    [Senate Hearing 111-189]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 111-189

         THE INCIDENCE OF SUICIDES OF UNITED STATES SERVICEMEMBERS AND
       INITIATIVES WITHIN THE DEPARTMENT OF DEFENSE TO PREVENT MILITARY
                                    SUICIDES

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

                                    HEARING

                                   before the

                           SUBCOMMITTEE ON PERSONNEL

                                     of the

                          COMMITTEE ON ARMED SERVICES
                              UNITED STATES SENATE

                         ONE HUNDRED ELEVENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 MARCH 18, 2009

                                   __________

             Printed for the use of the Committee on Armed Services

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                          COMMITTEE ON ARMED SERVICES

                         CARL LEVIN, Michigan, Chairman

    EDWARD M. KENNEDY, Massachusetts     JOHN McCAIN, Arizona
    ROBERT C. BYRD, West Virginia        JAMES M. INHOFE, Oklahoma
    JOSEPH I. LIEBERMAN, Connecticut     JEFF SESSIONS, Alabama
    JACK REED, Rhode Island              SAXBY CHAMBLISS, Georgia
    DANIEL K. AKAKA, Hawaii              LINDSEY GRAHAM, South Carolina
    BILL NELSON, Florida                 JOHN THUNE, South Dakota
    E. BENJAMIN NELSON, Nebraska         MEL MARTINEZ, Florida
    EVAN BAYH, Indiana                   ROGER F. WICKER, Mississippi
    JIM WEBB, Virginia                   RICHARD BURR, North Carolina
    CLAIRE McCASKILL, Missouri           DAVID VITTER, Louisiana
    MARK UDALL, Colorado                 SUSAN M. COLLINS, Maine
    KAY R. HAGAN, North Carolina
    MARK BEGICH, Alaska
    ROLAND W. BURRIS, Illinois

                       Richard D. DeBobes, Staff Director

                   Joseph W. Bowab, Republican Staff Director

                                     ______

                           Subcommittee on Personnel

                     E. BENJAMIN NELSON, Nebraska, Chairman

    EDWARD M. KENNEDY, Massachusetts     LINDSEY GRAHAM, South Carolina
    JOSEPH I. LIEBERMAN, Connecticut     SAXBY CHAMBLISS, Georgia
    DANIEL K. AKAKA, Hawaii              JOHN THUNE, South Dakota
    JIM WEBB, Virginia                   MEL MARTINEZ, Florida
    CLAIRE McCASKILL, Missouri           ROGER F. WICKER, Mississippi
    KAY R. HAGAN, North Carolina         RICHARD BURR, North Carolina
    MARK BEGICH, Alaska                  DAVID VITTER, Louisiana
    ROLAND W. BURRIS, Illinois           SUSAN M. COLLINS, Maine

                                      (ii)

                                C O N T E N T S

                                   __________

                        CHRONOLOGICAL LIST OF WITNESSES

         The Incidence of Suicides of United States Servicemembers and
       Initiatives within the Department of Defense to Prevent Military
                                    Suicides

                                 march 18, 2009

                                                                       Page

    Levin, Hon. Carl, U.S. Senator from the State of Michigan........     4
    Cornyn, Hon. John, U.S. Senator from the State of Texas..........     6
    Chiarelli, GEN Peter W., USA, Vice Chief of Staff, United States
      Army...........................................................     8
    Walsh, ADM Patrick M., USN, Vice Chief Of Naval Operations,
      United States Navy.............................................    12
    Amos, Gen. James F., USMC, Assistant Commandant of the United
      States Marine Corps............................................    18
    Fraser, Gen. William M., III, USAF, Vice Chief of Staff, United
      States Air Force...............................................    22
    Freakley, LTG Benjamin C., USA, Commanding General, U.S. Army
      Accessions Command, Deputy Commanding General, Initial Military
      Training.......................................................    52
    Rubenstein, MG David A., USA, Deputy Surgeon General, United
      States Army....................................................    56
    Sutton, BG Loree K., USA, Director, Defense Centers of Excellence
      for Psychological Health and Traumatic Brain Injury............    58
    Linnington, BG Michael S., USA, Commandant, U.S. Corps of Cadets,
      United States Military Academy.................................    63
    Power, A. Kathryn, M.Ed., Director, Center for Mental Health
      Services, Substance Abuse and Mental Health Services
      Administration, Department of Health and Human Services........    67

                                     (iii)

         THE INCIDENCE OF SUICIDES OF UNITED STATES SERVICEMEMBERS AND
       INITIATIVES WITHIN THE DEPARTMENT OF DEFENSE TO PREVENT MILITARY
                                    SUICIDES

                                  ----------

                           WEDNESDAY, MARCH 18, 2009

                                   U.S. Senate,
                             Subcommittee on Personnel,
                                   Committee on Armed Services,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 3:34 p.m. in
    room SH-216, Hart Senate Office Building, Senator E. Benjamin
    Nelson (chairman of the subcommittee) presiding.
        Committee members present: Senators E. Benjamin Nelson,
    Levin, McCaskill, Hagan, Begich, Graham, Thune, and Collins.
        Committee staff members present: Richard D. DeBobes, staff
    director, and Leah C. Brewer, nominations and hearings clerk.
        Majority staff members present: Jonathan D. Clark, counsel;
    Gabriella Eisen, counsel; Gerald J. Leeling, counsel; and
    William K. Sutey, professional staff member.
        Minority staff members present: Joseph W. Bowab, Republican
    staff director; Diana G. Tabler, professional staff member; and
    Richard F. Walsh, minority counsel.
        Staff assistants present: Jessica L. Kingston, Christine G.
    Lang, and Ali Z. Pasha.
        Committee members' assistants present: Jay Maroney,
    assistant to Senator Kennedy; Thomas L. Gonzales, assistant to
    Senator Byrd; Ann Premer, assistant to Senator Ben Nelson;
    Gordon I. Peterson, assistant to Senator Webb; Stephen C.
    Hedger, assistant to Senator McCaskill; and Michael Harney,
    assistant to Senator Hagan; Clyde A. Taylor IV, assistant to
    Senator Chambliss; Adam G. Brake, assistant to Senator Graham;
    Jason Van Beek, assistant to Senator Thune; Brian W. Walsh,
    assistant to Senator Martinez; and Chip Kennett, assistant to
    Senator Collins.

       OPENING STATEMENT OF SENATOR E. BENJAMIN NELSON, CHAIRMAN

        Senator Ben Nelson. Good afternoon. I apologize for the
    delay. These votes somehow get in the way of the rest of our
    business. I appreciate everyone's patience. I'm happy to see
    you all here, and I look forward to the testimony.
        As the Personnel Subcommittee hearing comes to order, we
    meet today to receive testimony on the incidence of suicides
    among United States servicemembers and initiatives within the
    Services and the Department of Defense (DOD) to prevent
    military suicides.
        I'm honored to welcome back Senator Graham as this
    subcommittee's ranking member. Senator Graham will be joining
    us shortly. He and I, along with the rest of the subcommittee,
    intend to do everything we can to ensure that our
    servicemembers and their families are well taken care of.
        We've been alarmed, like the rest of the Country, at the
    rising rates of suicide by military servicemembers. Between
    2007 and 2008, suicide rates per 100,000 personnel have
    increased in every Service: from 16.8 to an estimated 20.2 in
    the Army; from 11.1 to 11.6 in the Navy; from 16.5 to 19 in the
    Marine Corps; and from 10 to 11.5 in the Air Force. These
    numbers indicate that, despite the Services' best efforts,
    there's still much work to be done to prevent military
    suicides.
        Each of these deaths marks a life filled with potential but
    cut short by personal torment. Each marks a family confronted
    by loss and grief. Each marks the sad end of an American who
    nobly served our Country and preserved the freedoms we all
    cherish. Each marks the responsibility we all have to our men
    and women in uniform today to help those who are troubled so
    that they don't become the tragedies of tomorrow.
        About a year ago, on February 27, 2008, we held a Personnel
    Subcommittee hearing where the issue of suicide was discussed.
    I raised several points that I felt needed further explanation,
    and I asked personnel leaders of the Service branches to
    discuss their suicide prevention programs, the challenges they
    face, and successes they had achieved. I was told that there
    was a focus on removing the stigma associated with seeking
    mental health support, and that there was no data tracking the
    high operations tempo with an increase in suicides. So, one
    purpose of this hearing is to find out where we stand on those
    issues, what progress has been made, if any, to reduce military
    suicides, what challenges remain, and to determine whether
    Congress needs to take any action to reduce these troubling
    incidents in the future. We know that more is needed, and it's
    needed now. That's why we're here today because the suicide
    rates are going up, not down. The question is: What can we do
    right now to address this problem?
        There are several risk factors that experts say may
    increase a person's risk of committing suicide, regardless of
    whether they're military or civilian. Financial troubles,
    marital and relationship issues, and legal or disciplinary
    problems are all common factors to incidents of suicide. In
    addition to these common factors, military service adds unique
    stressors. Undoubtedly, repeated and extended deployments and
    the intensity of the conflicts in Iraq and Afghanistan are
    taking a toll on the mental health of our troops and their
    families. This hearing will help all of us understand what
    initiatives and programs each Service, as well as the DOD, has
    in place to prevent suicide among servicemembers, and what
    improvements can be made.
        We know there's a shortage of mental health providers, that
    a stigma still lingers in the military--and in our culture, for
    that matter--against seeking mental health help, and that we're
    not doing enough to treat overall force wellness. Approximately
    2 years ago, the Defense Centers of Excellence for
    Psychological Health and Traumatic Brain Injury was created. I
    want to understand what we can do today to treat and care for
    our servicemembers to ensure the overall health and wellness of
    our Armed Forces.
        On our first panel, we are pleased to welcome Senator
    Cornyn, who, while, unfortunately, is no longer a member of the
    Senate Armed Services Committee, continues to be a tireless
    advocate for our servicemembers. Senator Cornyn has been
    closely following the investigations of suicide of four
    recruiters in the Army's Houston Recruiting Battalion since
    2005. In response to our concerns about the stress that our
    military recruiters deal with on a daily basis, especially in
    the Army, we have the commanding general of U.S. Army
    Accessions Command here to discuss these deaths and other
    aspects of recruiting assignments and duty that may warrant
    special attention by the services.
        Senator Cornyn, thank you for taking the time to be with us
    today. We look forward to your testimony on this issue and your
    participation in today's hearing.
        For our second panel, the Vice Chiefs of Staff of each
    service will discuss suicide prevention initiatives and
    programs in their respective Services. I'll introduce them when
    the second panel convenes.
        On our third panel, we have various representatives from
    Army leadership who will discuss more specific aspects of
    suicide policies and programs in the Army, as well as a
    representative from DOD who will speak to DOD suicide
    prevention initiatives and research. Also on the final panel,
    we're honored to have a civilian witness from the Department of
    Health and Human Services (HHS), Substance Abuse and Mental
    Health Services Administration (SAMHSA). I'll introduce these
    witnesses when we begin the third panel.
        We look forward to learning what policies, programs, and
    initiatives each of the Services, as well as DOD, has
    implemented and identified to ensure that our servicemembers in
    both the Active Duty and Reserve components, and their
    families, remain resilient, and that our All-Volunteer Force
    can continue to perform its mission, with the help and support
    of the services that they need and deserve.
        In the National Defense Authorization Act for Fiscal Year
    2009, Congress attempted to help open the lines of
    communication on best practices across the Services and
    throughout DOD by requiring the Department to establish a
    suicide task force to address these issues on a larger scale.
    While we consider the establishment of this task force a
    priority, and we're eager to hear about the status of that this
    afternoon, we expect the Services to continue to intervene with
    urgency to reverse the trend of increasing servicemember
    suicides. The numbers in every Service have increased in the
    past 2 years and that trend must not continue. We must pay
    particular attention to the Army and Marine Corps, as their
    rates of suicide have increased more than other Services. While
    these rates are disheartening, the truly distressing factor is
    that, in the first 2 months of this year, January and February,
    the Army's actual numbers of suicides have dramatically
    increased. There are reasons that the Army's numbers are the
    highest, but the problem is not isolated. Perhaps, today, each
    of the Services can share best practices learned thus far in
    their work on suicide prevention and what actions may be taken
    at this time to combat the problem.
        So, I want to thank all of our witnesses in advance today
    for being here.
        Senator Graham is not here for an opening statement, but
    the chairman of the Senate Armed Services Committee, Senator
    Levin, is here, and I would ask him if there are any opening
    statements he might make.

     STATEMENT OF HON. CARL LEVIN, U.S. SENATOR FROM THE STATE OF
                                MICHIGAN

        Senator Levin. Thank you, Senator Nelson. I will be very
    brief, and ask that you put my entire statement in the record.
        I want to thank you, first, for holding this hearing at
    your subcommittee. The Personnel Subcommittee is a subcommittee
    which is critically important to us, focusing on the kind of
    issues that dramatically impact our personnel.
        As you pointed out, the increase in suicides of military
    personnel in the last few years is alarming. In 2006, 102 Army
    soldiers committed suicide. That number was 128 in 2008.
    Twenty-five marines committed suicide in 2006, 41 in 2008.
    There are a number of additional cases where the Armed Forces
    medical examiner has not yet concluded whether the deaths are
    by suicide, so the 2008 numbers will likely be even higher.
        We owe maximum efforts to the men and women who wear our
    uniform who are, tragically, the victims of suicide, their
    loved ones, and the communities which love them so much.
        Senator Cornyn, welcome back to our committee for this
    hearing. You've been especially concerned about this issue,
    including that spike of recruiters from the Army's Houston
    Recruiting Brigade who committed suicide between January 2005
    and September 2008.
        Congress has recognized the strain on our ground forces and
    has authorized increases of 65,000 soldiers in the Army and
    22,000 in the Marines. It is one way, hopefully, of reducing
    the stress upon them. It is our intent that these increases
    will help to relieve the stress on our forces, but we also have
    to make sure that the Department is able to provide all of the
    assistance to our troops that they need to cope with the stress
    that they are facing and have experienced.
        We have an increasing number of troops returning from
    combat with post-traumatic stress disorder (PTSD), a condition
    that many believe contributes to the increase in the number of
    suicides. I know that many are reluctant to seek help because
    they perceive a stigma will attach to them when they receive
    mental health care. We have to eliminate that stigma.
        I was very pleased to learn, recently, that two Army
    generals have publicly acknowledged that they have sought
    counseling for the emotional trauma they experienced as a
    result of deployments to combat areas. One of them, Brigadier
    General Patton, said, ``We need all of our soldiers and leaders
    to approach mental health like we do physical health. No one
    would ever question or ever even hesitate in seeking a
    physician to take care of their broken limb or gunshot wound or
    shrapnel or something of that order. We need to take the same
    approach towards mental health.''
        Finally, we're here because the American people want us to
    do everything that we can to support our troops. We're here to
    learn how we can translate that support and respect of the
    American people for our troops into the reduction of the number
    of suicides.
        Suicide is, first and foremost, a tragic loss of an
    individual and a tragedy for the family and friends of the
    person who took his own life, but it is also a tragedy for our
    Nation.
        Again, I want to thank you and thank our witnesses and,
    again, welcome our colleague, Senator Cornyn.
        [The prepared statement of Senator Levin follows:]
                    Prepared Statement by Senator Carl Levin
        Thank you, Senator Nelson, for holding this very important hearing.
        The increase in suicides by military personnel in the last few
    years is alarming. In 2006, 102 Army soldiers committed suicide; 115 in
    2007; and 128 in 2008. This translates to an increase in suicide rates
    per 100,000 of 15.3 in 2006; 16.8 in 2007; and 20.2 in 2008. Similarly,
    25 marines committed suicide in 2006; 33 in 2007; and 41 in 2008. This
    is a suicide rate per 100,000 of 12.9 in 2006; 16.5 in 2007; and 19 in
    2008. I understand that there are a number of additional cases where
    the Armed Forces Medical Examiner has not yet concluded whether the
    deaths are by suicide, so the 2008 numbers will likely be even higher.
    These increases are not acceptable! We must improve our suicide
    prevention efforts to reverse the number of servicemembers taking their
    own lives.
        Senator Cornyn, welcome back to the committee for this hearing. I
    know that you have been very concerned about a spike of recruiters from
    the Army's Houston Recruiting Brigade committing suicide. Four suicides
    between January 2005 and September 2008 is cause for concern. I thank
    you for your personal interest in ensuring that these suicides were
    fully investigated and that measures are taken to prevent additional
    suicides in the high-stress recruiting field. I understand that
    Lieutenant General Freakley, the Commander of the United States Army
    Accessions Command is here as a witness today to discuss his
    investigation of these recruiter suicides and changes made to prevent
    additional suicides.
        I am also concerned about a recent spike in suicides and suicide
    gestures by cadets at the United States Military Academy. In 2 months,
    December 2008 and January 2009, two cadets committed suicide and two
    more attempted suicide. These are the first suicides at the Academy
    since 2005. What has changed that caused this spike? Brigadier General
    Linnington, the Commandant of Cadets at the Academy, is here to share
    his insights regarding these suicides and suicide attempts.
        I am pleased that the Vice Chiefs and Assistant Commandant are here
    today as witnesses to help us understand what is happening and how to
    improve suicide prevention in the military. Their presence here says a
    lot about the importance they attach to this issue.
        As military leaders, I know that each of you is very concerned
    about the recent increase in the number of suicides in your Service.
    The numbers of suicides have increased in every Service, but
    significantly more so in the Army and Marine Corps, the two Services
    most heavily engaged in ground combat in Iraq and Afghanistan.
        Congress has recognized the strain on these ground forces and has
    authorized increases of 65,000 soldiers in the Army and 22,000 in the
    Marines. It is our intent that these increases will help to relieve the
    stress on your forces, but we also have to make sure that you are able
    to provide all of the assistance your troops need to cope with the
    stress that they are experiencing.
        The professionals tell us that common issues leading to suicide
    include relationship problems, financial problems and legal problems,
    as well as mental health issues. I know that each of your services have
    programs to address these as part of your suicide prevention efforts.
    Undoubtedly, the 15 month deployments have contributed to these
    underlying problems that are linked with suicides. Perhaps Brigadier
    General Sutton, the Director of the Defense Center of Excellence for
    Psychological Health, and Ms. Kathryn Power from the Department of
    Health and Human Services, can help us to better understand conditions
    that may lead to suicide and additional efforts that can be taken to
    prevent suicides.
        I am concerned about the increasing number of troops returning from
    combat with Post-Traumatic Stress Disorder, a condition that many
    believe contributes to the increase in the number of suicides. I know
    that many are reluctant to seek help because of the stigma that they
    perceive attaches when they receive mental health care. We have to
    eliminate this stigma I was very pleased to learn recently that two
    Army generals have publicly acknowledged that they have sought
    counseling for the emotional trauma they experienced as a result of
    deployments to combat areas. General Carter Ham and Brigadier General
    Gary Patton have set the example for all soldiers who are experiencing
    menial issues as a result of their service. I agree with Brigadier
    General Patton when he said: ``We need all our soldiers and leaders to
    approach mental health like we do physical health. No one would ever
    question or ever even hesitate in seeking a physician to take care of
    their broken limb or gunshot wound, or shrapnel or something of that
    order. We need to take the same approach towards mental health.''
        I commend the Army for working with the National Institute of
    Mental Health on a 5-year project to develop intervention and
    mitigation strategies to help decrease the number of suicides in the
    Army. While this is an important effort, we cannot wait 5 years for the
    results. We must identify actions and take them now to reduce suicides.
        I am looking forward to hearing more about your suicide prevention
    programs and learning how we can help you to address the increase in
    suicides in the military.

