just be done in the
military academies that are producing the officer corps, but
also is it being done to any extent, and should it be done more
as part of the basic training of all of our servicemen and
women?
Dr. Berger. Certainly, Congressman Hall. I am aware, it was
announced in the press that the Army has instituted a
resiliency program down at Fort Stewart. Now, what is the
resiliency program? I don't know, I haven't been able to get a
hold of the copy of the curriculum. I don't know who is
teaching it, I don't know anything about it. And obviously
there is no data on the outcomes. But if it is happening and it
follows those standards, principles and practices that some of
us in the clinical side know about resiliency, then that is a
great step forward for our folks who are in basic training.
Mr. Hall. I am out of time, but Mr. Chairman, if you would
like to allow the other two witnesses to answer if they wish.
Mr. Gadd. I will go ahead. Sir, the American Legion, in our
recommendations, had said training, education and outreach are
all important components there.
I think having the suicide prevention coordinator on the
DoD installation side is going to be helpful, too, like VA has
them in all of 153 hospitals, something to that sort. And part
of the testimony we talked about psychologists and the
shortage, 3,000 moving to 10,000, there is still a shortage in
DoD as well with psychologists, but just having that training
component at the installation level will be helpful in helping
this problem.
Mr. Embree. Yes, sir. Thank you for the question because I
think one of the things that is very important, like I
mentioned before, I do think that there needs to be a training
for your corporals course, your sergeants course, your staff
NCOs, your lieutenants and your captains because these are the
folks that, for a young Marine or soldier just coming to the
military world, these folks are like God to them. They tell
them when to get up in the morning and when to go to sleep at
night. They tell them when they are getting paid, they tell
them when they are going to eat chow. So these folks need to be
the ones that can recognize private--I am trying to refrain
from using military terminology or Marine Corps terminology, at
least--Private Smith, let's say, if Private Smith is acting
funny, the platoon sergeant or the squad leader is going to be
the first one to recognize this, and they are going to be the
ones that say you need to go get treatment for your mental
health because that way you make the fighting force stronger.
Because we PT to make sure our legs are strong so we can run
across the battlefield. We lift weights to make sure we can
throw our buddy over our shoulder when we need to get him out
of harm's way in a kill zone. We need to make sure that we are
also exercising our minds and that we can recognize injuries.
You can recognize when someone rolls an ankle or blows out a
knee. You need to be able to recognize if they are having a
mental health issue, be it depression, be it combat stress.
So I think we need to make sure that the folks that have
the everyday interaction with our young soldiers, sailors,
airmen and Marines, need to be the ones that--they don't have
to be taught to be a clinician by any way, shape or form, they
need to be taught just to recognize that someone needs to go
get that mental health treatment.
Mr. Hall. Thank you, Mr. Chairman.
Mr. Mitchell. Thank you very much.
I want to again thank you on behalf of all of us for the
service that you have given to this country. Thank you.
I would now like to welcome Panel three to the witness
table. For our third panel, we will hear from Colonel Robert
Saum, Director of Defense Centers of Excellence (DCoE) for
Psychological Health and Traumatic Brain Injury, U.S.
Department of Defense; and Dr. Robert Jesse, Principal Deputy
Under Secretary for Health, U.S. Department of Veterans
Affairs. Dr. Jesse is accompanied by Dr. Janet Kemp, the
National Suicide Prevention Coordinator for the Department of
Veterans Affairs.
Colonel Saum, you are recognized for 5 minutes.
STATEMENTS OF COLONEL ROBERT W. SAUM, USA, DIRECTOR, DEFENSE
CENTERS OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND TRAUMATIC
BRAIN INJURY, U.S. DEPARTMENT OF DEFENSE; AND ROBERT JESSE,
M.D., PH.D., PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY JANET KEMP, RN, PH.D., NATIONAL SUICIDE
PREVENTION COORDINATOR, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF COLONEL ROBERT W. SAUM, USA
Colonel Saum. Thank you, Chairman Mitchell, Ranking Member
Roe, and the Subcommittee Members. Thank you for the invitation
to talk about the Department of Defense suicide prevention
programs and related outreach efforts.
I am not here only today as the Director of the Defense
Centers of Excellence for Psychological Health and Traumatic
Brain Injury, but also as the father of an Army sergeant who
after two tours in Iraq, suffered a mild traumatic brain injury
and post-traumatic stress. He has considered suicide. It wasn't
until my family and I intervened that he sought care and
recovery.
Our servicemembers, veterans and families have, and
continue to display, strength and resilience. They have raised
their hands and volunteered to serve their country and lay down
their lives, if necessary, and we owe them the very best.
The largest barrier we face as a military and a society is
preventing suicide and the stigma that is associated with it.
Stigma prevents our warfighters, veterans and their loved ones
from reaching out in the most troubling of times.
In May of 2009, DCoE launched the Real Warriors Campaign, a
public education initiative specifically designed to combat
stigma associated with seeking help. Realwarriors.net is
accessible globally and has reached 72,000 unique warriors and
visitors, with more than 110 visits and 781,000 pages viewed.
The campaign partners with more than 100 organizations
throughout the country to increase visibility and outreach.
Additionally, DCoE has partnered with the Department of
Veterans Affairs to coordinate information and resources
specifically designed for the military community when calling
the National Suicide Prevention Hotline, 1-800-273-TALK. This
number continues to be displayed on all Web sites and
resources, such as Military OneSource, the go-to resource for
servicemembers and their families. The Department of Defense
and the Department of Veterans Affairs continually collaborate
on suicide awareness, creating resources, coordinating with the
services and other relevant organizations to send messages to
the widest possible audiences.
Another important aspect of our suicide prevention efforts
is to increase awareness and knowledge. The DCoE Outreach
Center is staffed by health resource consultants who are
available 24/7 by phone, by e-mail, by chat, and they are there
to answer questions and refer callers to a wide range of
resources on psychological health and traumatic brain injury.
The Reengineering System of Primary Care Treatment in the
Military, RESPECT-MIL, is a collaborative effort and a care
model that enables health care providers to screen patients for
post traumatic stress disorder, depression in the primary care
clinics. Since its inception in 2007, RESPECT-MIL has screened
approximately 350,000 Army personnel at medical treatment
facilities. They identified 2,528 soldiers with suicidal
ideation and provided the appropriate intervention and care.
The program will be implemented across the Services very
shortly.
Another facet of DCoE's outreach is our partnership with
the Congressionally mandated Yellow Ribbon Reintegration
Program. This program proactively reaches out to our National
Guard and Reserve members and their families, and since its
inception in 2008, more than 2,000 events have been held for
nearly 300,000 servicemembers, enabling them to successfully
reintegrate back into their families and their communities of
choice.
DCoE's collaboration with the Sesame Street Workshop
launched the Sesame Street Family Connections Program. The
Emmy-nominated program releases 700,000 bilingual dual DVD kits
that provide videos featuring Elmo and his family working
through the difficult issues, and includes materials for adults
on how to discuss the sensitive issue with children of a lost
parent from combat, illness, or suicide.
I want to thank you for the opportunity to highlight some
of DCoE's and DoD's suicide prevention outreach efforts, and I
look forward to your questions.
[The prepared statement of Colonel Saum appears on p. 64.]
Mr. Mitchell. Thank you.
The Subcommittee has been trying to determine the VA's
vision and its strategic plan on moving forward with their
suicide prevention outreach program. So at this time we are
going to show a short video display of some of that vision.
[Video shown.]
Mr. Mitchell. Thank you.
Dr. Jesse.
STATEMENT OF ROBERT JESSE, M.D., PH.D.
Dr. Jesse. Chairman Mitchell, Ranking Member Roe, and
Members of the Subcommittee, thank you for the opportunity to
appear before you today to discuss the Department of Veterans
Affairs efforts to reduce suicide amongst American veterans.
I am accompanied today by Dr. Janet Kemp, VA's National
Suicide Prevention Coordinator. Before I begin, I would like to
thank the Committee, and you, Chairman Mitchell, for your
continued advocacy on this issue and your leadership in this
area.
I would also like to thank the VSOs for their insight. But
mostly I would like to thank Ms. Bean for being here today. I
can't begin to comprehend her personal pain, but I would like
to acknowledge that sharing that and opening that public
dialogue I think really is, as Congressman Adler said, it is
the PSA that is important, that we continue to discuss this in
a public fashion.
I would also like to thank Dr. Kemp for being here. She
truly is the brilliance and the spark behind the VA's suicide
prevention initiatives and clearly leads the country in this
area.
I don't think anybody in this room would deny how important
this issue is to the VA. We have initiated several programs
that have put the VA in the forefront of suicide prevention in
the Nation, including the establishment of the National Suicide
Hotline. The addition of a chat service I think has been an
extremely important addition to that, the national advertising
campaigns to promote that hotline and phone number to all
veterans and their families. The placement of suicide
prevention coordinators in all VA facilities, and expanding
their role and interaction into the communities, expansion of
mental health services, and to my mind most important, the
integration of mental health services into primary care as a
major effort to reduce the stigma of those seeking mental
health care.
In response to the urgent need to reduce the incidence of
veterans and servicemember suicides, the VA has been
significantly expanding its suicide prevention program since
2005. We work in close collaboration with other Federal
partners, including our colleagues at the Department of
Defense, to discuss and facilitate ways that we can reduce the
prevalence of suicide amongst veterans and servicemembers. Part
of that collaboration includes the Defense Centers of
Excellence and Veterans Integrated Services Network as a formal
partner in the Real Warriors anti-stigma campaign. We also
serve as a member of the DoD Suicide Prevention and Risk
Reduction Committee to ensure that suicide prevention efforts
are coordinated between the two Departments.
The VA Call Center for Suicide Prevention Hotline, since
its creation in 2007, has now received just shy of 300,000
calls. And we just recently have led to more than 10,000
rescues, more than 35,000 referrals to the suicide prevention
coordinators.
Since its inception, the VA call line has also helped more
than 3,700 active-duty servicemembers. And during 2009, the
hotline services were supplemented with the veterans Chat,
which has been receiving more than 20 contacts a day, again, to
engage the younger servicemembers and veterans who would prefer
that rather than a phone call.
VA suicide prevention coordinators work hard to raise the
awareness about warning signs associated with suicide and the
availability of both treatment and support. In addition to
these measures, VA has been aggressively advertising this
information, improving outreach to veterans and family members.
In 2009, VA began an advertising campaign in Dallas, Los
Angeles, Las Vegas, Miami, Phoenix, San Francisco, and Spokane.
The metropolitan areas second campaign is displaying suicide
prevention advertisements in the interior of transit public
buses. This effort has reached more than 4.3 million daily
riders in 124 markets and covering 42 States and 21,000 buses.
VA is reviewing the association between exposure to public
health media messaging, knowledge of the hotline use, and self-
reported likelihood of hotline use if needed. Preliminary data
indicate an increase in the number of calls originating in the
areas where these advertisements were deployed, and based on
these promising efforts, VA is pursuing two contracts to
further promote our suicide prevention efforts.
First, we are soliciting bids to contract to support an
expanded presence on public buses and mass transit bid options.
And secondly, we are pursuing a second generation of suicide
prevention outreach that is based on a comprehensive strategy
developed with social marketing experts, implemented through a
newly created national outreach contract.
We are working towards suicide prevention coordinators to
secure air time locally for new public service announcements,
and our goal is to have these PSAs at more than 70 percent of
the 153 local markets, particularly during the National Suicide
Awareness Week in September.
Mr. Chairman, the VA has taken a number of steps to provide
comprehensive suicide prevention services, and the data
indicate our efforts are succeeding, though not complete. Our
mission will not be fully achieved until every veteran
contemplating suicide is able to secure services he or she
needs.
I thank you for your support of our work in this area, and
we are prepared to answer your questions.
[The prepared statement of Dr. Jesse appears on p. 67.]
Mr. Mitchell. Thank you.
Dr. Jesse, who is in charge now of making sure the progress
of moving forward on the momentum that was built in the pilot
program that ended in the fall of 2009?
Dr. Jesse. Mr. Chairman, we see this as a team effort, that
there are----
Mr. Mitchell. Who is the captain of the team?
Dr. Jesse. Well, Dr. Kemp, I believe, is truly the captain
of this team.
Mr. Mitchell. So she is in charge of making sure that we
move on from the momentum that was stopped after the pilot
program ended in 2009?
Dr. Jesse. Well, yes, sir. But I am not sure if we would
say that that pilot was stopped. That pilot is phasing into----
Mr. Mitchell. Well, let me move on. Why did the
responsibility for the pilot program move from Tammy
Duckworth's office to the VHA?
Dr. Jesse. I don't mean to sound like I am dodging your
question, but I just simply can't answer that. I can certainly
get back to you on the record for it.
[The VA subsequently provided the following information.]
The responsibility for the pilot program never changed. Public
Affairs are overseen by Assistant Secretary Duckworth's office but the
program elements are the responsibility of the program office,
specifically the Office of Mental Health Services. VHA programs that
spend more than $10,000 on marketing and advertising have their plans
approved by Assistant Secretary Duckworth and this campaign falls into
that category. We have included that policy in a directive that has
just been released so everyone has a better understanding of
responsibilities and oversight.
Mr. Mitchell. Sure. I want to know why the VA stopped
airing public service announcements late last year? Now, I
understand the need for a thorough evaluation to determine the
effectiveness of this outreach, and I applaud the VA's
accountability. But your own testimony, in the written
testimony, indicates that preliminary data indicates that the
advertising had been successful and has resulted in an increase
in calls to the suicide hotline. As of April, 2010, the VA
reported nearly 7,000 rescues of actively suicidal veterans
which are attributed to seeing the ads, PSAs, or promotional
products, and referrals to VA's mental health services have
increased.
Instead of suspending relatively low-cost outreach efforts
like the public service announcement, which cost only $200,000
to produce, why not keep it on air while you complete your more
comprehensive evaluation of its overall effectiveness?
Dr. Jesse. I am going to ask Dr. Kemp to address that
fundamentally, and I will come back on the back side if that is
okay.
Mr. Mitchell. All right.
Ms. Kemp. Thank you, sir.
First I want to stress that we did not stop airing the
PSAs. The contract that we had was for distribution. They were
distributed. Radio stations and TV stations across the country
have them, and we continually make stations aware of the fact
that they have them.
We track the number of airings that we see. They are still
available to be aired, and we still are encouraging local
stations to use them whenever they can.
One of the ways that we have found we were most effective
in getting stations across the country to air the announcements
was to have local people at their sites call them and encourage
them to use them. So we have moved into a mode where the
suicide prevention coordinators will continue to have the PSAs
available, continue to make sure that they are there at their
local stations, and will continue to----
Mr. Mitchell. Let me just interrupt real quickly. On March
17th of this year, the VA was in this room testifying, and the
question is, are the PSAs still airing? Their answer was, no,
the PSAs are not airing. However, they are available, but they
are not airing. And this was what the VA said on the 17th of
March.
Ms. Kemp. Right. And we, at that point, asked our suicide
prevention coordinators to contact their local stations,
continue to ask them to show them, and they have been airing
since that time.
Mr. Mitchell. Can you give us a number later of how many
airings they have had since April of last year?
Ms. Kemp. No, but I certainly can get that to you.
[The VA subsequently provided the following information.]
We asked the Nielsen Corporation to track the airings of the PSA
over the past year. Since January of 2010 (through August, 2010) there
have been 4,279 airings across the country and they are continuing to
air. We have placed the PSA's on Facebook and during fiscal year 2010,
the Gary Sinise video received approximately 4,800 hits and the Deborah
Norville video over 1400 hits.
Mr. Mitchell. And the next question I have for Dr. Jesse,
we have approximately 23 million veterans in this country and
only 8 million are enrolled in VA care. What about the
remaining 15 million? Do you really think that stopping the
airing of a PSA is the best way to serve them right now amidst
the epidemic of veteran suicides?
Dr. Jesse. Well, I think Dr. Kemp addressed the issue of
stopping the airing. I think part of that answer is, what is
the most effective way to reach out to those veterans? So, for
instance, two of the highest days' volumes to the call centers
were, one, I think when Ms. Duckworth was on CNN, and two, when
Dr. Phil had a thing on suicide and we ran the number as a
trailer underneath the dialogue. That taught us an important
lesson, that, particularly the local suicide coordinators,
because they know what is going on in the local markets, if
those kind of discussions are going on or being aired on TV,
that they can encourage the stations to run that number. That
turns out to be hugely effective strategy. We are doing a lot
of strategies like that.
Now, in terms of reaching out and bringing in the remainder
of the veterans, as I am sure you are all aware, there has been
a lot of discussion between the Secretary of the Veterans
Administration and Congress about how we get the rest of those
veterans to come into the system, including opening up--as you
know, President Obama and Secretary Shinseki have committed to
opening up to the remainder of the Category 8 veterans.
Mr. Mitchell. Right. I just note that, as I said earlier,
during the period of this testimony today, one or two veterans
will have committed suicide. And even from your own VA, it was
reported that there were 7,000 rescues of actively suicidal
veterans that were attributed to the PSAs. So I think these
were pretty good, and I would have kept them on. In any case, I
have used up my time.
Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman. Good points made.
Colonel, a couple of questions I have is, why are active-
duty suicides increasing? Is it the multiple deployments? Is it
military occupations speciality (MOS)? Is it a difference
between Iraq and Afghanistan? Is it the length of service? Are
there more Reservists than active duty? I mean, I don't have
any of that information to know who to target. And let me just
give you an example.
The question I have is, is training going on for the young
officer corps and the NCOs to identify--because I read an
article in the paper a week or 2 ago where apparently this is
going, this training is going on, a young soldier's buddy
recognized that he might be having problems, took the firing
pin out of his weapon. And when he attempted to commit suicide,
the weapon didn't fire.
And he later got help and is now doing fine.
And is that training going on now for the online on-duty
soldiers? And the other information, is it available and why is
it increasing? Why do you we think it is?
Colonel Saum. Yes, sir, excellent question and a
complicated answer. The training is ongoing, and General Casey
has introduced a program called Comprehensive Soldier Fitness.
And it addresses not only the physical fitness but the mental
health fitness and resource availability to the NCOs and the
officer corps so that training, you are correct, is going on
and the buddy-buddy system of taking care of each other is one
of the primary things that that program addresses.
The statistics you are looking for about what are the
primary causes for increased suicide among soldiers, I would
have to take that to record and get back to you. I believe
there are data points that have been collected, but I have been
sitting in this chair 14 days and I have not been exposed to
it.
[The DoD subsequently provided the following information:]
While the data show an increase in suicide rates among active-duty
servicemembers, the primary causes of these increases are not
definitively known. The causes for suicide are multifactorial,
interlinked, cumulative, often repetitive, and progressive over a
period of time. Demographic risk factors include male, Caucasian, E-1
to E-4, younger than 25-years old, GED or less than high school
education, divorced, and in the Regular Component (active-duty,
including National Guard and Reserve). Other potential contributing
factors can include real or perceived relationship, financial, and/or
legal difficulties. Loss of protective factors may stem from having
lowered social and family support during deployment.
The Department of Defense Suicide Event Report (DoDSER) is a
monitoring tool designed to facilitate standardized data collection and
reporting across DoD. Over 250 data points per suicide are captured
including personal characteristics, historical factors, suicide event
details, and clinical history. Over time, the DoDSER can help the DoD
better identify potential risk factors for suicide events and help
inform areas to focus prevention efforts.
Mr. Roe. I think the importance of it is that if your
training doesn't do anything good, if there is not training to
pick up the indicators of who might commit suicide; in other
words, if somebody has been to Iraq four times are they much
more likely, or whatever, if my MOS is combat or medic or
whatever, it may be there are identifiers out there that you
could look for.
Colonel Saum. Absolutely, sir. And one of the things we are
finding, and I will get that report to you, is that it is the
first deployment we see the most suicides. It appears that
repeat deployments, there is a decrease of suicide among
redeployed individuals.
[The DoD subsequently provided the following information:]
A report, pending publication by the American Association of
Suicidology*, analyzed suicide risk associated with deployments.
Analysis of suicide risk associated with deployments was demonstrated
by comparing Service suicide rates in 2005 when all Service's rates
were within historic norms, with suicide rates in 2007, which were
higher across the Services. The analysis indicates that among the
Regular Component of the Army, risk of suicides, measured by an odds
ratio, dropped from 1.60 for one deployment to 1.10 for two or more
deployments in 2005 and the ratio dropped from 2.03 to 1.25 in 2007.
The difference was not as dramatic for the other Services. However, it
is important to keep in mind that the Army deployed the most and had
more suicides compared to the other Services. The results of this
analysis may illustrate the ``healthy warrior effect,'' which refers to
servicemembers who are more at risk of suicide being removed from the
pool of servicemembers, because unfit servicemembers are not deployed.
In 2007, for both the Air Force and Army, there was a much greater
increase in deployment/no deployment suicide risk odds ratios compared
to the Navy and Marines. A possible explanation may be the increasing
lengths of deployment over that period of time for both the Air Force
(4 to 6 months) and Army (12 to 15 months), while length of deployments
for the Marine Corps and Navy did not change.
* July 2010--Manuscript submitted for publication, The Journal of
Suicide and Life-Threatening Behavior. ``A study of suicide incidence
and risk in an Active Duty United States Department of Defense
population.'' Hyman, J., Frost, L.Z., Ireland, R., Cottrell, L.
Mr. Roe. I think that is a very important right there; that
is an incredibly important piece of information, I think.
And this is for Dr. Kemp and Dr. Jesse, and has the VA--and
obviously most veterans don't commit suicide. Most veterans if
you look at the vast majority of us, we don't. You have 23
million of us running around, we don't.
Have we done those same identifiers in the veteran
population and are we screening for that so you can pick those
folks out and not have to wait until you get to a hotline to
make a call in the middle of the night?
Ms. Kemp. We are, sir. We know a lot about the veterans who
do die by suicide in the VA. We know about their
characteristics and have implemented several screening programs
to help us identify those ahead of time. We do have what we
call a high risk list that we place veterans on if they meet
our high risk criteria, which ensures that they get what we
call an enhanced level of care with safety plans that you heard
about earlier and other sorts of treatment modalities.
The other news is that we do know that veteran suicide
rates have decreased in the time period from 2001 to 2007 among
those veterans who get care within the VA.
Mr. Roe. Is the suicide rate different in the 15 million of
us that are not in the VA system versus 8 million who are?
Ms. Kemp. Yes. The suicide rate actually among veterans who
get care within the VA is slightly higher, but we believe that
is because of case mix and the high risk nature of veterans who
do get care within the VA, especially in our older population
groups. But we have been able to decrease that rate over the
past 6 years.
Mr. Roe. I agree with you on that. It depends on who you
are seeing. So the group at the VA, the rate is higher but you
are right, it may be more indigent.
Ms. Kemp. People at risk in general.
Dr. Jesse. I would like to just tack on to that just as an
example of the very high touch and close hold on this. In these
patients that are on that high risk designation the suicide
coordinators will literally put the hotline phone number into
their cell phones so that they have it readily handy as part of
their risk plan.
Mr. Roe. I think one of the most important people--and Tim
hit on this just a minute ago when he was speaking--is the
person most likely to observe your behavior is the person
closest to you, the guy next to you, he is going to watch out
for you the most and that is your buddy, your family, in this
case for a veteran it may be the wife, the child, the worker at
your job. So those are the folks that need to keep an eye on
us. And I also think--and I am closing. My time is up, too--
that the VSOs have a tremendous opportunity to help here. I
think that the American Legion, Vietnam-era veterans, and Iraq,
all of those organizations I think are doing a wonderful job at
making veterans more aware that there is help out there and
thank them for that.
Dr. Jesse. Absolutely. If I might I think also it is
important to mention the chaplain services, I think both in the
Department of Defense and VA, in their outreach programs into
the community chaplaincies to teach them particularly for the
Guard who are going home not with the benefit of going home as
a unit what to look for, so that the chaplains know that there
are particular issues with the veterans that they need to watch
out for and they can counsel the families and intervene early
on. I think this very comprehensive approach is extremely
important.
Mr. Mitchell. Thank you. Just excuse me just a minute, Mr.
Walz. I have heard also that there has been an increase in the
suicide rate among chaplains. And I don't know if you have
looked at that at all but I have heard because they are seeing
the same thing veterans are seeing and talking to them and
there is real work that needs to be done with chaplains that
should be done.
Dr. Jesse. Gosh, I am not aware of that, but I certainly
will look into that and get back to you.
[The DoD subsequently provided the following information.]
There were four active-duty and one reserve chaplain suicides in
the FY 2007-2010 time period. Data by year and by Service are below.
Chaplain population numbers are:
2,800 active-duty chaplains in FY 2007;
2,900 active-duty chaplains in FY 2008;
211 Naval Reserve chaplains in FY 2009;
2,973 active-duty chaplains in FY 2009; and
3,023 active-duty chaplains in FY 2010.
