[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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                     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.
---------------------------------------------------------------------------
    \1\ In 2009, a record 334 servicemembers committed suicide.
    \2\ http://www.armytimes.com/news/2010/04/
military_veterans_suicide_042210w/
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \3\ http://www.armytimes.com/news/2010/04/
.military_veterans_suicide_042210w/.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \4\ http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1707.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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?
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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, 
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \14\ ``Calls To Veterans' Suicide Hot Line Double.'' http://
cbs3.com/national/veterans.affairs.
suicide.2.781329.html
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \15\ The Relationship Between PTSD and Suicide--National Center for 
PTSD http://www.ptsd.va.gov/professional/pages/ptsd-suicide.asp.
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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!
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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/
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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/
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \34\ http://www.valleyforgecenter.org/
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.

                                 
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