        Senator Ben Nelson. Senator Cornyn.

     STATEMENT OF HON. JOHN CORNYN, U.S. SENATOR FROM THE STATE OF
                                 TEXAS

        Senator Cornyn. Thank you, Chairman Nelson.
        I want to begin by thanking you and Ranking Member Graham
    for agreeing to hold this important hearing to shed light on an
    alarming trend of rising suicides in our Armed Forces. I want
    to thank Chairman Levin and Ranking Member McCain for their
    leadership on this critical issue and ensuring that it gets the
    necessary oversight by the Senate Armed Services Committee.
        Nearly 2 million U.S. troops have been deployed to Iraq or
    Afghanistan since September 11, 2001. Many of them, as we know,
    multiple times. This repeated combat service, combined with the
    associated separation from loved ones, has taken a great toll
    on them, as you might expect, both physically and mentally.
    Undoubtedly, combat-related mental health conditions have
    emerged as a significant health issue for these troops. Today's
    hearing is necessary to look at these increased suicide rates
    and any relationship they may have to these stresses and
    strains.
        Last year, as the committee knows, I learned of a string of
    suicides at the Army Houston Recruiting Battalion, and I
    subsequently heard from numerous constituents with direct
    knowledge of recent events within this unit. Based on their
    allegations of poor morale, a hostile combat command climate
    within the unit, and my request, the Army launched a
    comprehensive investigation into these issues. The
    investigation confirmed much of the information shared with me
    by my constituents. I want to commend the Army, particularly
    Secretary Geren, General Freakley, and General Turner, who
    actually conducted much of the investigation, for not only
    their candor, but their diligence in pursuing this inquiry and
    their commitment, and the Army's commitment, to take care of
    its soldiers.
        I want to highlight, briefly, some of the issues that
    emerged from the investigation. The geographic isolation of
    many recruiting stations presents challenges for soldiers
    trying to access services that are available on most military
    installations, but may not be available where they are actually
    located. In addition, the investigation reported that Army
    recruiters assigned to these remote locations suffer from a
    lack of peer support.
        The investigation also examined the Army's processes for
    assigning recently-returned combat veterans to recruiting duty,
    and found that the Army's selection policies are sound, but
    they're not consistently applied. Consequently, less than 60
    percent of the applicants for recruiting duty are vetted in
    accordance with the Army's prescribed policy, resulting in many
    soldiers being sent to Recruiting and Retention School without
    adequate mental health screening themselves.
        I recently visited a local recruiting station in Houston
    and met with a group of recruiters to hear firsthand about
    their experiences and their daily challenges. They related to
    me the tremendous stresses involved in their work. We owe it to
    them and to their families to put better safeguards in place to
    prevent future suicides both within the Houston Recruiting
    Battalion and across our armed services. We must be fully
    cognizant of the challenges in the recruiting mission, and we
    must assure ourselves that those who lead our recruiters are
    both respectful and compassionate towards them while demanding
    high standards of performance.
        We are a Nation at war, and our recruiters are absolutely
    critical to maintain the All-Volunteer Force and win on all
    fronts in the global war on terror. It's critical that we honor
    the memory of these fallen soldiers by taking every possible
    step to prevent this kind of tragedy from reoccurring in the
    future. I look forward to participating in this hearing today
    and learning how the military plans to confront this serious
    problem.
        Again, in closing let me say, Mr. Chairman--Chairman
    Nelson, Chairman Levin--I appreciate your leadership and
    support in giving us the opportunity to look more closely at
    this and, more importantly, listening to the Military Service
    Vice Chairmen and other leaders as to what their plans are to
    alleviate this problem and address it in the future.
        Thank you very much.
        [The prepared statement of Senator Cornyn follows:]
                   Prepared Statement by Senator John Cornyn
        Mr. Chairman. I would like to start off by thanking you and Ranking
    Member Graham for agreeing to hold this important hearing to shed
    additional light on the alarming trend of rising suicides in our Armed
    Forces. I would also like to thank Chairman Levin and Ranking Member
    McCain for their leadership on this critical issue and ensuring that it
    gets the necessary oversight by the Armed Services Committee.
        Nearly 2 million U.S. troops have deployed to Iraq or Afghanistan
    since September 11, 2001. Many of them multiple times. This repeated
    combat service, combined with the associated separation from loved
    ones, has taken a great toll on them, both physically and mentally.
    Undoubtedly, combat-related mental health conditions have emerged as a
    significant health issue for these troops. Today's hearing is a
    necessary look at the increased suicide rates in the military.
        Last year, I learned of a string of suicides in the Army Houston
    Recruiting Battalion, and I subsequently heard from numerous
    constituents with direct knowledge of recent events within this unit.
    Based on their allegations of poor morale and a hostile command climate
    within the unit, at my request, the Army launched a broad,
    comprehensive investigation into these issues. The investigation
    confirmed much of the information shared by my constituents. I commend
    the Army for its candor in this inquiry and its commitment to taking
    care of soldiers.
        I would like to highlight some of the issues that emerged from the
    investigation. The geographic isolation of many recruiting stations
    presents challenges for soldiers trying to access services that are
    available on most military installations. In addition, the report noted
    that Army recruiters assigned to these remote locations suffer from the
    lack of a peer support network. The investigation also examined the
    Army's process for assigning recently returned combat veterans to
    recruiting duty, and found that the Army's selection policies arc
    sound, but are not applied consistently. Consequently, less than 60
    percent of applicants for recruiting duty are vetted in accordance with
    the Army's prescribed policy, resulting in many soldiers being sent to
    Recruiting and Retention School without adequate mental health
    screening.
        I recently visited a local recruiting station in Houston and met
    with a group of recruiters to hear first-hand about their experience
    and daily challenges. They related to me the tremendous stresses
    involved in their work. We owe it to them and their families to put
    better safeguards in place to prevent future suicides both within the
    Houston Recruiting Battalion and across our Armed Forces. We must be
    fully cognizant of the challenges in the recruiting mission, and we
    must ensure that those who lead our recruiters are both respectful and
    compassionate towards them while still demanding high standards of
    performance.
        We are a nation at war, and our recruiters are absolutely critical
    to maintain the All-Volunteer Force and win on all fronts in the war on
    terror. It is critical that we honor the memory of these fallen
    soldiers by taking every possible step to prevent this kind of tragedy
    in the future. I look forward to participating in the hearing today and
    learning how the military plans to confront this serious problem.

        Senator Ben Nelson. Thank you, Senator Cornyn, for your
    thoughtful testimony. We invite you to join us here at the
    dais, if you like. We would be honored to have you.
        On the second panel, we're honored to have General Peter W.
    Chiarelli, who is the Vice Chief of Staff of the Army; Admiral
    Patrick M. Walsh, who's the Vice Chief of Naval Operations
    (CNO); General James F. Amos, who is the Assistant Commandant
    of the Marine Corps; and General William M. Fraser, who is the
    Vice Chief of Staff of the Air Force. If you would, please join
    us at the table.
        We welcome you back, and we look forward to hearing about
    each of your Service's suicide prevention initiatives and
    programs, and mental health efforts, especially in light of the
    fact that, as noted, each of the Services have had increased
    rates of suicide between calendar years 2007 and 2008.
        General Chiarelli?