The chaplain suicide numbers are too small to perform a
statistical test for trends.
FY 2003: Army 0; Navy 0; AF 0
FY 2004: Army 0; Navy 0: AF 0
FY 2005: Army 0; Navy 0; AF 0
FY 2006: Army 0; Navy 0; AF 0
FY 2007: Army 1; Navy 0, AF 0
FY 2008: Army 2; Navy 0; AF 0
FY 2009: Army 0; Navy 1 (Reserve, not on duty); AF 0
FY 2010-Present: Army 0; Navy 0; AF 1.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman, and thank you all for
being here. You certainly could have chosen to do something
else, go into the private sector. You did not, you chose to
serve our Nation and our veterans, and for that I am incredibly
grateful.
I think you hear from us, and I said it before, I am the
staunchest advocate of our VA and the care of our veterans and
because of that I also can be some of the harshest critics. I
think that is how I am as a parent I guess, too, because we
care so deeply to get this right. But I don't think we say it
enough. Thank you for all you are doing.
I think it is a great step to have DoD and VA sitting at
the same table. It is something around here we don't see that
much and I will be honest with you I will get criticism for
saying this but I am going to say it, but we have no one here
from Armed Services Committee sitting with us. And I don't know
why we can't do joint hearings. I don't know why we can't get
together on this because we will ping pong it back and forth.
And it is a very frustrating thing.
I don't want to send Tom off back there, but Tom, until you
and I think of a better name the seamless transition will come
back and I will ask on this.
Dr. Roe was hitting on a very important point here on data
driven and I applaud him for that and I know that that is where
all of you operate from, too. And we need to do better with
that. We need to have that data.
I would just ask a question because I am curious about
this, we were discussing the VA, active and all that, society
as a whole because sometimes I think we need to be very careful
with the VA. We had a hearing this week, very critical, and an
error that shouldn't have happened down in St. Louis. It
happens once in a while. But the one thing is I think we need
to be clear is the VA reports medical errors, the private
sector does not at the same level of scrutiny and things like
that. So I am just wondering, obviously with this risk factor,
but I would think there are some comparative peer groups out
there, police officers, firefighters in tough areas or anything
if we are seeing that. Are we bringing in those lessons
learned? Are we bringing in those best practices from those?
And maybe Dr. Kemp, it may be, or Dr. Jesse start out coming on
your side of things.
Dr. Jesse. That is actually very true and a very important
statement and why I think that the dialogue about suicide needs
to address vulnerable populations like those people who have
post-traumatic stress disorder, if you will, which is not
limited to veterans. It includes clergy and firefighters and
the like, but very important that this become a national
dialogue. It is not a dialogue about veterans, it is a dialogue
about suicide and identifying people at risk, identifying the
warning signs and, as was pointed out, it is knowing that the
families, the people who are closest to those folks, the clergy
are the first to see those signs and need to be both empowered
and have access to the kind of help that they need to help
prevent suicides.
Mr. Walz. I think it is true. I think it is a true
statement, and we will hear from Dr. Kemp, because I think the
systemic issue here is mental health parity and society in
general reaction to it. So I think that is a very important
point that we need to broaden this because I think to a certain
degree you may be swimming upstream as the VA, and we have that
responsibility, and all those who have said it, until we get
everyone right we won't rest, but we may get some help from the
outside on that.
Ms. Kemp. One of the things we made a conscious decision
about in the beginning of the inception of our suicide
prevention program and hotline was that we did want to partner
with the Nation in addressing this issue. So our hotline
actually was founded through interagency agreement with the
Substance Abuse and Mental Health Services Administration
(SAMSHA) and we have decided that we all need to have the same
number available to call for help, whether you are a veteran or
a community member or a service person, I mean that there are
some options on that one national number if you are an active-
duty servicemember or a veteran.
But as a result of that, what we have been able to do is
garner in all of the national resources, through SAMSHA, using
national data, being able to look at best practices, be a part
of the SAMSHA best practice registry and both the DoD and VA
have partnered with them.
Mr. Walz. That is smart and I know that no one is as
frustrated as you if we are failing on certain areas. But I
think it is a broader dialogue.
I want to end with just a quick question to Colonel Saum.
First of all, your personal story is very powerful. And when
you tell that story about your son that makes a huge difference
and they have the right guy in the right job now and I feel
good about that. The Yellow Ribbon Campaign is something that
originated as a long-time member of the National Guard in
Minnesota. I watched this from its inception, infancy to being
implemented. How are we dropping the ball on IRR soldiers? How
are we dropping the ball on our first panelists where they get
the ball dropped on that? How does that happen, Colonel?
Colonel Saum. Sir, I think that was very well addressed. It
is a communication education, but most importantly, we are not
giving them the skills when we demob. They do get the
pamphlets. They do get the information about what the resources
are. There is not a skill level of how to call, who to call or
reaching the families of the IRR member. I think that is one of
the key elements we need to focus on, who is getting that
information. As Dr. Roe said, the buddy, and the buddy for the
IRR is the family and the people in the community. And I think
that is one of the things we have to focus on as we reorganize
that ourselves and put that information out.
Mr. Walz. Are you confident we can capture those, that we
can get that safety net under those IRR soldiers, too?
Colonel Saum. I believe we can do much better, sir.
Mr. Walz. Thank you and I yield back.
Mr. Mitchell. I would just like to ask Dr. Jesse another
question. Dr. Berger on the last panel mentioned the Blue
Ribbon Committee, titled the Blue Ribbon Work Group on Suicide
Prevention in the Veteran Population. And then he goes on to
say, however, it has been almost 2 years since the Blue Ribbon
Work Group finished its work and we have yet to see any formal
action plan that addresses each of the Group's findings and
recommendations in a comprehensive prioritized fashion.
Are you aware of this Blue Ribbon Committee and its
findings?
Dr. Jesse. I am aware of the Committee. It has been my
understanding that those issues have been addressed, but I
would like to refer the specifics of that to Dr. Kemp.
Ms. Kemp. We certainly formed a suicide prevention steering
committee after the Blue Ribbon panel gave us their findings
back. We do have a plan and have addressed each one of those
recommendations. We have completed the major recommendations
and most of the additional key findings. We continue to meet on
a regular basis, and I will be glad to supply that plan and
where we are on those recommendations to you.
Mr. Mitchell. Not only myself but I think the VSOs ought to
know this. People ought to know if we spend money on a Blue
Ribbon Committee and no one believes that anything is done,
this just reflects bad.
Ms. Kemp. Right. The past 2 years of my life have been
spent completing those, so we would be glad to share that.
Mr. Mitchell. I think you ought to share those with Dr.
Berger.
Ms. Kemp. We will be happy to.
[The VA subsequently provided the following information.]
The Blue Ribbon Panel recommendations and outcomes are attached.
These items are in the Suicide Prevention Strategic Plan which
continues to guide the current the current Outreach program.
Attachment A--Blue Ribbon Work Group on Suicide Prevention--Recommendations
--------------------------------------------------------------------------------------------------------------------------------------------------------
Key Recommendations Summary Recommendation Progress as 12/31/08 Status as of 12/00/09
--------------------------------------------------------------------------------------------------------------------------------------------------------
1 VHA should establish an An initial review of methods Workgroup has been
analysis and research plan used in published and established and is making
in collaboration with other unpublished veteran suicide recommendations for joint
Federal agencies to resolve reports has been conducted. use of both national and
conflicting study results . This document will be agency data. A common
. . to ensure . . . a circulated shortly to the nomenclature system has been
consistent approach to Federal Work Group. adopted by both the VA and
describing the rates of the DoD and is in varying
suicide and suicide attempts Planning is underway for a stages of implementation.
in veterans. face-to-face meeting of the See # 4 on Attachment B.
Work Group for late January/
early February to review
differences in calculating
veteran suicide rates and
definitions of suicide
attempts. Methodology for a
potential study of veteran
suicide will also be
developed and discussed at
the in-person meeting.
--------------------------------------------------------------------------------------------------------------------------------------------------------
2 VA should revise and A VA work group completed a Recommendation is completed.
reevaluate the current review of VA current Current policy continues,
policies regarding mandatory practices as well as the clinical reminder is built,
suicide screening evidence-base on screening implemented and being used
assessments. and the evaluation of on a daily basis.
suicidality. It recommended
continuation of VA's current
policy requiring a clinical
evaluation of suicidality
for evaluation of patients
who screen positive for
conditions such as
depression and PTSD. It
further recommended use of a
clinical reminder, currently
available, with four
standardized questions from
VA's Suicide Prevention
Pocket Care, to guide the
clinical evaluations.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3 Proceed with the planned Based on experience with 6 Category II flag is still in
implementation of the months of pilot use, the place and fully implemented.
Category II flag with Category II flag has been Flagging program is placed
consideration given to pilot implemented nationally, with and tracked in 100 percent
testing the flag in one or use monitored by the of facilities.
more regions before full National Suicide Prevention
national implementation. Coordinator. There have been
no reports of unintended
consequences related to
privacy issues.
There are still 9 sites that
do not have any patients
``flagged'' as of December
1st. All of these sites
indicate that they do have
processes in place to being
flagging as of some time in
December. This program will
require continued
monitoring.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4 Ensure that suicides and VA's National Center for Common nomenclature terms
suicide attempts that are Patient Safety and the have been implemented and
reported from root cause National Suicide Prevention all aggregate RCAs are now
analyses use definitions Coordinator have reached sent to the Office of
consistent with broader VHA consensus on terminology and Suicide Prevention, Single
surveillance efforts. definitions, and are using RCA's go to the NCPS and are
them as a basis for tracked as part of the
coordination of their patient safety program, The
suicide prevention Office of Mental Health and
activities. NCPS share information
regularly.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5 VHA should ensure that Plans regarding a national Program fully implemented
specific pharmacotherapy ``academic detailing'' and funded for FY 2011.
recommendations related to program are being reviewed
suicide or suicide behaviors as a component of the draft
are evidence-based. VHA Comprehensive Strategy
for Suicide Prevention.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6 VA should continue to pursue Based on evidence for a National public awareness
opportunities for outreach positive impact of the plan put into place for FY09
to enrolled and eligible Washington, DC pilot and FY10 including
veterans and to disseminate program, VA is expanding its multimedia and public
messages to reduce risk public awareness advertising transit systems. FY11 plan
behavior associated with campaign to additional in development with the use
suicidality. markets. In addition, VA has of an outside public
developed a released public relations firm.
service announcements that
have been broadly used.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7 The issue of confidentiality VA policy on sharing of Discussions continue. This
of health records of clinical information with is an ongoing issue and we
Operation Enduring Freedom DoD needs to be specified by continue to work on policy
(OEF)/OIF servicemembers who senior leadership. to guide us.
receive care through the VHA
should be clarified both for
patient consent to care and
for general dissemination to
Reserve and Guard
servicemembers contemplating
utilizing VHA medical system
services to which they are
entitled.
--------------------------------------------------------------------------------------------------------------------------------------------------------
8 In order to maximize the The National Suicide Ongoing and monthly reports
effectiveness of the Suicide Prevention Coordinator and scorecards demonstrate
Prevention Coordinators continues to monitor the ongoing work of the SPCs.
program, it is recommended work load and activities of
that there be ongoing the facility-based suicide
evaluation of the roles and prevention teams.
workloads of the SPC
positions.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Attachment B--Blue Ribbon Work Group on Suicide Prevention--StrategicPlan
--------------------------------------------------------------------------------------------------------------------------------------------------------
Other Recommendations Summary Recommendation Progress as 12/31/08 Status as of 10/00/2010
--------------------------------------------------------------------------------------------------------------------------------------------------------
1 Adopt a standard VA awaits action from CDC, New nomenclature system
nomenclature/definition for the Federal lead on adopted and implemented in
suicide and suicide attempt nomenclature, definitions, VA with expectation of
that is consistent with and standards for self-harm continued training and
other Federal organizations and suicide related events. implementation.
such as the CDC and the
scientific community.
--------------------------------------------------------------------------------------------------------------------------------------------------------
2 Prepare a single document The draft VHA Comprehensive Suicide Strategic Plan in
that details the Plan for Suicide Prevention, place.
comprehensive suicide modified during the
prevention strategic plan concurrence process, awaits
outlined to the Work Group review by senior leadership.
in different briefs and
documents in order to
facilitate more efficient
review of suicide prevention
progress.
--------------------------------------------------------------------------------------------------------------------------------------------------------
3 The VHA framework for See response to item 2. See above.
suicide prevention should
consider a public health
approach that goes beyond
secondary and tertiary
prevention.
--------------------------------------------------------------------------------------------------------------------------------------------------------
4 Portfolio for suicide 1. Specifically related to Portfolio is growing and
research across VHA should suicide prevention, HSR&D being monitored.
be expanded with suicide DHI 08-096: Outcomes and
prevention prioritized as a Correlates of Suicidal
research area. Ideation in OEF/OIF
Veterans; Steven K. Dobscha
MD; VA Medical Center,
Portland; Portland OR;
Funding Period: October
2008--September 2011.
2. From the August 2008
HSR&D review, one additional
study that specifically
addresses suicide prevention
is likely to be funded when
the IRB approval is
received.
3. Of the 23 mental health
related (substance abuse,
depression, TBI, PTSD) HSR&D
proposals in review this
cycle (March 2009), one is
specifically related to
suicide prevention.
--------------------------------------------------------------------------------------------------------------------------------------------------------
5 Consider establishing an The Advisory Board has been Advisory Board established
Advisory Board of key VHA convened. It meets monthly and meets monthly.
stakeholders involved in by conference call. Agendas
suicide prevention education and minutes are posted on
treatment and research to its SharePoint site at http:/
monitor and evaluate suicide /vaww. national.cmop.va.gov/
programs and policies on an MentalHealth/VHA%20
ongoing basis, establish Suicide%20Prevention%20
research priorities and Steering%20Committee /Forms/
provide advice to senior VHA AllItems.aspx.
leadership on existing and
new initiatives.
--------------------------------------------------------------------------------------------------------------------------------------------------------
6 The VA's efforts to reach Funding for the SAFE VET SAFE VET project on-going.
out to community emergency demonstration project for FY
departments to improve care 09 has been sent to the COE
for active service and at Canandaigua. Completion
veterans at risk for of the project will require
suicidal behavior are approximately $2 million in
encouraged. FY 2010 and in FY 2011.
The protocol as submitted
from the COE is attached
below. In response to VACO
input, the evaluation
component has been revised
to include information about
the timeliness and processes
for the transfer of care
from community setting to
VA.
The SAFE VET team is working
on developing the
infrastructure for this
project, which includes
confirming the project sites
and the recruitment of the
Acute Service Coordinators
at the VA hubs sites. The
team is also planning for
the training of the Acute
Service Coordinators during
early-mid February 09, and
developing a common database
for data collection to be
housed on a secure server at
the Canandaigua VA medical
center.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7 The VA should continue its Ongoing training for the Annual DoD/VA conferences
efforts to promote training Suicide Prevention established. January 2010
in implementing suicide Coordinators and their teams was held in Washington DC.
prevention programs. is continuing on an ongoing March 2011 is arranged in
basis. The next formal, Boston.
large scale training will be
coordinated with the VA-DoD
National Suicide Prevention
Conference to be held in San
Antonio during the week of 1-
12-09.
More detailed plans for
continuation of training are
included in the draft VHA
Comprehensive Strategic Plan
for Suicide Prevention that
is currently being reviewed
by Senior Leadership.
--------------------------------------------------------------------------------------------------------------------------------------------------------
8 Promising followup A report on the Caring Caring letters continued.
interventions designed to Letters pSafety planning as an
prevent veterans identified in the Facility Report Care intervention implemented and
as being at risk from attached to the update for continues.
``falling through the Key Recommendation 8.
cracks'' should be evaluated
and, if deemed effective,
implemented further.
--------------------------------------------------------------------------------------------------------------------------------------------------------
9 The VA should work The general issue remains on On-going. VA Chat Service
collaboratively with other the agenda for the Federal implemented in July 2009 and
Federal agencies to Partners Work Group on continues to receive chats.
understand and evaluate the Suicide Prevention.
implications of new
technologies for suicide The National Suicide
prevention (e.g., social Prevention Coordinator and
networking, text messaging, the COE in Canandaigua have
etc). developed a Web Based Chat
Room program that would
connect veterans accessing a
highly publicized, non-VA
Suicide Prevention Web Site
with professional responders
at Canandaigua. The Chat
Room would be anonymous and
private. The primary goal
would be to facilitate calls
to the Hotline or help-
seeking at VA facilities.
Implementation of the Chat
Room project is on-hold,
awaiting permission to
either load the needed
software on VA computers, or
for providing VA responders
with authorization to use
non-VA computers for this
program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
10 The VA should design and Dissemination of the Completed.
disseminate psycho-education Resource Guide for Family
material for families of members is underway. Dr.
veterans who are at risk for Kemp has forwarded it to
suicide, particularly, those Suicide Prevention
hospitalized for suicide Coordinators and Dr. Karlin
attempts. to Home Based Primary Care
Mental Health Providers. The
guide is also posted on the
Veterans Integrated Services
Network (VISN) 19 MIRECC Web
site--http//
www.mirecc.va.gov /visn19/
docs/ Resource_Guide_
Family_Members.pdf
A product under development
is a brief guide for parents
to assist them in discussing
family member suicide
attempts with their children
in a developmentally
appropriate manner.
--------------------------------------------------------------------------------------------------------------------------------------------------------
12 VA should review approaches This is included in the VHA See strategic plan--this is
for better integrating VA Comprehensive Plan for an on-going item.
chaplaincy and pastoral care Suicide Prevention that is
services and traditional currently under review by
mental health services. . . senior leadership.
The Work Group further
recommends that the VA
collaborate with other
public and private partners
to reach out to faith-based
communities that can assist
veterans at risk.
--------------------------------------------------------------------------------------------------------------------------------------------------------
13 Work Group recommends that Funding has been sent to the Currently in year 2 of a 3
the VA implement a gun COE in Canandaigua New York year project. Several
safety program directed at to implement this program hundred thousand gun locks
veterans with children in for FY 09. have been distributed.
the home, both as a child
safety measure and as a The draft of the Statement
suicide prevention efforts. of Work document with the
National Shooting Sports
Foundation (NSSF) is
awaiting final cost figures
for the education materials
and gun locks from the
Foundation. The draft of the
Sole Source Justification
document utilizing the
unique program operated by
NSSF has been completed. It
is anticipated that the
contract will be awarded by
the end of January 2009.
Five hundred thousand gun
locks will be delivered to
the 153 VA Medical Centers
within the first year of the
3 year program. Under the
current timetable, gun locks
should start to arrive at VA
locations on May 1st, 2009.
It is anticipated that gun
locks will be available to
veterans, their families and
VA employees through
collaboration with the VAMC
Police Departments and other
points of contact. Each VA
facility will be responsible
for development of a locally
specific policy for
distribution of the gun
locks and educational
materials. The Center of
Excellence is currently
developing the process for
tracking distribution and
collecting data.
--------------------------------------------------------------------------------------------------------------------------------------------------------
11 For veterans who exhibit Following his initial DBT training programs being
chronic suicidal behavior, evidence summary suggesting implemented and DBT
and who do not respond to that Dialectical Behavioral treatment is being used
short term therapies, more Therapy (DBT) may be throughout VA. Additional
intensive modalities should effective in preventing EBT programs established.
be considered. Additionally, suicidal behavior
the evaluation of intensive specifically in patients
outpatient alternatives to with Borderline Personality
hospitalization should be Disorder (BPD), Dr. Karlin
promoted. evaluated rates of BPD
diagnoses at all medical
centers, and found several
facilities with
exceptionally high rates.
One, Portland, was in a
geographical area with high
suicide rates. In evaluating
services at this facility,
he found a well-established
DBT program. The next step
in evaluating need and
feasibility for enhancing
DBT programs in VA will be a
survey of other facilities
to account for, quantify,
and document where and to
what extent DBT is currently
available throughout the
system, and to relate its
available to diagnoses of
BPD.
--------------------------------------------------------------------------------------------------------------------------------------------------------
14 The Work Group recommends As previously noted, Closed. New PTSD legislation
that VA analyze entitlement implementation of this has been helpful.
changes required to allow recommendation could only be
treatment of combat related accomplished through
conditions to reduce Congressional action.
suicides in un-entitled
veteran populations.
Currently, VA treatment of
mental health and substance
use disorders in some combat
veterans is not allowed
because of the category of
their discharge, such as
dishonorable discharge.
Congressional authorization
to treat some combat
conditions in this
population may enhance their
outcomes and reduce suicide.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Program Office: Office of Mental Health
Mr. Mitchell. I would like also to thank Colonel Saum for
your service, your son's and your family's because your wife is
as much of what we are doing here as you and your son. So I
want to thank you for your service.
And I want to ask kind of a followup on Mr. Walz very
quickly, when a person is in the Ready Reserve and not on
active duty, are they under the, I guess they are under VA and
not DoD, when they are called active duty they go under DoD. Is
there a disconnect sometimes between when a person is in
between deployments?
Colonel Saum. I am sorry, sir, deployments or active duty
to Reserve you mean? I believe that is what you mean.
Mr. Mitchell. Right, I am sorry.
Colonel Saum. No. It is a seamless transition as far as the
benefits when you come from the Reserve Component National
Guard to active duty because the pre-mob that they do at the
Reserve Guard units gets the families enrolled and gets the
individual enrolled. Where we are looking at--and we have a
program called Transition for when they demob and they are
leaving, say, Fort Sill, Oklahoma, and going to California,
that transition program is in place and giving them the
information during transition home for resources that they
would have for resources within the DoD.
Mr. Mitchell. So when that soldier goes back to California
he is now under the VA system, not DoD?
Colonel Saum. No. There is a transition system where he is
still covered by us.
Mr. Mitchell. Thank you. And again Dr. Roe.
Mr. Roe. Just very briefly, I am sitting here, I sat here
today and heard a lot of compelling testimony and I am trying
to get a take-away from this, and part of it is, I believe, and
one of the things I am going to do is make sure that it is on
my official House Web page, that that hotline number is on
there; number two on my campaign Web page that I put it on
there and veterans have access to it. So I would encourage all
of our House Members to do those two things. You can cover a
lot of people. We get a lot of hits on the Web site.
The other that I hadn't appreciated as much is how the
Committees, our own Committees, haven't interacted, and it has
been brought, Sergeant Major Walz brought it up, the Chairman
brought it up, and Mr. Hall brought it up, about how the Armed
Services Committee and this Committee haven't coordinated this
at all, and so I don't really see as much coordination between
DoD and VA as I think we need and I need a little better
clarification on what the DoD is doing in training the buddies.
I think that may be going on right now. I believe that General
Casey said he is in the process of doing that. I think this
Committee needs to know how that is going on and then how that
information can be shared with the VA, so that we know that
soldiers who have maybe been trained to look for things in
their buddies that that is actually being done, because I
believe that has as much to do with it on the active-duty side
than the VA, the veterans side where I am, and where the
sergeant major is, is a totally different issue and are we
doing enough there. And I am not there yet that we are.
I really appreciate you being here, all the witnesses being
here, and Colonel, so much, I look at your chest and you are a
patriot and I appreciate you coming back on the service to help
veterans and help active-duty soldiers.
Colonel Saum. Thank you, sir.
Mr. Mitchell. Again on behalf of this Committee and the
Congress, we want to thank all of you for your service. I do
want to let you know that there will be followup with these
questions from our Committee staff. And with that this hearing
is adjourned.
[Whereupon, at 12:25 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Harry E. Mitchell, Chairman,
Subcommittee on Oversight and Investigations
Good morning and welcome. I appreciate everyone being here today,
and for your interests and concerns on the progress of suicide
prevention outreach efforts. Before we begin, I want to acknowledge a
positive step that the VA has taken recently to help veterans suffering
from Post-Traumatic Stress Disorder, or ``PTSD''. The VA recently
announced that it is easing the evidentiary hurdle that veterans must
clear to receive treatment for PTSD. This is a step in the right
direction, and I am glad they're doing it.
However, to be truly effective in reaching all the veterans who
need help--not just those who are already showing up the VA and asking
for it--the VA also needs an effective outreach strategy. We have 23
million veterans in this country--only 8 million of which are enrolled
to receive care with the VA. The VA has an obligation to the 15 million
who are not enrolled for care--not just the 8 million who are already
enrolled. If these other veterans have PTSD--or are at risk for
suicide--the VA has an obligation to reach out to them, as well--and
let them know where they can turn for help. Last year, upwards of
30,000 people took their lives by suicide in the United States. Twenty
percent of these deaths were veterans. Each day, an estimated 18
veterans commit suicide. By the time this hearing concludes--between
one and two veterans will have killed themselves by suicide. These
statistics are startling.
As you know, many of our newest generation of veterans, as well as
those who served previously, bear wounds that cannot be seen and are
hard to diagnose. Proactively bringing the VA to them, as opposed to
waiting for veterans to find the VA, is a critical part of delivering
the care they have earned in exchange for their brave service. No
veteran should feel they are alone.
As Chairman of this Subcommittee, I have repeatedly called upon the
VA to increase outreach to veterans who need mental health services and
are at risk of suicide--and members on both sides of the aisle have
urged the same. In 2008, the VA finally reversed its long-standing
self-imposed ban on television advertising and launched a nationwide
public awareness campaign to inform veterans and their families about
where they can turn for help. As part of the campaign, the VA produced
a public service announcement featuring Gary Sinise, and distributed it
to 222 stations around the country that aired it more than 17,000
times. The VA also placed print ads on buses and subway trains.
According to the VA's own statistics, the effort proved successful. As
of April 2010, the VA has reported nearly 7,000 rescues of actively
suicidal veterans, which were attributed to seeing the ads, PSAs, or
promotional products. Additionally, referrals to VA mental health
services increased.
However, despite this success, late last year the public service
announcement stopped airing. I don't understand this. If anything, it
seems to me we need to be increasing outreach to veterans at risk for
suicide, not stopping it. It is my understanding the VA is planning to
produce a new public service announcement, which will be ready by the
end of this year.
However, the question remains--why did the VA stop running the
first public service announcement while they work on the second one?
How does it help veterans to go dark for more than a year?
While I commend the additional expansion in outreach that has grown
in the way of brochures and other useful steps, I do not think the VA
should suspend--even temporarily--outreach efforts like the public
service announcement that have proven successful. It is also imperative
for the VA to utilize and adapt to technology, including the use of
Facebook and Twitter to reach the latest generation of veterans. Doing
so, I believe will help transform VA into a 21st century organization
and most importantly save lives.
Today, the Subcommittee is assessing the suicide prevention
outreach program on national implementation and achievements. We have a
wide range of testimony that will be presented today and I look forward
to hearing all that will be said on this vitally important issue. We
appreciate our panelists' dedication in the formulation of a more
comprehensive and targeted suicide prevention outreach program. These
struggling veteran's deserve our help, and we must work in a bipartisan
way to ensure that the VA delivers it to them.
Prepared Statement of Hon. David P. Roe, Ranking Republican Member,
Subcommittee on Oversight and Investigations
Thank you Mr. Chairman.
I appreciate you calling this hearing today to review what the VA
has done in the area of outreach to the veterans in our communities who
are feeling vulnerable and uncertain of their future. I cannot imagine
what goes through the mind of someone seeking to end their life, but we
must do anything we can to ease their pain and help them through the
crisis that they find themselves in, so that they can move forward and
heal from the wounds from which they are suffering.
Public Law 110-110 was signed on November 5, 2007, by President
Bush. This law, as part of the comprehensive program for suicide
prevention among veterans provided that the Secretary may develop a
program for a toll-free hotline for veterans available and staffed by
appropriately trained mental health personnel at all times, and also
designated that the Secretary would provide outreach programs for
veterans and their families.
As part of this outreach, the VA contracted with the PlowShare
Group, Inc. to distribute, promote and monitor a Public Service
Announcement (PSA) featuring actor Gary Sinise, who played Lt. Dan in
the movie ``Forrest Gump,'' and also performs in the Lt. Dan Band. This
moving PSA, which can still be found on YouTube (http://
www.youtube.com/watch?v=x1QXoVJQdDm), encourages veterans to contact
the toll-free national Suicide hotline number in an emotional crisis.
According to PlowShare, their work on this campaign was successful, as
they were able to generate nearly $4 million in donated media, and the
suicide hotline saw an increase in activity during the campaign.
The VA also piloted outreach advertising right here in the metro
area of Washington, DC. Driving around the city and on the metro system
buses and signs could be seen in various locations promoting the
hotline to veterans.
What I look forward hearing today is the following: Have we seen a
reduction in the number of veteran suicides since the inception of the
PSAs; what plans are there to continue the PSAs now that the contract
for the previous PSAs has expired; How has the National Suicide Hotline
helped in the reduction of veteran suicides, and where do we go from
here?
I am pleased that we have witnesses from our veteran community here
today, as well as the VA, so that we can hear from everyone how useful
the previous PSAs were, and what other kinds of outreach efforts need
to be made to reach not just our older veteran population but our new
veterans coming out of Iraq and Afghanistan. How is VA using new media
to get information out to our new set of veterans who may not be aware
of all the services the department provides?
We need to review and evaluate the success of these outreach
efforts on an ongoing basis, and see where they can be improved, and
enhanced, as well as how frequently they are being broadcast to the
general public.
Again, thank you Mr. Chairman, and I yield back my time.
Prepared Statement of Warrant Officer Melvin Cintron, USA (Ret.),
Manassas, VA (Gulf War Veteran and OIF Veteran)
Distinguished Members of the Committee on Veteran Affairs, my name
is Melvin Cintron. I am a veteran of both Desert Storm and the current
war in Iraq. In Desert Storm I worked as a flight medic conducting
forward area medical evacuation support of both U.S. and enemy injured
and wounded personnel, both civilian and military with a large portion
of those being children and a portion of those that died in transport
in our aircrafts. Additionally, although I had been inactive for
approximately 6 years, I also received notification of my reactivation
into active duty beginning 2004 for a period of 18 months for the war
in Iraq. While I could have chosen at that time to seek the avenue of
many of those who were in my condition and were activated I chose not
to seek deferment or to make any attempt to shy away from my
responsibility in responding to my country's call. I did this, as our
oath requires, without purpose of evasion or mental reservation because
I knew that if I did not go then some other father, mother, son or
daughter would have to have the same painful conversation with their
family that I had with my family when I received my letter, because
someone else would have to go in my place because I didn't and that was
not an acceptable option for me so I chose to answer this Nation's call
and serve it proudly and honorably. In the first Gulf War I was
submitted for a combat air medal for part of my efforts and the conduct
of my duties in support of our units mission. In my second activation I
was submitted and received the army's Bronze Star medal for my
contributions and performance as the unit's aviation maintenance
officer in the 1159th medical evacuation company. My and my team's
combined efforts led to our unit having the following approximate
statistics in our Medical Evacuation mission; over 2400 U.S. Military,
over 700 U.S. civilian and Coalition and more then 150 EPW (Enemy
Prisoners of War). Within these there where over 2100 Litter patients
and over 1700 ambulatory
While I feel that I served honorably and at great cost to myself
financially, physically and mentally and to my quality of life, and at
a much higher cost to my family and my children and yet I have no
regrets of having answered a call and would proudly do so again. And
yet my sacrifice to me seems so small and I consider myself often
ashamed to enter the VA to seek help when I have seen so many of my
colleagues who have faced so much of a higher price than I and some who
I've seen pay the ultimate price. I have never been nor will I ever be
ashamed of the service that I have performed for my country nor will I
ever cease to be proud of what I have seen my fellow soldiers do in
answering their call to duty. This goes to a sharp and contrary
contrast to the service provided by the VA to those men and women whom
like me have served proudly and selflessly. When I walk into the VA
medical center I see in the walls posters that say ``it takes the
courage of a warrior to ask for help'', but I am here to tell you that
it really should read not that ``it takes the courage of a warrior to
ask for help'', but ``it takes the courage of a warrior to ask for help
from the VA''. I can give countless examples of many of the failures
encountered by our veterans daily in seeking help from the VA, but that
is a different chapter. This Committee as I understand it is seeking
input on the suicide prevention hotline and efforts of the VA. Make no
mistake, I consider myself extremely blessed with all the blessings
that God has and continues to bestow on me regardless of my deserving
or not. But there are many who are not as blessed and their need for
good timely help from the VA should never be compromised as I believe
it is now. But I digress so I will state that I believe that the VA
suicide prevention hotline and suicide prevention efforts in my
singular opinion are not working. I often call the VA for medical
appointments and there is a message that comes on and it says that if I
or a loved one is at risk for committing suicide to call the suicide
hotline. I'm here to tell you that while I have never considered
suicide nor see that as an option in my life I have often desired
someone to talk to or share with when I've had a bad day who would
understand, however never would I consider calling a suicide hotline if
it is not something that I see as an option in my life. I believe that
there are many veterans whose faith might be different and for whom
suicide is not as foreign a thing as I consider it to be in my life.
However these veterans too seek no more than someone to talk to or help
them get through a certain hour in their life. However the VA in my
experience does not provide for that, what it provides for is suicide
so a veteran would have to have reached the point of actually
considering suicide to actually call the suicide hotline and I would
submit that by then for some it could have prevented or that might have
been prevented it would already have been too late. I am not an expert
in these matters but I would think that providing for the mental well
being of our returning soldiers in a manner that allows them to seek
and get help without tying to them the stigma of ``you are considering
suicide so you need to call this number''. In my 19 plus years since
coming back from desert storm as well as in the last 5 years in coming
back from Iraq this time I have met many veterans who have seen fit to
talk to me about their experiences and who have broken down in the
middle of telling these experiences to me. These have been things
they've held in for a long time. I've asked them why they don't go to
the VA for help already knowing the answer. I've also advised them of
calling the VA and they too have shared with me that they are not
suicidal nor would they want to risk such a label for fear within their
job, their family or their social circles.
Much to my discomfort I interact with the VA on a regular basis and
in all of the time that I interact with the VA I have been keenly aware
of the suicide prevention and the posters suggesting that you call for
help. What I have not readily and easily encountered is a system that
puts strong emphasis, however if in all these years of dealing with the
VA I am ignorant of the easily accessible and readily available
intermediate or non-suicidal hotline efforts going on then I apologize,
however the fact that I don't know it means that that system needs help
in its promotion, marketing and easy accessibility for our veterans to
seek and receive help long before the point of resorting to a suicide
hotline by which time I would consider we've missed the help
opportunity.
As stated earlier, I am one who is blessed beyond anything I could
ever earn. I have 2 arms to hug my children with, I have full sight to
see my family and my blessings and 2 legs which easily led me here
today to testify not for my need but in hopes that others who are not
as blessed and who have need of better support from their government
would hopefully receive it and if I can be a part of making their
support easier then I am proud to have come and testified before this
Committee. And I hope that instead of just suicide prevention that we
also attack the problem at a point long before our system would lead
another veteran to just a dire end. I am not aware of ongoing efforts
but if not considered I would strongly recommend that those more
learned than I would seek to establish a system of continuity support
or life intervention type program that would address a basic need to
our soldiers to talk without acquiring the stigma of, or being
considered, a suicidal risk or at least without having the perception
whether real or not that you need to talk a suicide hotline because you
are now suicidal just because you wanted someone to talk to on any
given day and in any given hour.
In addition to such a continuity support/life intervention program
I also feel that a peer mentor program would be an effective approach
to helping veterans before they reach the point of considering suicide.
On a personal note, I just as many of my peers, was hesitant to make
any formal approach to the VA or another medical facility to talk about
any problems because of the stigmas I noted previously. However, if
there are mentors or peers who had lived through the same experiences
and with whom soldiers could express themselves as counterparts and
receive guidance on how to deal with their emotions and move forward
with their lives, this would have provided a much more approachable
solution for their problems rather than a sterile doctor's office or an
open forum. Only those who have lived through these experiences can
truly listen and understand those who have.
However for such a program to be successful it must start not only
at the VA but in our services. As an example, when returning from Iraq,
as we out processed in Fort Dix, New Jersey, in an auditorium, a
sergeant asked ``Is there anybody here who feels they need to talk to
someone about anything they saw or did?'' Nobody raised their hand. He
then stated, if you want to do it confidentially please sign the roster
that will be in the adjoining room. On the day prior to our leaving the
out processing center the sergeant again addressed the crowd of
soldiers and with the pad in his hand he read out the names of those
soldiers that had signed up confidentially for the offer made the
previous day and asked do you still need to see somebody. Needless to
say, nobody responded with a yes. I was one of those soldiers.
I further recommend that we have a program within each unit to help
identify both formal and informal leaders within the groups that can be
trained on a voluntary basis to be outreach mentors or peer confidants
who could informally reach out as colleagues or fellow soldiers to talk
to them as friends or as fellow soldiers who have been through similar
situations and can equally share discussions outside of to structured a
program although it could lean towards a more structured group help
type program should it be needed down the road as they currently exist
today (group therapy programs).
In a magazine I read many years ago there was a picture of a wall
that was depicted as a wall where people where executed by firing
squads it read ``you have never lived till you've almost died, for
those who fight for it, life has a flavor that the protected will never
know'' I would at that such a taste also has a price that no soldier
should be left to pay alone.
I thank you for this opportunity and pray that my contribution may
in some way help my fellow men and women of our armed forces and others
who support our countries efforts in combat zones or in harm's way.
Prepared Statement of Linda Bean, Milltown, NJ
(Mother of OIF Veteran)
Mr. Chairman and Members of the Subcommittee.
Thank you for allowing me to appear before you. And thank you, Rep.
Holt, for standing with me and my family.
I testify today because my son, U.S. Army Sgt. Coleman Bean, 25 and
a veteran of two tours of duty in Iraq, shot and killed himself on
Sept. 6, 2008. I am grateful for this opportunity; I have a duty to
Coleman and I owe a debt to those with whom he served.
It is my hope that these observations, which are drawn from a
shared experience of loss, will be useful to you as you oversee the
continued development and implementation of suicide-prevention
programs.
First, we need to accept these facts: Many veterans come home to
families and towns that are a far remove from VA hospitals or Vet
centers. Some veterans at risk for suicide would not describe
themselves as suicidal and some veterans will not or cannot use VA
mental-heath services.
I believe it is crucial that the VA:
Identify and publicize civilian counseling alternatives,
including The Soldier's Project, GiveAnHour and The National Veterans
Foundation.
Partner with civilian organizations to assure that all
vets have immediate access to a wide range of mental-health care, and
Encourage media outlets to publish local information on
mental-health resources for veterans.
Second, I believe it is critical to implement a simple,
straightforward public information campaign geared specifically to
veterans' family members and friends. It may fall to a grandmother, a
best friend or a favorite neighbor to seek out help for a veteran who
is suffering. Make information on available services easy to find and
understand and publish it broadly. The suicide hotline number is not
enough.
Help veterans help each other. The VA is confronting PTSD and
suicide with new programs and new research, good and important work.
But that hasn't always been the case and there are vets who will tell
you that they have had to scrap and fight for every VA service they've
received. In addition to the official patient-advocacy complaint
resolution program, please establish a peer body--made up of the most
feisty, tenacious veterans. They will help assure that no vet gives up
because it just got too hard or took too long to navigate the VA
system.
My son joined the Army when he was 18, enlisting on Sept. 5, 2001.
The terrifying tragedy of Sept. 11 reaffirmed for Coleman the rightness
of his commitment. Home on leave, he took a pair of socks that had been
lovingly laundered by his mother and refolded them to comport with Army
specifications. It was his intention, Coleman said, to be a perfect
soldier.
In the days following Coleman's death, our family had the humbling
opportunity to meet men with whom he had served; they traveled from
around the country to be with us, and with each other. It was clear to
us then that many of these men carried their own devastating burdens.
I spent hours on the telephone, trying to identify services for
these young men, reaching out first to the VA facilities in the States
where they lived. My inquiries netted mixed results.
A VA representative in Texas, horrified when I describe our fears
for a young veteran there, said ``just tell me where he is and I will
go there. I'll get in my car right now.''
By contrast, a man in Maryland was firm: ``If they won't come here,
we can't help them,'' he said.
That simply is not right. Of course we can help them and we can
help their families. And it is our duty--not theirs--to figure out how.
Prepared Statement of Timothy S. Embree, Legislative Associate,
Iraq and Afghanistan Veterans of America
Mr. Chairman, Ranking Member, and Members of the Committee, on
behalf of Iraq and Afghanistan Veterans of America's one hundred and
eighty thousand members and supporters, thank you for the opportunity
to testify before you today. My name is Tim Embree. I am from St.
Louis, MO and I served two tours in Iraq with the United States Marine
Corps Reserves. Veteran suicide is an issue that resonates with all of
our members and we are grateful that you are holding this hearing. As
an IAVA member recently told us:
``For most of the past year I thought about suicide almost
every hour of every day, and I felt so ashamed for this. I wondered
what was wrong with me, why I couldn't get rid of it.''--IAVA Member
And this issue is of particular importance to me because I lost one
of my Marines to suicide in 2005.
The Most Dangerous Part Of Going To War These Days Is Coming Home.
``Since my return, I have lost 2 close friends to suicide, 2.
. . I said 2, from my platoon. That is the sick reality.''--IAVA Member
Last year, more U.S. servicemembers died by their own hands than in
combat in Afghanistan.\1\ Most Iraq and Afghanistan veterans know a
fellow war fighter who has taken their own life since coming home. The
numbers do not even include the veterans who commit suicide after their
service is complete. They are out of the system and their deaths are
often unknown and uncounted. Recently the Army Times reported ``18
veterans commit suicide each day . . . an average of 950 suicide
attempts each month [are] by veterans who are receiving some type of
treatment from the Veterans Affairs Department''. \2\ Worse yet, the
Department of Defense (DoD) recently released numbers showing that we
are on track to surpass last year's 30-year-high suicide rate.
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\1\ In 2009, a record 334 servicemembers committed suicide.
\2\ http://www.armytimes.com/news/2010/04/
military_veterans_suicide_042210w/
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As the suicide rate of our servicemembers and veterans continues to
increase, without any signs of abating, we must acknowledge that
suicide is only one piece of the mental health epidemic plaguing our
returning war fighters. Left untreated, mental health problems can and
do lead to substance abuse, homelessness and suicide. A 2008 RAND study
reported that almost 20 percent of Iraq and Afghanistan veterans
screened positive for Post Traumatic Stress Disorder (PTSD) or major
depression. A recent Stanford University study found that this number
might actually be closer to 35 percent. Compounding the problem is the
fact that fewer than half of those suffering from mental health
injuries are receiving sufficient treatment.
Suicide Hotline is a Real Lifesaver.
The VA National Suicide Prevention Lifeline (800-273-TALK) is a 24-
hour hotline for veterans in crisis, which fields nearly 10,000 calls a
month. These calls have rescued more than 7,000 veterans wrestling with
suicide.\3\ IAVA proudly supported the Joshua Omvig Veteran Suicide
Prevention Act which established this important hotline. Our members
continually inform us that they have used this valuable service for
themselves and have referred it to their friends.
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\3\ http://www.armytimes.com/news/2010/04/
.military_veterans_suicide_042210w/.
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We know this because IAVA hosts an online community for Iraq and
Afghanistan veterans to connect. Across the country, through
CommunityofVeterans.org, they share their challenges and support one
another as only they can. CommunityofVeterans.org also connects
veterans with private and VA mental health support information--
including the VA National Suicide Prevention Lifeline. Recently a
veteran asked,
``How often do YOU think of suicide? It kinda creeps up on me
every couple of days, I toss the idea in my head around a little bit,
then tuck it away again till the next time. It mildly disturbs me
because I don't WANT (consciously) to kill myself, but sometimes it
just seems easier.''--IAVA Member
One of the many veterans who reached out to this vet responded,
``Maybe you should call that National hotline, just to ask a
couple more questions. I am pretty sure it's a free service, and
they're there to listen a bit, and could tell you if it's more serious
or not.''--IAVA Member
For a veteran considering suicide, the act of reaching out to those
close to them can often seem overwhelming. The act of a simple
anonymous call to the VA's National Suicide Prevention Lifeline might
be enough to save the life of a veteran who is sitting alone, with a
gun and a bottle of booze. Veterans in these desperate situations can't
wait for regular business hours to seek help. Thankfully, the National
Suicide Prevention Lifeline is available 24 hours a day, 7 days a week.
The National Suicide Prevention Lifeline recently added a live chat
feature which allows veterans to express their fears, anger, and
sadness in a confidential manner, 24 hours a day, with a trained
professional on-line. This on-line chat is a good way to reach
suffering veterans not reachable through the hotline.
``When the online counselor said, `I hear you' I knew I was
going to be ok,''--IAVA Member
Outreach, Outreach, Outreach.
The Department of Veterans Affairs must develop a relationship with
servicemembers while they are still in the service. Like many
successful college alumni associations that greet students at
orientation and put on student programs throughout their time in
college, the VA must shed its passive persona and start recruiting
veterans and their families more aggressively into VA programs. Once a
veteran leaves the military, the VA should create a regular means of
communicating with veterans about events, benefits, programs and
opportunities. If a veteran received half as many letters and emails
from the VA, as college grads do from their alumni association, we
would be getting somewhere.
Moreover, the VA must aggressively promote all VA programs and
reach out to veterans who have yet to access their VA benefits.
``The VA could be more aggressive in contacting OIF/OEF
veterans and at least talking to them before the veteran has a mental
health crisis. They need to be proactive instead of reactive.''--IAVA
Member
To begin the shift from a passive to an active agency, IAVA
believes the VA must prioritize outreach efforts and include a distinct
line item for outreach within each VA appropriation account. This line
item should fund successful outreach programs such as the OEF/OIF
Outreach Coordinators, Mobile Vet Centers, and the VA's new social
media presence on Facebook and Twitter. In their current forms, these
outreach programs are much too small to make a transformative
difference. IAVA was disappointed that there were only a few brief
mentions of outreach activities in the President's VA budget
submission. Regrettably, none of them were to a dedicated outreach
campaign.
The VA's current outreach campaign is disappointing. When the VA
announced that it had placed ads on more than 21,000 buses
nationally,\4\ to spread the word about the suicide prevention
lifeline, we were initially enthusiastic; an image of the ad is below.
When we saw the ad, it was clearly a failure. The ad has over 30 small
print words; the average bus ad is limited to 5-10 words. In the short
time in which a bus passes, a veteran would have to go by the bus
repeatedly to even read the hotline number.
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\4\ http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1707.
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IAVA has run one of the largest non-governmental outreach campaigns
in history, through a partnership with the Ad Council and some of the
world's best advertizing firms. We have learned a lot about the best
ways to communicate complex and serious issues through television and
print. We are ready to work with the VA and share our expertise.
[GRAPHIC] [TIFF OMITTED] T8058A.000
The World's Best Mental Health Program Will Still Fail If No One Uses
It.
The heavy stigma associated with mental health care stops many
servicemembers and veterans from seeking treatment. More than half of
soldiers and Marines in Iraq who tested positive for a psychological
injury reported concerns that they will be seen as weak by their fellow
servicemembers. One in three of these troops worried about the effect
of a mental health diagnosis on their career. Even in an anonymous
survey we conducted in December of last year, more than 10 percent of
our members selected ``prefer not to answer'' in response to the
question of whether they had sought care for a mental health injury. It
is easy to conclude that those most in need of treatment may never seek
it out.
``paradigm shift must occur. . . . `you're a wimp if you see
the wizard' needs to go away and be replaced with `everyone needs
someone'.''--IAVA Member
To end the suicide epidemic and forever eliminate the stigma
associated with combat stress, the VA and DoD must declare war on this
problem. They must launch a nationwide campaign to combat stigma and to
promote the use of DoD and VA services such as Vet Centers and the
National Suicide Prevention Lifeline.
This campaign must be well-funded, research-tested and able to
integrate key stake-holders such as veteran service organizations and
community-based non-profits. Furthermore, the VA must develop and
aggressively deploy combat-stress injury training programs for civilian
behavioral health professionals who treat veterans outside of the VA
(e.g., college counselors, rural providers, behavioral health grad
students, and professional associations).
The VA must allocate specific resources toward battling this
dangerous stigma, or we will never see a critical mass of veterans
coming in to seek help.
Department of Veterans Affairs, IAVA Has Your Back.
Through our own historic Public Service Announcement (PSA) campaign
with the Ad Council, IAVA has learned a lot about stigma busting and
veteran outreach campaigns. Millions of Americans continue to see our
iconic PSAs, like the one featuring two young veterans shaking hands on
an empty New York street.
``The Iraq and Afghanistan Veterans of America brilliantly
portrayed this feeling of isolation in a 2008 ad where a soldier
returning from the war walks through an empty airport. He continues
through downtown Manhattan, which is also completely empty. No cars. No
people. It isn't until a young veteran approaches the soldier with a
handshake, a smile and pat on the back saying, `Welcome home, man,'
that the street becomes populated.
I was a bit shaken the first time I saw it, as it immediately
resonated with me. It hit an exposed nerve, and I knew that those guys
at the IAVA `got it.' They knew exactly where we were coming from.
The problem, of course, is that we, as veterans, live the rest
of our young lives in the `civilian' world and not on the battlefield.
It took me several months to fully comprehend this. After realizing
that my sense of isolation was alienating me from those I loved, I made
the conscious decision to use my experiences in combat as a source of
great strength, versus letting them become a weakness.'' \5\
\5\ ``Back from Iraq war, and alone.'', Mike Scotti, March 10,
2010; http://www.cnn.com/2010/OPINION/03/10/scotti.war.veterans/
index.html?iref=allsearch.