    STATEMENT OF GEN PETER W. CHIARELLI, USA, VICE CHIEF OF STAFF,
                           UNITED STATES ARMY

        General Chiarelli. Mr. Chairman, Ranking Member Senator
    Graham, Chairman Levin, distinguished members of the committee,
    I thank you for the opportunity to appear before you today to
    provide a status on the Army's efforts to reduce the number of
    suicides across our force.
        I have also submitted a statement for the record, and I
    look forward to answering your questions at the conclusion of
    my opening remarks.
        First, on behalf of our Secretary, the Honorable Pete
    Geren, and our Chief of Staff, George Casey, I would like to
    take this opportunity to thank you for your continued strong
    support and demonstrated commitment to our soldiers, Army
    civilians, and family members. As all of you know, it's been a
    busy time for our military. We are at war, and we have been at
    war for the past 7-plus years. That has undeniably put a strain
    on our people and our equipment. The reality is, we're dealing
    with a tired and stressed force, and the effect, in the most
    extreme cases, has been, unfortunately, an increased incidence
    of suicide. Other senior leaders of the Army and I recognize
    that we must find ways to relieve some of this stress,
    particularly the stress caused by deployments and frequent
    lengthy periods of separation. However, the level of stress is
    directly related to demand, and, as you well know, demand is
    high and not expected to diminish significantly for the
    foreseeable future. In the meantime, our efforts are focused on
    mitigating the stress as much as possible. We are also taking
    steps to eliminate the stigma that has frequently kept soldiers
    from seeking help.
        The reality is, there is no simple solution. In fact, it is
    going to require a multidisciplinary approach and a team effort
    at every level of command and across all Army components, all
    Services and jurisdictions, as well as cooperation with
    partners outside of our organization. I can assure you, the
    members of this committee, that this challenge will remain a
    top priority for our Army's senior leaders.
        Chairman, members of the committee, I thank you, again, for
    your continued generous support of the outstanding men and
    women of the United States Army and their families, and I look
    forward to your questions.
        [The prepared statement of General Chiarelli follows:]
               Prepared Statement by GEN Peter W. Chiarelli, USA
        Chairman Nelson, Ranking Member Graham, distinguished members of
    the Senate Committee on Armed Services; I thank you for the opportunity
    to appear here today to provide a status on the Army's efforts to
    reduce the number of suicides across our Force. This is my first
    occasion to appear before this esteemed committee, and I pledge to
    always provide you with an honest and forthright assessment.
        On behalf of our Secretary, the Honorable Pete Geren and our Chief
    of Staff, General George Casey, I would also like to take this
    opportunity to thank you for your continued, strong support and
    demonstrated commitment to our Soldiers, Army Civilians, and family
    members.
        As all of you know, it has been a busy time for our Nation's
    military. We are at war, and we have been at war for the past 7-plus
    years. That has undeniably put a strain on our people and equipment. In
    spite of this, I continue to be amazed by the resiliency of the Force.
    The men and women serving in the Army today are well-trained, highly-
    motivated, and deeply patriotic, and they are doing an outstanding job
    on behalf of the Nation.
        As leaders, we have a responsibility to look out for our Soldiers'
    physical and mental well-being. The culture of the Army is that of a
    team; and, in everything that we do--how we train, how we fight--we are
    guided by the warrior ethos, ``No soldier left behind.'' I can assure
    the members of this committee that we are addressing the issue of
    suicides across our Army with that same attitude.
                calendar year 2008 and 2009 army suicide reports
        On January 29, 2009, the Army released its annual report on
    suicides for calendar year 2008. The statistics cover active duty
    soldiers, including activated members of the National Guard and U.S.
    Army Reserve. There were 140 suicides of soldiers on active duty over
    the 12-month period (this figure includes 7 unconfirmed cases still
    under review); the confirmed rate was 20.2 per 100,000. This is an all-
    time high for the Army.
        For the first time in history, the number of suicides in calendar
    year 2008 (19.5 per 100,000) also exceeded the national average (11.0
    per 100,000). However, it should be noted that the most recent data
    from Centers for Disease Control and Prevention (CDC) is for 2005, so a
    true side-by-side comparison cannot be made. The CDC figures, for
    example, do not yet reflect the impact of the financial downturn that
    occurred in the latter half of 2008.
        Unfortunately, this alarming trend has continued in calendar year
    2009. The number of suicides for calendar year 2009 by active duty
    Soldiers, including activated members of the National Guard and
    Reserves is currently 48 (out of a total population of 700,000)
    (includes 29 pending, but not yet confirmed); and, the corresponding
    number of suicides for calendar year 2009 by Reserve component and Army
    National Guard soldiers not on active duty is currently 18 (out of a
    total population of 400,000) (includes 11 pending, but not yet
    confirmed).
        I, and the other senior leaders of our Army, readily acknowledge
    that these current figures are unacceptable.
                              reasons for suicides
        Individuals who make the decision to commit suicide usually do so
    based upon a combination of factors. For example: investigations have
    concluded that the vast majority of Soldiers who committed suicide in
    calendar year 2008 were dealing with some type of relationship problem
    (i.e., marital discord, break-up, divorce, family disagreements); and,
    many of the soldiers were also experiencing legal, financial, and
    occupational difficulties. On their own, each problem may be
    manageable--or even avoidable--but, problems are often exacerbated by
    the added stress and helplessness a soldier can feel when deployed.
        The reality is we are dealing with a tired and stretched force. In
    calendar year 2008, over two-thirds of the soldiers who committed
    suicide were either deployed or had deployed in the past. In this era
    of--what I like to refer to as ``persistent engagement''--soldiers are
    required to maintain a heightened state of readiness and operate at an
    exigent tempo for prolonged periods of time. This contributes
    significantly to their level of stress and anxiety.
        Looking ahead, I--and, the other senior leaders of the Army--
    recognize that we must find ways to relieve some of the stress on our
    Force, particularly the stress caused by deployments and frequent,
    lengthy periods of separation. However, the level of stress is directly
    related to demand--and, as you well know, demand is high and not
    expected to diminish significantly for the foreseeable future. In the
    meantime, our efforts are focused on mitigating the stress as much as
    possible. Shortening the length of deployments from 15 to 12 months
    will help, but even that is going to take time. We are still dealing
    with the impact of the Surge. The Army will not get our last Combat
    Brigade off of a 15-month deployment until June 2009, and our last
    Combat Support (CS)/Combat Service Support (CSS) unit off of 15-month
    deployment until September 2009.
                  addressing the challenge of soldier suicides
        As you all know, I was given the mission by Secretary Geren and the
    Chief, General Casey, to develop a plan to significantly reduce the
    high number of suicides across the Army. I can assure the members of
    this committee--this is not business as usual. I am conducting weekly
    meetings and VTCs with many of the Army's senior leaders, Army Service
    Component Commands, and Direct Reporting Units around the globe.
    Beginning next week, I plan to travel to seven Army installations to
    assess implementation of our strategy.
        The increased trend in soldier suicides is impacting every segment
    of the Army--Active, Reserve, and National Guard; officer and enlisted;
    male and female; deployed, nondeployed, and never deployed. The reality
    is there is no simple solution. In fact, it is going to require a
    multi-disciplinary approach; and, the Army is taking a hard look at
    every single facet of our organization to make a determination on what
    can and should be done to address this problem. We are also reviewing
    and reemphasizing those basic practices that were so effective in the
    past at keeping our suicide numbers down, such as asking a buddy if he
    or she needs help and making sure he or she is linked up with a
    chaplain or mental health provider.
        In January, Secretary Geren directed an Army-wide stand-down to
    address the problem of suicides. During the 30-day window between
    February 15 and March 15, unit commanders took a 2- to 4-hour period to
    conduct a training session with their soldiers and Army civilians. A
    standardized training support package was provided to each unit,
    including a DVD, ``Beyond the Front.'' This interactive learning video
    was developed in conjunction with Lincoln University, WILL Interactive,
    Inc., and the Army Research Institute, and it presents soldiers with
    two very realistic scenarios that address some common stresses and
    hardships that can lead to thoughts of suicide. Unit leaders were
    onhand at the training sessions to answer questions and to help
    soldiers work through the issues presented.
        Also as part of the stand-down, unit commanders conducted training
    on one of the Army's primary programs--the Ask, Care, Escort program,
    commonly referred to as ACE. In some cases, a soldier may be struggling
    with a problem, but he is not willing to talk about it because of
    potential stigmas or fear of ridicule from fellow soldiers. The ACE
    program reminds soldiers that they have a responsibility to look out
    for one another and help--not deride or ostracize--a buddy who is
    having problems.
        This stand-down is being followed by a chain-teaching program
    focused on suicide prevention that will allow leaders to communicate
    with every soldier. This chain-teach will be conducted during a 120-day
    period that began on March 15, 2009. The intent is to inform and
    educate soldiers and DA civilians about the resources and services
    available; motivate soldiers to maintain both physical and mental
    health wellness; engage leaders at all levels of the Army to foster an
    environment of reduced stigma associated with seeking mental health
    care; and, enhance the capability of soldiers, DA civilians, Army
    leaders, family members, and others to take necessary action to help
    individuals at risk.
                                a team approach
        Effectively addressing the challenge of soldier suicides is going
    to require a team effort across all Army components, jurisdictions, and
    commands, as well as cooperation with partners outside of our
    organization, such as the Department of Veterans Affairs and the
    National Institute of Mental Health (NIMH).
        The Army signed a Memorandum of Agreement with NIMH in October
    2008, and the Institute is currently conducting long-term research
    aimed at helping to identify those soldiers most at risk, as well as
    developing intervention and mitigation strategies that will help
    decrease the number of suicides across the Army. This is the largest
    single study on the subject of suicide that NIMH has ever undertaken.
    It is expected to last 5 years, and will include soldiers from every
    component of the Force--Active Army, Army National Guard, and Army
    Reserve. Intermediate data will also be available throughout the study
    period to inform the Army's ongoing intervention strategies. The
    findings will benefit the Army, the other military Services, as well as
    the U.S. population overall, and may lead to more effective
    interventions for both soldiers and civilians.
        Within the Army, Unit Ministry Teams (UMT) play a critical role in
    addressing this issue. These teams are comprised of chaplains and
    chaplain's assistants. Today, there is a unit ministry team assigned to
    most battalions in the Army. They deploy with the units, and work with
    other supportive agencies and health professionals to assist soldiers
    and their families. UMTs are able to provide a quick and effective
    response to crises, including suicidal crises, as a result of their
    integration with the unit, credibility with their soldiers, and
    superior pastoral skills and experience. UMTs also provide countless
    interventions to prevent self-destructive behavior, not only at the
    point of suicidal crisis, but also in working with distressed soldiers
    and family members prior to a crisis.
        The Army is also in the process of hiring more mental health care
    practitioners, including psychiatrists, psychologists, and marriage and
    family therapists. We are educating more primary care providers on the
    symptoms and courses of action for depression and post-traumatic stress
    disorder. What we discovered is that soldiers who are unwilling to seek
    help from a mental health care professional will oftentimes go to a
    primary care physician instead. So, it is important for these doctors
    to know what to look for and how best to care for these individuals.
                         comprehensive soldier fitness
        The Army is in the process of developing its Comprehensive Soldier
    Fitness Program. The objective is to raise mental fitness up to the
    same level of attention as we have historically given only to physical
    health and fitness. Multiple studies have shown that mental and
    emotional strength are just as important as physical strength to the
    safety and well-being of our soldiers. In fact, a soldier who is
    mentally and emotionally fit is better prepared to withstand the
    challenges and adversity of combat. We recognize that people come into
    the Army with a very diverse range of experiences, strengths, and
    vulnerabilities in their mental as well as physical condition. So we
    will start with an assessment at accession, and provide training and
    education as needed.
        As part of this effort, the Army has instituted Battlemind
    training, with modules for essentially every juncture in a soldier's
    career--from Basic Training to the Pre-Command Course. There are also
    pre- and post-deployment modules for both soldiers and spouses. To
    date, Battlemind is the only mental health and resilience training
    program demonstrated to reduce symptoms of post-traumatic stress upon
    redeployment. People who participated in Battlemind also have reported
    fewer stigmas attached to getting mental health care if needed than
    people who had not had the training.
                           changing the army culture
        Today, there is a wide range of programs and services available.
    However, soldiers are frequently reluctant to seek help. This is the
    other piece we recognize needs work; we need to change the culture of
    our Army. In the past, there has been a stigma associated with seeking
    help from any kind of mental health professional. Soldiers avoided
    seeking this type of assistance for fear that it might adversely affect
    their careers. However, that is not the case; and, we are taking the
    necessary steps to change this misperception across the Army.
        In 2008, the Department of Defense revised question number 21 on
    the questionnaire for national security positions regarding mental and
    emotional health. The revised question now excludes non-court ordered
    counseling related to marital, family, or grief issues, unless related
    to violence by members; and counseling for adjustments from service in
    a military combat environment. Seeking professional care for these
    mental health issues should not be perceived to jeopardize an
    individual's professional career or security clearance. On the
    contrary, failure to seek care actually increases the likelihood that
    psychological distress could escalate to a more serious mental
    condition, which could preclude an individual from performing sensitive
    duties.
        We recognize that we need to do more, and we are committed to
    getting the message out to soldiers that it is okay to get help. We are
    making progress. In fact, recent mental health assessments conducted in
    theater have shown a marked increase in the percentage of soldiers
    willing to seek mental health care without undue concern that it will
    be perceived as a sign of weakness or negatively impact their careers.
                                    closing
        In my 36-year career in the Army, I have never dealt with a more
    difficult or critical mission than the current charge to reduce the
    number of soldier suicides. Any time an individual makes the decision
    to commit suicide; the loss affects family and friends, fellow
    soldiers, and the Army.
        Stress, anxiety, or depression affecting a soldier can be caused by
    a variety of factors, including relationship problems and financial,
    legal, and occupational difficulties. One at a time or in certain
    situations each factor may be manageable--or even avoidable. But, when
    they happen in some combination or all at once, and especially when a
    soldier's anxiety is further compounded by the stress of a deployment--
    he (or she) can reach a point of desperation. If left unaided, this
    individual could make the fateful decision to end his or her own life.
        The reality is every suicide is unique, and there is no simple
    solution. In fact, to significantly reduce the number of suicides will
    require a team effort across the Army by soldiers of every rank and at
    every level of command. Long-term, the Army's senior leaders recognize
    that we need to find ways to relieve some of the stress on our force,
    particularly the stress caused by deployments and frequent, lengthy
    periods of separation. We also acknowledge that this stress is an
    effect of increased demand on the force, and the reality is this demand
    is not expected to diminish in the foreseeable future. In the meantime,
    we are taking immediate steps to mitigate some of the stress on our
    soldiers and their families by helping them to better cope with
    difficult situations. We are also in the process of changing the
    culture of the Army to ensure Soldiers are aware of available programs
    and services; and are willing to seek help whenever necessary--for
    themselves or for a buddy.
        Again, I can assure the esteemed members of this committee that
    there is no greater priority for me and the other senior leaders of the
    United States Army than the safety and well-being of our soldiers. The
    men and women who wear the uniform of our Nation are the best in the
    world, and we owe them and their families a tremendous debt of
    gratitude for their service and for their many sacrifices.
        Chairman, members of the committee, I thank you again for your
    continued and generous support of the outstanding men and women of the
    United States Army and their families. I look forward to your
    questions.

        Senator Ben Nelson. Admiral Walsh?