The TV ads are just one component of this groundbreaking campaign.
They are complemented by billboards, radio commercials, and web ads
which have blanketed the country and touched countless Americans. In
just the first year of the campaign, IAVA secured $50 million in
donated media while reaching millions of veterans and their families.
This campaign is an example of the innovation coming out of the VSO
and non-profit communities, which the VA should treat as an asset. This
cutting-edge campaign directs veterans to an exclusive online
community, mentioned above, that strongly shows our Nation's new
veterans that ``We've Got Your Back''. It also directs them to a wide
range of mental health, employment and educational resources--operated
by both private non-profits and the Department of Veteran Affairs.
Innovative, aggressive outreach programs like this should become part
of the new VA culture and they can fuel-inject outreach efforts. IAVA
is learning what works, and we want to share our knowledge.
``Eight Weeks To See A Counselor?''
``It took me over 6 months for a mental health appt through VA
and this was after I told them I was having suicidal and homicidal
ideations. I'm still waiting now for some appointments.''--IAVA Member
Convincing a veteran to overcome his fear of ostracism and choose
to seek help is an uphill battle. We must ensure that when they do seek
treatment, there is ready access to the necessary care. Regrettably,
many of our veterans have complained about long wait times and
inconvenient hours.
The VA must focus on dramatically increasing the number of mental
health providers within the Department of Veteran Affairs. This
increase will reduce wait times and improve overall quality of care.
``I went 80 miles to the local VA outpatient treatment
facility, they did not have anyone on staff to talk to. They have group
meetings, but again, its 80 miles roundtrip and I would have to be
there by 4. I work till 5. That means that I would have to leave almost
2 hours early to drive 80 miles roundtrip just to talk to someone who
had a similar experience. I can't do that.''--IAVA member
``We need a `surge' of mental health professionals! It is time
the rest of the country steps up and begins to sacrifice as well.''--
IAVA Member
Additionally, IAVA supports creative solutions for rural veterans.
Many veterans live too far from local VA facilities to receive
treatments at traditional brick and mortar VA facilities. We support
contracting with local community mental health clinics and extending
grants to groups that provide programs such as peer-to-peer counseling.
Veterans must be able to receive mental health care near their personal
support system, whether that system is in New York City or Peerless,
Montana.
Our veterans are facing a mental health epidemic. Unless we address
the overall issue of mental health stigma, we will never be able to
stem the growing tide of suicides. The VA and DoD have created many
programs that are extremely effective in helping servicemembers and
veterans who are hurting. But great programs are worthless if
servicemembers and veterans don't know they exist, can't access them,
or are ashamed to use them.
IAVA is proud to speak on behalf of the thousands of veterans
coming home every day. We work tirelessly so veterans know we have
their back. Together, with this Congress and the Department of Veteran
Affairs, every veteran must be confident that America has their back.
Thank you.
Prepared Statement of Jacob B. Gadd, Deputy Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to submit The American Legion's
views on progress of the Suicide Prevention efforts at the Department
of Veterans Affairs (VA) to the Subcommittee today. The American Legion
commends the Subcommittee for holding a hearing today to discuss this
timely and important issue.
Suicide among servicemembers and veterans has always been a
concern; it is the position of The American Legion that one suicide is
one too many. However, since the war in Iraq and Afghanistan began, the
numbers of servicemembers and veterans who have committed suicide have
steadily increased. As our servicemembers are deployed across the world
to protect and defend our freedoms, we as a Nation cannot allow them to
not receive the care and treatment they need when they return home. The
tragic and ultimate result of failing to take care of our Nation's
heroes' mental health illnesses is suicide.
Turning first to VA's efforts in recent years with Mental Health
Care, The American Legion has consistently lobbied for budgetary
increases and program improvements to VA's Mental Health Programs.
Despite recent unprecedented increases in the VA budget, demand for VA
Mental Health services is still outpacing the resources and staff
available as the number of servicemembers and veterans afflicted with
Post Traumatic Stress (PTS) and Traumatic Brain Injury (TBI) continues
to grow. This naturally leads to VA's increase in mental health
patients.
In 2008, RAND's Center for Military Health Policy Research, an
independent, nonprofit group, released a report on the psychological
and cognitive needs of all servicemembers deployed in the past 6 years,
titled, ``Invisible Wounds of War: Psychological and Cognitive
Injuries, Their Consequences, and Services to Assist Recovery,'' which
estimated that more than 300,000 (20 percent of the 1.6 million) Iraq
and Afghanistan veterans are suffering from PTS or major depression and
about 320,000 may have experienced TBI during deployment.
The Centers for Disease Control and Prevention estimates 30,000-
32,000 U.S. deaths from suicide per year among the population. VA's
Office of Patient Care and Mental Health Services reported in April
2010 that approximately 20 percent of national suicides are veterans.
The National Violent Death Reporting System reports 18 deaths per day
by veterans and VA's Serious Mental Illness Treatment, Research and
Evaluation Center reported about five deaths occur each day among VA
patients. In a recent AP article, it was cited that there have been
more suicides than servicemembers killed in Afghanistan.
The Veterans Health Administration (VHA) has made improvements in
recent years for Mental Health and transition between DoD and VA such
as the Federal Recovery Coordinators, Polytrauma Rehabilitation System
of Care, Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF) case management teams, integrating mental health care providers
into primary care within VA Medical Center Facilities and Community
Based Outpatient Clinics (CBOCs), VA Readjustment (Vet) Centers hiring
of Global War on Terrorism (GWOT) Counselors, establishing directives
for TBI screening, clinical reminders and a new symptom and diagnostic
code for TBI.
Regarding suicide prevention outreach efforts, VA founded the
National Suicide Prevention Hotline, 1-800-273-TALK (8255) by
collaborating with the National Suicide Prevention Lifeline where
veterans are assisted by a dedicated call center at Canandaigua VA
Medical Center in New York. The call center is staffed with trained VA
crisis health care professionals to respond to calls on a 24/7 basis
and facilitate appropriate treatment. VA reported in 2010 a total of
245,665 calls, 128,302 of which were identified as veterans. Of these
veterans, 7,720 were rescues.
VA hired Local Suicide Prevention Coordinators at all of the 153 VA
Medical Centers nationwide in an effort to provide local and immediate
assistance during a crisis, compile local data for the national
database and train hospital and local community on how to provide
assistance. One of primary responsibilities of the Local Suicide
Prevention Coordinators is to track and monitor veterans who are placed
on high risk of suicide (H.R.S). A safety plan for that individual
veteran is created to ensure they are not allowed to fall through the
cracks.
In 2009, VA instituted an online chat center for veterans to
further reach those veterans who utilize online communications. The
total number of VeteransChat contacts reported since September 2009 was
3,859 with 1471 mentioning suicide. VA has also had targeted outreach
campaigns which included billboards, signage on buses and PSA's with
actor Gary Sinise to encourage veterans to contact VA for assistance.
The American Legion Suicide Prevention and Referral Programs
The American Legion has been at the forefront of helping to prevent
military and veteran suicides in the community. The American Legion
approved Resolution 51, The American Legion Develop a Suicide
Prevention and Outreach Referral Program, at the 2009 National
Convention. In addition, VA's National Suicide Prevention Coordinator
Dr. Janet Kemp facilitated an Operation S.A.V.E. Training for our
Veterans Affairs and Rehabilitation Commission members. VA&R Commission
members and volunteers subsequently developed American Legion State,
district and post training programs to provide referrals for veterans
in distress with VA's National Suicide Prevention Hotline. The American
Legion currently has over 60 posts with active Suicide Prevention and
Referral Programs.
In December 2009, The American Legion took the lead in creating a
Suicide Prevention Assistant Volunteer Coordinator position, under the
auspices of VA's Voluntary Service Office. Each local suicide
prevention office is encouraged to work with veteran service
organizations and community organizations to connect veterans with VA's
programs in their time of transition and need. The Suicide Prevention
offices can increase their training of volunteers to distribute
literature and facilitate training in order to further reach veterans
in the community.
This year, The American Legion entered into a partnership with the
Defense Centers of Excellence's Real Warrior Campaign to educate and
encourage our members to help transitioning servicemembers and veterans
receive the mental health treatment they need. Additionally, during our
2010 National Convention we will have a panel to discuss prevention,
screening, diagnosis and treatment of TBI with representatives from
DoD, VA and the private sector.
Challenges
Despite recent suicide prevention efforts, yet more needs to be
done as the number of suicides continues to grow. The American Legion's
System Worth Saving (SWS) program, which conducts site visits to VA
Medical Center facilities annually, has found several challenges with
the delivery of mental health care. VA has the goal to recruit
psychologists from their current nationwide level of 3,000 to 10,000 to
meet the demand for mental health services. However, VA Medical Center
Facilities have expressed concerns with hiring and retaining quality
mental health specialists and have had to rely on fee basis programs to
manage their workload.
The American Legion applauds last year's action by Congress in
passing Advance Appropriations for mandatory spending. However,
problems exist in VA itself in allocating the funds from VA Central
Office to the Veteran Integrated Service Networks (VISNs) and to the
local facilities. This delay in funding creates challenges for the VA
Medical Center Facility in receiving its budget to increase patient
care services, hiring or to begin facility construction projects to
expand mental health services. VA's 2011 budget provides approximately
$5.2 billion for mental health programs which is an 8.5 percent, or
$410 million, increase over FY 2010 budget authorization. The American
Legion continues to be concerned about mental health funds being
specifically used for their intent and that Congress continue to
provide the additional funding needed to meet the growing demand for
treatment.
Challenges in preventing suicide include maintaining
confidentiality and overcoming the stigma attached to a servicemember
or veteran receiving care. Additionally, the issue of a lack of
interoperable medical records between DoD and VA, while being addressed
by Virtual Lifetime Electronic Records (VLER), still exists. The
American Legion has supported the VLER initiative and the timely and
unfettered exchange of health records between DoD and VA.
Unfortunately, DoD and VA still have not finalized both agencies AHLTA
and VistA architecture systems since the project began in 2007, which
limits DoD and VA's ability to track and monitor high risk suicide
patients during their transition from military to civilian life. The
American Legion recommends VA take the lead in developing a joint
database with the DoD, the National Center for Health Statistics and
the Centers for Disease Control and Prevention to track suicide
national trends and statistics of military and veteran suicides.
The American Legion continues to be concerned about the delivery of
health care to rural veterans. As mentioned, a nationwide shortage of
behavioral health specialists, especially in remote areas where
veterans have settled, reduces the effectiveness of VA's outreach. No
matter where a veteran chooses to live, VA must continue to expand and
bring needed medical services to the highly rural veteran population
through telehealth and Virtual Reality Exposure Therapy (VRET). DoD and
VA have piloted VRET at bases at Camp Pendleton, Camp Lejuene and the
Iowa City VA Medical Center. VRET is an emerging treatment that exposes
a patient to different computer simulations to help them overcome their
phobias or stress. The younger generation of veterans identifies with
computer technology and may be more apt to self-identify online rather
than at a VA Medical Center or CBOC.
Both DoD and VA have acknowledged the lack of research on brain
injuries and the difficulties diagnosing PTS and TBI because of the
comorbidity of symptoms between the two. The Defense and Veterans Brain
Injury Center (DVBIC) developed and continues to use a 4-question
screening test for TBI today. At the same time, Mount Sinai School of
Medicine in New York developed the Brain Injury Screening Questionnaire
(BISQ), the only validated instrument by the Centers for Disease
Control to assess the history of TBI, which has over 100 questions with
25 strong indicators for detecting TBI. Mount Sinai has published data
that suggest some of the symptoms, particularly those categorized as
``cognitive,'' when found in large numbers (i.e. 9 or greater),
indicate the person is experiencing complaints similar to those of
individuals with brain injuries. The American Legion wants to ensure
that DoD and VA are working with the private sector to share best
practices and improve on evidence-based research, screening, diagnosis
and treatment protocols of the ``signature wounds'' of Iraq and
Afghanistan.
Recommendations
The American Legion has seven recommendations to improve Mental
Health and Suicide Prevention efforts for VA and DoD:
1. Congress should exercise oversight on VA and DoD programs to
insure maximum efficiency and compliance with Congressional concerns
for this important issue.
2. Congress should appropriate additional funding for mental
health research and to standardize DoD and VA screening, diagnosis and
treatment programs.
3. DoD and VA should expedite development of a Virtual Lifetime
Medical Record for a single interoperable medical record to better
track and flag veterans with mental health illnesses.
4. Congress should allocate separate Mental Health funding for
VA's Recruitment and Retention incentives for behavioral health
specialists.
5. Establish a Suicide Prevention Coordinator at each military
installation and encourage DoD and VA to share best practices in
research, screening and treatment protocols between agencies.
6. Congress should provide additional funding for telehealth and
virtual behavior health programs and providers and ensure access to
these services are available on VA's web pages for MyHealthyVet, Mental
Health and Suicide Prevention as well as new technologies such as
Skype, Apple i-Phone Applications, Facebook and Twitter.
7. DoD and VA should develop joint online suicide prevention
servicemember and veteran training courses/modules on family, budget,
pre, during and post deployment, financial, TBI, PTSD, Depression
information.
In conclusion, Mr. Chairman, although VA has increased its efforts
and support for suicide prevention programs, it must continue to reach
into the community by working with Veteran Service Organizations such
as The American Legion to improve outreach and increase awareness of
these suicide prevention programs and services for our Nation's
veterans. The American Legion is committed to working with DoD and VA
in providing assistance to those struggling with the wounds of war so
that no more veterans need lose the fight and succumb to so tragic a
self-inflicted end.
Mr. Chairman and Members of the Subcommittee, this concludes my
testimony.
Prepared Statement of Thomas J. Berger, Ph.D., Executive Director,
Veterans Health Council, Vietnam Veterans of America
Chairman Mitchell, Ranking Member Roe, and Distinguished Members of
the HVAC Subcommittee on Oversight and Investigations, Vietnam Veterans
of America (VVA) thanks you for the opportunity to present our views on
``Examining the Progress of Suicide Prevention Outreach Efforts at the
VA''. We should also like to thank you for your overall concern about
the mental health care of our troops and veterans.
The subject of suicide is extremely difficult to talk about and is
a topic that most of us would prefer to avoid. Although statistics on
suicide deaths are not as accurate as we would like because so many are
not reported, as veterans of the Vietnam War and those who care for
them, many of us have known someone who has committed suicide and
others who have attempted it. But as uncomfortable as this subject may
be to discuss, VVA believes it to be a very real public health concern
that needs solutions now.
Suicide is most often the result of unrecognized and untreated
mental health injuries. Depression, Post-Traumatic Stress Disorder
(PTSD) and Traumatic Brain Injury (TBI) are three of the most common
mental health injuries and conditions that can lead to suicide. The
three conditions in particular are medical conditions that can be life-
threatening.
In more than 120 studies of a series of completed suicides,
according to the American Foundation for Suicide Prevention, at least
90 percent of the individuals involved were suffering from a mental
illness at the time of their death. The most important interventions
are recognizing and treating these underlying illnesses, such as
depression, alcohol and substance abuse, post-traumatic stress and
traumatic brain injury. Many veterans (and active duty military) resist
seeking help because of the stigma associated with mental illness, or
they are unaware of the warning signs and treatment options. These
barriers must be identified and overcome.
Consider the facts: earlier this spring, troubling data showed an
average of 950 suicide attempts by veterans who are receiving some type
of treatment from the VA. Seven percent of the attempts are successful,
and 11 percent of those who don't succeed on the first attempt try
again within 9 months. These numbers show about 18 veteran suicides a
day and about five by vets receiving VA care. These numbers are simply
unacceptable to both the veterans' community and the American public.
To be fair, since media reports of suicide deaths and suicide
attempts began to surface back in 2003, the VA has claimed to have
developed prevention strategies to reduce suicides and suicide
behaviors that includes: the establishment of the Suicide Prevention
Hotline in partnership with the Substance Abuse and Mental Health
Administration; the institution of suicide prevention coordinator
(SPCs) positions at all VA medical facilities whose duties include
education, training, and clinical quality improvement for VHA staff
members; increased screening and monitoring of individuals who have
been identified as being at high risk for suicide; and research efforts
utilizing cognitive-behavioral interventions that target suicidal
ideation and behaviors. While these efforts are laudable, VVA continues
to believe they have not gone far enough.
In May 2008, then-VA Secretary Peake chartered ``The Blue Ribbon
Work Group on Suicide Prevention in the Veteran Population''. Its
function was to provide advice and consultation to him on various
matters relating to research, education, and program improvements
relevant to the prevention of suicide in the veteran population.
Although their report was not made public, the Work Group panel
presented a series of findings and recommendations to improve relevant
VA programs, with the primary objective of reducing the risk of suicide
among veterans.
The panel's work was not made public because some in the VA claimed
that even talking about suicide made it much more likely to occur among
veterans and soldiers. VVA takes the view that transparency in
government in general, and at the VA in particular, leads to better and
more consistent application of the very evidence based medicine that is
founded on peer reviewed science. It also would be in keeping with the
proclaimed principles of the Administration of President Obama. Perhaps
most importantly, it will lead to much more accountability in
government. It is past time for the VA to make the full report public.
The Work Group report discussed eight key findings and
recommendations:
Panel Finding 1. Conflicting and inconsistent reporting of veteran
suicide rates were observed across various studies.
Blue Ribbon Recommendation 1: VHA should establish an analysis
and research plan in collaboration with other Federal agencies to
resolve conflicting study results in order to ensure that there is a
consistent approach to describing the rates of suicide and suicide
attempts among veterans.
Panel Finding 2. Suicide screening processes being implemented in
VHA primary care clinics go beyond the current evidence and may have
unintended effects.
Blue Ribbon Recommendation 2: The VA should revise and
reevaluate the current policies regarding mandatory suicide screening
assessments.
Panel Finding 3. The VA is attempting to systematically provide
coordinated, intensive, enhanced care to veterans identified as being
at high risk for suicide. However, the criteria for being flagged as
high risk are not clearly delineated; nor are criteria for being
removed from the high risk list.
Blue Ribbon Recommendation 3: Proceed with the planned
implementation of the Category H flag, with consideration given to
pilot testing the flag in one or more regions before full national
implementation.
Panel Finding 4. The root cause analyses presented to the Work
Group did not distinguish between suicide deaths, suicide attempts, and
self-harming behavior without intent to die.
Blue Ribbon Recommendation 4: Ensure that suicides and suicide
attempts that are reported from root cause analyses use definitions
consistent with broader VHA surveillance efforts.
Panel Finding 5. The emphasis by VHA leadership on the use of
clozapine and lithium does not appear to be sufficiently evidence-
based.
Blue Ribbon Recommendation 5: VHA should ensure that specific
pharmacotherapy recommendations related to suicide or suicide behaviors
are evidence-based.
Panel Finding 6. Efforts to improve accurate media coverage and
disseminate universal messages to shift normative behaviors to reduce
population suicide risk behavior are not being fully pursued.
Blue Ribbon Recommendation 6: The VA should continue to pursue
opportunities for outreach to enrolled and eligible veterans, and to
disseminate messages to reduce risk behavior associated with
suicidality.
Panel Finding 7. Concerns about confidentiality for OIF/OEF
servicemembers treated at VHA facilities may represent a barrier to
mental health care.
Blue Ribbon Recommendation 7. The issue of confidentiality of
health records of OIF/OEF servicemembers who receive care through the
VHA should be clarified both for patient consent-to-care and for
general dissemination to Reserve and Guard servicemembers contemplating
utilizing VHA medical system services to which they are entitled.
Panel Finding 8. The introduction of Suicide Prevention
Coordinators (SPCs) at each VA medical center is a major innovation
that holds great promise for preventing suicide among veterans;
however, there is insufficient information on optimal staffing levels
of SPCs.
Blue Ribbon Recommendation 8. In order to maximize the
effectiveness of the Suicide Prevention Coordinators program, it is
recommended that there be ongoing evaluation of the roles and workloads
of the SPC positions.
In addition to the above central findings and recommendations, the
Work Group panel identified fourteen other areas for possible action,
including:
adopting a standard definition for suicide and suicide
attempts;
preparing a single document that details the
comprehensive suicide prevention strategy;
considering a public health approach as part of the VA
framework for suicide prevention that goes beyond secondary and
tertiary prevention;
expanding the portfolio for suicide research across the
VA, with suicide prevention prioritized as a research area;
considering the establishment of an Advisory Board of key
VA stakeholders involved in suicide prevention, education, treatment,
and research;
increasing VA efforts to reach out to community emergency
departments to improve care for active duty servicemembers and veterans
at risk for suicide;
continuing efforts to promote training in implementing
suicide prevention programs;
developing and implementing followup interventions for
veterans identified as being at risk;
working collaboratively with other Federal agencies to
understand the implications of new technologies for suicide prevention;
designing and disseminating psycho-education materials
for families of veterans at risk for suicide, particularly those
hospitalized for suicide attempts;
considering more intensive therapies for veterans who
exhibit chronic suicidal behavior;
more effectively integrating pastoral care services and
traditional mental health services;
implementing a gun safety program directed at veterans
with children in the home; and
analyzing entitlement changes required to allow treatment
of combat-related conditions to reduce suicides in un-entitled veteran
populations.
Suicide prevention, of course, starts with leadership. However it
has been almost 2 years since the Blue Ribbon Work Group finished its
work and we have yet to see any formal action plan that addresses each
of the Group's findings and recommendations in a comprehensive,
prioritized fashion. In fact, no one outside a select circle of
bureaucrats at the Veterans Health Administration (VHA) has ever seen
the complete report of this panel, which was of course, funded with
taxpayer dollars.
Why not?
There are no valid reasons for keeping this report a secret. The
Russians do not have spy networks out looking for copies of this
report, so there is no valid national security reason not to make this
report available to the Congress, to veterans advocates, to VA's own
clinicians at the service delivery level, and to the public. The reason
for the delay initially was to give the VHA time to design a good
implementation plan to carry out all of the panel's recommendations,
and to take steps to address concerns raised by the report, it seems to
us at Vietnam Veterans of America (VVA) that 21 months is enough time
to do that, even with the change in formal leadership as to the
Undersecretary of Health. Dr. Petzel has now been on the job long
enough to review any such plans, and be ready to implement the
recommendations in a timely way.
This Subcommittee must ensure that our veterans and their families
are given access to the resources and programs necessary to stem the
tide of suicide. The first step in that process is knowing what has
been recommended by the best medical scientists the VA could assemble
to study the problem (the above referenced report), and what is being
done to implement the recommendations and address the findings of those
experts.
While we do not mean to distract from the basic thrust of this
hearing, VVA points out that PTSD is a common condition among veterans
that often leads to suicide attempts. We continue to be troubled that
VHA has also not implemented, nor seemingly even tried to implement,
the recommendations of the report commissioned by the VA and delivered
by the Institute of Medicine (IOM) of the National Academies of
Sciences (NAS) on June 16 of 2006 entitled ``Posttraumatic Stress
Disorder: Diagnosis and Assessment.'' (http://iom.edu/Reports/2006/
Posttraumatic-Stress-Disorder-Diagnosis-and-Assessment.aspx) Even more
troubling is that the Department of Defense has not tried to
systematically implement these very important findings as to the best
medical science can recommend as to proven techniques and procedures
for accurately diagnosing and properly assessing Post traumatic Stress
Disorder (PTSD). If you do not accurately diagnose and accurately
assess a veterans' (or a returning war fighters') condition as PTSD
which may be so acute that he or she is at risk of attempting to take
their own life, then there is no way that you can effectively intervene
or treat that American who has put their life on the line for our
country. This is bad medicine, and it leaves our veterans at risk. VVA
hopes that this distinguished Subcommittee will take a look at this
issue, perhaps as a followup to this hearing.
Once again, on behalf of VVA National President John Rowan and our
National Officers and Board, I thank you for your leadership in holding
this important hearing on this topic that is literally of vital
interest to so many veterans, and should be of keen interest to all who
care about our Nation's veterans. I also thank you for the opportunity
to speak to this issue on behalf of America's veterans.
I shall be glad to answer any questions you might have.
Prepared Statement of Colonel Robert W. Saum, USA, Director,
Defense Centers of Excellence for Psychological Health and
Traumatic Brain Injury, U.S. Department of Defense
Introduction
Chairman Mitchell, Congressman Roe, distinguished Members of the
Committee; thank you for the opportunity to appear here today to talk
to you about the Department of Defense's (DoD) suicide prevention
programs and related outreach efforts.
On behalf of DoD, I want to take this opportunity to thank you for
your continued support and demonstrated commitment to our
servicemembers, veterans, and their families.
Over the last 9 years, a new era of combat emerged where our
servicemembers are constantly challenged by the demands of a high
operational tempo. Despite these challenges, they continue to meet the
increasing demands placed upon them with resilience, dedication and
remarkable ability.
However, the constant stress placed upon our servicemembers is
taking its toll. The loss of even one life to suicide is unacceptable
and of deep concern at all levels of DoD leadership. DoD has developed
many resources and tools for servicemembers, veterans and families;
however we realize utilization of these resources is dependent upon
prevention education and communication about their existence.
Therefore, continued outreach to servicemembers, veterans and families
is an essential part of the Department's overall suicide prevention
strategy. Today, I will share with the Committee our current suicide
prevention outreach efforts.
Suicide has a multitude of causes, and no simple solution.
Recognizing this, DoD is using a multi-pronged strategy involving
comprehensive prevention education, research, and outreach. We believe
in fostering a holistic approach to treatment, engaging the community,
leveraging primary care for early recognition and intervention, and,
when needed, providing innovative specialty care. This includes a
proactive preventive approach addressing multiple stressors. Some of
these stressors include relationship failures, legal/work/financial
problems and substance misuse.
Outreach is only one part of DoD's overall strategy, but is an
essential part. As we shift to a culture focused on building resilience
and improving the well-being of the force, we need to educate our
servicemembers, veterans and families on the available resources to
achieve and sustain a healthy lifestyle. DoD conducts outreach through
a variety of mechanisms to disseminate available resources, promote
awareness and encourage servicemembers, veterans and families to seek
help when they need it.
Collaborative Outreach Efforts
Continued collaboration and coordination with the Department of
Veterans Affairs (VA) and other Federal, private, and academic
organizations is the key to ensuring we reach our military community in
the most meaningful way. We collaborate with the VA on many outreach
initiatives to ensure that servicemembers, veterans and their families
receive resources and access to services on a continued and consistent
basis.
In November 2007, the DoD established the Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injury (DCoE)
to offer a central coordinating point for activities related to
psychological health concerns and traumatic brain injuries. DCoE
focuses on the full continuum of care and prevention to enhance
coordination among the Services, Federal agencies, and civilian
organizations. DCoE works to identify best practices and disseminate
practical resources to military communities.
DCoE works closely with the VA to coordinate information and
resources with the National Suicide Prevention Lifeline (1-800-273-
TALK). This partnership facilitated a modification to the introductory
message on the Lifeline, by pressing the number 1, that enables
veterans, servicemembers, or callers concerned about a veteran or
servicemember to access a crisis counselor who is knowledgeable about
the military and has access to resources designed specifically for this
community.
The DCoE Outreach Center is staffed by health resource consultants
(licensed mental health and traumatic brain injury clinicians) who are
available to listen, answer questions, and refer callers, to a wide
range of resources. These consultants include licensed nurses, social
workers, and doctoral-level clinical psychologists. In March 2010, the
Outreach Center health resource consultants attended and completed the
American Association of Suicidology (AAS) ``Recognizing and Responding
to Suicide Risk'' 2-day training program. Since then, the Outreach
Center utilized AAS' best practice methodologies and constructed a
lethality assessment document as well as a safety plan document to
further assess suicide risk and need for intervention. Since its launch
in January 2009, the Outreach Center has been utilized by approximately
5,000 people.
DoD and VA collaborate to educate and train regional suicide
prevention coordinators each year on innovative programs, best
practices and new platforms for outreach.
DoD and VA are collaborating annually to promote suicide awareness
week, creating common theme materials such as factsheets and
coordinating with the Services and other relevant organizations to
disseminate messages to the widest audience possible.
The Suicide Prevention and Risk Reduction Committee (SPARRC) has
served and will continue to serve as the venue for inter-Service and
interagency collaboration on suicide prevention activities. Members
include Suicide Prevention Program Managers from the Services and
representatives from the National Guard Bureau, Office of the Assistant
Secretary of Defense for Reserve Affairs, VA, Office of Armed Forces
Medical Examiner, National Center for Telehealth and Technology (T2),
Substance Abuse Mental Health Services Administration (SAMHSA), and
others. This Committee is the main forum for ensuring coordination and
consistency in system-wide communication related to suicide, risk
reduction policy initiatives, and suicide surveillance metrics across
the military.
DoD Outreach Initiatives
Each of the Services has a variety of suicide prevention programs
and outreach efforts tailored to their specific population. They
utilize multiple communication avenues to increase awareness of
available resources. In addition, DoD has many efforts currently in
place to raise awareness and increase leadership involvement in
promoting healthy choices. The initiatives listed below are not
dedicated solely to suicide prevention, but they feature a variety of
resources for psychological health, including suicide prevention, and
offer the opportunity to increase outreach to servicemembers, veterans
and families.
Real Warriors Campaign
Stigma is a toxic threat to our servicemembers, veterans and
families receiving the care they need. We recognize that outreach is
essential for combating stigma, encouraging help-seeking behaviors and
promoting awareness of resources.
In May 2009, DCoE launched the Real Warriors Campaign, a multimedia
public education initiative designed to combat the stigma associated
with seeking psychological health care and encourage servicemembers to
reach out for the care they may need. Under the theme ``Real Warriors,
Real Battles, Real Strengths,'' this effort provides concrete examples
of servicemembers who sought care for psychological health concerns and
are maintaining a successful military career.
While primarily focused on combating stigma, the Real Warriors
Campaign addresses the issue of suicide in a number of ways:
The Web site, www.realwarriors.net, prominently displays
the National Suicide Prevention Lifeline on every page.
Two video profiles of servicemembers involved in the
campaign openly discuss their struggles with thoughts of suicide by
demonstrating that they reached out for care, received it and that
action has enabled them to continue to lead a fulfilling personal and
professional life.
The site allows servicemembers, veterans, families and
health professionals to confidentially reach out to health consultants
for assistance around the clock through the Real Warriors Live Chat
feature or by calling the DCoE Outreach Center.
The Campaign's message boards include numerous posts from
servicemembers who share their coping strategies for dealing with
suicidal ideation. The site includes content that focuses on suicide
prevention and substance abuse, which is a potential contributing
factor to suicide. Short, documentary-style videos illustrate the
resilience exhibited by servicemembers, their families and caregivers.
The Real Warriors campaign has reached thousands since the Campaign
launched in May 2009. The Web site, www.realwarriors.net, which
servicemembers can access globally, has reached 72,239 unique visitors,
with more than 110,000 visits and 781,600 page views. The campaign is
featured in the Army G-1 Suicide Prevention Program and the Air Force
Surgeon General's Office used the campaign in a Suicide Prevention
Stand Down in May 2010. In addition, the campaign has partnered with
more than 100 organizations to increase their visibility and reach
among servicemembers, veterans and military families.
Military OneSource
Military OneSource, the ``go-to'' resource for servicemembers and
families, prominently features the National Suicide Prevention Lifeline
on its home page and provides suicide prevention information.
Yellow Ribbon Program
DCoE is an active contributor to the legislatively mandated Yellow
Ribbon program and working group, which provides suicide prevention
information, services, referrals and proactive outreach programs to
servicemembers of the National Guard and Reserves and their families
through all phases of the deployment cycle. The intent of the program
is to proactively prevent suicide by reaching out to National Guard and
Reserve members and their families to prepare them for deployment;
sustaining their families during the deployment; and reintegrating the
servicemembers with their families, communities and employers upon re-
deployment or release from active duty. The Yellow Ribbon program also
conducts outreach to help servicemembers and their families navigate
through the numerous DoD, VA, and State systems to ensure they receive
information and assistance regarding all the benefits and entitlements
they have earned as a result of deployment. The working group is
conducting a gap analysis of existing suicide prevention programs
specific to the National Guard and Reserve populations.
Afterdeployment.org
DoD is leveraging technology to conduct outreach in real time and
connect servicemembers, veterans and families to resources. Web-based
resources such as afterdeployment.org provide a safe platform to better
understand and increase awareness of substance misuse, depression and
other mental health related issues. In August 2008, the National Center
for Telehealth and Technology (T2) launched the Web site
afterdeployment.org to support servicemembers, veterans and families
with adjustment concerns that often occur after a deployment. The Web
site provides interactive, self-paced solutions addressing post-
traumatic stress, depression, relationship problems, substance abuse,
and several other health issues including mild traumatic brain injury
and spirituality concerns. Site features include quick health tips,
self-assessments, e-libraries, self-paced workshops, warrior and family
stories, community forum, RSS feeds, and daily topical quotes.
Additionally, a Google map locator helps users find providers close to
home. Visitors to the site can benefit from a sense of community by
joining the Facebook group, receive Twitter messages, and download
podcasts from iTunes or Zune depicting warrior stories.
Afterdeployment.org surpassed the 100,000 visitor milestone in April
2010.
Telebehavioral Health
T2 is developing and testing multiple technologies that will
provide ways to supply timely telebehavioral health services to enable
a broad telehealth network for servicemembers and their families across
the deployment cycle of support. Populations with access to care
barriers such as geography, mobility, and stigma can benefit greatly
from telebehavioral health services, which refer to the use of
telecommunications and information technology for clinical and non-
clinical behavioral health care. Leveraging these technologies enables
DoD to reach out to a broad array of populations and provide
servicemembers, veterans and their families access to patient-centric
behavioral health care even in the most extreme and/or remote
circumstances.
Caring Letters
An outreach effort that has shown significant promise to reduce
suicides in the civilian sector is the Caring Letters Program. In a
randomized clinical trial, sending brief letters of concern and
reminders of treatment to patients hospitalized for suicide attempts,
ideation or for a psychiatric condition was shown to dramatically
reduce the risk of death by suicide following their hospitalization. In
an effort to determine the applicability to military populations, T2 is
piloting a program at Ft Lewis, Washington. Efforts are currently
underway to plan a multi-site randomized control trial.
Way Forward
DoD has made much progress in suicide prevention outreach, but we
recognize that there is still much to be done.
DoD and VA are currently developing a strategic action plan for the
next 3 years. This plan will: create consistent communication of
suicide data between DoD and VA; improve communication to
servicemembers, veterans and families on available suicide prevention
practices, programs and tools; continue resource and information
sharing between VA and DoD; and coordinate training efforts to educate
community members, suicide prevention coordinators and medical staff
throughout both agencies.
Families play a vital role in preventing suicides among
servicemembers and veterans. A current Suicide Prevention and Risk
Reduction Committee (SPARRC) initiative is focused on identifying
available resources for families and dissemination platforms used
throughout DoD in order to increase outreach efforts targeted to
families.
In addition to numerous existing DoD web-based resources, the
SPARRC is developing a Web site to serve as the clearinghouse for
suicide prevention information, contacts, innovative approaches, and
tools. This Web site will be open to anyone looking for suicide
prevention information specific to the military and will leverage
existing resources. The Web site will provide a platform to increase
awareness and streamline access to current suicide prevention
initiatives and resources.
Conclusion
The Department of Defense is aggressively pursuing new ways to
address suicide prevention in collaboration with our partners at the
VA. Outreach is a crucial part of DoD's multi pronged suicide
prevention strategy which emphasizes education, early recognition and
intervention, and providing the best treatment possible.
On behalf of the DoD, thank you for the opportunity to address this
vital issue. I look forward to your questions.
Prepared Statement of Robert Jesse, M.D., Ph.D., Principal
Deputy Under Secretary for Health, Veterans Health Administration,
U.S. Department of Veterans Affairs
Chairman Mitchell, Ranking Member Roe, and Members of the
Subcommittee: Thank you for the opportunity to appear before you today
to discuss the Department of Veterans Affairs' (VA) efforts to reduce
suicide among America's Veterans. I am accompanied today by Dr. Janet
Kemp, VA National Suicide Prevention Coordinator. My testimony today
will cover four areas: first, data on suicidality in Veterans and VA's
Suicide Prevention Program; second, VA's National Suicide Prevention
Hotline and Veterans Chat (an online resource); third, VA's outreach
and informational awareness efforts to reduce suicide among Veterans;
and finally, VA's impact on reducing the risk of suicide among
Veterans.
Let me begin by saying how very important this issue is to VA and
all of us in the VA health community. We have initiated several
programs that put VA in the forefront of suicide prevention for the
Nation. Chief among these are:
Establishment of a National Suicide Prevention Hotline,
including a major advertising campaign to provide the hotline phone
number to all Veterans and their families;
Placement of Suicide Prevention Coordinators at all VA
medical centers;
Significant expansion of mental health services; and
Integration of primary care and mental health services to
help alleviate the stigma of seeking mental health assistance.
I will discuss these initiatives in detail later in my testimony.
VA's Suicide Prevention Program
A suicide by a Servicemember or Veteran is a tragedy for the
individual, his or her friends and family, and the Nation. Data
indicate that while civilian suicide rates have remained fairly static
over the past 30 years, there has been a deeply concerning increase in
the suicide rate among members of the Armed Forces over the last 5
years. Eighteen deaths per day among the Veteran population are
attributable to suicide. Approximately 50 percent of suicides among VA
health care users are among patients with a known mental health
diagnosis.
These are staggering numbers, and the data fail to reveal the true
cost of suicide among Veterans. In response to this urgent need, VA has
been significantly expanding its suicide prevention program since 2005,
when it initiated the Mental Health Strategic Plan and the Mental
Health Initiative Funding. In 2006, VA supported two conferences on
evidence-based interventions for suicide and provided funding to begin
integrating mental health care into primary care settings and expanding
services at community-based outpatient clinics (CBOC) for treatment of
mental health conditions such as post-traumatic stress disorder (PTSD),
and substance use disorders (SUD). In 2007, VA began providing specific
funding and training for each facility to have a designated Suicide
Prevention Coordinator; it also held the first Annual Suicide Awareness
and Prevention Day and opened the National Suicide Prevention Hotline
in partnership with the Department of Health and Human Services'
Substance Abuse and Mental Health Services Administration (SAMHSA).
VA also established new access standards that require prompt
evaluation of new patients (those who have not been seen in a mental
health clinic in the last 24 months) with mental health concerns. New
patients are contacted, within 24 hours of the referral being made, by
a clinician competent to evaluate the urgency of the Veteran's mental
health needs. If it is determined that the Veteran has an urgent care
need, appropriate arrangements (e.g., an immediate admission), are to
be made. If the need is not urgent, the patient must be seen for a full
mental health diagnostic evaluation and development and initiation of
an appropriate treatment plan within 14 days. Across the system, VA is
meeting this standard 95 percent of the time. The same year, VA
initiated system-wide suicide assessments for those Veterans screening
positive for PTSD and depression in primary care, instituted training
for Operation S.A.V.E. (which trains non-clinicians to recognize the
SIGNS of suicidal thinking, to ASK Veterans questions about suicidal
thoughts, to VALIDATE the Veteran's experience, and to ENCOURAGE the
Veteran to seek treatment), and required Suicide Prevention
Coordinators to begin tracking and reporting suicidal behavior. In
addition, VA added more suicide prevention coordinators and suicide
prevention case managers in its larger medical centers and community-
based outpatient clinics, doubling the number of dedicated suicide
prevention staff in the field.
By 2008, VA had re-established a monitor for mental health followup
after patients were discharged from inpatient mental health units,
developed an online clinical training program, and held a fourth
regional conference on evidence-based interventions for suicide. In
2009, VA launched the Veterans Chat Program to create an online
presence for the Suicide Prevention Hotline. VA also added a clinical
reminder flag to patient records to notify physicians of patients at
risk for suicide. This year, VA has already held a Suicide Prevention
Coordinator conference and co-hosted a conference with the Department
of Defense (DoD) to discuss ways VA and DoD can reduce the prevalence
of suicide among Veterans and Servicemembers.
VA has adopted a broad strategy to reduce the incidence of suicide
among Veterans. This strategy is focused on providing ready access to
high quality mental health and other health care services to Veterans
in need. This effort is complemented by helping individuals and
families engage in care and addressing suicide prevention in high risk
patients. VA cannot accomplish this mission alone; instead, it works in
close collaboration with other local and Federal partners and brings
together the diverse resources within VA, including individual
facilities, a Center of Excellence in Canandaigua, New York; a Mental
Illness Research and Education Clinical Center in Veterans Integrated
Service Network (VISN) 19; VA's Office of Research and Development; and
clinicians.
During fiscal year (FY) 2009, VA's Suicide Prevention Coordinators
reported 10,923 suicide attempts among patients and non-patients, 673
of which were fatal (6.2 percent). There were 9,297 unique Veterans who
attempted suicide and survived in FY 2009; 811 of these Veterans made
repeated attempts, and 42 died from suicide after they survived an
initial attempt during the year. Approximately 47 percent of those who
attempted suicide in FY 2009 attempted it for the first time, and more
than 31 percent of reported deaths from suicide involved cases where
the individual had previously attempted suicide in 2009 or before.
It is not possible to determine if the reported cases are
representative of suicidality in VA's patient population, but we do
know that suicidality can be both an acute and a chronic condition.
Those who survive attempts are at high risk for reattempting and dying
from suicide within a year, so it is essential that we engage survivors
in intensified treatment to prevent further suicides. It is precisely
because of this concern that VA has initiated the post-discharge
followup for patients leaving its inpatient mental health units. The
data reported above include self-reporting of previous suicide attempts
that have not been validated by VA, and all estimates are based on
events reported in the Suicide Prevention Coordinator database and may
not represent the complete number of suicide attempts among Veterans.
Also, the records of suicide attempts for 136 Veterans were incomplete
and omitted from this analysis.
This evidence clearly demonstrates that once a person has
manifested suicidal behavior, he or she is more likely to try it again.
As a result, VA has adopted a comprehensive treatment approach for high
risk patients. This includes a flag in a patient's chart, necessary
modifications to the patient's treatment plan, involvement of family
and friends, close followup for missed appointments, and a written
safety plan included in the Veteran's medical record. This plan is
shared with the Veteran and includes six steps: (1) a description of
warning signs; (2) an explanation of internal coping strategies; (3) a
list of social contacts who may distract the Veteran from the crisis;
(4) a list of family members or friends; (5) a list of professionals
and agencies to contact for help; and (6) a plan for making the
physical environment safe for the Veteran.
VA's Vet Centers also fulfill a critical role in reducing the risk
of Veteran suicide. The Vet Centers screen all Veterans who visit them
for potential harm to themselves or others; in FY 2009, this resulted
in 174,700 assessments. Vet Centers intervened in 132 cases of
potential suicide or homicide in the Center or in the community. There
were no negative outcomes and their engagement potentially saved at
least as many lives. All Vet Center staff members have been trained in
the Gatekeeper suicide prevention model, based on the U.S. Air Force's
similar approach. Vet Centers also participate in outreach and
community education projects with local county, State, Federal and DoD
components and can identify Veterans at risk during these events.
Suicide Prevention Hotline and Veterans Chat
Between its creation in 2007 and March 2010, the VA Call Center for
the Suicide Prevention Hotline (1-800-273-TALK) has received more than
256,000 calls. Approximately a third of these calls are from non-
Veterans. These calls have led to 8,183 rescues of those determined to
be at imminent risk for suicide and 30,176 referrals to VA Suicide
Prevention Coordinators at local facilities. The VA Call Center has
received calls from 3,270 active duty Servicemembers, a little more
than 1 percent of all calls. To address the needs of the active duty
population, VA worked with SAMHSA to modify the introductory message
for Lifeline (their well-established hotline that feeds calls to the VA
Suicide Hotline) developed memoranda of understanding with DoD, and
established processes for facilitating rescues, including
collaborations with the U.S. Armed Services in Iraq. During 2009, the
Hotline services were supplemented with Veterans Chat, which has been
receiving more than 20 contacts a day.
The Hotline has 15 active phone lines, 1 warm transfer line, and
151 employees, consisting of 123 Hotline responders, 17 health
technicians, 6 shift supervisors, 3 administrative staff, 1 clinical
care coordinator and psychologist, and 1 supervising program
specialist. There is also a director, a deputy director, and their
program support assistant. After receiving a call from a Veteran,
Servicemember or family member, the responder conducts a phone
interview to assess the emotional, functional and psychological
condition. The responder then determines the level of the call, namely
whether it is emergent, urgent, routine or informational.
Emergent calls require emergency services to keep the caller (or
the person about whom the caller is concerned) safe; urgent care
requires same day services at a local VA facility; and routine calls
require a consultation by the local Suicide Prevention Coordinator.
Consults occur if a Veteran consents to a consultation or if emergency
services are required. They are simply alerts to the Suicide Prevention
Coordinator and do not mean the Veteran is suicidal. Even if the
Veteran is already engaged in treatment, a consultation can be done to
alert the Suicide Prevention Coordinator to changes in the Veteran's
circumstances or to other needs he or she may have. VA analyzed data
from the Hotline and identified the top 10 reasons for calls:
1. Mental Health Needs 59 percent
2. Substance Abuse 28 percent
3. Other 21 percent
4. Loss of Home/Job/Finances 15 percent
5. Physical Health Problems 15 percent
6. Relationship Issues 10 percent
7. Loneliness 7 percent
8. Sleep Problems 6 percent
9. Death of Friend/Family Member/Pet 5 percent
10. Questions about VA 4 percent
The warm transfer line referenced above is a special phone line
that is staffed 24 hours a day, 7 days a week and accepts calls from
sites or other call centers who want to transfer a caller to VA
directly, without having to call the main 1-800 number. VA has pre-
arranged agreements to do this with over 20 entities, as well as all
other community crisis centers.
The online version of the Hotline, Veterans Chat, enables Veterans,
family members and friends to chat anonymously with a trained VA
counselor. If the counselor determines there is an emergent need, the
counselor can take immediate steps to transfer the visitor to the
Hotline, where further counseling and referral services can be provided
and crisis intervention steps can be taken. Veterans Chat and the
Hotline are intended to reach out to all Veterans, whether they are
enrolled in VA health care or not. Since July 2009, when Veterans Chat
was established, VA has learned many valuable lessons. First, it is
clear that conversations are powerful and capable of saving lives. As a
result, opening more avenues for communications by offering both an
online and phone service is essential to further success. Second,
training and constant monitoring is very important, and VA will
continue pursuing both of these efforts aggressively.
The Lifeline and VA Call Center may be the most visible components
of VA's suicide prevention programs, but the Suicide Prevention
Coordinators are equally important. Both the VA Call Center and
providers at their own facilities notify the Suicide Prevention
Coordinators about Veterans at risk for suicide. The Coordinators then
work to ensure the identified Veterans receive appropriate care,
coordinate services designed specifically to respond to the needs of
Veterans at high risk, provide education and training about suicide
prevention to staff at their facilities, and conduct outreach and
training in their communities. Other components of VA's programs
include a panel to coordinate messaging to the public, as well as two
Centers of Excellence charged with conducting research on suicide
prevention: one, in Canandaigua, NY, focused on public health
strategies, and one in Denver, CO, focused on clinical approaches. VA
also has a Mental Health Center of Excellence in Little Rock, Arkansas,
focused on health care services and systems research.
Outreach and Awareness of VA's Suicide Prevention Efforts
As discussed previously, VA's Suicide Prevention Coordinators do a
tremendous amount of work to raise awareness about warning signs
associated with suicide and the availability of treatment and support.
For example, in February 2010, VA's Suicide Prevention Coordinators
provided 614 informational and outreach programs in their local
communities. As a result, VA added 1,511 Veterans to its High Risk List
and 1,353 (90 percent) have completed safety plans. In addition to
these measures, VA has been aggressively advertising this information
and improving outreach to Veterans and family members alike. Perhaps
the most notable examples of this outreach are the public service
announcements (PSA) featuring actor Gary Sinise and broadcaster and
journalist Deborah Norville. All told, these PSAs have been shown more
than 17,000 times and represent a significant cost savings. The two
PSAs cost approximately $200,000 to produce, while the estimated value
of the air time in which they were broadcast is $3.8 million.
Another major effort in this regard is the advertising VA developed
and placed on buses and Metro trains in the Washington, D.C. area,
resulting in a significant increase in calls to the Hotline from the
area. In 2009, VA began an advertising campaign in Dallas, Los Angeles,
Las Vegas, Miami, Phoenix, San Francisco and Spokane metropolitan areas
(all locations where the suicide rate among Veterans is greater than
the national average). The table below contains specific information on
the forms and extent of outreach VA pursued in these areas. These
advertisements ran for 12-week, non-concurrent periods starting in late
spring and ending in early fall 2009. ``Units'' refer to each specific
location, so a bus displaying side, taillight and interior
advertisements would count as three units. A second advertising
campaign is being pursued through a contract with BluLine Media, Inc.
and is producing and displaying suicide prevention advertisements in
the interior of public transit buses. This effort has reached 4.3
million daily riders in 124 markets covering 42 States and 21,000
buses. The total cost for these two campaigns was approximately $1.4
million.