      STATEMENT OF ADM PATRICK M. WALSH, USN, VICE CHIEF OF NAVAL
                     OPERATIONS, UNITED STATES NAVY

        Admiral Walsh. Chairman Nelson, Chairman Levin,
    distinguished members of the subcommittee, thank you for this
    opportunity to testify about the command and organizational
    level of efforts that are underway to prevent suicides in the
    Navy.
        Suicide ranks as the third-leading cause of death in the
    Navy. It's a loss that destroys families, devastates
    communities, unravels the cohesive social fabric and morale
    inside our commands. While the symptoms of those who
    contemplate suicide are unique to each person, a common thread
    to all victims is a sense of psychological emptiness that
    leaves individuals impaired and unable to resolve problems.
    Therefore, solutions to this tragedy must address the
    underlying causes that affect the ability of an individual to
    recover from change or misfortune and regain their physical and
    emotional stamina.
        The target of our policy and practice is the resilience of
    individual sailors and their families. This means that leaders
    must look for, and connect to those individuals challenged by
    seemingly intractable troubles, with relationships and work,
    financial and legal matters, deteriorating physical health, as
    well as mental health issues and depression.
        We must eliminate the perceived stigma, shame, and dishonor
    of asking for help. This is not simply an issue isolated to the
    medical community to recognize and resolve; commands have a
    critical role to play in setting a supportive climate for those
    who need to admit their struggle and seek assistance.
        Some of our more important policy and programmatic
    initiatives are directed by the CNO to establish the Navy
    Preparedness Alliance, a consortium led by our Chief of Naval
    Personnel, our Reserve Chief, Bureau of Medicine, and our Shore
    Installation Commander to address a continuum of care that
    covers all aspects of individual medical, physical,
    psychological, and family-readiness issues across the Navy.
        Additionally, the CNO instituted an Operational Stress
    Control Program, which is a comprehensive approach designed to
    address the psychological health needs of sailors and their
    families. It's a program led by operational leadership,
    supported by the naval medical community, and provides
    practical decisionmaking tools for sailors, leaders, and
    families so they can identify stress responses and problematic
    tension. By addressing problems early, individuals can mitigate
    the effects of personal turmoil and get the necessary help when
    professional counseling or treatment warrants.
        Through training, intervention, response, and reporting,
    the Navy executes prevention programs for all sailors that
    focus on operational commands to take ownership of suicide
    training initiatives and tailor them to their unique command
    cultures.
        Feedback is an important element of policy development. The
    Navy polls extensively and tracks statistics on personal and
    family-related indicators, such as stress, financial health,
    command climate, as well as sailor and family support. We use
    this data to monitor the trends in the Force and make
    recommendations for adjustments in deployment of practices, as
    well as track all suicidal acts and gestures.
        In conclusion, on behalf of the men and women of the United
    States Navy, I thank you for your attention and commitment to
    the critical issue of suicide prevention. By teaching sailors
    better problem-solving skills and coping mechanisms for stress,
    the Navy will make our Force more resilient. We will do
    everything possible to support our sailors so that, in their
    eyes, their lives are valued and are truly worth living.
        Thank you, sir.
        [The prepared statement of Admiral Walsh follows:]
                Prepared Statement by ADM Patrick M. Walsh, USN
        Chairman Nelson, Senator Graham, and distinguished members of this
    subcommittee, I would like to thank you for this opportunity to testify
    about the organizational and command level efforts to prevent suicides
    in the Navy.
        Suicide ranks as the third leading cause of death in the Navy
    behind accidents and natural causes. It is a loss that destroys
    families, devastates communities, and unravels the cohesive social
    fabric and morale inside our commands. While suicide is a difficult,
    emotional issue riddled with complexities, we have learned to
    understand, appreciate, and identify key factors that put a sailor on
    the path to suicide. Symptoms are unique to each person, but a thread
    that is common to all victims is a sense of psychological emptiness and
    ache that leaves individuals impaired and unable to resolve problems.
        Therefore, solutions to this tragedy must address the underlying
    causes that affect the ability of an individual to recover from change
    or misfortune and regain their physical and emotional stamina. The
    target of our policy and practice is the resilience of individual
    sailors and their families. We consider it a core responsibility to
    build a resilient force, which means that leaders must look for and
    assist those challenged by seemingly intractable troubles with
    relationships and work, financial and legal matters, deteriorating
    physical health, as well as mental health issues and depression,
    similar to issues that affect suicide rates in the general U.S.
    population.
        A successful prevention program must address sailors on an
    individual level with an effort that can penetrate through a tough
    external veneer, made more challenging by a very real sense of personal
    vulnerability, fear, and cultural aversion to discussions about our own
    mental fitness or welfare. The Navy Suicide Prevention Program requires
    awareness and action at many leadership and policy levels to build
    lives that are resilient, that can cope with personal adversity, and
    capable of responding to personal and professional challenges.
        The Navy's suicide rate was 11.6 per 100,000 sailors in 2008, for a
    total of 41 suicides. This loss reinforces the urgency for increased
    vigilance with suicide prevention efforts. When considering deployment
    as a possible risk factor, analyses over the last 5 years show a weak
    correlation between suicide and deployment history. From 2003-2008, the
    Navy suffered 240 suicides. Approximately half (48 percent) of suicides
    had not deployed at all in the previous 3 years; most (64 percent) of
    suicides had not deployed specifically in support of Operation Iraqi
    Freedom (OIF) or Operation Enduring Freedom (OEF); one-third (31
    percent) had previously deployed for OIF/OEF; eight (3.3 percent) were
    in OIF/OEF at the time of suicide; one Individual Augmentee (IA) died
    from suicide while in OIF/OEF and one sailor died 14 months after
    returning home from a 12-month IA assignment. Three Navy suicides had
    Post-Traumatic Stress Disorder (PTSD) diagnosis history whereas 22 had
    substance disorder diagnoses, and 58 had other mental health diagnoses,
    including depression.
                       the role of operational leadership
        Suicide prevention is an all hands evolution. Through training,
    outreach, intervention and reporting, the Navy executes prevention and
    intervention programs for all sailors. Medical personnel, chaplains,
    Fleet and Family Support Center counselors, health promotion program
    leaders, the Navy Reserve Psychological Health Outreach team and
    substance-abuse counselors support commanding officers (COs) with
    information in their areas of expertise, intervention services, and
    assistance in crisis management. We place strong emphasis in primary
    prevention efforts of building resilience and addressing early
    intervention for associated stressors. The Navy directs local commands
    to take ownership of suicide outreach and training initiatives and
    tailor them to their unique command cultures, because we are a diverse
    force with many different missions.
        Navy leadership actively conducts real time, down-range
    surveillance and assessment of the mental health of our troops. Between
    August 2007 and August 2008, sailors deployed to Iraq, Afghanistan,
    and/or Kuwait, and completed the Behavioral Health Needs Assessment
    Survey (BHNAS) (a battery of anonymous self-reports to evaluate their
    psychological well-being), told us that fatigue/lack of sleep were
    their most common problems. Scientific research indicates that these
    factors may contribute to PTSD and depressive symptoms. Similarly, unit
    cohesion was the most powerful protective factor that contributed to
    decreasing PTSD and clinically significant depression. Some missions,
    such as detainee operations and specific unit experiences, such as a
    mass casualty, significantly increase the likelihood that a sailor will
    develop PTSD and depression. BHNAS also suggested other extremely high
    tempo of operations missions, such as annually recurring aviation
    combat deployments, have a greater risk for marital and family problems
    during deployment. The BHNAS also revealed many sailors reported
    personal growth while on deployments, even when they also report
    symptoms of PTSD. Armed with these findings, Navy amended work
    schedules, changed staffing levels, and modified deployment extensions
    accordingly.
        Operational Stress Control (OSC) \1\ is a comprehensive approach
    designed to address the psychological health needs of sailors and their
    families; it is a program led by operational leadership and supported
    by the naval medical community. OSC provides practical decisionmaking
    tools for sailors, leaders and families so they can identify stress
    responses and mitigate problematic tension. By addressing problems
    early, individuals can mitigate the effects of personal turmoil, and,
    get the necessary help when professional counseling or treatment
    warrants. The Stress Continuum \2\ is an evidence-informed model that
    highlights the shared responsibility that sailors, their families, and
    their leadership have for maintaining optimum psychological health.
    ---------------------------------------------------------------------------
        \1\ NAVADMIN 332/08 dated 21 November 08 established the Navy's
    Operational Stress Control program.
        \2\ The Navy and Marine Corps utilize the Stress Continuum Model.
    Historically, Navy viewed those under stress as either fit or unfit
    whereas now we understand four distinct stages of stress responses:
    Ready (Green), Reacting (Yellow), Injured (Orange), or Ill (Red). This
    model is used to recognize and intervene when early indicators of
    stress reactions or injuries are present before an individual develops
    a stress illness, such as PTSD or depression.
    ---------------------------------------------------------------------------
        The stigma associated with the assessment and treatment of
    depression and substance abuse are barriers for those who need to seek
    help. Stigma, better thought of as a reluctance or resistance to
    accepting one's emotional difficulties can be derived from internal,
    external or institutional sources. We must endeavor to eliminate the
    perceived shame and dishonor (internal source) of asking for help, and
    take the charge given to all of us by the Chairman, Joint Chiefs of
    Staff, ``that the act of reaching out for help is, in fact, one of the
    most courageous acts and one of the first big steps to reclaiming your
    career, your life and your future.'' \3\ Eliminating peer-to-peer
    (external) stigma is challenging, Navy leadership can and must address
    institutional stigma. Some strides have already been made.\4\ Our
    commands have an important role to play in setting a helpful,
    supportive climate for those who need to admit their struggle and seek
    assistance.
    ---------------------------------------------------------------------------
        \3\ Admiral Michael Mullen, May 01, 2008
        \4\ The DOD has recently amended the security clearance
    questionnaire exempting a servicemember from disclosing psychological
    services obtained for combat related stress or family difficulties.
    ---------------------------------------------------------------------------
        The Navy has supported an initiative for a standardized network of
    Command-sponsored Suicide Prevention Coordinators to communicate Navy-
    wide initiatives while also encouraging individual commands to take
    ownership of the programs and teach sailors effective responses to
    stress. Some efforts include command led programs to de-glamorize
    alcohol, prevent drug abuse, encourage physical fitness, and teach
    problem-solving skills. Medical professionals provide support and treat
    depression, anxiety and sleep problems. In addition to command
    involvement, the Navy empowers Fleet and Family Services, ombudsmen,
    spiritual and religious ministries to foster cohesive units, families,
    and communities.
        Healthy factors, such as positive attitude, solid support networks,
    good problem solving skills, and healthy stress controls reduce the
    risk of intentional self-harm. Preventing suicide in the Navy begins
    with promoting health and wellness consistent with keeping
    servicemembers ready to accomplish the mission.
                    policy, procedures, and responsibilities
        The Chief of Naval Operations (CNO) directed the establishment of
    the Navy Preparedness Alliance (NPA) to address a continuum of care
    that covers all aspects of individual medical, physical, psychological,
    and family readiness across the Navy. The forum has proven to be a
    valuable venue to examine the tough readiness issues that cross
    stakeholder boundaries and make informed decisions on identified
    issues. For example, the Navy placed a limitation on the tour length
    for personnel assigned to detainee operations, based upon a review of
    the results of BHNAS. The Chief of Naval Personnel chairs the NPA and
    routinely reports its findings directly to the CNO.
        Operational leadership sets the climate to facilitate early actions
    to prevent suicide. At the highest levels, Navy leadership maintains a
    close watch on the tone of the force, by conducting a comprehensive
    quarterly review of personal and family readiness metrics and trends.
    The Navy polls extensively and tracks statistics on personal and
    family-related indicators such as stress, financial health, and command
    climate, as well as sailor and family satisfaction with the Navy. The
    Navy conducts a BHNAS for targeted groups of deployed sailors.
        Over the past year, Navy Safe Harbor \5\ has expanded its mission
    to non-medical support for all seriously wounded, ill, and injured
    sailors and their families, increasing its capabilities with the
    establishment of a headquarters element to support Recovery Care
    Coordinators and Non-medical Care Managers covering 15 locations. With
    these changes, Safe Harbor's enrolled population has increased from 145
    to over 350. Safe Harbor is providing recovering sailors a lifetime of
    individually tailored assistance designed to optimize the success of
    their recovery, rehabilitation, and reintegration activities.
    ---------------------------------------------------------------------------
        \5\ Safe Harbor is a Navy program, established in 2005, for the
    non-medical care management of severely wounded, ill, or injured
    sailors and their families. Safe Harbor sailors have had no suicides.
    ---------------------------------------------------------------------------
        The Navy outlines its policies, procedures and responsibilities for
    its Suicide Prevention Program in Office of the Chief of Naval
    Operations (OPNAV) Instruction 1720.4.\6\ The program aims to reduce
    the risk of suicide for all Department of the Navy (DON) members,
    minimize adverse effects of suicidal behavior on command readiness and
    morale, and preserve mission effectiveness and warfighting capability.
    Specifically, the Navy has implemented an action plan for all Active-
    Duty and Reserve sailors to address negative suicide risk factors and
    strengthen associative protective factors through the following four
    key elements: Training, Intervention, Response and Reporting.
    ---------------------------------------------------------------------------
        \6\ A revision to the 28 Dec 2005 instruction, OPNAV Instruction
    1720.4A, is currently under review.
    ---------------------------------------------------------------------------
    Training
        All sailors receive annual suicide prevention training with plans
    to extend this training to civilian employees and full-time contractors
    who work on military installations. Suicide prevention training
    includes, but is not limited to: everyone's duty to obtain assistance
    for others in the event of suicidal threats or behaviors; recognition
    of specific risk factors for suicide; identification of signs and
    symptoms of mental health concerns and operational stress; protocols
    for responding to crisis situations involving those who may be at high
    risk for suicide; and contact information for local support services.
        Life-skills/health promotion training, such as alcohol abuse
    avoidance, parenting skills, personal financial management, stress,
    conflict resolution, and relationship building enhance resilience and
    mitigate problems that might detract from personal and unit readiness.
        Highly stressful experiences often cause breakdowns in
    communication between sailors and their families. A recent Center for
    Naval Analysis study on family attitudes and reactions resulting from
    Combat and Operational Stress demonstrated that over 40 percent of Navy
    spouses rate the training and services as ``low'' experienced by their
    military spouse for deployment related stress. A novel program
    developed by the University of California, Los Angeles, and partnered
    with the Navy, Project Families Overcoming Under Stress (FOCUS) now
    provides structured activities and developmentally appropriate combat
    stress and deployment education. By creating a ``family tool box'' in
    order to address difficulties and operational stressors that
    servicemembers, families, and children face during multiple
    deployments, Project FOCUS also helps develop critical skills related
    to emotional regulation, problem solving and communication. These
    early, resilience-based interventions build social support with family-
    level techniques, tools which highlight areas of strength and
    resilience within the family and identify areas in need of growth and
    change. The Navy finds that when a family becomes resilient and able to
    deal with the stresses of deployments, sailors and marines are better
    equipped to carry out their missions.
        COs provide current suicide prevention information and guidance to
    all personnel, which emphasizes promoting the health, welfare, and
    readiness of the Navy community, providing support for those with
    personal problems, and ensuring access to care for those who seek help.
        Each CO appoints a suicide prevention coordinator to ensure that
    the command implements each facet (training, outreach, and response) of
    the suicide prevention. Commands must have a written crisis response
    plan so duty officers have ready access to emergency contacts,
    guidance, and basic safety precautions to assist a sailor at risk.
        The  Navy  continues  a  robust  communications  plan  about
    suicide  awareness  and  promoting the core message: ``Life Counts!'' A
    dedicated Web site (www.suicide.navy.mil), poster series, brochures,
    videos, leadership messages and newsletters all communicate the Navy's
    messages on suicide prevention.
    Intervention
        Initially piloted by Navy Seabees, one of the most heavily deployed
    communities within the Navy, the Warrior Transition Program is a 3-day
    respite in Kuwait offered to de-escalate and wind down from the
    adrenaline-soaked states of mind warriors develop over combat
    deployments. Functionally analogous to the long voyage home experienced
    by World War II veterans, all Individual Augments undergo this process
    of decompression routinely called (and offered by most North Atlantic
    Treaty Organization countries) as Third Location Decompression.
    Conducted by counselors, chaplains, and peers, sailors spend 2 to 3
    days in reflection and recollection and are provided time for
    appropriate rituals of celebration or grief, restoration of normal
    sleeping patterns, and importantly, time to say their good-byes. We
    feel this best practice is critical in preparing returning warriors to
    resume the role of parent, spouse, shipmate, and neighbor.
        COs are directed to have written suicide prevention and crisis
    intervention plans that include the process for identification,
    referral, treatment, and follow-up for personnel who indicate a
    heightened risk of suicide. In addition, they are entrusted to promote
    activities to improve psychological health in the unit.
        COs provide support for those who need help with personal problems.
    Access is provided to prevention, counseling, and treatment programs
    and services supporting the early resolution of mental health, family,
    and personal problems that can underlie suicidal behavior.
        If an Active-Duty or Reserve sailor's comment, written
    communication, or behavior leads the command to believe there is an
    imminent risk that the person may cause harm to himself or others,
    command leadership will take safety measures that include increased
    supervision, restricting access to instruments that can be used to
    inflict harm and seeking an emergency mental health evaluation.
        Providing mental health support and suicide prevention to the
    Reserve sailors is a challenging yet integral component of Navy mental
    health, given the many valued contributions the Naval Reserves continue
    to make in Overseas Contingency Operations. To meet this challenge, the
    Navy implemented the Reserve Psychological Health Outreach (RPHO)
    Program in fiscal year 2008. This program provides two RPHO
    Coordinators and three Outreach team members (all licensed clinical
    social workers) to each of the five Navy Reserve Regions. As a result
    of this program, naval reservists can now call upon a dedicated team of
    mental health professionals for mental health support. The RPHO teams
    engage in active outreach, clinical assessment, referral to care, and
    follow-up services to ensure the mental health and well-being of
    Reserve sailors. The RPHO teams are thus the Navy's first line of
    defense in suicide prevention, and if necessary, intervention for
    Reserve sailors.
        Since the inception of the RPHO program in fiscal year 2008, the
    program has contacted 719 Reserve sailors and provided 314 clinical
    assessments. The RPHO coordinators have also played a critical part in
    helping 2,078 reservists and their spouses attend 20 mental health
    retreats called ``Returning Warrior Weekends'' where sailors and their
    spouses are provided a chance to share deployment experiences with
    fellow servicemembers as well as seek one-on-one support from chaplains
    and mental health counselors. In addition, Navy Medicine has hired a
    full-time Director of Psychological Health for Navy Reserve to oversee
    and expand Reserve Navy Reserve psychological health programs.
                             response and reporting
        In the event of a suicide or suicide-related behavior, command and
    local mental health resources provide support for sailors and their
    families. Navy commands assess requirements for supportive
    interventions for units and affected servicemembers and coordinate with
    all local resources to implement interventions when needed. The Navy
    reports all suicides and suicide-related behaviors. In instances when
    the medical examiner has made an undetermined cause of death and has
    not excluded suicide, commands complete the Department of Defense
    Suicide Event Report (DODSER) within 60 days of notification of death.
        As a result of a CNO directed review of our suicide prevention
    program, we are improving how commands report active-duty suicide
    attempts (or Reserve in drill or activated status). In these
    situations, the military treatment facility responsible for the
    individual's assessment, care, or referral also has responsibility for
    completing the DODSER within 30 days of the event.
        We monitor the number of suicides, follow trends, as well as
    coordinate the development and maintenance of an appropriate Navy
    database to track all suicides in the Navy. Additionally, there is
    continual coordination and collaboration with Navy Behavioral Health,
    Navy Casualty Office, the Office of the Armed Forces Medical Examiner,
    and the Defense Centers of Excellence for Psychological Health and
    Traumatic Brain Injury. New policy will also gather data on sailor
    suicide attempts. Nevertheless, our primary goal remains saving and
    improving lives.
        In conclusion, on behalf of the men and women of the United States
    Navy, I thank you for your attention and commitment to the critical
    issue of suicide prevention. By teaching sailors better problem solving
    skills and coping mechanisms for stress, the Navy will make our force
    more resilient. The Navy is committed to a culture that fosters
    individual, family and command well-being. We honor the service and
    sacrifice of our members and their families, and we will do everything
    possible to support our sailors, so that in their eyes, their lives are
    valued and are truly worth living.

        Senator Ben Nelson. Thank you, Admiral.
        General Amos?