----------------------------------------------------------------------------------------------------------------
City Media Form Number of Units
----------------------------------------------------------------------------------------------------------------
Dallas Bus: Side, Taillight, and Interior Ads 275
----------------------------------------------------------------------------------------------------------------
Los Angeles Bus: Taillight and Interior Ads 1,700
----------------------------------------------------------------------------------------------------------------
Bus Shelter Ads 40
----------------------------------------------------------------------------------------------------------------
Rail Car Ads 105
----------------------------------------------------------------------------------------------------------------
Las Vegas Bus: Side, Taillight and Interior Ads 1,112
----------------------------------------------------------------------------------------------------------------
Bus Shelter Ads 150
----------------------------------------------------------------------------------------------------------------
Miami Bus: Side, Taillight, and Interior Ads 310
----------------------------------------------------------------------------------------------------------------
Rail Station Ads 22
----------------------------------------------------------------------------------------------------------------
Rail Car: Interior Ads 136
----------------------------------------------------------------------------------------------------------------
Phoenix Bus: Side, Taillight and Interior Ads 950
----------------------------------------------------------------------------------------------------------------
Bus Shelter Ads 25
----------------------------------------------------------------------------------------------------------------
San Francisco Bus: Taillight and Interior Ads 1,265
----------------------------------------------------------------------------------------------------------------
Rail Car Ads 336
----------------------------------------------------------------------------------------------------------------
Rail Station Ads 140
----------------------------------------------------------------------------------------------------------------
Spokane Bus: Side, Taillight, and Interior Ads 348
----------------------------------------------------------------------------------------------------------------
VA is continuing to conduct assessments of these programs. The
Center of Excellence at Canandaigua is reviewing the associations
between exposure to public health media messaging, knowledge of Hotline
use among those known to the participant, and self-reported likelihood
of Hotline use if in need. The current evaluation strategy aims to
collect data from three random samples of approximately 500 community
members from each of the 2009 media campaign implementation sites. To
identify any long-term associations between exposure to media messaging
and likelihood of Hotline use, data are collected at baseline (the time
the campaign was initiated), and 6 and 12 months following the start of
the campaign. This study is not complete, but preliminary data indicate
an increase in the number of calls originating in the areas where these
advertisements were deployed. Phoenix, for example, saw a 234 percent
increase in calls from the 602 area code within 30 days of the start of
the media campaign. This change is all the more notable due to the
contrast between it and the more modest change or even decrease among
calls originating from other Arizona area codes during those same time
periods. Based on these promising efforts, in FY 2011 VA will pursue a
``next generation'' of suicide prevention outreach based on a
comprehensive strategy developed with ``social marketing'' experts and
implemented through a newly created national outreach contract.
VA's Impact on Reducing Suicide
On the macro level, one way to evaluate the impact of VA mental
health care and its suicide prevention program is to evaluate suicide
rates. However, before addressing this issue, it is important to
consider who accesses VA health care. For this, it is useful to refer
to findings on those Veterans returning from Afghanistan and Iraq who
participated in the Post-Deployment Health Re-Assessment (PDHRA)
program administered by DoD. Between February 2008 and September 2009,
approximately 119,000 returning Veterans completed PDHRA assessments
using the most recent version of DoD's form. Of the more than 101,000
who screened negative for PTSD, 43,681 came to VA for health care
services (43 percent). Among 17,853 who screened positive for PTSD,
12,674 came to VA for health care services (71 percent). These findings
demonstrate that Veterans screening positive for PTSD were
substantially more likely to come to VA for care. Findings about
depression were similar. Both sets of findings support earlier evidence
that those Veterans who come to VA are those who are more likely to
need care and to be at higher risk for suicide. The increased risk
factors for suicide among those who came to VA is often referred to as
a case mix difference.
Working with the Centers for Disease Control and Prevention's
National Violent Death Reporting System, VA recently calculated rates
of suicide for all Veterans, including those using VA health care
services and those who do not. This analysis included data from 16
States for individuals aged 18-29, 30-64, and 65 and older for the
years 2005, 2006, and 2007 (during the period of VA's mental health
enhancement process). The year 2005 marked the beginning of
enhancement, while the year 2007 is the most recent one for which data
are available.
Suicide rates for Veterans using VA health care services aged 30-
64, and those 65 and above were higher than rates for non-users, and
they remained higher from 2005 to 2007, probably a reflection of the
case mix discussed above. However, findings for those aged 18-29 were
quite different. In 2005, younger Veterans who came to VA for health
care services were 16 percent more likely to die from suicide than
those who did not. However, by 2006, those younger Veterans who came to
VA were 27 percent less likely to die from suicide, and by 2007, they
were 30 percent less likely. This difference appears to reflect a
benefit of VA's enhancement of its mental health programs, specifically
for those young Veterans who are most likely to have returned from
deployment and to be new to the system.
Because the number of Veterans from the 16 States in this group is
relatively low, the rates are, for statistical reasons, variable.
Nevertheless, they demonstrate important effects. In 2005, 2006, and
2007, respectively, those who came to VA were 56, 73, and 67 percent
less likely to die from suicide. Those who utilized VA services, to
some extent, showed a lower rate of suicide with an effect that
appeared to increase during the time of VA's mental health
enhancements. More broadly, the rate of suicide among Veterans
receiving health care from VA has declined steadily since FY 2001;
specifically, the rate declined more than 12 percent during this time.
From a public health perspective, the decline in rates is significant,
corresponding to about 250 fewer lives lost as a result of suicide. A
chart detailing the VHA suicide rate from FY 2001 through FY 2007 is
attached.
Conclusion
Mr. Chairman, as my testimony demonstrates, VA has taken a number
of steps to provide comprehensive suicide prevention services, and the
data indicate our efforts are succeeding. But our mission will not be
fully achieved until every Veteran contemplating suicide is able to
secure the services he or she needs. I thank you again for your support
of our work in this area, and for the opportunity to appear before you
today. I will be happy to respond to any questions from you or other
Members of the Subcommittee.
Statement of Paula Clayton, M.D., Medical Director,
American Foundation for Suicide Prevention
Chairman Mitchell, and Ranking Member Stearns, and Members of the
Committee. Thank you for inviting the American Foundation for Suicide
Prevention (AFSP) to provide a written statement on the issue of
suicide and suicide prevention among our Nation's veterans. My name is
Paula Clayton. I am a physician. I currently serve as AFSP's medical
director. My responsibilities include overseeing and working closely
with the AFSP's scientific council to develop and implement directions,
policies and programs in suicide prevention, education and research. I
also supervise staff assigned to the research and education departments
within AFSP.
Prior to joining AFSP, I served as professor of psychiatry at the
University of New Mexico School of Medicine in Albuquerque. I also
currently serve as professor of psychiatry, Emeritus, for the
University of Minnesota, where I was a professor and head of the
psychiatry department for nearly 20 years. My research on bipolar
disorder, major depression and bereavement allow me to understand some
of the antecedents of suicide and to appreciate medical research and
public/professional education programs aimed at preventing it.
AFSP is the leading national not-for-profit organization
exclusively dedicated to understanding and preventing suicide through
research, education and advocacy, and to reaching out to people with
mental disorders and those impacted by suicide. You can see us at
www.asfp.org.
To fully achieve our mission, AFSP engages in the following Five
Core Strategies, (1) Funds scientific research, (2) Offers educational
programs for professionals, (3) Educates the public about mood
disorders and suicide prevention, (4) Promotes policies and legislation
that impact suicide and prevention, (5) Provides programs and resources
for survivors of suicide loss and people at risk, and involves them in
the work of the Foundation.
I have provided the Committee staff with a Power Point presentation
I delivered here in Washington, DC on March 8, 2010, entitled,
``Suicide Prevention--Saving Lives One Community at a Time.'' I also
included a copy of AFSP's 2010 Facts and Figures on Suicide. Both
documents will provide Committee members and their staff an overview on
the issues associated with suicide in America today, along with some
examples of programs and services to prevent this major public health
problem.
Chairman Mitchell, Ranking Member Stearns, suicide in America today
is a public health crisis. Consider the facts:
More than 34,500 people die by suicide each year in the
United States. Approximately 20 percent of those individuals--or one in
five--are veterans.
Suicide is the 4th leading cause of death in the United
States for adults 18--65 years old and the third leading cause of death
in teens and young adults from ages 15--24. Currently 67 percent of all
Marines are between the ages of 17 and 25.
Male veterans are twice as likely to die by suicide as
male non-veterans. On average 18 veterans commit suicide each day.
Men account for 80 percent of all completed suicides in
America.
A suicide occurs approximately every 15 minutes, totaling
over 90 suicides a day.
Suicide in the military is not just a mental health
problem; it is a public health problem. The number of suicide attempts
by Army personnel has increased six-fold since the wars in Afghanistan
and Iraq began.
Depression, Post Traumatic Stress Disorder and traumatic
brain injury are real medical conditions.
We need to let our veterans know that seeking help for mental
health and substance abuse problems is a sign of strength. The keys to
improving these statistics are reducing the stigma associated with
mental illness, encouraging help-seeking behavior, and being aware of
warning signs and treatment options.
Suicide is the result of unrecognized and untreated mental
disorders. In more than 120 studies of a series of completed suicides,
at least 90 percent of the individuals involved were suffering from a
mental illness at the time of their deaths. The most common is major
depression, followed by alcohol abuse and drug abuse, but almost all of
the psychiatric disorders have high suicide rates.
So the major risk factors for suicide are the presence of an
untreated psychiatric disorder (depression, bipolar disorder,
generalized anxiety and substance and alcohol abuse), the history of a
past suicide attempt and a family history of suicide or suicide
attempts. The most important interventions are recognizing and treating
these disorders. Veterans have strong biases against doing that. These
must be identified and overcome.
Whether a civilian or a veteran, there are signs that health care
professionals look for, what we call risk factors. In addition to those
above, they include:
Difficulties in a personal relationship;
A history of physical, sexual or emotional abuse as a
child;
Family discord;
Recent loss of a loved one;
A recent arrest;
Sexual identity issues;
Availability of firearms.
Protective factors or interventions that work, again in the general
population and for veterans include:
Regular consultation with a primary care physician;
Effective clinical care for mental and physical health,
substance abuse;
Strong connections to family and community support;
Restricted access to guns and other lethal means of
suicide.
It is vitally important that we communicate effectively with our
veterans that consulting a health care professional does not in and of
itself preclude an individual from obtaining a security clearance. On
May 7, 2010, Admiral Mike Mullen, stated concerning behavioral health
issues, ``If you feel as though you or a close family member needs
help, please don't wait. Tell someone. Asking for help may well be the
bravest thing you can do.'' Mr. Chairman, and Members of the Committee,
we must make sure that Admiral Mullen continues to be heard loud and
clear inside and outside the military and veteran community.
AFSP is pleased to report that help is available. The Department of
Veterans Affairs (VA), Veterans Health Administration (VHA) founded a
national suicide prevention hotline to ensure veterans in emotional
crisis have free, 24/7 access to trained counselors. To operate the
Veterans Hotline, the VA partnered with the Substance Abuse and Mental
Health Services Administration (SAMSHA) and the National Suicide
Prevention Lifeline. Veterans can call the Lifeline number, 1-800-273-
TALK (8255), and be routed to the Veterans Suicide Prevention Hotline.
This Hotline is available 24 hours a day, 7 days a week. It is
important to note that friends and family members of veterans in crisis
are welcome to call the Veterans Hotline.
The VA has expanded an advertising campaign that debuted in
Washington DC, and is now active in 124 cities with advertisements on
local buses. The ads are designed to make veterans and their family
members aware of the VA Suicide Prevention Lifeline. The VA has also
been distributing brochures, wallet cards, bumper magnets and other
educational items to veterans, their families and VA employees to
promote awareness of the Lifeline number. These items serve to educate
the public, veterans and family members about suicide risk factors and
how to get help for those veterans that need it. They are all important
building blocks in our efforts, both public and private, to get the
word out regarding the services and programs available.
Another valuable service that veterans, their family members, and
even friends can access, is a program called Veterans Chat through the
National Suicide Prevention Lifeline Web site. Veterans Chat enables
veterans, their families and friends to go online where they can
anonymously chat with a trained VA counselor. If the chats are
determined to be a crisis, the counselor can take immediate steps to
transfer the individual to the VA Suicide Prevention Hotline, where
further counseling and referral services are provided and crisis
intervention steps can be taken.
Additionally, AFSP supports President Obama and the new VA policies
that will make it easier for war zone veterans with PTSD to receive
disability benefits by stripping the requirement to produce evidence
that a specific incident triggered their stress disorder. This policy
has kept those who served in non-combat roles in war zones from getting
the care they need and the new policy changes will expand access to
care for those veterans.
AFSP would like to commend the U.S. Department of Veteran Affairs,
Dr. Antonette Zeiss and Dr. Jan Kemp for their leadership and vision in
constructing and implementing this program designed to help our
veterans contemplating suicide. We urge this Subcommittee, the full
Committee and the entire Congress to fully support Dr. Zeiss and Dr.
Kemp in their important efforts.
Chairman Mitchell, Ranking Member Stearns, suicide in Veterans is
an absolute crisis. Depression can be fatal. Excessive drinking or drug
use can be fatal. The fatality is mainly by suicide. Culturally
sensitive but sustained efforts with multiple approaches offer our best
hope to get veterans into treatments. We must reduce this fatal
outcome. The American Foundation for Suicide Prevention is ready and
willing to offer our expertise and advice to this Committee and to all
Members of Congress as you make the important decisions on how to
reduce suicide among our veterans.
Statement of Penny Coleman, Rosendale, NY, Author,
Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of
War
Mr. Chairman, Ranking Member, and Members of the Subcommittee, I
thank you for the opportunity to share my views and concerns on the
very important issue of the VA's national suicide prevention outreach
efforts, which are based on the reported success of a pilot program
that encouraged veterans at-risk for suicide to call the VA suicide
hotline.
I have several concerns about the current suicide prevention
outreach efforts:
a. that it is being called a success when there is little evidence
of that,
b. that it is a non-evidenced-based strategy, and
c. that it intervenes with the problem of suicide at the moment of
crisis rather than providing a more proactive and systematic approach.
I will first address each of these in turn. Following that, I will
present a number of suggestions for alternative strategies:
1. Make VA enrollment automatic and universal
2. Integrate and coordinate DoD and VA their health care
transition
3. Hire more mental health care providers
4. Give the VA a budget that will not require outsourcing of
services
5. Reinstitute VA counseling for incarcerated veterans
6. Establish Veterans Programs in the Nation's prisons
7. Support Community Living projects like Valley Forge Village
and most importantly,
8. Establish more Vet Centers
a. My first concern is that the stated purpose of these hearings
is based on the assumption that the pilot suicide hotline program was a
success.
In 2008, Lisette Mondello, Assistant Secretary for Public and
Intergovernmental Affairs for the VA, reported to this Committee that
the pilot program, a televised public service announcement and posters
placed on area trains and buses encouraging veterans considering
suicide to call the VA's suicide hotline, had produced a 50 to 100
percent increase in calls from the area where the advertising ran.\1\
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\1\ House Committee on Veterans' Affairs, Subcommittee on Oversight
and Investigations, Lisette M. Mondello, Assistant Secretary for Public
and Intergovernmental Affairs, U.S. Department of Veterans Affairs,
September 23, 2008. http://veterans.house.gov/Media/File/110/7-15-08/
Demvaqfrs.htm
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The 50 to 100 percent increase may sound substantial, but it
actually refers to only eight more calls a week in the D.C. area, nine
more in Northern Virginia, and 17 more in Maryland. And there is no
indication that even those small numbers are indicative of success. For
one thing, Assistant Secretary Mondello's statement fails to
acknowledge that calls to the VA's hotline more than doubled in the
first 6 months of 2008 nationwide, independent of the Washington metro
ad campaign.\2\ Second, rather than a measure of the pilot's success,
that increase in calls can also be interpreted as a warning that
failures of our military and veterans' mental health care systems were
leaving increasing numbers of the men and women who so desperately need
them on the brink of crisis. Thus, my first concern is whether this
program should in fact be considered successful. In other words, is it
working?
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\2\ ``Calls To Veterans' Suicide Hot Line Double,'' Jul 28, 2008.
http://cbs3.com/national/veterans.affairs.suicide.2.781329.html
b. That there is no viable data to suggest that it is brings me to
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my second concern: that this is not an evidence-based strategy.
In the fall of 2008, the VA's blue ribbon panel of experts
recommended that the VA ``apply evidence-based research'' in their
intervention efforts. In January 2009, VA's Health Services Research
and Development Service (HSR&D) published a pamphlet called
``Strategies for Suicide Prevention in Veterans'' in which the authors
state categorically that they ``found no studies that assessed the
specific effectiveness of any hotlines.'' \3\ The peer review comments
(Appendix D) \4\ specifically chide the VA for withholding data
describing the impact of their national suicide prevention hotline.
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\3\ ``Strategies for Suicide Prevention in Veterans.''
www.hsrd.research.va.gov/publications/. . ./Suicide-Prevention-2009.pdf
\4\ ``Strategies for Suicide Prevention in Veterans,'' Appendix D:
The VA National Center for Suicide Prevention and the MIRECC in Denver
may have at least some published data describing the impact of the
recent VA national suicide prevention hotline. This would obviously be
the most relevant information, yet there was no mention of this in the
project synthesis. It would be helpful if the document states
explicitly one way or another if there is any recent data to be
factored from either of these VA suicide prevention centers, either in
the literature, in press or otherwise. www.hsrd.research.va.gov/
publications/. . ./Suicide-Prevention-2009.pdf
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In April 2010, Dr. Janet Kemp, the national suicide-prevention
coordinator for the VA, proudly told the American Forces Press Service
that the advertising campaign, now in 124 cities nationwide, had
increased the hotline call volume to about 10,000 calls a month, or
about 25 percent in 2 years.
But she offered no information about who is calling, what era and
branch of service they represent, how many of those callers have
attempted suicide in the past, what kind of followup procedures are in
place, how many of the callers are already enrolled in the VA system,
how many are re-routed to back-up call centers, and nothing to back up
her claim that the calls to the hotline were responsible for stopping
7000 in-process suicides.
Instead of data, Dr. Kemp offered an anecdote about a veteran who
was in the process of writing a suicide note when he happened to notice
a poster with the hotline number on it and placed the call. ``He's now
alive and well and telling his story of success.'' \5\
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\5\ Donna Miles. ``VA officials strive to prevent veteran suicides'
'' American Forces Press Service, 4/23/2010. http://www.af.mil/news/
story.asp?id=123201368
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This is not evidence-based intervention.
In June of 2010, doctors from the Los Angeles VA and the RAND Corp.
did a systematic review of suicide prevention programs developed for
military and veterans world wide. This program is not listed among
them. The review found that all of the programs developed for the
military reported declines in suicides and suicide attempts, but all
were so badly designed, so inadequately documented and the data so
poorly analyzed that ``it was not possible to infer causality from the
reported associations.'' And they found no studies focusing on
veterans. Their conclusion that ``(t)here is an urgent need for
continued research in this area'' seems restrained.\6\
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\6\ Steven C. Bagley, MD, MS, Brett Munjas, BA, and Paul Shekelle,
MD, PhD. ``A Systematic Review of Suicide Prevention Programs for
Military or Veterans Suicide and Life-Threatening Behavior,'' 40(3),
June 2010, p. 263-4. www.hsrd.research.va.gov / publications / . . . /
Suicide-
Prevention-2009.pdf
---------------------------------------------------------------------------
These hearings are evidence that the VA is still asking Congress to
take this program seriously, yet in 2 years they have produced nothing
to back up their claim that what they are doing is working. In fact,
there is no way to distinguish between those callers who have been
driven to their limits by service-related injuries and those who have
been driven to their limits by the failure of the VA to deliver the
care and support that are so desperately needed.
While there is a lack of convincing evidence that the hotline has
been successful as an suicide intervention strategy, there is no lack
of evidence that it has not. Military suicides have continued to rise
across all branches of service: in 2009, the suicide rate in the Marine
Corps was 24-per-100,000; it was 23 in the Army; 15.5 in the Air Force;
and 13.3 in Navy, all, by the way, higher than in 2008\7\ and all
significantly higher than the civilian suicide rate which has held
steady at 11.1 for some years.\8\ The VA acknowledges that 18 veterans
take their lives every day, the same number the VA accepted in 2007
when confronted with the CBS investigation.\9\ That is 6570 veteran
suicides a year, or almost 60,000 in the 9 years since these wars
began.\10\
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\7\ Gregg Zoroya, ``No Letup in Marine attempted Suicides,'' U.S.A
Today, June 8, 2010. http://www.usatoday.com/news/military/2010-06-07-
marine-suicides_N.htm
\8\ Suicide Facts. http://www.athealth.com/Consumer/issues/
factsuicide.html
\9\ Armen Keteyian. ``VA Hid Suicide Risk, Internal E-Mails Show:
Follow-Up Reporting On Exclusive Investigation Reveals Officials Hid
Numbers, April 21, 2008. http://www.cbsnews.com/
stories/2008/04/21/cbsnews_investigates/main4032921.shtml
\10\ http://www.chron.com/disp/story.mpl/nation/6428651.html
c. My final concern with the hotline program is its centrality to
the VA's suicide prevention efforts. I take no issue with a hotline,
only with the suggestion that it is anything more than an 11th-hour
prayer. Rather than waiting until veterans are at the edge of the
precipice and relying on haphazard message to pull them back, the VA
should be focusing their attention on evidence-based interventions,
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interventions with documented histories of success.
In 2008, when the pilot was announced, CBS News quoted David Rudd,
a former army psychologist, warning that after the posters and the
public service ads have directed veterans to turn to the VA for help,
the VA had best be prepared to deliver. Specifically, they had best
reduce delays and provide the services that will keep veterans in care.
``Those are the things we know reduce death rates.'' \11\
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\11\ Pia Malbran, ``VA To Test Suicide Public Service Ads,'' July
14, 2008. http://www.cbsnews.com/stories/2008/07/14/
cbsnews_investigates/main4260904.shtml
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A 2008 RAND Corporation report warned that fully a third of
returning veterans were suffering from post-traumatic stress
injuries.\12\ In 2008, that was 300,000 troops. In 2010, over 2 million
troops have been deployed in Iraq and Afghanistan, and a third is just
shy of 700,000, a number that continues to grow.\13\ The magnitude of
that crisis requires a response of commensurate magnitude. A hotline
doesn't belong at the top of the list.
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\12\ Tanielian, T., and Jaycox, L.H. (2008). Invisible Wounds of
War Psychological and Cognitive Injuries, Their Consequences, and
Services to Assist Recovery. Santa Monica, CA: Rand Corporation.
Accessed July 1, 2008. http://www.rand.org/pubs/monographs/MG720/
\13\ VCS Fact Sheet: Consequences of Iraq and Afghanistan Wars.
Updated March 13, 2010 using documents obtained from the Department of
Veterans Affairs (VA) under the Freedom of Information Act (FOIA).
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In that vein, the following are offered as an incomplete list of
suggestions for evidence-based interventions that prioritize prevention
rather than crisis management, and avoid raising hopes and expectations
that will not be met. Perhaps even more to the point, invest in
programs that offer the hope of dignity and independence.
1. Make VA enrollment automatic and universal.
In 2008, Congressman Harry Mitchell, who has been instrumental in
pushing the VA to improve its suicide outreach, told CBS News, ``We
can't just wait for veterans to come to us, we need to bring the VA to
our veterans.'' \14\ The VA should take him at his word. When
servicemembers are being processed out of the military, when they are
cut loose and sent home, the VA should be sitting in the room signing
them up, simply and automatically.
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\14\ ``Calls To Veterans' Suicide Hot Line Double.'' http://
cbs3.com/national/veterans.affairs.
suicide.2.781329.html
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Post-traumatic stress injuries are unique among anxiety disorders
in that they are significantly associated with suicide, suicidal
ideation and attempts.\15\ If suicide prevention is the issue, it is
surely counter productive to make access to support and services
dauntingly complicated and selectively exclusive. Especially if
betrayal of expectations and frustration with what are perceived to be
gratuitously forbidding procedures are going to exacerbate their post-
traumatic stress symptoms and make disaster more likely.
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\15\ The Relationship Between PTSD and Suicide--National Center for
PTSD http://www.ptsd.va.gov/professional/pages/ptsd-suicide.asp.
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It is also well understood that the stigma associated with mental
health issues prevents those who need it most from asking for help.
Especially with new veterans, the VA should take advantage of the
anonymity of universality. If everybody does it, nobody is exposed.
Contrary to popular belief, currently, only about 20 percent of all
of America's veterans are enrolled in the VA and make use of their
health care services. Far too many are excluded, far too many are
daunted and overwhelmed, and far too many need help with the process.
The VA has recently been pointing out that if there is any cause for
optimism in the recent suicide data it is that it appears that veterans
using VA health care seem increasingly less likely to take their own
lives than those who did not.16,17
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\16\ http://www.cbsnews.com/stories/2010/01/11/national/
main6083072.shtml
\17\ Interestingly, the number of veterans under VA care who took
there own lives in 2007, five, is the same number cited by the VA in
2005.