    STATEMENT OF GEN. JAMES F. AMOS, USMC, ASSISTANT COMMANDANT OF
                     THE UNITED STATES MARINE CORPS

        General Amos. Thank you, Chairman Nelson, Ranking Member
    Graham, and Chairman Levin, who just departed, and
    distinguished members of this committee, for this opportunity
    to report on the Marine Corps suicide-prevention efforts.
        On behalf of more than 239,000 Active and Reserve marines
    and their families, I'd like to extend my appreciation for the
    sustained support Congress has faithfully provided its Corps.
    As we begin this hearing, I would like to highlight a few
    points from my written statement.
        The tragic loss of a marine to suicide is deeply felt by
    all of us who remain behind. We lost 41 marines to suicide in
    2008, up from 33 in 2007, and up from 25 in 2006. That is
    unacceptable. We are taking action to turn this around. I care
    deeply about this, and I am committed to work with the
    leadership of the Marine Corps to fix it.
        The data shows that the most likely marine to die by
    suicide corresponds to our institutional demographics. He is a
    young Caucasian male, 18 to 24 years old, between the ranks of
    private and sergeant, E1 through E5. The most likely cause is a
    failed relationship with a woman. Male marines are at a greater
    risk of suicide than are female marines. The most common
    methods of suicide are gunshot or hanging, similar to our
    civilian counterparts. Suicide prevention is required training
    for recruits in boot camp and for all of our new officers at
    the basic school. It is part of the curriculum at our staff
    noncommissioned officer (NCO) academies, our commanding officer
    courses, and all other professional military education courses.
    Simply put, suicide prevention training is incorporated into
    our education and training at all levels of professional
    development and throughout the marine's entire career.
        At a planning session this past November, some of our
    Corps' very best NCOs came to Quantico and asked us to provide
    them with additional training such that they could take
    ownership of the suicide prevention effort for their peers and
    for their marines. Our NCOs have the day-to-day contact with
    marines, and therefore, the best opportunity to see changes in
    behavior and other problems that can identify marines in need
    of further assistance. As a result, we are developing a high-
    impact leadership training program focused on our NCOs and our
    corpsmen, and giving them additional tools to identify and
    assist marines at risk for suicide.
        With great support from the United States Navy, we are
    increasing the number of our mental health professionals and
    embedding more of them in our operational units, where they can
    develop close relationship with our marines as they deploy
    forward. This helps to reduce the stigma of seeking help and
    identify potentially affected individuals early.
        While there is no single answer that will solve this crisis
    of rising suicides, we are committed to exploring every
    potential solution and using every resource we have available.
    We will not rest until we have turned this around.
        I thank each of you for your continued faithfulness to our
    Nation and your confidence in the leadership and the commitment
    of your Corps. I request that my written testimony be accepted
    for the record, and I look forward to your questions.
        Senator Ben Nelson. It will be accepted.
        [The prepared statement of General Amos follows:]
                 Prepared Statement by Gen. James F. Amos, USMC
                                i. introduction
        Chairman Nelson, Senator Graham, and distinguished members of the
    subcommittee: On behalf of your Marine Corps, I would like to thank you
    for your generous and faithful support and look forward to this
    opportunity to discuss the efforts we are taking to prevent suicides in
    the Marine Corps. Your marines know that the people of the United
    States and their Government are behind them; your support has been
    exceptional.
        The loss of a marine is deeply felt by all those who remain behind.
    When a marine dies by suicide, the needless loss of life is a tragedy,
    and the family members and fellow marines who are left behind must
    grapple with the painful questions of why and how. Why did this happen?
    How can we avert a future tragedy? What lessons can be learned that can
    be used to prevent another loss? What actions did we take or fail to
    take, and what could we have done to identify these marines who most
    needed our help and get them that support? As marines, we pride
    ourselves in ``taking care of our own;'' it is this commitment to one
    another that will mark our efforts in learning from these tragedies and
    guide us in our vital work of suicide prevention.
                        ii. understanding the statistics
        Between 2001 and 2006, the number of suicides in the Marine Corps
    fluctuated between 23 and 34, but in the past 2 years we have seen a
    disturbingly sharp increase. From a recent low point of 25 suicides in
    2006, the number increased to 33 in 2007, and in 2008, the Marine Corps
    had 41 confirmed or suspected suicides. Our preliminary suicide rate in
    2008 of 19.0 suicides per 100,000 marines approaches the national
    civilian rate of 19.8 per 100,000 when that rate is adjusted to match
    the demographics of the Marine Corps. In 2008, we had 146 reported
    suicide attempts, a significant increase from 99 attempts in 2006 and
    103 in 2007. The number of marine suicide attempts has consistently
    been between three and four times the number of actual suicides.
        These increases are unacceptable. We have looked at the data to try
    to find answers that will enable us to address this needless loss of
    life. The data shows that the most likely marine to die by suicide
    corresponds to our institutional demographics: Caucasian male, 18-24
    years old, and between the ranks of private and sergeant (E1-E5). The
    most likely cause is a failed relationship with a woman. Male marines
    are at greater risk of suicide than female marines, similar to the
    civilian population. The most common methods of suicide are gunshot or
    hanging, also similar to our civilian counterparts.
        We have been concerned that one outcome of the stress from
    operational deployments might be increased suicides; however, to date,
    we have not seen that hypothesis prove out. Although the number of
    marines who kill themselves and have a deployment history has
    increased, that increase is proportionate with the overall deployment
    history of all marines. In 2008, 68 percent of our confirmed or
    suspected suicides were marines with a current or past deployment
    history in support of Operation Enduring Freedom (OEF)/Operation Iraqi
    Freedom (OIF), which is almost exactly the same as the percentage of
    all marines with deployment experience (69 percent). Marines with
    multiple deployments are similarly not over-represented in the suicide
    population. For the 6-year period of 2003-2008, 16 percent of marine
    suicides occurred in the OEF or OIF area of operations, 32 percent were
    marines with a deployment history, and 52 percent were marines with no
    OIF/OEF deployment history. Taken together, this data suggests that
    while the continuing stress resulting from overall tempo of operations
    may be a factor in our increasing suicide rate, there does not appear
    to be a difference in suicide risk resulting from deployment history.
    Preliminary data from a current analysis of suicide and deployment
    related factors suggest that there is no specific time period post
    deployment associated with increased risk for suicide for marines.
                  iii. suicide reporting, risks, and stressors
        We review all non-hostile casualty reports to identify possible
    suicides and coordinate weekly with the Armed Forces Institute of
    Pathology, who is the final arbiter on manner of death for the Marine
    Corps. Investigations into the possible suicide of a aarine often
    include the command investigation and reports from the Naval Criminal
    Investigative Service, the Armed Forces Medical Examiners Office, and
    civilian police and medical personnel. After each suicide, we do an
    extensive review of the factors leading up to the suicide. We seek
    information from leaders, co-workers, friends, and medical personnel.
    We do not require information from family members so as not to burden
    the family at a time of such tragic loss and grief, but include it when
    available in such a manner that will not compound their loss. A
    comprehensive survey tool, the Department of Defense Suicide Event
    Report, is required for all marine suicides and suspected suicides. We
    are currently determining the best approach to facilitate the use of
    that survey tool for all marine suicide attempts as well.
        From our analysis, the most common risk factors associated with
    suicides include a history of depression, psychiatric treatment,
    anxiety, and a sense of failure. As we look deeper into these cases,
    the most prevalent associated stressors we find are romantic
    relationship troubles, work-related problems, pending adverse legal or
    administrative actions, physical health problems, and job
    dissatisfaction. While all these risks and stressors can be commonly
    found in the civilian sector, they are exacerbated in the young, male,
    single population that makes up much of the Marine Corps. In many
    cases, our younger marines are still developing the life skills and
    resiliency that will enable them to better cope with the stressors in
    their lives.
        We continue to look at our data to identify actionable differences.
    Unfortunately, the relatively small size of our suicide population
    limits in--depth analysis into causal factors or contributors. In most
    cases, multiple stressors and risk factors are present. In a third of
    our suicides, we have found more than 10 stressors or risk factors
    present. We are confident that there is no single answer that will
    prevent suicides, and solutions must include initiatives that approach
    the problem from multiple angles and from multiple disciplines.
                               iv. actions taken
    Training and Education
        Suicide awareness has been an annual training requirement for all
    marines since 1997. This requirement is inspected by the Marine Corps
    Inspector General (IG) at every command inspection visit and has been a
    Commandant Special Interest area for the IG for over a year. Suicide
    prevention is required training for recruits in boot camp and for new
    officers at The Basic School. It is part of the curriculum at our Staff
    Noncommissioned Officer Academies, Commanders Courses, and other
    professional military education courses. We have incorporated suicide
    prevention training into the Marine Corps Martial Arts Program, a
    program practiced by all marines. Simply put, suicide prevention
    training is incorporated into our formal education and training at all
    levels of professional development and throughout a marine's career.
        One of our relatively new initiatives is Frontline Supervisors
    Training, a 3- to 4-hour gatekeeper-type training for marines in
    leadership positions. The training reinforces the leadership skills all
    NCO and SNCO marines have learned and further teaches these leaders how
    to recognize the signs of distress, engage their marines in a
    discussion about suicide related thoughts and risk, effectively refer
    them to local support resources, and recognize the importance of
    sustained effort even after a marine has received professional
    assistance. We have trainers at all marine installations who are
    actively training NCOs, SNCOs, and junior officers with this course.
        Last November, I met with our two- and three-star commanding
    generals, their sergeants major, and representative noncommissioned
    officers (NCOs) to review our suicide awareness and prevention program
    in depth. At that meeting, the NCOs present asked us to provide them
    with additional training so that they could take ownership of suicide
    prevention for their peers and their marines. The goal of this
    initiative is to fully engage our noncommissioned officer leaders by
    providing them marine relevant information to assist them in
    identifying and responding to distress in their marines. To accomplish
    this, we are developing a mandatory high-impact leadership training
    program, focused on our noncommissioned officers and corpsmen, to
    provide them additional tools to identify and assist marines at risk
    for suicide. Our NCOs have the day-to-day contact with marines and the
    best opportunity to recognize changes in their behavior. Properly
    equipped, we believe our NCOs, the first line of defense, will have a
    real impact. This training program will be ready for use across the
    Marine Corps this summer.
        One challenge we must overcome is the perception that asking for
    help will damage your career or somehow makes you less of a marine. We
    are combating this stigma with focused leadership, communicating the
    message that it is okay to seek help. Marines must know that being
    ready for the mission means ready in every way, and getting help is a
    duty, not an option. We teach marines at all levels that seeking help,
    and looking out for their buddy, is the right and necessary thing to
    do. One initiative aimed at reducing stigma is the creation of suicide
    prevention leadership videos by all commanders, colonel and above.
    These 3-5 minute personal videos include messages from senior
    leadership designed to demonstrate the importance of addressing this
    tragedy at the most senior levels and reduce the stigma inherent
    throughout society of asking for help.
        To rapidly raise the level of awareness across the Marine Corps,
    all marines will receive additional training on suicide prevention this
    month. We will complete this all hands training by 31 March. The
    training package will be delivered by Marine leaders and will educate
    all marines on warning signs, engagement with their buddies, and how to
    access the variety of local and national support resources.
    The Combat Operational Stress Control Program
        The Combat Operational Stress Control Program (COSC) is a program
    through which Marine leaders are trained by mental health professionals
    and chaplains in the operating forces to detect stress problems in
    warfighters as early as possible. COSC provides leaders with the
    resources to intervene and manage these stress problems in theater or
    at home. Collaboration between warfighters in the Marine Expeditionary
    Forces, Navy Medicine, and Navy Chaplains resulted in the Combat Stress
    Continuum Model. This tool facilitates the identification of distress
    in marines and offers a decision tree to guide leaders in what to do.
        To assist with prevention, rapid identification, and effective
    treatment of combat operational stress, we are expanding our program of
    embedding active duty Navy mental health professionals in operational
    units--the Operational Stress Control and Readiness (OSCAR) Program--to
    directly support all Active and Reserve ground combat elements and
    eventually all elements of the Marine Air Ground Task Force. We
    currently have three teams with forward deployed units. By embedding
    OSCAR teams in our operating force units, we make it easier for marines
    to develop a relationship with and seek help from mental health
    professionals. We are in the process of growing the program and
    providing those resources to units at home as well as when deployed. In
    addition, Navy Medicine has increased the number of mental health
    providers in Deployment Health Clinics and in the TRICARE network over
    the past 2 years.
        We coordinate our suicide prevention efforts with other experts
    from across the Federal Government, civilian expertise, and with
    international military partners. We actively participate as a member of
    the DOD Suicide Prevention and Risk Reduction Committee (SPARRC),
    meeting monthly with our DOD and Veterans Affairs (VA) partners to join
    efforts in reducing suicides. The Marine Corps currently chairs the
    Federal Executive Partners Priority Workgroup on Suicide Prevention.
    This program, led by the Department of Health and Human Services (HHS),
    provides an opportunity to share best practices and build collaboration
    between all of our Federal partners. Besides the VA and HHS, this
    workgroup includes members from 12 other Federal agencies working
    together to facilitate efforts in support of the National Strategy on
    Suicide Prevention. The Marine Corps also chairs the International
    Association of Suicide Prevention Task Force on Defense and Police
    Forces. This Task Force includes membership from 15 different countries
    working together to develop effective suicide prevention programs,
    building on shared unique experiences in military culture that crosses
    national boundaries.
        Prior to deployment, all marines complete a comprehensive Pre-
    Deployment Health Assessment which gives us a chance to identify and
    respond to problems before marines leave their home station. During the
    re-deployment process, marines complete a Post-Deployment Health
    Assessment designed to alert medical personnel to medical and mental
    health issues. Within 90-120 days after return to home installations, a
    Post-Deployment Health Reassessment is conducted. This is designed to
    identify problems that might not have surfaced immediately upon their
    return home. These examinations provide us another opportunity to
    detect marines who may be at risk.
                                 v. conclusion
        We believe that focused leadership at all levels is the key to
    having an effect on the individual marine and reducing suicides.
    Understanding that there is no single suicide prevention solution, we
    are actively engaged in a variety of prevention efforts and early
    identification of problems that may increase the risk of suicide. We
    are working to reduce the stigma sometimes associated with seeking help
    by creating a command climate in which it is not only acceptable to
    come forward, but is a duty of all marines in taking care of our own.
        Suicides are a loss that we simply cannot accept, and leaders at
    all levels are personally involved in efforts to address and prevent
    future tragedies. Taking care of marines is fundamental to our ethos
    and serves as the foundation of our resolve to do whatever it takes to
    help those in need. Thank you again for your concern on this very
    important issue.

        Senator Ben Nelson. Thank you, General Amos.
        General Fraser?

     STATEMENT OF GEN. WILLIAM M. FRASER III, USAF, VICE CHIEF OF
                     STAFF, UNITED STATES AIR FORCE

        General Fraser. Mr. Chairman and Senator Graham, members of
    the committee, I want to thank you for the opportunity to be
    here today and to address this very serious issue.
        It's a privilege to join with the other Vice Chiefs of our
    sister Services in addressing this tremendously important issue
    with members of this committee. I echo their sentiments on the
    need to further advance our work in preventing suicides among
    our servicemembers.
        In the Air Force, we believe that when an airman raises
    their hand and takes the oath, their lives are forever changed
    in the name of service. As they do so, they incur a commitment;
    and likewise, we have a reciprocal commitment to them and to
    their families. Part of that commitment means ensuring that we
    have programs in place that adequately address the stresses of
    a military life. Whether deployed in combat or at home station,
    there are immense pressures on our men and women in uniform.
    Through a total-force approach, we are doing all we can to
    focus on suicide prevention while heightening awareness and
    exploring new approaches on this issue affecting our Air Force
    and our airmen.
        With our sustained operations tempo and expeditionary
    culture, we are taking important steps to ensure airmen are as
    mentally prepared for deployments and redeployments as they are
    physically and professionally, yet, at the same time, we are
    providing the full support to those military families that are
    left behind.
        We continue to make strides in implementing our Air Force
    Suicide Prevention Program and further enhancing our
    psychological health treatment and our management programs, and
    in strengthening our continued partnerships with our sister
    Services and our interagency colleagues. It is, indeed, a team
    effort.
        While we recognize the successes that our programs are
    yielding, we also know that a single suicide is one too many.
    So, we remain committed to these programs, individually and
    collectively, as a part of a larger effort to take care of our
    Air Force's most valuable assets: its people.
        I want to thank you again for your continued support of
    America's airmen. I look forward to your questions and to our
    ongoing dialogue as how best we can serve those who serve our
    Nation.
        Thank you, Mr. Chairman.
        [The prepared statement of General Fraser follows:]
             Prepared Statement by Gen. William M. Fraser III, USAF
                                1. introduction
        America's Air Force provides critical capabilities across the
    spectrum of conflict for the joint team and the Nation. The Air Force
    mission to ``fly, fight, and win . . . in air, space, and cyberspace''
    has never been more vital to the Nation's defense. The ability to think
    and act globally; ready to deliver humanitarian relief or hold targets
    at risk within hours; provide unrivaled global positioning. navigation
    and timing through advanced space infrastructure; or defend our
    Nation's net-centric information architectures are just a portion of
    what the United States Air Force contributes as part of the Joint.
    Coalition and interageney collaboration that protect and defend the
    United States and its global interests.
        Our airmen are proud to provide these contributions to our Nation's
    defense. After 18 years of continual presence in the Middle East, our
    current force is the most battle-tested group of airmen in our history.
    Yet this era of increasing demands continues to place a heavy burden on
    our airmen and their families. These airmen have responded
    magnificently to their Nation's call. Nevertheless, we see evidence of
    the strain on personal and family relationships from frequent
    deployments, increased workload, and other environmental factors such
    as economic pressures, and are witnessing an increase in some negative
    behaviors and in the physical and psychological injuries home by our
    force from the current conflicts.
        The Air Force is dedicated to supplying, training, and equipping
    our airmen with the best means possible in our Nation's defense. As
    part of our key priority to develop and care for airman and their
    families, we are also dedicated to the well-being of our airmen and
    their overall physical and mental health. The tragedy that is suicide
    has the potential to strike across our Air Force. It is not limited
    only to those airmen who have deployed or will deploy, nor is it bound
    by rank, gender, ethnicity, or geography. Any attempted or successful
    suicide receives the highest attention from Air Force leadership.
        Today I would like to share with the committee data pertaining to
    suicide rates in the Air Force and address what steps we are taking to
    combat such trends, as well as report on the policies and support
    programs we have in place to deal with suicides. In a broader sense,
    the Air Force is making progress in treating psychological injuries to
    include Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain
    Injury (TBI). The Air Force is using modern tools to address the total
    mental health of our airmen. In conjunction with our Department of
    Defense (DOD) and Department of Veterans Affairs (VA) counterparts, we
    are making significant progress in the quality of medical care that our
    Airmen receive and deserve.
        Recognizing that no one is immune to the consequences of this
    destructive act, we are doing all we can to heighten awareness, focus
    on prevention, prepare airmen for deployments and redeployments,
    support military families, and take care of our Air Force's most vital
    asset: its people.
               2. air force suicide rates and prevention programs
        We recognize the personal tragedy of any suicide attempt. While any
    discussion here will necessarily focus on statistics and measure
    effectiveness through quantifiable data, each case represents a unique
    scenario and personal crisis for one of our airmen. Each incident
    further ripples through family, friends, co-workers, and the community.
        The Air Force has experienced a slight increase in the suicide rate
    for calendar year 2008 of 11.5 suicides per 100,000 people when
    compared to its 10 year average of 9.7 suicides per 100,000. Since the
    beginning of major combat operations in Iraq, the 5 year average
    (calendar years 2003-2008) for Air Force suicides is 11 per 100,000.
        We have unfortunately experienced a small number of suicides thus
    far in 2009, consistent with identified suicide trends during the full
    reporting year of 2008. The Air Force experienced 38 suicides by active
    duty members in calendar year 2008, with some observable patterns.
    Thirty-six of the suicide victims were male (95 percent), while there
    were two female victims (5 percent). Officers accounted for 4 suicides
    (11 percent), while the other 34 were spread across the enlisted ranks.
    Over half of the victims were married (55 percent). For comparison, of
    the active duty Air Force population, nearly 20 percent are women, 20
    percent are officers, and 60 percent are married. Another identifiable
    trend is the presence of firearms in 58 percent of the incidents.
    Medical record reviews of recent victims also indicate that a majority
    of victims had utilized some form of mental health services for issues
    ranging from alcohol abuse to marriage counseling. There does not
    appear to be a strong correlation between deployments and suicide, with
    only one airman committing suicide while deployed in Afghanistan in
    2007. From 2003 to 2008, 39 suicide victims had deployed in the
    previous 12 months but 150 victims had never deployed. While these
    numbers are specific to our Active Duty component, we find similar
    trends across the Air Force Reserve and Air National Guard components
    of our Total Force.
        In response to recent suicides, our Air Force Chief of Staff,
    General Norton Schwartz, communicated the importance of supporting
    Airmen in distress to all Air Force Major Command (MAJCOM) commanders.
    We have also re-invigorated the components of the Air Force Suicide
    Prevention Program (AFSPP) with a renewed focus on the following areas:

             Male E1-E4s between the ages of 21 and 25 are at the
            highest risk for suicide.
             Relationship problems continue to be a key risk
            factor.
             Members who receive care from multiple clinics or
            agencies are at high risk for a poor hand-off.
             Airmen appear most at risk to commit suicide between
            Friday and Sunday, highlighting the need by leadership to
            stress weekend safety planning.
             Good communication between commanders, first sergeants
            and mental health providers and staff is critical for the
            success of this team effort.