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So make it accessible. Make enrollment simple and automatic and
universal. The new rules streamlining the process for filing disability
claims is a long overdue improvement, but already the posturers are
lining up wagging fingers and tongues about how veterans are gaming the
system and taking advantage of easy handouts.\18\ There will be Fraud!
There will be Malingering! There will be Chronic Dependency! And there
will be Budget Deficits!
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\18\ Allan Breed, ``Tide of new PTSD cases raises fears of fraud:
Some veterans have learned to game the system to get disability
payments,'' May 2, 2010. http://www.msnbc.msn.com/id/36852985/ns/
health-mental_health/page/2/Tide of new PTSD cases raises fears of
fraud.
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Shame on their selective memories. It has only been 5 years since
the VA was directed to review the claims files of the 72,000 most
fragile, most vulnerable (most expensive to maintain) veterans, those
with 100 percent disability ratings for post-traumatic stress. After a
review of a sample 2100 of those files, a review that was so stressful
that one veteran was driven to suicide, the Inspector General's report
found not a single case of fraud on the part of a veteran. What it did
find was an administrative mess. Then-Secretary Nicholson called off
the review and promised to improve VA employee claims handling and
administrative oversight.\19\
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\19\ No Across-the-Board Review of PTSD Cases--Secretary Nicholson,
Public and Intergovernmental Affairs, November 10, 2005, http://
www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042
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When there is real fraud at the VA, it is almost always at the top
and very expensive, not just in dollars, but in lives.\20\ And though
the VA declined to be the object of a lawsuit in 2007, it was not
because they were innocent of the charges leveled against them, but
because of a legal technicality that prevented the lawsuit from
proceeding.\21\
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\20\ The scandal at Walter Reed (http://www.washingtonpost.com/wp-
dyn/content/article/2007/03/04/AR2007030401394.html), was followed by
stories of VA using veterans as guinea pigs in dangerous drug trials
(http://www.washingtontimes.com/news/2008/jun/17/va-testing-drugs-on-
war-veterans/), and then by the revelation that VA employees had taken
$24 million in bonuses (http://www.veteranstoday.com/2009/08/21/va-24-
million-bonus-scandal/), to the multiple scandals that resulted in the
``retirement'' of the director of the Philadelphia VA (http://
www.vawatchdog.org/10/nf10/nffeb10/nf021710-6.htm). Just Google VA
scandal.
\21\ Veterans For Common Sense et al. v. Peake, Case No. C 07 3758,
U.S.D.C. (N.D. Cal. 2007) http://www.veteransptsdclassaction.org/
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And as to budget deficits, the RAND Corporation estimates the costs
of the psychological and neurological injuries suffered by Iraq and
Afghanistan veterans at between $4 and $6.2 billion, just in the first
2 years after combat. Providing proper evidence-based care for all of
these veterans would lower that cost to society by about 27
percent.\22\
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\22\ Terri Tanielian and Lisa H. Jaycox, Eds., ``Invisible Wounds
of War: Psychological and Cognitive Injuries, Their Consequences, and
Services to Assist Recovery,'' RAND, 2008: http://www.rand.org/pubs/
monographs/MG720/ p.17.
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2. Integrate and coordinate DoD and VA their health care transition.
There is no logical or moral justification for the chasm that is
allowed to exist between the two agencies--only an apparently
territorial one and the ubiquitous financial one. Both agencies are
confronting the same terrible problem with suicide, and their attempts
at intervention have produced the same disappointing results. There
will be fewer suicides, on whichever side of the tally sheet they are
finally counted, if soldiers and veterans who are at-risk for suicide
aren't allowed to get lost in the system--or worse, to it.
If the DoD wanted enlisted men and women to know about the programs
that will be available to them after they leave the service, they have
a captive audience. Veterans who left the service years ago and
veterans who left months ago tell the same story: suicide awareness and
intervention options are touched on in a single sentence, at the last
minute, as a footnote in an overwhelmingly condensed out-processing
ordeal.\23\
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\23\ I have only heard variations on what is essentially the same
story from veterans: ``They try to fill your head at the last formation
before the weekend, the last day before you get out. Everybody's trying
to sit in the back of the room, just waiting for a smoke break, with
shades on because we'd drunk too much the night before because we were
going home and what were they going to do to us anyway? Give us an
Article 15?'' ``VA eligibility, TRICARE, the GI Bill, and a million
other things were covered. The suicide hotline got one sentence.'' Did
he still have all the handouts he got in his ACAP[23] folder? ``I took
what was important, the GI Bill and TRICARE stuff and tossed the rest
without reading it.''
---------------------------------------------------------------------------
One recently returned veteran compared the suicide awareness
presentations given at out-processing to pharmaceutical ads on TV:
don't pay any attention to this list of lethal side effects that we are
reading through as fast as we can; just keep your eye on the seductive
fantasy payoff: happiness, health, sanity, and especially home.
If suicide awareness and intervention options are important to both
agencies, perhaps some thought should be given to how and when and with
what degree of seriousness and urgency they are presented by the
military and then what the VA can do to followup and reinforce the
message.
Perhaps more to the point, after years of stalling, the VA and the
DoD have yet to implement a fully interoperable electronic health
record systems. It is those who are most at risk who most need
continuity of care, and continuity of care is exactly what gets lost in
the tug of war over whose software system is going to win.
3. Hire more mental health care providers.
The significant association of post-traumatic stress injuries with
suicide\24\ makes the availability of adequate numbers of trained
providers key to any suicide intervention strategy. It is not enough to
say that an additional 2000 or 4000 or 6000 have been hired, if at-risk
veterans are not seen in a timely fashion and given care that lives up
to best-practice standards.
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\24\ The Relationship Between PTSD and Suicide--National Center for
PTSD http://www.ptsd.va.gov/professional/pages/ptsd-suicide.asp.
---------------------------------------------------------------------------
If experienced therapists continue to leave both the military and
the VA because they can get higher paying, less stressful jobs in the
private sector, then the budget for mental health services must include
higher salaries and incentives to induce them to stay.\25\ If younger,
less experienced providers are more easily available, then they must be
hired immediately, as it will take time to train them in cultural
competencies essential to establishing the trusting relationships with
veterans that will keep them in care.
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\25\ Paul Rieckhoff, ``A Memo to Obama from America's Vets,''
Military.com, November 06, 2008. http://www.military.com/opinion/
0,15202,178674,00.html
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In fact, if a hotline generates 50,000 calls a day, 100,000, and
the services and support advertised are not actually available, it can
only add to a caller's despair, and may even make it more likely that
he or she will give up.
4. Give the VA a budget that will not require outsourcing of services.
Contracting out the responsibilities of the VA may be an attractive
short-term solution to a very real problem, but it is a solution that
leaves the 3 million veterans who live in rural areas that are
underserved by VA facilities particularly vulnerable.
In three short years, Project HERO, run by Humana, has expanded
from an experimental pilot program specifically charged with providing
health care to rural veterans into an entity providing a full range of
services in metropolitan areas--in direct competition with established
VA Medical Centers. The Business Section of the Milwaukee Journal
referred to that phenomenon as ``big business for Humana, Inc.'' \26\
The VA is dependent on Project HERO for 30 percent of their fee-based
contracts nationwide,\27\ and so far they have managed to keep
providers ``stepping up'' and ``doing the right thing,'' but the more
dependent the VA gets on Humana, the less leverage they will have over
their service delivery and fees.
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\26\ Ed Green, New Veterans unit could be big business for Humana
Inc.--June 1, 2007. http://louisville.bizjournals.com/louisville/
stories/2007/06/04/story6.html
\27\ Dennis Douda, ``Expanding Private Medical Care For Veterans,''
(WCCO), Feb 19, 2009. http://wcco.com/health/
project.hero.veterans.2.939294
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Humana was generously excused for their slow start, for the time it
took to establish a network of providers, but it is still ostensibly on
trial, and already it is ``not living up to its contractual obligations
for timely referrals and communication with FB (fee-based) providers''
at the Orlando VMHC.\28\ In June, the VA Inspector General found that
veterans were waiting for referrals, for appointments, for test
results, and for medical record updates for up to 3 months.
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\28\ Healthcare Inspection Inadequate Coordination of Care Orlando
VA Medical Center Orlando, Florida--Report Number 10-00219-180, 6/24/
2010. http://www4.va.gov/oig/54/reports/VAOIG-10-00219-180.pdf
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Furthermore, the new Web site of the Office of Management and
Budget, PaymentAccuracy.gov, which showcases Federal ``high-error''
programs, included Project Hero in their June audit, identifying $11.6
million in potentially erroneous payments.\29\
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\29\ Alice Lipowitz, ``Agencies Faulty Claims make OMB site hit
list,'' June 25, 2010, http://washingtontechnology.com / Articles /
2010 / 06 / 25 / OMB - sets - up - new - Web - site - to - track -
improper -
payments-by-agencies.aspx?Page=2
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Outsourcing VA services delays the construction of new VA
facilities and the training and hiring of VA staff. Vet Centers will
not be established, VA mental health teams will stop building travel to
Community Based Clinics into their schedules, the burgeoning fleet of
mobile VA clinics will be side-lined rather than expanded.
The wars in Iraq and Afghanistan have drawn heavily on recruits
from rural areas, and the need for VA services will only continue to
grow. The Reserve is also largely drawn from those same communities and
already exceptionally at-risk for suicide. In 2009, Army Reserve
suicides were up 26 percent.\30\
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\30\ Danny Spatchek, ``Chiarelli: suicides down, but not enough,''
Jun 25, 2010. http://www.army.mil/-news/2010/06/25/41363-chiarelli-
suicides-down-but-not-enough/
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For all its challenges and problems, the VA still manages to
deliver the best medical care to the most people at the best price in
the country. Humana never promised to be cheaper, only to give the VA a
chance to catch up with the overwhelming needs of a rapidly expanding
veteran population. Rural veterans at-risk for suicide need reliable,
accessible mental health services. The VA should be funded at the
levels required to put that system in place.
5. Reinstitute VA counseling for incarcerated veterans.
Current regulations restrict VA from providing counseling to
incarcerated veterans because it is the duty of ``another government
agency,'' in this case the criminal justice system, to provide that
care. They don't.
The most recent Bureau of Justice estimate of incarcerated veterans
in 2007 was 228,700,\31\ many, perhaps most, as a result of their
untreated, service-related psychic injuries. That is only an estimate
though. No one actually knows because the Federal Government doesn't
require prison authorities to ask.\32\
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\31\ Christopher Mumola and Margaret E. Noonan, ``Justice involved
Veterans,'' Bureau of Justice Statistics, Power Point presentation: The
VHA National Veterans Justice Outreach Planning Conference, Dec. 2,
2008 Baltimore.
\32\ In 1994, a few concerned members of Congress managed to get a
provision attached to the Violent Offender Incarceration and Truth in
Sentencing Incentive which would have rewarded the operators of
correctional facilities for adopting policies that would identify the
veterans among their inmates. Those incentive grants were passed, but
they were rescinded by the Gingrich Congress before they were ever
implemented.
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Prison is a terrible place for veterans suffering from post-
traumatic injuries. Left untreated, PTSD predictably gets worse and
becomes chronic, making one of two scenarios far more likely:
recidivism or suicide. The suicide rate in jails is an astonishing 47
per 100,000. The Army's is now 23 per 100,000, and everyone agrees that
is a crisis.
And no one knows how many of the suicides in jails and prisons are
veterans, but an article published last year in the Journal of the
American Academy of Psychiatry and Law, points to the ``absolute dearth
of data,'' and suggests that ``defining the scope of this problem
should be an absolute priority.'' \33\
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\33\ Hal S. Wortzel, MD, Ingrid A. Binswanger, MD, MPH, C. Alan
Anderson, MD and Lawrence E. Adler, MD. ``Suicide Among Incarcerated
Veterans,'' J Am Acad Psychiatry Law 37:1:82-91 (2009). http://
www.jaapl.org/cgi/content/full/37/1/82
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To whatever extent PTSD and TBI and the other emotional, cognitive,
and behavioral consequences of such injuries account for criminal
behaviors, throwing this vulnerable population behind bars, where they
will not get treatment, is compounding the risk that they will not
survive. The probability that the produces an excess of suicides should
be reason enough for the VA to re-institute counseling for incarcerated
veterans.
6. Establish Veterans Programs in the Nation's prisons.
The relatively new phenomenon of veterans' courts is a laudable
attempt to intervene in an historical injustice. Veterans with service-
connected mental injuries whose symptomatic behaviors get them in
trouble with the law can opt into a treatment program rather than going
to jail or prison. But those courts can't yet begin to deal with the
numbers and only a few are willing to accept veterans whose crimes are
considered violent.
In the meantime, veterans with felony convictions are more likely
to be unemployed or homeless, both of which contribute to hopelessness
and despair.
In 1993, New York State had Veterans' Programs in 19 of its
facilities that offered VA substance abuse and PTSD counseling, and
education and job training opportunities. They had a documented
recidivism rate of 8.9 percent after 5 years for veterans who completed
the program, compared to 51.6 percent for non-veterans.
Those programs have been eviscerated or killed, but the model
exists and would be a valuable component of any suicide intervention
strategy.
7. Support Community Living projects like Valley Forge Village
Valley Forge Village,\34\ outside of the Twin Cities, is a 240-acre
community for that will house 200 veterans coping with mental health
conditions and cognitive impairments and their families. As conceived,
it will be a place for veterans to go to heal and learn new skills.
Organic farming and sustainable practices will be taught in a
therapeutic setting. Residents can go to school in the surrounding area
and business start-up skills and development training are an integral
part of the program.
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\34\ http://www.valleyforgecenter.org/
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Valley Forge Village is one of a growing number of privately funded
intentional communities that will serve as models for the future. The
combination of therapy, and farming in a peaceful, therapeutic,
predominately peer environment is one the VA might do well to watch. As
a suicide intervention strategy, it holds great promise.
8. Establish more Vet Centers
For 25 years, Vet Centers have been the first line of defense
against suicide. They are walk-in clinics, designed to be less
intimidating than the large VA medical centers. They are largely
staffed by veterans, and unlike the big medical centers, they offer
counseling to veterans regardless of discharge status and to their
family members as well.
It is family members who are most likely to notice behaviors or
attitudes suggestive of suicidal ideation, and Vet Center counselors
can help them decide how best to help. It is the families who are best
positioned to encourage traumatized veterans, especially those who are
in denial about or ashamed of their mental health issues, to get the
help they need.
Vet Center counselors are specifically trained to deal with combat-
and other service-related issues, and they are fluent in with necessary
cultural competencies. They offer an array of social support services,
employment and addiction counseling, sexual trauma and family
counseling, as well as housing and legal support.
Vet Centers are not the answer to the homelessness and unemployment
problems that so disproportionately affect the veteran community, and
it is the co-occurrence of multiple issues that is most likely to leave
a veteran feeling the despair and hopelessness that can lead to self-
destructive behaviors.\35\
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\35\ Steven C. Bagley, MD, MS, Brett Munjas, BA, and Paul Shekelle,
MD, PhD. ``A Systematic Review of Suicide Prevention Programs for
Military or Veterans Suicide and Life-Threatening Behavior,'' 40(3),
June 2010, p. 263-4. www.hsrd.research.va.gov / publications / . . . /
Suicide-
Prevention-2009.pdf
---------------------------------------------------------------------------
Expanding this system of small, local, largely veteran staffed,
walk-in clinics, as General Shinseki has proposed, is an evidence-based
suicide intervention strategy that has an undeniable documented history
of success.
Advertising the existence of the Vet Centers and the services they
provide would help to prevent veterans from ever reaching the crisis
state in which a call to a suicide hotline appears to be the only
option.
Statement of Oregon Partnership, Portland, OR
Chairman Mitchell, Ranking Member Roe, and Members of the
Committee, an alarming threat to the well-being of our active military
and veterans is emerging.
In the past several years, members of the military, veterans and
their families have placed an increasing number of calls to Oregon's
statewide crisis lines, operated by the nonprofit Oregon Partnership
(OP).
While calls to Oregon Partnership's 24-7 Suicide Interventionline
have more than doubled since June of 2008 because of the economic
downturn, we were surprised to learn of a corresponding increase in
calls from the military. Since March 2009, OP's Crisis Lines have
received over 1,600 calls from members of the military, veterans and
their families.
These calls have run the gamut--from suicide and substance abuse to
concerns about symptoms of post traumatic stress disorder, depression,
and questions about jobs about health benefits.
As a result, this past spring Oregon Partnership established a
Military Helpline to meet the tremendous and growing need for
compassionate, confidential crisis intervention and referral. The
line--one of five specifically targeted crisis lines at OP--is operated
by highly trained and dedicated staff and volunteers who are on hand
around the clock. Some possess a military background, bringing a strong
understanding of the daunting challenges our citizen soldiers and their
families face.
There is no question that America must do right by the men and
women who have served and continue to serve our country.
After experiencing war, life back home can be overwhelming. Issues
such as unemployment, family strife, the loss of a home, PTSD and other
serious health care concerns descend as soldiers return from long--and
often repeated--deployments. These challenges may stop them from
seeking help at all.
What Oregon Partnership found was a huge gap in services--a gap
that is serious and time-sensitive.
Soldiers, veterans and their families desperately need the
immediate and confidential help that 24-hour crisis lines offer--crisis
lines operated outside the military and the Veterans Administration.
There is a clear and present stigma in the military culture about
seeking help for mental illness, emotional distress and contemplation
of suicide. Recent efforts by the Department of Defense to diffuse this
are to be applauded, but have decades of practice to overcome.
Many active duty soldiers or members of the reserves are hesitant
to seek help within the military health care system because of fear
that it would appear on their military record, jeopardize their
security clearance and/or impact promotion opportunities.
So often, men and women separating from the military are reluctant
to access the VA because of perceived agency dysfunction, claims
denial, red tape, and frustration about the length of the process.
It is vital that veterans and active military can call a
confidential line and speak anonymously if they so choose. It's all
about reacting quickly, compassionately and effectively in time-
sensitive situations, and providing for the safety of those suffering
from invisible wounds.
Recently, a severely depressed and suicidal veteran called our
helpline. Wheelchair-bound and without transportation to the VA to get
his prescribed medication, he was ready to kill himself. We connected
him with the Portland VA Medical Center's suicide prevention team and
secured a quick resolution to his life-threatening situation. Without
our helpline, he was tragically slipping through the cracks.
A confidential military helpline is a valuable tool for returning
soldiers who struggle with PTSD. Early intervention and assessment is
key. And Oregon Partnership's Military Helpline provides that, guiding
individuals and families on a path to safety and healing.
In establishing the Military Helpline, Oregon Partnership has
received unwavering support from the Oregon Military Department and the
Oregon National Guard. They have been and will continue to be
tremendous partners in this life-saving work.
The brave men and women who have served us so faithfully deserve
our faithfulness in return. Oregon Partnership urges Congress to help
robustly support these non-military lifelines.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
July 28, 2010
Honorable Robert M. Gates
Secretary of Defense
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301
Dear Secretary Gates:
Thank you for the testimony of Colonel Robert W. Saum, USA,
Director of the Defense Centers of Excellence for Psychological Health
and Traumatic Brain Injury at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Oversight and
Investigations hearing that took place on July 14, 2010, entitled
``Examining the Progress of Suicide Prevention Outreach Efforts at the
U.S. Department of Veterans Affairs.''
Please provide answers to the following questions by Friday,
September 10, 2010, to Todd Chambers, Legislative Assistant to the
Subcommittee on Oversight and Investigation.
1. Can you give examples of how DoD has used multi-media to
prevent suicide prevention within its own ranks? I know you have only
been on the job for about a month, but what are your impressions so far
on ways VA could improve outreach to at risk veterans and
servicemembers contemplating suicide?
2. Can you explain how the DoD and VA coordinate to help activated
guard and reserve members--and ensure that they have the resources they
need to help prevent them from becoming suicidal?
3. During the July 15, 2008 hearing on Media Outreach, then
Ranking Member Ginny Brown-Waite asked if there was a prohibition on
using email addresses, or social media sites such as Facebook or
Twitter to contact veterans regarding services available to them. At
that time, Ms. Mondello, the Assistant Secretary of Public and
Intergovernmental Affairs for VA stated that VA is working to enable
Federal representation of citizen information on social media Web
sites, and is planning an initial social media presence on four of the
most popular networking Web sites: Facebook, MySpace, YouTube, and
Second Life. What is the current status on the use of these types of
Web sites by the Department of Defense, and how is the Department
integrating its suicide prevention outreach into these social media?
4. According to a fact-sheet we received from the VA on suicide
statistics, there are between 30,000 and 32,000 U.S. deaths from
suicide per year among the population in the U.S. overall. Of these
about 20 percent are veterans, about 18 deaths from suicide per day are
veterans. Does your Department also keep statistics on active duty
personnel, as well as Guard and Reservists with relation to the rate of
suicides?
5. On June 8, 2010, there was an article in Marine Times about the
rise in suicide attempts by Marines. In the report, it indicated that
``recent improvements in tracking suicide attempts may have contributed
to more reports.'' What is the Department of Defense currently doing to
track suicide attempts amongst not only its active duty personnel, but
also among the National Guard and Reserve units, and the Individual
Ready Reserve?
6. What is the Department of Defense doing to combat the stigma,
or the worry that they are possibly jeopardizing the military career if
a servicemember calls a hotline, or sought other help when they have
suicidal thoughts? What reassurances do servicemembers have that when
they call for help, they will not be tagged as a weakling or someone
not worthy of being in the military?
7. How does the Department of Defense reach out to servicemembers
who may be at risk for suicidal ideation?
8. Would the Department of Defense be interested in working on a
coordinated effort with the VA on working to prevent suicides amongst
our Nation's servicemembers and veterans through outreach and media
advertising?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers. If you have any
questions concerning these questions, please contact Martin Herbert,
Majority Staff Director for the Subcommittee on Oversight and
Investigations at (202) 225-3569 or Arthur Wu, Minority Staff Director
for the Subcommittee on Oversight and investigations at (202) 225-3527.
Sincerely,
David P. Roe
Harry E. Mitchell
Ranking Republican Member
Chairman
MH:tc
__________
Hearing Date: July 14, 2010
House Committee on Veterans' Affairs
Member: Congressman Mitchell
Witness: Colonel Saum
Question 1: Can you give examples of how DoD has used multi-media
to prevent suicide prevention within its own ranks? I know you have
only been on the job for about a month, but what are your impressions
so far on ways VA could improve outreach to at risk veterans and
servicemembers contemplating suicide?
Answer: The Department of Defense and the Military Services have
designed and implemented multimedia programs to promote the processes
of building resilience, facilitating recovery, and supporting
reintegration for returning Servicemembers and their families. The
Defense Centers of Excellence for Psychological Health and Traumatic
Brain Injury's Real Warriors Campaign is a multimedia public education
initiative that is designed to break down the barriers to care for the
invisible wounds of war and to encourage Servicemembers to reach out
for the care they may need. Visitors to www.realwarriors.net who are
experiencing suicidal ideation--or who know someone who is--will find
articles, video profiles, and message boards that focus on suicide
prevention as well as combat-related stress, traumatic brain injury and
other invisible wounds. The Web site also includes a live chat feature
that makes it easy for visitors to confidentially connect to health
consultants with expertise in psychological health and traumatic brain
injury for information 24 hours a day/7 days a week/365 days a year.
Many of our campaign materials were developed in collaboration with the
VA, and all materials are in the public domain.
There are also multimedia initiatives within each of the Services
to encourage Servicemembers to reach out for necessary care before they
reach a moment of crisis. The Army Suicide Prevention Office's
``Shoulder to Shoulder'' program includes the video ``I Will Never Quit
on Life,'' which includes vignettes and testimonials of members of Army
families who received help for psychological stress or who assisted
individuals in need. The Navy Suicide Prevention Program includes
posters and other materials, such as brochures and public service
announcements to educate sailors about the signs and symptoms of
combat-related stress and available treatment resources. The Air Force
Suicide Prevention Program includes tools and resources for Airmen and
their families, commanders, leaders, and health professionals, as well
as videos addressing ways Airmen can help their fellow Servicemembers
who are experiencing combat-related stress.
Question 2: Can you explain how the DoD and VA coordinate to help
activated guard and reserve members--and ensure that they have the
resources they need to help prevent them from becoming suicidal?
Answer: When Guard and Reserve members are activated, they are
fully eligible for care through the Department's Mental Health System.
In addition, there are numerous suicide prevention programs within the
Department of Defense (DoD) to which activated Guard and Reserve
members are exposed and have access to. The DoD and Department of
Veterans Affaoirs (VA) coordinate their outreach and suicide prevention
resources for activated Guard and Reserve members through: (1) the DoD/
VA Integrated Mental Health Strategy, (2) the National Suicide
Prevention Lifeline, and (3) National Suicide Prevention Week
activities.