        We are giving renewed attention to the 11 initiatives in our AFSPP
    with a leadership emphasis on help-seeking behaviors, stigma reduction,
    and managing personnel in distress. Our wingman concept develops a
    culture of looking out for fellow airmen. We are also standardizing
    risk assessments and enhancing treatment of suicidal members while
    providing high-quality annual training on suicide risk factors to all
    airmen.
    2.1 Air Force Suicide Prevention Program
        The Air Force has a long history of focusing on suicide prevention
    and is recognized as a key leader in this field. The AFSPP is defined
    in Air Force Pamphlet 44-160. This program was initiated in 1996 with
    the purpose of reducing the number of lives lost to suicide. The
    program has achieved dramatic results. The pre-AFSPP suicide rate from
    1987 to 1996 was 13.5 suicides per 100.000. The post-AFSPP suicide rate
    average from 1997 to 2008 is 9.8 suicides per 100,000, resulting in a
    28 percent rate reduction. The AFSPP centers on effective education,
    detection and treatment for persons at risk. Since its inception, the
    AFSPP has heightened community awareness of suicide and suicide risk
    factors. Additionally, it has created a safety net that provides
    protection and adds support for those in trouble. The AFSPP is a
    nationally recognized program and was one among the first three suicide
    prevention programs to he listed on the Substance Abuse and Mental
    Health Services Administration National Registry.
        There is no easy solution to preventing suicides: it requires a
    total community effort using the full range of tools at our disposal.
    However, we have seen a marked difference through the AFSPP. Going
    forward, the Air Force is committed to continued emphasis on the proven
    AFSPP as the best approach to dealing with those at risk of suicide.
        The AFSPP is a commander's program, and thus it is the
    responsibility of every commander to ensure the AFSPP is fully
    implemented as we continue to develop effective tools to assist
    potential victims.
    2.2 Air Force Suicide Prevention Program Initiatives
        The AFSPP consists of 11 specific policy and training initiatives
    which collectively comprise our approach to taking care of our airmen
    in this critical area. These initiatives include:
        Leadership Involvement
        Air Force leaders actively support the entire spectrum of suicide
    prevention initiatives in the Air Force community. Regular messages
    from the Air Force Chief of Staff, other senior leaders and commanders
    at all levels motivate airmen to fully engage in suicide prevention
    efforts.
        Addressing Suicide Prevention Through Professional Military
            Education
        Suicide prevention education is included in all formal military
    training.
        Guidelines for Commanders: Use of Mental Health Services
        Commanders receive training on how and when to use menial health
    services and their role in encouraging early help-seeking
    behavior.Community Preventive Services. Community prevention efforts
    carry more impact than treating individual patients one at a time. The
    Medical Expense and Performance Reporting System was updated to
    effectively track both direct patient care activities and prevention
    services.
        Community Education and Training
        Annual suicide prevention training is provided for all military and
    civilian employees in the Air Force.
        Investigative Interview Policy
        The period following an arrest or investigative interview is a
    high-risk time for suicide. Following any investigative interview, the
    investigator is required to hand-off the individual directly to the
    commander, first sergeant or supervisor. The unit representative is
    then responsible for assessing me individual's emotional state and
    contacting a menial health provider if any question about the
    possibility of suicide exists.
        Trauma Stress Response (formerly Critical Incident Stress
            Management)
        Trauma Stress Response teams were established worldwide to respond
    to traumatic incidents such as terrorist attacks, serious accidents or
    suicide. These learns help personnel deal with their reactions to
    traumatic incidents.
        Integrated Delivery System (IDS) and Community Action Information
            Board (CAIB)
        At the Air Force, MAJCOM, and base levels, the IDS and CAIB provide
    a forum for the cross-organizational review and resolution of
    individual, family, installation and community issues that impact the
    readiness of the force and the quality of life for Air Force members
    and their families. The IDS and CAIB help coordinate the activities of
    the various agencies at all levels to achieve a synergistic impact on
    community problems.
        Limited Privilege Suicide Prevention Program
        Patients declared at risk for suicide are afforded increased
    confidentiality when seen by mental health providers as part of the
    Limited Privilege Suicide Prevention Program. Additionally, Limited
    Patient-Psychotherapist Privilege was established in 1999, limiting the
    release of patient information to legal authorities during UCMJ
    proceedings.
        IDS Consultation Assessment Tool (formerly Behavioral Health
            Survey)
        The IDS Consultation Assessment Tool was released in December 2005.
    This tool, administered upon the request of the commander, allows
    commanders to assess unit strengths and identify areas of
    vulnerability. Commanders use this tool in collaboration with IDS
    consultants and other AFSPP initiatives to design interventions to
    support the health and welfare of their personnel.
        Suicide Event Surveillance System
        Information on all Air Force active duty suicides and suicide
    attempts are entered into a central database that tracks suicide events
    and facilitates the analysis of potential risk factors for suicide in
    Air Force personnel. To further enhance the AFSPP program, we are
    focusing our prevention efforts on effective detection and treatment.
    The Air Force implemented computer-based training in 2007 as part of
    the Chief of Staffs Total Force Awareness Training initiative, and
    continues to monitor the impact of this training through ongoing
    research studies. The Air Force has also recently introduced a new tool
    for leadership known as the Frontline Supervisors Training. This half-
    day class enhances supervisor skills for assisting airmen in distress.
                         3. air force support programs
        In support of our AFSPP initiatives, we have also developed other
    programs dedicated to recognizing and aiding airmen at risk. Our Air
    Force Community and Family Readiness programs follow a community-based
    approach and build resilience and strength in Airmen and their families
    by equipping them with the skills to adapt to the demands of military
    life.
        These programs provide early interventions to support airmen and
    families at risk. They also help families cope with issues such as
    relocation and transition assistance and assist families with
    deployment and reintegration. Further, to support the unique situations
    that our airmen and their families face as part of the military
    lifestyle, we offer military family life consultants to provide
    individual, marriage and family counseling: special needs families
    assistance: financial education services; and education, advocacy, and
    intervention for domestic violence and new parent issues. Additionally,
    through the Military OneSource program, the Air Force provides an
    information hotline that is available 24 hours a day, 7 days a week and
    allows for immediate referrals into the mental health system. These
    programs provide the necessary support networks, education, skill-
    building services and counseling to help airmen at risk successfully
    adapt to their current environment.
        Another key source of support available to all airmen is found in
    our chaplaincy. Our military chaplains are trained and ready to help
    airmen in facing difficult social and domestic issues as well as
    providing for their spiritual well-being.
                     4. deployment and psychological health
        The current environment for many of our airmen is one of increased
    operational tempo and includes more frequent and longer deployments.
    With this heightened operations tempo, we remain mindful of the
    increased stresses and requirements placed on our airmen and their
    families. The Air Force employs a variety of screening tools to monitor
    airmen's health, increase awareness of psychological issues and provide
    for early intervention when required.
        All airmen are screened for menial health concerns upon accession
    and annually via the Preventive Health Assessment (PHA). Additionally,
    those that deploy complete a Post-Deployment Health Assessment (PDHA)
    at the time they leave theater and 90 to 180 days after returning from
    deployment complete the Post-Deployment Health Reassessment (PDHRA). At
    an enterprise level, the PDHA identifies airmen exposed to trauma in
    theater. The Air Force tracks symptoms from all airmen exposed to
    trauma in theater to identify Air Force-wide trends. The PHA/PDHA/PDHRA
    process facilitates the identification and treatment of airmen with
    significant trauma exposure history and/or traumatic stress symptoms.
    It also increases awareness by commanders and unit members who can
    refer airmen to appropriate Military Treatment Facilities.
    Additionally, the PHA/PDHA/PDHRA screen also identifies depression,
    alcohol abuse, and family problems that are all warning signs of at-
    risk airmen.
        The PDHRA completion rate for Active Duty airmen is 89 percent,
    with the remaining 11 percent past due, or over the 180 day window.
    Nearly half of the PDHRA participants screened positive for physical or
    emotional symptoms. Of these screened positive, 80 percent receive
    medical follow-up within 30 days, with the remaining 20 percent that
    have not received treatment within the 30-day window contacted
    regarding their extenuating circumstances. The PDHRA is a survey with a
    positive algorithm that is intentionally overly sensitive to act as an
    initial filter for possible medical assistance. We continue to closely
    monitor these metrics, working to ensure all airmen receive the
    screenings, and if necessary, the follow-on medical attention within a
    timely window.
    4.1 Landing Gear Program
        Just as an aircraft's landing gear serve as the critical component
    during launch and recovery, we recognize that the time immediately
    surrounding departure and homecoming are critical phases of a
    deployment for airmen. Our Landing Gear Program is centered on
    effective risk recognition and help-seeking for airmen during these
    difficult times of adjustment. Landing Gear serves as a bridge to care
    designed to increase the recognition of airmen suffering from traumatic
    stress symptoms and connect them with helping resources. It provides a
    standardized approach to the mental health requirements for pre-
    exposure preparation training for deploying airmen and reintegration
    education for redeploying airmen.
        Twenty percent of airmen in theater are exposed to traumatic
    events. Groups at the highest risk include security forces, explosive
    ordnance disposal crews, medics, airmen imbedded with other service
    combat units, and those with multiple deployments or deployments
    greater than 180 days. This exposure to battlefield trauma places
    airmen at risk for PTSD and other mental health problems. While less
    than 2 percent of deploying airmen develop PTSD, the brief training
    developed for Landing Gear is effective at identifying those at risk
    and getting them the necessary help. Recent data suggests that prompt
    medical intervention greatly improves the outcomes for airmen dealing
    with PTSD and related mental injuries.
                5. psychological health treatment and management
        The signature injury to our airmen and troops in the current
    conflicts may be TBI. We are training, our medical professionals to
    recognize and effectively deal with TBI. Flight Nurse, Aeromedical
    Evacuation Technician, and Critical Care Air Transport Team courses all
    now provide training on TBI. We are making significant progress in
    training these first responders to injured warriors by updating our
    training objective thus year to accomplish an in-theater TBI
    assessment.
        We have also made psychological health treatment more accessible to
    our airmen. Since 2007. the Air Force has hired 91 contract mental
    health providers. Our standard of access for routine appointments is 7
    days. We have trained an additional 400 mental health providers on
    optimal PTSD treatment solutions to better deal with an increasing
    number of airmen suffering from PTSD.
        Finally, we have made significant progress in decreasing the
    stigmas attached for airmen seeking help with mental issues. Our mental
    health providers have been placed in primary care clinics to emphasize
    the similarities of treatment for mental and physical conditions, and
    working to reach these airmen for treatment when they exhibit signs of
    Post-Traumatic Stress, and before their stresses reach the Disorder
    diagnosis. Air Force leaders advocate for help-seeking behavior in
    multiple forums and we are emphasizing a culture where seeking help is
    seen as a virtue rather than a failure.
                    6. participation in dod and va programs
        While we are making significant progress on suicide and mental
    health issues within the Air Force, we are fully committed to
    partnering with our sister services and interagency associates. Other
    military Services have enjoyed successes with recent programs. The Air
    Force collaborates with our sister service suicide prevention offices
    to share and adopt best practices. The Army has recently developed a
    series of interactive videos that we are exploring to determine
    adoption into our own suicide prevention efforts.
        The Air Force is completely engaged with the Defense Center of
    Excellence to address psychological health and TBI issues that are
    experienced across the Joint Force. We are fully committed to
    participating in the medical advances and ground-breaking work that
    occurs in this area.
        One of our priorities is to work closely with the VA to perform
    smooth transitions for returning OIF/OEF veterans and ensure their
    continued healthcare. When a deployed airman is ill or injured, we
    respond rapidly through a seamless system from initial field response,
    to stabilization care at expeditionary surgical units and theater
    hospitals, to in-the-air critical care in the aeromedical evacuation
    system, and ultimately home to a military or VA medical treatment
    facility. Our goal is to keep wounded airmen on active duly until we
    are assured that they have received all necessary follow up care, and
    should a combat wounded airman want to reenlist, we will provide every
    opportunity for them to remain a part of the Air Force learn. In fact
    we have recently formalized policies that will afford our wounded
    airmen opportunities for retention, priority retraining, and
    promotions. If airmen are separated from active duty, they are covered
    by the TRICARE Transitional Health Care Program until their transition
    to VA is completed.
        It is our solemn pledge that all combat wounded and other disabled
    veterans will receive complete information and assistance in obtaining
    all services from DOD, the VA. and the Department of Labor to which
    they are entitled by virtue of their service to their country.
                                 7. conclusion
        Our Air Force leadership is committed to providing the best
    possible training and care to our airmen and their families. We
    recognize the serious threat that suicide represents to our airmen and
    its tragic consequences for airmen, their families, and our Air Force
    community. We have seen measurable successes with the programs we have
    implemented, and we continue to focus on providing every necessary tool
    to commanders and Air Force leadership to assist airmen in distress.
        Airmen serving in the current conflicts are not immune from
    psychological injuries. The Air Force is proceeding deliberately with
    programs and policies designed to improve our airmen's total mental
    health, collectively and individually. We are committed to working
    closely with our DOD and VA counterparts to ensure a continuity of care
    and treatment options. Caring for our airmen is a moral duty that we
    require of ourselves and that the Nation expects. We look forward to
    executing these programs and supporting our airmen and their families.

        Senator Ben Nelson. Thank you.
        Senator Graham has arrived, so I now recognize him for an
    opening statement.