First, through DoD/VA Integrated Mental Health Strategy, the two
Departments will be coordinating suicide surveillance standards,
trainings and suicide prevention outreach efforts for Servicemembers,
including activated Guard and Reserve members, and veterans. Second,
the VA National Suicide Prevention Lifeline offers suicide prevention
services with trained crisis counselors for Active Duty Servicemembers,
including activated Guard and Reserve members, and veterans. There is
also a process in development for warm transfers between DoD call
centers and the VA Lifeline. The VA Lifeline serves as the primary
crisis counseling resource for DoD servicemembers and their families.
Third, the DoD and VA are coordinating activities for National Suicide
Prevention Week, which begins September 6, 2010. Both departments will
be cross-promoting each other's activities and resources such as
webinars and suicide prevention factsheets. In addition, the DoD and VA
are working with the American Association of Suicidology so that
veterans and activated Guard and Reserve members receive all relevant
and appropriate resources.
Question 3: During the July 15, 2008 hearing on Media Outreach,
then Ranking Member Ginny Brown-Waite asked if there was a prohibition
on using email addresses, or social media sites such as Facebook or
Twitter to contact veterans regarding services available to them. At
that time, Ms. Mondello, the Assistant Secretary of Public and
Intergovernmental Affairs for VA stated that VA is working to enable
Federal representation of citizen information on social media Web
sites, and is planning an initial social media presence on four of the
most popular networking Web sites: Facebook, MySpace, YouTube, and
Second Life. What is the current status on the use of these types of
Web sites by the Department of Defense, and how is the Department
integrating its suicide prevention outreach into these social media?
Answer: Social media are an integral part of Department of Defense
(DoD) operations. The Services have social media platforms, including,
but not limited to, Facebook, Twitter, YouTube, and Flikr. The DoD has
created a special Web site designed to help the DoD community use
social media and other Internet-based capabilities responsibly and
effectively, both in official and unofficial capacities. Each of the
Services uses social media to drive traffic to their respective suicide
prevention Web sites and programs. The Service-specific social media
outlets can be found online at http://socialmedia.defense.gov/services/.
The Defense Centers of Excellence for Psychological Health and
Traumatic Brain Injury (DCoE) also uses social media to guide those who
may need help or information on suicide prevention and available
psychological health resources; to promote psychological resilience;
and to combat stigma. The DCoE social media team provides information
on suicide prevention programs and access to a 24/7 call center through
its pages on Facebook, Twitter, and the DCoE blog.
Question 4: According to a fact-sheet we received from the VA on
suicide statistics, there are between 30,000 and 32,000 U.S. deaths
from suicide per year among the population in the U.S. overall. Of
these about 20 percent are veterans, about 18 deaths from suicide per
day are veterans. Does your Department also keep statistics on active
duty personnel, as well as Guard and Reservists with relation to the
rate of suicides?
Answer: Yes. The DoD maintains suicide statistics on Active Duty,
Guard, and Reserve personnel and calculates the rate on an annual
basis. In calendar year (CY) 2008, the suicide rate among Active Duty
personnel, including activated Guard and Reserves was 16.2 per 100,000
per year. In CY 2009, the suicide rate was 18.4 per 100,000 per year,
for the same population. An annual report with suicide data, historical
and civilian context, and summaries of DoD suicide prevention
initiatives are submitted to the Secretary of Defense. The DoD also
began tracking Inactive National Guard and Reserves suicide data
starting in 2009.
Question 5: On June 8, 2010, there was an article in Marine Times
about the rise in suicide attempts by Marines. In the report, it
indicated that ``recent improvements in tracking suicide attempts may
have contributed to more reports.'' What is the Department of Defense
currently doing to track suicide attempts amongst not only its active
duty personnel, but also among the National Guard and Reserve units,
and the Individual Ready Reserve?
Answer: The Department of Defense (DoD) uses a standardized
surveillance system called DoD Suicide Event Report (DoDSER) to track
suicide attempts among Active Duty personnel. The DoDSER captures data
points such as personal characteristics, historical factors, event
details, and clinical history for each suicide or suicide attempt. Some
of the Services also collect this information on suicide attempts among
the National Guard and Reserve units. At this time, the DoD does not
track suicide attempts among the Individual Ready Reserve members.
Created to facilitate collaboration and synchronize suicide
prevention surveillance across the Services, the DoDSER tool has been
used to capture information on suicides since January 1, 2008. As of
January 12, 2010, as directed by the Under Secretary of Defense for
Personnel and Readiness, the DoDSER has been used by all the Services
to track suicide attempts.
Question 6: What is the Department of Defense doing to combat the
stigma, or the worry that they are possibly jeopardizing the military
career if a servicemember calls a hotline, or sought other help when
they have suicidal thoughts? What reassurances do servicemembers have
that when they call for help, they will not be tagged as a weakling or
someone not worthy of being in the military?
Answer: To successfully encourage at-risk veterans and
Servicemembers who are experiencing suicidal ideation to reach out for
help, we must prove to them that every warrior experiences some
deployment stress; treatment and resources are readily available and
they work; and reaching out is a sign of strength and not automatically
a career-ender.
The warriors profiled on www.realwarriors.net are sharing their own
stories of resilience, recovery, and reintegration because they want to
encourage others to reach out for necessary care. They are proof that
Servicemembers need to know that reaching out makes a difference for
their mental health but not in their careers. Many of the
Servicemembers profiled on the Web site have been promoted since
seeking care for their invisible wounds. We hope that these real-life
stories are inspiring others to reach out and access psychological
health resources such as the Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury's Outreach Center and
``GiveAnHour,'' which can be accessed online and by telephone to
provide confidential assistance.
As part of encouraging Servicemembers to reach out without fear of
repercussion, in May 2008, Defense Secretary Robert M. Gates announced
the change to Question 21 on the National Security Background
Questionnaire (SF-86), which asks security clearance applicants to
indicate whether they had ever received psychological health care. The
question now excludes counseling related to service in combat.
Question 7: How does the Department of Defense reach out to
servicemembers who may be at risk for suicidal ideation?
Answer: The Department of Defense (DoD) leverages a variety of
approaches to reach out to Servicemembers, including education
campaigns and interactive Web sites. There are practical challenges to
identifying individuals who are at risk for suicidal ideation,
therefore the DoD and the Services have designed and implemented broad
outreach initiatives to encourage Servicemembers to seek help and to
educate them on all the available resources.
The Defense Centers of Excellence (DCoE) for Psychological Health
and Traumatic Brain Injury's Real Warriors Campaign is a multimedia
public education initiative designed to break down the barriers to
care, and to encourage Servicemembers to reach out for the care they
may need. The Real Warriors Campaign provides real-life examples of
Servicemembers and veterans who have had the strength to reach out for
care for psychological health concerns, including suicidal ideation.
They illustrate the importance of support from friends, families and
units, and show examples of individuals who are now maintaining
successful careers either in the military or as civilians. For example,
our most recently featured Real Warrior speaks candidly about suicidal
ideation after losing his leg as a result of an improvised explosive
device. He had the strength to reach out for care and continues to
serve the military community in a civilian career.
The Web site, www.realwarriors.net, also includes a live chat
feature that enables visitors to confidentially connect to health
consultants with expertise in psychological health and traumatic brain
injury for information 24 hours a day, 7 days a week, 365 days a year.
The Caring Letters Project is an outreach program that involves
sending brief letters of concern and reminders of treatment
availability at regular intervals to individuals at high risk for
suicide following psychiatric hospitalization. The Caring Letters
Project has proven to be a successful intervention practice in the
civilian sector. The DCoE's National Center for Telehealth and
Technology is currently piloting a Caring Letters program at Madigan
Army Medical Center.
In addition, DCoE's web-based platform www.afterdeployment.org,
offers a safe and interactive platform to better understand and
increase awareness of substance misuse, depression, and other mental
health related issues. The site features include quick health tips,
self-assessments, e-libraries, self-paced workshops, personal stories,
and a community forum. There is also a Google map locator tool to help
users find providers close to home.
Question 8: Would the Department of Defense be interested in
working on a coordinated effort with the VA on working to prevent
suicides amongst our Nation's servicemembers and veterans through
outreach and media advertising?
Answer: The Department of Defense (DoD) is interested in expanding
our collaboration with the Department of Veterans Affairs (VA) on
outreach and media advertising efforts. Currently, the DoD is
coordinating with the VA on outreach and media advertising for the
National Suicide Prevention Lifeline, which is a crisis hotline.
Promotional materials and public service announcements attempt to
increase awareness of the crisis line as a resource for Active Duty
Servicemembers as well as veterans and their families.
In addition, the DoD and VA are coordinating to prevent suicides
among Servicemembers and veterans through outreach during National
Suicide Prevention Week, which begins September 6, 2010. Both
departments will be cross promoting each other's activities and
resources such as webinars and suicide prevention factsheets. In
addition, the DoD and VA are working with the American Association of
Suicidology so that veterans and activated Guard and Reserve members
receive all relevant and appropriate resources. Lastly, there are plans
included in the DoD/VA Integrated Mental Health Strategy for increasing
coordination on communication and outreach to families of
Servicemembers and veterans in the area of suicide prevention.
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
July 28, 2010
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20420
Dear Secretary Shinseki:
Thank you for the testimony of Robert L. Jesse, M.D., Ph.D.,
Principal Deputy Undersecretary for Health, Veterans Health
Administration, U.S. Department of Veterans Affairs, accompanied by
Janet Kemp, R.N., Ph.D., National Suicide Prevention Coordinator, U.S.
Department of Veterans Affairs at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Oversight and
Investigations hearing that took place on July 14, 2010, entitled
``Examining the Progress of Suicide Prevention Outreach Efforts at the
U.S. Department of Veterans Affairs.''
Please provide answers to the following questions by Friday,
September 10, 2010, to Todd Chambers, Legislative Assistant to the
Subcommittee on Oversight and Investigations.
1. What progress have you made in advancing the VA's use of multi-
media in outreach efforts since the pilot program ended in the fall of
2009?
2. What lessons did the VA learn from the suicide prevention
outreach pilot?
a. How is the VA planning on utilizing the lessons learned going
forward?
3. In your testimony you state that in 2009, VA launched the
Veterans Chat Program to create an online presence for the Suicide
Prevention Hotline. Do you think this initiative is doing what it was
designed to do, and how do you track whether this initiative is
succeeding?
4. You stated in your testimony that all Vet Center staff members
have been trained in the Gatekeeper suicide prevention model and that
the Vet Centers participate in outreach and community education
projects. Do you think there is a better way for VA to do this by using
the power of multi-media? If so, in what ways?
5. How was the hand off of the success of the pilot program
carried out in the transition of power from the last administration to
the current one?
6. During the July 15, 2008 hearing on Media Outreach, then
Ranking Member Ginny Brown-Waite asked if there was a prohibition on
using email addresses, or social media sites such as Facebook or
Twitter to contact veterans regarding services available to them. At
that time, Ms. Mondello, the Assistant Secretary of Public and
Intergovernmental Affairs for VA stated that VA is working to enable
Federal representation of citizen information on social media Web
sites, and is planning an initial social media presence on four of the
most popular networking Web sites: Facebook, MySpace, YouTube, and
Second Life. What is the current status on the use of these Web sites
by VA, and how is VA integrating its suicide prevention outreach into
these social media?
7. Members of your staff recently briefed the Senate and House
staff on the progress being made by the Suicide Hotline in preventing
suicides amongst veterans. Included in the discussion was an update on
the calls to the hotline during times when VA made a concerted effort
to advertise the hotline in major media outlets, including the Public
Service Announcement (PSA) featuring actor Gary Sinise. These
statistics showed that during peak advertising periods, the rate of
calls to the hotline increased. What is your plan for your outreach and
advertising campaign for 2011?
8. Is there a one-stop shop, so to speak for an individual to go
to when they are feeling depressed, want someone to talk to, and need
help regardless of whether they are a veteran, a servicemember, a guard
or reservist, or even just a regular citizen on the street? What occurs
when someone calls into your existing hotline who is not a member of
the armed forces, or a veteran?
9. The New York Police Department has a partnership with an
organization called POPPA, Police Organization Providing Peer
Assistance, to help the NYPD officers deal with the stress of their
jobs. This mainly serves as a 24-hour helpline staffed by other police
officers who volunteer to act as suicide counselors. Officers often
feel most comfortable talking anonymously to fellow members of the
force. The POPPA helpline is credited with saving the lives of 80 NYPD
officers in the last 14 years, and the rate of suicides within the
department has fallen 40 percent. What efforts has the VA made to make
peer-to-peer counseling available to veterans? Are there any plans to
expand this, and has the VA considered partnering with other
organizations that have developed such programs?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers. If you have any
questions concerning these questions, please contact Martin Herbert,
Majority Staff Director for the Subcommittee on Oversight and
Investigations at (202) 225-3569 or Arthur Wu, Minority Staff Director
for the Subcommittee on Oversight and Investigations at (202) 225-3527.
Sincerely,
David P. Roe
Harry E. Mitchell
Ranking Republican Member
Chairman
MH:tc
__________
Questions for the Record
The Honorable Harry E. Mitchell, Chairman
The Honorable David P. Roe, Ranking Republican Member
Subcommittee on Oversight and Investigations
House Committee on Veterans' Affairs
``Examining the Progress of Suicide Prevention Outreach Efforts at the
U.S. Department of Veterans Affairs''
July 14, 2010
Question 1: What progress have you made in advancing the VA's use
of multi-media in outreach efforts since the pilot program ended in the
fall of 2009?
Response: Veterans Health Administration (VHA) social media
outreach continues to expand. Suicide prevention themes remain a core
message. VHA Facebook fans currently are about 35,000. Twitter
followers are over 3,500. We monitor Facebook for Veterans who express
suicidal thoughts and reach out and contact them directly and have been
successful in getting these Veterans help when needed. In addition, the
Veteran's Chat Service was implemented in 2009, since then over 7,000
``chatters'' have worked with VA counselors on a one-on-one basis using
the chat. We continue to work with our Substance Abuse and Mental
Health Services Administration (SAMHSA) and Lifeline Partners to market
the service and increase usage. We continue to do local outreach
efforts including poster placement at various VA and Community sites,
Suicide Prevention Coordinator training in the community, and regular
``awareness'' activities.
Question 2: What lessons did the VA learn from the suicide
prevention outreach pilot?
Question 2(a): How is the VA planning on utilizing the lessons
learned going forward?
Response: VA learned the following lessons as a result of the
suicide prevention outreach pilot:
A lesson learned early on from Veterans' focus groups was
the need to prevent possible feelings of shame and stigma from being
attached to a Veteran's possible ``emotional problems.'' The lesson was
that careful selection of slogans served both to reaffirm the Veteran's
positive character traits, while simultaneously promoting the
acceptability of calling the suicide prevention hotline when having
symptoms of mental distress. This helped us to select the campaign's
central message and slogan ``It takes the courage and strength of a
warrior to ask for help''.
Veterans' feedback noted it was important to deflect
attention away from the Veteran as the exclusive target audience. Thus,
rather than focusing solely on the Veteran as the one most likely to
need help dealing with depression, the campaign message became ``If you
or someone you know is in an emotional crisis, call . . . '' This
allowed the Veteran the option to refer a military ``buddy'' to the
suicide prevention hotline but did not rule out that he or she could
also call the hotline for their own personal needs.
We learned that an aggressive outreach to our target
audiences ``wherever they are'' was needed. Accordingly, the Transit
Authority Suicide Prevention Campaigns used thousands of Transit
Authority vehicles of various kinds, metro and bus station dioramas,
``street furniture'' provided by the Transit Authorities for
advertisements, metro rail cars, etc. Feedback from Veterans, however,
included advice to use fewer words on these materials. This will be
implemented in the future. We observed that television and radio were
potent means for outreach to Veterans in their homes and cars.
We also learned that the choice of a spokesperson for a
Public Service Announcement (PSA) is important. The PSA featuring actor
Gary Sinise may appeal to older Veterans, but younger Veterans from
Iraq and Afghanistan have noted in testimony that they do not relate to
this actor. Experts advise that many effective and memorable PSA's do
not rely on ``talking heads,'' and we have learned that it is important
to work through experienced professional communications experts to
develop our next campaign. We will seek to collaborate with
organizations such as The Ad Council, which has been effective in
developing and promoting PSA's directed at Iraq and Afghanistan
Veterans. Our in-house pilot efforts resulted in 17,000 airings for the
Gary Senise PSA, but we know collaboration with communications experts
will help us to obtain the hundreds of thousands of airings needed in
an effective national effort.
We also learned that early notification should be given
to the Suicide Prevention Hotline responders regarding PSA airing
schedules. The first time the PSA's were shown on local TV stations
there were significant increases in the numbers of calls to the
Hotline. This coordination will be implemented in the future campaigns.
Finally, we learned that it is extremely important to do
the analysis and planning for advertising to reach targeted audiences--
both Veterans who may be at special risk as well as those who can
influence and intervene on behalf of Veterans--so that we can, in turn,
use professional industry analysis to evaluate the effectiveness of our
efforts. Our initial research in the pilot activity does, in fact, show
an encouraging relationship between our print and other communications
and the number of calls to the Hotline. But there are many intervening
variables that effect social behavior outside the realm of our pilot
communications. We will ensure that our future efforts include expert
formative research; careful, evidence-based logic models that show how
our communications actually affect our specific target audiences; and
model-based evaluative research that can show clearly our success. We
will engage social marketing experts in our partnership with the Office
of Public and Intergovernmental Affairs through a new National Outreach
Contract. This will add considerably to our capabilities to document,
evaluate and strengthen our delivery of effective health and wellness
messages to priority audiences.
Question 3: In your testimony you state that in 2009, VA launched
the Veterans Chat Program to create an online presence for the Suicide
Prevention Hotline. Do you think this initiative is doing what it was
designed to do, and how do you track whether this initiative is
succeeding?
Response: The Chat Program has been hugely successful. It was
designed to provide an alternative mechanism for Veterans to seek help
in times of emotional need. Since its inception in 2009, over 7,000
Veterans have opted to seek help over the Chat Service. We have been
able to transfer almost 800 of these chatters to the Suicide Hotline
for immediate services and we have provided on-line support for the
other Veterans. The number of Veterans who use this service continue to
grow and we feel the Veterans Chat Program is in a position to accept
more and more ``chatters'' as younger Veterans need services. We will
continue to expand this program as need dictates. Our on-line
relationship with the Lifeline has also allowed us to market the Chat
Service and the Hotline through non-VA social media sources which helps
us reach groups of Veterans who are not already enrolled or looking for
VA care. Most of our ``chatters'' are non-enrolled Veterans and we hope
we are providing a new avenue for them to seek services.
Question 4: You stated in your testimony that all Vet Center staff
members have been trained in the Gatekeeper suicide prevention model
and the Vet Centers participate in outreach and community education
projects. Do you think there is a better way for VA to do this by using
the power of multi-media? If so, in what ways?
Response: It will take a combination of both personal outreach and
the use of multi-media and social-media venues to reach everyone. There
are still large numbers of people who respond best to personal
interactions and there are people who respond better to media and non-
personal approaches and marketing. We have to use all of our people and
technological resources. VA employees at both the Medical Centers and
the Vet Centers are being given access to social media venues and we
are learning how to use them to reach out to people. We are using
broadcast media to promote selected aspects of our services such as the
Hotline. We will continue to explore new venues.
Question 5: How was the hand off of the success of the pilot
program carried out in the transition of power from the last
administration to the current one?
Response: The hand-off between the two administrations went
smoothly. The Transit Authority Suicide Prevention campaign concept
that was piloted in Washington, DC, between July and October of 2008,
was expanded in the summer of 2009 to seven metropolitan markets
including: Dallas, TX; Las Vegas, NV; Los Angeles, CA; Miami, FL;
Phoenix, AZ; San Francisco/Oakland, CA; and Spokane, WA.
Further, we entered into a contract with BluLine Media to provide
interior bus advertisement space on municipal buses in many markets
around the country. VA Suicide prevention advertisements were displayed
on 21,000 public transit buses in 124 cities in over 42 States across
the country. The 3-month campaign started in the summer and extended
into the fall of 2009.
In addition, the airings of our PSA's featuring actor Gary Sinise
and TV personality Deborah Norville, which started airing at the end of
2008, continued and in fact greatly expanded (particularly the Sinise
PSA) in 2009.
Question 6: During the July 15, 2008 hearing on Media Outreach,
then Ranking Member Ginny Brown-Waite asked if there was a prohibition
on using email addresses, or social media sites such as Facebook or
Twitter to contact Veterans regarding services available to them. At
that time, Ms. Mondello, the Assistant Secretary of Public and
Intergovernmental Affairs for VA stated that VA is working to enable
Federal representation of citizen information on social Web sites, and
is planning an initial social media presence of four of the most
popular networking Web sites: Facebook, MySpace, YouTube and Second
Life. What is the current status on the use of these Web sites by VA,
and how is VA integrating its suicide prevention outreach into these
social media?
Response: VHA currently has an active and dynamic presence in the
most popular social media sites, Facebook, Twitter and YouTube.
Veterans Health Administration and nearly 25 medical centers use
Facebook as a form of outreach, and, mindful of the audience of
Veterans at risk, as well as family members, they have made suicide
prevention one of the recurring messages. VA Medical Centers that use
Facebook routinely monitor the comments from readers that have
sometimes indicated an emotional crisis. The Suicide Prevention Hotline
staff use Facebook and also monitor VHA Facebook pages to directly
engage with Veterans and family members who may need help.
Twitter messages regarding suicide prevention resources are very
widely read and shared with other Twitter readers. We also continue to
have a presence on the virtual world of Second Life.
Question 7: Members of your staff recently briefed the Senate and
House staff on the progress being made by the Suicide Hotline in
preventing suicides amongst Veterans. Included in the discussion was an
update on the calls to the hotline during times when VA made a
concerted effort to advertise the hotline in major media outlets,
including the Public Service Announcement (PSA) featuring actor Gary
Sinese. These statistics showed that during peak advertising periods,
the rate of calls to the hotline increased. What is your plan for your
outreach and advertising campaign for 2011?
Response: We are in the process of developing a contract with a
public relations company that will assist us in interpreting the
results from the media campaign evaluation, as well as various focus
groups that we have conducted. We will use the input we have received
about our current products to develop a plan for FY 2011 that will
specifically help us address our identified target groups and reach as
many people as we can. We know that what we have done so far has
allowed us to reach many people but we do not know that it allowed us
to reach as many Veterans as possible. We expect that contract to be in
place very shortly and that the plan will be developed by the end of
the calendar year. In the meantime we are re-distributing the Public
Service Announcement and running a second mass transit campaign this
fall to maintain the momentum. The contract for this campaign has been
awarded and we anticipate the posters will be placed in buses in late
September.
Question 8: Is there a one-stop shop, so to speak for an individual
to go to when they are feeling depressed, want someone to talk to, and
need help regardless of whether they are a Veteran, a Servicemember, a
guard or reservist, or even just a regular citizen on the street? What
occurs when someone calls into your existing hotline who is not a
member of the armed forces, or a Veteran?
Response: The Hotline is available for anyone to call. We provide
services to all who call or enter the chat service. Rescues are
provided to everyone who is in imminent danger. Referrals are made to
whoever can help the caller. For non-Veterans ``Warm transfers'' are
made to community Lifeline crisis centers--who in turn send Veterans
and Servicemembers to us if they did not directly call the VA Center.
1-800-273-TALK is indeed a national one-stop shop for American citizens
and we are proud to be a critical part of this national program.
Question 9: The New York Police Department has a partnership with
an organization called POPPA, Police Organization Providing Peer
Assistance, to help the NYPD officers deal with stress of their jobs.
This mainly serves as a 24-hour helpline staffed by other police
officers who volunteer to act as suicide counselors. Officers often
feel most comfortable talking anonymously to fellow members of the
force. The POPPA helpline is credited with saving the lives of 80 NYPD
officers in the last 14 years, and the rate of suicides within the
department has fallen 40 percent. What efforts has the VA made to make
peer-to-peer counseling available to Veterans? Are there any plans to
expand this, and has the VA considered partnering with other
organizations that have developed such programs?
Response: We work closely with community organizations such as
POPPA. POPPA also has a Veterans line that routinely refers Veterans to
the Hotline or the local VA for care. We will continue to work with
these very critical community based agencies and support their efforts.
Our Vet Centers also provide peer counseling services and we do refer
Veterans to the Vet Center Call Center for help in non-crisis
situations or their local VA Medical Centers if they want longer term
peer-to-peer counseling services. Approximately 30 percent of our
Hotline staff is Veterans and within the Hotline, calls are transferred
to responders who may relate well with the caller. We agree that these
are valuable services and we will continue to seek out partnerships and
ways to work together.