                  STATEMENT OF SENATOR LINDSEY GRAHAM

        Senator Graham. Very briefly, Mr. Chairman.
        One, I look forward to working with you in this Congress as
    we've done in the past. This is one subcommittee, I think, that
    has really gotten the spirit of what we're all about here and
    tried to be as nonpartisan as possible, and I think we've been
    very good at that.
        This issue, obviously, is something that the Country is
    concerned with. What I want to know is: When we exceed the
    civilian population, in terms of military suicides, what's
    going on? The prevention programs you've described seem to be
    very aggressive.
        Being part of the military for a long time, I know there is
    a conflict here and a bit of a tension. If you step out and
    say, ``I'm having a problem,'' people worry that it's going to
    affect their ability to be promoted. I know that is something
    that everyone at the table is sensitive about, to make sure
    that our folks can self-identify, that one buddy can help the
    next.
        I look forward to learning about what you're trying to do
    to control this problem, and I appreciate the hearing.
    Hopefully, we can come up with some constructive solutions.
        [The prepared statement of Senator Graham follows:]
                  Prepared Statement by Senator Lindsey Graham
        Good afternoon Mr. Chairman. Senator Cornyn, welcome. You served
    for years on the Committee on Armed Services; it is great to have you
    back with us today.
        Senator Nelson, it is a great pleasure for me to serve with you in
    the 111th Congress and especially again as ranking member on the
    Personnel Subcommittee. I have to point out that with 16 members
    assigned to our subcommittee, we are not only the largest subcommittee,
    but I think we are larger than some committees in the Senate--so we
    must be doing something right!
        We are also doing something that is important--starting with our
    hearing today on the difficult subject of suicides by servicemembers.
        We know that statistically suicide is rare yet it remains one of
    the leading causes of death among young adults, and when a suicide
    occurs, it affects a part of every family, every military unit, every
    commander and citizen that it touches.
        Tragically, we have seen a steady rise in the number of suicides
    within the Army and Marine Corps since 2003, and for the first time,
    the suicide rate in the Army exceeds comparable civilian rates.
        I believe that the military has made progress on many fronts  in
    confronting the issue of stigma, in improving training and awareness
    about suicide risks at all levels. But we need to know more, and
    achieve a better result.
        I hope that this hearing will lead us to a better understanding of
    the factors that military organizations and families can positively
    influence in order to prevent the terrible and irreversible
    consequences of suicide by members of the military.
        I thank all of our witnesses today, and especially the Vice Chiefs
    of Staff of each of our armed services. I know you are working hard to
    protect our servicemembers and their families, using every resource
    available to prevent the often unpredictable and universally tragic act
    of suicide. I believe I speak for every member on our subcommittee when
    I say that we are committed to supporting you in those efforts.

        Senator Ben Nelson. General Chiarelli, last year during a
    Personnel Subcommittee hearing, General Rochelle testified that
    the Army was focused on removing the stigma of receiving mental
    healthcare, and that the Army had a task force in place to
    provide greater oversight in this area. As you and I have
    discussed, progress is being made. Can you tell us what the
    latest findings or actions are from the task force?
        General Chiarelli. Well, Senator, as you well know, the
    problem is not solved, but I think we are headed in the right
    direction. I think that the most important thing we've done in
    a long time, and a product of that task force, was an
    interactive video that we're using as the centerpiece of our
    stand-downs for the Active component force starting on March
    15, called ``Beyond the Front.'' It is an interactive piece
    that goes right to attacking that issue of stigma and helping
    soldiers and leaders work through that problem.
        In addition to that, the Chief of Staff of the Army and the
    Secretary of the Army have asked me to take on this particular
    issue. I'm spending a great deal of my time concentrating on
    this. I've stood up a task force that's working with me, under
    Brigadier General Colleen McGuire, who are looking at all
    aspects of this problem and collecting data.
        In addition to that, every single suicide that we have in
    2009, once confirmed, will be briefed to me. I held that first
    session with the leaders 2 weeks ago. During a 2\1/2\ hour
    session, 15 different suicides were briefed to me, and it was
    one of the most intense 2-hour periods that I've ever spent. I
    think this goes a long way in allowing everyone to learn about
    the lessons of each one, rather than only the lesson of the
    suicide that's closer to home, and I think it's going to pay
    huge dividends for the United States Army.
        Senator Ben Nelson. General Amos, the Marine Corps has an
    ongoing pilot program, the Operational Stress Control and
    Readiness (OSCAR) Program, embedding health professionals in
    units at the regimental level. You mentioned that you're
    getting support from the Navy in the areas of mental health
    professionals. Is there any evidence that embedding mental
    health professionals in units reduces suicides or suicide
    attempts by making mental healthcare more available? Has the
    Marine Corps concluded that this is, indeed, an efficient use
    of mental health providers?
        General Amos. Sir, we have 3 OSCAR teams currently deployed
    in Iraq right now, and one with the 2,000 marines that are
    deployed in Afghanistan, so we have a total of 4 forward-
    deployed. It's too soon to tell the real benefit of these.
    Anecdotally, we believe that this is going to be a significant
    force multiplier, reducing the stigma and allowing us to be
    able to actually look young marines in the eye with a mental
    health professional while they are deployed. That way, the
    mental health professional is part of the shared adversity and
    shared sacrifice of those marines that are forward, and
    therefore, identifies with them. So, we think it's going to
    work. It's too soon to tell. The Navy has come forward--and I
    think we have the numbers--55 mental health professionals
    forward-deployed in the U.S. Central Command right now, with
    marines.
        The real issue, and challenge across all of DOD, is that
    it's not a function of an unwillingness, it's a function of a
    shortage of mental health providers across our great Country,
    both in civilian life and in the military. So, I think it's too
    soon to tell. My anticipation and expectations are, Mr.
    Chairman, that it's going to pay rich dividends, and we intend
    to fully staff this out and push these mental health providers
    forward.
        Senator Ben Nelson. Now, you have the embedding when
    they're deployed. Is there an embedding when they return, in-
    between deployments?
        General Amos. Sir, the embedding right now begins in the
    predeployment training, during the 3- or 4-month workup, so
    that they begin to develop a relationship, so it's not a cold
    start in theater. When they come back, there will be the
    continued habitual relationships with those mental health
    providers. As you might imagine, it's a function of numbers
    right now; we just don't have enough to be able to provide all
    the ones that are working up and all the ones that have come
    back. We will get there, and that's where we're headed.
        Senator Ben Nelson. General Chiarelli, I understand you
    have an embedding program, as well. Maybe you can give us some
    indication of how this is working with the Army.
        General Chiarelli. Well, I would have to fully agree with
    General Amos; it's too early to tell. But, all anecdotal
    indications from units returning indicate that this is a great
    help to them. But, I think as you know, Senator, we rely on
    Professional Filler System (PROFIS) doctors. I want to lay it
    all out here. I have found that, because those PROFIS doctors
    were turned back, those are doctors--a mental healthcare
    provider would be the same--that come from the military
    treatment facility someplace, deploy with that unit, they
    deploy for that year or 15 months, but then, when they come
    back, if we're not watching it, they are immediately reassigned
    back to that medical facility, and we have a problem because
    that continuity is important when they're deployed, but the
    continuity is also needed when they come back and begin to go
    through many of the problems that they have when they come back
    to their units in their hometowns. It's just as important to
    have that continuity. We have to find a way to provide that
    continuity much better than we are today.
        Senator Ben Nelson. To the other Vice Chiefs, do you have
    any program similar to that, or are you considering programs
    similar to the embedding ones that the other services are
    using?
        We'll start with you, General Fraser.
        General Fraser. Sir, we, too, are experiencing a shortage
    of mental healthcare providers because of the shortage across
    the country. However, this last year, we took action to bring
    on more. In fact, within the last 12 months, we hired 97 new
    mental healthcare providers to place them with our units, so
    that, across all of our installations, we have our units
    covered.
        Now, we are also deploying a large number of our mental
    healthcare providers. I've talked with General Chiarelli, and
    I've talked with the other Vice Chiefs, too. When you have a
    lack of mental health providers in the other Services, then, as
    General Chiarelli just talked about, PROFIS have to go forward
    to fill the gap. What we want to make sure that we do, though,
    for those who support those types of taskings, is to ensure
    that we have a good handoff. We don't want providers to fall
    through the cracks. That is something that our healthcare
    providers are very intent on fixing because you can see how
    that would happen when they come back and they're no longer
    attached to those units, or they are deployed for less time
    than that unit. We know that the Army is on longer deployments.
    We are getting longer deployments of mental health providers in
    there, but yet, at the same time, we also realize there are
    other things that we have to do.
        The other thing that we're noticing, and that we want to do
    with these 97 mental healthcare providers, for instance, is
    when we started building our budget, we're taking a look at
    very seriously converting these to civilian positions so they
    become a part of the Air Force. These are other types of things
    that we're doing.
        Another thing that we're doing, not just with the embeds,
    sir, but we're finding great utility in the health assessments,
    not only the Periodic Health Assessments that folks do on an
    annual basis, but the pre- and post-deployment screening. The
    reassessment that occurs 90 to 180 days after a troop has
    returned is more important. What we're finding in that
    assessment, because it is a very sensitive assessment, is that
    a large number of the folks begin to exhibit stress. It's
    necessary, then, that we get them the care that they need to
    have. We're batting about 80 percent of getting those
    individuals in to see healthcare providers within a 30-day
    period. That additional 20 percent does not go unnoticed. We
    then follow up with them to get eyes on them and talk to them
    to see what else we can do to make sure. So, the Post-
    Deployment Health Reassessment Program is actually yielding
    great benefits after that deployment and being forward in the
    theater.
        Thank you, sir.
        Senator Ben Nelson. Admiral Walsh.
        Admiral Walsh. The concept of an embed here is a very
    important part of our deployment pattern; it's part of our
    force generation. So, if you were to look at the construct that
    we use for deploying carriers and carrier strike groups, you
    will find all the key elements of what you've described in the
    OSCAR team as part of our deploying units. You'll find medical
    help for mental health professionals, medical professionals, as
    well as chaplain support.
        I will point out that, statistically, where we find areas
    of vulnerability is when we step away from that coherent,
    cohesive construct. This is on the redeployment of troops when
    they come back. So, in the first 6-month period and in the
    period from 12 to 18 months, we see empirical evidence that
    focuses our attention, and it's not only suicide, but it's also
    other safety-related issues.
        So, these are areas where people have stepped away from the
    checks and balances, the lines of accountability, and the clear
    oversight that comes from a deploying unit, creating our areas
    of vulnerability.
        Senator Ben Nelson. Thank you. My time has expired.
        What we didn't talk about were the Guard and Reserve units'
    members who have come back, and how we will continue to provide
    for them, but we can get to that later.
        Senator Graham.
        Senator Graham. Thank you, Mr. Chairman.
        I think Senator Cornyn has to leave. Would you like to make
    a statement before you leave?
        Senator Ben Nelson. Oh, sure. Senator Cornyn.
        Senator Cornyn. Thank you very much, Senator Graham and
    Senator Nelson, for your courtesy. I do, like all of us, have
    multiple hearings and obligations at one time.
        But, I want to say again, General Chiarelli, how much I
    appreciate General Freakley, General Turner, and Secretary
    Geren for the seriousness with which the Army has taken the
    concerns that I first raised last September about what happened
    here. We can all see the concern because, of course, we've had
    many hearings and a lot of efforts have been undertaken to try
    to deal with everything from traumatic brain injury (TBI) to
    post-traumatic stress syndrome. We recognize the strains on
    families, with lengthy and multiple deployments, and a
    military, as far as the Army and Marine Corps are concerned,
    that is too small for our current obligations, on a worldwide
    basis.
        I say all that to say that it's hard, I think, to draw any
    grand conclusions, other than that we don't really know exactly
    what causes an individual to take his or her own life. That's
    what I hope comes out of this. I know Secretary Geren has
    entered into arrangements with the National Institute of Mental
    Health that, I think, with a lot of these tragedies, will
    perhaps allow us to save more lives, but certainly apply that
    science and that learning more broadly across the population,
    generally, to save a lot of families from this same tragedy
    that confronted these four families out of the Houston
    Recruiting Battalion.
        But, it doesn't seem to me that taking one's life is what
    you would call a normal response. In other words, we have an
    awful lot of soldiers, sailors, airmen, and marines, and
    others, who undergo the same or similar stresses and strains,
    and they don't take their lives. I'd be pleased if we could
    just go down the line and get your reaction: Is this something
    you think we need to try to do a better job identifying on the
    front end, when someone is recruited into the military? Is it
    something we need to do a better job of once they return from
    deployments, let's say, abroad in Afghanistan and Iraq? Where
    do you think that the key point in time is where we are most
    likely to identify an individual like this and intervene in a
    way that saves them and their family from this tragedy?
        General Chiarelli, do you have a thought about that?
        General Chiarelli. Well, Senator, that is a tough question.
    There is no doubt about it; we need to do everything we can to
    try to identify this on the front end. But, even if we were
    100-percent successful on the front end--and I think you know
    that--at least we're seeing in the Army, that 70 percent of our
    suicides that we had last year, 133 that we've confirmed so
    far, with another 7 pending, 70 percent of those, or a little
    bit greater than that, had some kind of relationship problem.
    But, it was normally not just a relationship problem, it was a
    relationship problem that was compounded with something else.
    It could have been a deployment, it could have been multiple
    deployments. I'm looking at a group of suicides now, nine
    suicides, where I have six out of nine soldiers who have
    deployment history. That about fits the statistics we're
    looking at: one-third deployed, one-third not deployed, and
    one-third, when they were deployed, committed the act. Of those
    six soldiers who have deployment history, four of them have
    multiple deployments. That doesn't normally fit. But, I think
    we have to attack this from a multidisciplinary approach and
    understand that we have to be able, at all points of a
    soldier's career, to have people ready to intervene and help
    that soldier, should that single event, like a relationship,
    compounded with a legal problem, financial problem, or a peer,
    cause an individual to contemplate suicide. It's going to take
    a multidisciplinary approach across the entire career of a
    soldier.
        Senator Cornyn. Admiral Walsh?
        Admiral Walsh. The benefit of these sorts of conversations
    is that we share among the Services because we have a very
    common set of problems here that we're trying to address, even
    though we have cultural differences and maybe deployment
    patterns that are different. What we have learned from this is
    that it is the shipmate, it is the battle buddy, it is the
    person that comes to the assistance of someone in need through
    programs that help to reduce the glamorization of alcohol, the
    stigma associated with asking for help, that a battle buddy or
    a shipmate can come forward and say he feels comfortable in
    either reporting his friend or bringing his friend to the kind
    of resource.
        We don't come before the committee today to say that we are
    resource-limited. We are attacking this on many different
    fronts. The committee has been very supportive, in terms of
    supporting us with everything that we've ever asked for. The
    challenge that we have is really getting to a climate that
    allows, in a command organization, for people to feel
    comfortable being vulnerable, that they are comfortable, both
    on a professional level, that they won't be hurt, and on a
    personal level, that they won't be stigmatized, that they can
    come forward and ask for help.
        What we have learned is the importance of demanding
    feedback, to demand a dialogue. For our particular Service,
    what that means is, I'm going to get one set of answers if I
    survey the member, but if I survey the family, I'm going to get
    a different set of answers. That to me is the way we go out,
    proactively, to look for these problems before they present
    themselves to us.
        Senator Cornyn. General Amos, do you have anything you'd
    like to add in that regard?
        General Amos. Sir, I echo what Admiral Walsh and General
    Chiarelli have said. You asked, is there anything we could do
    early on during recruiting with an assessment of the young
    recruit, maybe before they actually become, in our Service, a
    U.S. marine? We've been fortunate because we are the smallest
    Service, we have a niche of society that we recruit, and it has
    gone quite well. With the help of Congress, we've grown the
    Marine Corps, as you said, Mr. Chairman, 22,000 up to almost
    202,000, as of today.
        The quality has not decreased; in fact, the quality has
    increased. The numbers of high school graduates have increased.
    The numbers of waivers have decreased. So, you would think,
    intuitively, that you were getting a higher-quality product,
    and we are. We put them through 12 weeks of boot camp, and our
    boot camp is legendary, and is designed to do a whole lot of
    things, in addition to imbuing the DNA of being a U.S. marine.
    But, one of the things it's designed to do is to put that young
    recruit through as stressful an environment, to look for those
    areas where he or she needs improvements or where he or she
    needs our help. We're pretty good at that. Those drill
    instructors are pretty good.
        So at the end of 12 weeks at Parris Island or San Diego, on
    that Friday morning, I would say that we've probably done a
    pretty good job of filtering out those that we might otherwise
    cut. You and I might think that there's probably not a
    potential candidate here for making a decision to take their
    own life. It's a mystery.
        I will tell you that the next part for us is the resilience
    training, and that's what we are working on right now. How do
    you build a young man or a woman and make them strong enough so
    that, when a relationship fails or when something happens at
    home, that person has the ability to withstand that? So, we're
    working on that right now, sir, through our training.
        Finally, the last thing I would say in my list is that we
    don't, and marines don't, leave marines on the battlefield.
    That theme needs to be carried over to everything we do in
    taking care of our young marines. We are not going to leave
    them behind.
        Senator Cornyn. General Fraser?
        General Fraser. Senator, thank you very much.
        I, too, would echo the comments of my colleagues here.
    There's no one suicide that's exactly the same as another, and
    that's why we, as a Service, investigate every single one, to
    try and understand, Is there something that we can learn from
    this?
        Through the Air Force Suicide Prevention Program, we have
    11 initiatives within that program because we think it is
    multifaceted, since no one is exactly the same. As we learn
    from each suicide, we then take that into account across those
    11 initiatives; but, moreover, we take into account the
    community where they live. Every community is different,
    whether it's in North Dakota, Texas, Florida, or Alaska. The
    other thing that we've done, through the Community Action
    Information Board, is to get that information out there. These
    meet, not only at the wing level, but they meet at the major
    command level. These are outbriefed at the major command level
    so that they can understand. We, in the Pentagon, even at the
    Air Staff level, hold a Community Action Information Board so
    that we can better understand what we can do with our
    processes, procedures, or resources given the needs of our
    troops out there to provide that support for them, but also for
    their families.
        The other program that I think has yielded some dividends
    is our Wingman Program. It's the battle buddies because, as
    they begin, from the day of accession, as we go through
    education and training, through detection, all the way up to
    getting them help, we have found that the Wingman Program has
    been very beneficial. It helps break down that stigma. The
    stigma is no longer there, so that maybe they can get them the
    care that they need. It's that person that knows them better.
    In fact, we have gone so far as to move those mental healthcare
    providers who used to be in a different organization. We,
    ourselves, reorganized, and they are in our military treatment
    facilities now. If you come in for some other kind of care,
    then you can be looked at in that area, and it's not like
    you're going someplace else that's going to stand out, that
    they see your vehicle, they see you're going in there. It's a
    part of our military treatment facilities.
        These are some of the things that we're learning. We
    continue to go back and look over those 11 initiatives, based
    on the cases that we have.
        The other thing, sir, that we're doing is partnering with
    our sister Services here. We, right now, are taking a look at
    the video that General Chiarelli talked about. We think there's
    something that we can learn from that, in that interaction in
    today's high-risk youth. We see the same things that the other
    Services do. We think there's some utility there, and so, we're
    looking at adapting that, because that's another tool in our
    kit that we can use to help our young airmen out. It's
    multifaceted.
        Senator Cornyn. Thank you very much. My time has expired.
        Senator Ben Nelson. Senator Graham.
        Senator Graham. Thank you, Mr. Chairman.
        I would request that Senator McCain's opening statement be
    placed in the record, if that's appropriate.
        Senator Ben Nelson. It will be accepted.
        Senator Graham. Okay.
        [The prepared statement of Senator McCain follows:]
                   Prepared Statement by Senator John McCain
        I thank Senator Cornyn for requesting this hearing, and Senators
    Nelson and Graham for promptly scheduling this hearing aimed at finding
    ways to prevent suicide by members of the Armed Forces.
        Because the response to this problem relies so heavily on
    leadership and the military chain of command, we have asked the Vice
    Chiefs of Staff of the Services to testify today.
        I hope this hearing will lead us all to a better understanding of
    why suicides occur in the Armed Forces, and who may be at risk. We seek
    assurances from the senior military leadership that resources and
    actions are being directed effectively and urgently to address any
    factor which has been shown to place a servicemember, his or her
    military unit and family at risk for the consequences of suicide. We
    need to understand what lessons have been learned by each of the
    Services when, at various points in their history--during peace and
    war--suicide rates have unpredictably risen or fallen in response to
    specific interventions.
        There has been speculation about the impact of wartime operations
    on suicide rates. I want to hear more about the facts relating to
    suicide and military operations, and make sure that we are directing
    our efforts in the right direction. I have seen evidence of the
    dedication and resilience of our military personnel a thousand times
    over throughout the world--and that has not changed. We mourn the loss
    of every servicemember who falls in the defense of freedom, including
    by his own hand.
        The bond of military Service is a strength like none other, based
    not on pursuit of individual achievement but on the performance and
    cohesion of military units. We must build on that strength to protect
    each member who commits his or her life to the defense of our Nation. I
    am confident that is what we will do.
        Thank you Mr. Chairman, Senator Nelson, Senator Graham, Senator
    Cornyn and my colleagues on the Senate Armed Services Committee.
        I look forward to your statements and to the testimony of our
    witnesses today.

        Senator Graham. What brings us here is the spike in
    suicides. I mean, there's a reason for this hearing, there's a
    reason you're doing all the preventive action and that we're
    all-hands-on-deck, so to speak. The Army's suicide rate has
    doubled from 2004 to now, from 9.6 per 100,000 to 20.2. Any
    indication as to why, General Chiarelli?
        General Chiarelli. Senator, I'm amazed every day at the
    resiliency of the Force, but I also know that it is a stressed
    and tired Force. You can look at the numbers and try to make
    yourself feel it's not totally dependent on that stress, by
    looking and saying that one-third of those individuals don't
    have any deployment history at all.
        Senator Graham. Right.
        General Chiarelli. But, I just don't think that's the case.
    I think it's a cumulative effect of deployments that run from
    12 months to 15 months. I think most of America thinks that we
    are off the 15-month deployment; we will not get our last
    brigade back off of 15-month deployment until June of this
    year, and our last combat service support unit, those enablers
    you often hear about, until September 2009. We can do a lot,
    but we can't control the demand, and we expect the demand to
    continue for all of 2009 and into 2010.
        So, if you were to ask me to identify one thing that I
    think has caused that spike, that is, in fact, it.
        Senator Graham. Sure. On the Air Force side, from 2004
    until 2008, the suicide rate has been reduced in half in 2005
    and, this year, is still a third less than 2004. How do you
    account for that? How has the deployment activity in the Air
    Force been from 2004 to 2008?
        General Fraser. Sir, we've actually not seen a direct
    correlation to deployments.
        Senator Graham. Have you been deployed substantially from
    2004 to 2008?
        General Fraser. Yes, sir. In fact, if you take into account
    Operations Northern Watch and Southern Watch, we have actually
    been engaged for over 18 years in a rotation and in a cycle.
        We think that the most positive thing that we did was our
    Air Force Suicide Prevention Program, in those 11 initiatives,
    and the fact that we continue to review those and bring in
    other things that we can do to take care of our airmen and to
    take care of their families. However we're not resting on that,
    because we have seen, as the chairman pointed out in his
    opening remarks, a bit of a tick up, if you please. We have to
    stay on top of this.
        Senator Graham. From the 30,000-foot level here, for the 4-
    year period I just described, Air Force deployments have not
    come down. Is that a fair statement?
        General Fraser. That's correct, sir.
        Senator Graham. They probably have gone up, I would
    imagine. But, your suicide rates have come down. We just need
    to know more about the Air Force program, I suppose.
        Now, on the Navy/Marine Corps side, I may be wrong, but it
    seems like you've had a pretty consistent suicide rate from
    2004 to 2008. Is that correct?
        Admiral Walsh. For Navy, that's correct, sir.
        Senator Graham. Okay. What about the Marine Corps?
        General?
        General Amos. Sir, we've gone up. Since 2006, 2007, and
    2008, we've gone up at a rate that's unacceptable.
        Senator Graham. Okay. Now, what do you attribute that to,
    General?
        General Amos. Sir, I think it's a lot of what General
    Chiarelli talked about. I mean, it's the reality of where we
    are with the stress on the Force, and it's exacerbated by
    deployments. We are a very deploying force. Senator, many of
    our units are right around the one-to-one deployment-to-dwell
    ratio. So, that's the reality of the demand side of it right
    now. But, in our Service, the thing that exacerbates this is,
    we are the youngest Service. Not only are we the smallest
    Service, but we are the youngest. For instance, today we have a
    little over 201,000 marines on Active Duty; 160,000 of those
    are on their first 4-year enlistment. So the typical age of our
    marines is very, very young. So they fit this model of 18- to
    24-year-old male and, again, on his first enlistment, or hers,
    that become the prime candidate to take their life. I think
    it's a host of things that are stressors on our young marines.
    The answer is the resilience, and the answer, I think, from our
    perspective, is going to be the NCO.
        Senator Graham. Finally, as to the Navy, what would be your
    view of fairly level rates?
        Admiral Walsh. This is very difficult to penetrate with a
    program. I'm from a generation of naval officers who remembers
    exactly where they were when Admiral Boorda committed suicide
    as the CNO in May 1996.
        This has been difficult to penetrate. We started our
    program in 1998.
        Senator Graham. Have your deployment schedules gone up or
    down from 2004 to 2008?
        Admiral Walsh. Our deployment rates have increased. Our
    dwell time has been preserved. Our most vulnerable population
    is the individual augmentees who come outside of the typical
    deployment patterns for Navy.
        Senator Graham. Have they had a higher suicide rate than
    the Service as a whole?
        Admiral Walsh. No, sir. One individual augmentee and one
    who returned from individual augmentee status about 18 months
    later.
        Senator Graham. Okay.
        Mr. Chairman, I'd like to put these charts into the record.
    I think they're pretty informative.
        Senator Ben Nelson. Without objection.
        [The information referred to follows:]

        Senator Ben Nelson. Senator Collins.
        Senator Collins. Thank you, Mr. Chairman.
        Mr. Chairman, let me first thank you, Senator Graham, and
    Senator Cornyn for your leadership on this extraordinarily
    troubling issue.
        I want to commend the members of our panel for the actions
    that you're taking in each of the Services to address this
    issue in a forthright manner. I think the kinds of tapes,
    videos, publications, cards, and guidance that you're providing
    are excellent, and they'll be extremely helpful as they're used
    more widely.
        I am concerned, however, about the problems that occur
    after the men and women come home from deployment or after they
    have been discharged. When I look at the cases that we have had
    in Maine, they involve soldiers who have come back home and do
    not have the kind of support system that you have described
    today as being potentially effective.
        For example, I remember well a young soldier who came home
    from Iraq missing a limb, was discharged from the Service, went
    back to his small community in Maine, was very isolated and no
    longer getting the support that he needed, and attempted to
    commit suicide after a number of months. In another case, a
    National Guard member who came back home, back to his civilian
    life, did successfully commit suicide.
        What struck me in hearing your testimony today is, it's
    evident that the military Services are taking this problem very
    seriously and are developing good programs and procedures. But,
    I'd like each of you to discuss how you're coordinating with
    the Department of Veterans Affairs (VA), for example, and the
    National Guard, because the problems I'm seeing in Maine
    involve the members of the Guard who have come back home to
    resume their civilian lives or, in some cases, it's people who
    have gotten out of the Services. So, what kind of aftercare, if
    you will, or coordination, is being provided for those who have
    been recently discharged but have serious problems and need
    mental health services?
        General, we'll start with you and go down the table.
        General Chiarelli. Well, this is a real issue for us. When
    you get psychologists and psychiatrists in a room, you can get
    them to agree on little, but most of them will agree that those
    that are found in geographically isolated areas have a higher
    incident of suicide. The Army Science Board, who did a study
    for us, proved that to be the fact. They said it was
    statistically provable that that is, in fact, a true statement.
    When you realize that over half of the Army, in our National
    Guard and Reserve components, go on Active Duty and then do
    exactly what you described, Senator, return to their
    communities, we have to find a way to deliver those services to
    them.
        One of the things that I think is having a big benefit
    today is the Yellow Ribbon Program, where National Guard and
    Reserve units come back at the 30-, 60-, and 90-day period and
    go through some reintegration training, much the same as the
    Active component does for 10 days when they come back. I think
    you know that the desire has always been to demobilize the
    National Guard and the Reserves as fast as you possibly can,
    and I think that is sometimes to their detriment. I think the
    Yellow Ribbon Program goes a long way in getting us to where we
    need to be in providing them those services.
        But, we're also looking for innovative ways to provide
    mental healthcare online. In the National Defense Authorization
    Act, there was some language put in by Representative Dicks,
    who asked us to go out and look at the possibility of doing
    this. I think it shows great promise. It's not without
    problems. The credentialing of a doctor that lives in North
    Dakota giving advice to a soldier that's in California, across
    State lines, raises some problems that we're working our way
    through. There are also problems in finding the way to pay for
    this and to work it into the overall TRICARE plan. But, these
    are the kinds of things we're doing to try to deliver these
    things to the majority of our population that do return, many
    times to geographically isolated locations away from the
    support of our posts, camps, and stations.
        Senator Collins. Thank you.
        Admiral Walsh?
        Admiral Walsh. Senator, while we don't have the Guard
    issue, I would apply it to our Reserves.
        Senator Collins. Right.
        Admiral Walsh. The issue in the Reserves is having
    visibility on reservists. So, those who affiliate, those who
    serve, are part of our database. We've had success with
    programs for our severely wounded, ill, and injured who are
    transitioning out of DOD and through the VA system. That Safe
    Harbor Program today has about 250 or so personnel. We've had
    no incidence of suicide in that kind of framework, where we
    have good control over, and maintain contact with, people as
    they make their transition from DOD through the nonmedical
    sorts of services that they need. It's a support system, and
    one that's accountable to the active line.
        Where we are less visible, where we have less control, are
    those reservists who no longer affiliate and move on into the
    civilian population. We do not have visibility on them. So we
    have less programmatic impact on them.
        Senator Collins. Is there coordination with the VA
    healthcare system to try to help in that area?
        Admiral Walsh. I know there are initiatives underway,
    ma'am, in order to do that, but I can take that for the record
    and get back to you. [Refer to the questions for the record
    section for a variety of programs, coordination, and treatment
    explanations.]
        Senator Collins. Okay.
        General Amos?
        General Amos. Senator, we don't have a Guard; we have
    Reserves.
        Senator Collins. Right.
        General Amos. But, we are a total force, and all our
    Reserves, for the most part, are deployed at least twice in the
    Reserves. So, we are actually integrated, and we track them
    very carefully. When we talk about programs, whether it be
    mental health programs, tracking wounded, or care for families,
    we really talk about everybody, together--the 239,000 Active
    and Reserve marines. We bring them together, and they are an
    integral part of that.
        The Wounded Warrior Regiment (WWR), when it has stood up by
    our Commandant 2 years ago, was designed to provide the
    continuity of care and attention that marines want to provide
    for those that are wounded. Right now, we have a little over
    8,800 marines that have been wounded, many of whom stayed on
    active duty, but a large percentage of them have moved on into
    the VA and on to the next parts of their life. We track all
    8,800 through the WWR. We have the call center that was
    established a year and a half ago and made over 37,000 phone
    calls. They call the wounded marines, they call their mothers,
    and they call their wives. The idea is to ask, ``How are you
    doing?'' You get a lot simply by talking to mothers, sometimes,
    because the marine himself may not give you the straight scoop,
    but we've found, over time, moms will and wives will. So, we
    track that.
        Where I think there's work to be done, in our case, is with
    those marines that perhaps would qualify or be classified as
    someone that has a mental health issue and otherwise are
    perfectly fine; their bodies are healthy and whole, maybe
    something happened that caused them to seek a mental health
    provider, and then they finish their enlistment and they move
    on to the next part of their lives. We don't track them,
    because they're not a wounded marine, necessarily. They're
    wounded if it's PTSD, and we track some of those that are more
    severe. But, I would say, if there's work to be done, it's
    probably in this area, where we take a young marine that's
    faithfully served and has some type of mental health issue, and
    we do the battle handover to the VA. I don't think we're doing
    that right now, and I think it's something that we need to do.
        Senator Collins. Thank you.
        General Fraser?
        General Fraser. Senator, we too are a total force, and all
    the tools that are available to the Active Duty, the Guard, and
    the Reserve both participate in. So they're a part of our
    Suicide Prevention Program, and have access, and we utilize all
    of those tools to help them.
        But, once they go home, there are issues that come up. One
    of the things, though we've not hesitated to do, and we've
    worked through this, is that, if they need help, we will
    immediately help assist them, the Guard or the Reserve, to get
    them back on orders and get them the help they need.
        Senator Collins. Good.
        General Fraser. There's no time lost if it's identified
    that someone needs help. We're part of the Yellow Ribbon
    Program, and we're doing all kinds of other things. The Landing
    Gear, which I've not talked about, is another program where we
    think that that's beginning to pay dividends, too. That program
    is across all of the Active Duty, the Guard, and the Reserve
    now, which helps, both in the predeployment, on expectations
    and an understanding of the individual and where they are, but
    post, when they come home and then--if they need some follow-
    on--because we are seeing a large increase in PTSD. Ensuring,
    as General Amos was talking about, that we take care of them
    and continue to follow on is a key thing that we're doing. But,
    that's just an example of some of the things.
        Senator Collins. Thank you.
        Mr. Chairman, I know my time has expired. Just a suggestion
    for our panel. I realize my time has expired, so I won't ask
    for a response today, but in your response to the record, and
    that is, as a result of work that many of us on this committee
    have done, there now is screening for TBI, both pre- and post-
    deployment. I wonder if that could be expanded to also be a
    screen for mental health problems. If you did it predeployment,
    and that's the concept to identify TBI, then you'd have a
    baseline that you could compare with post-deployment screening.
    If you did it as part of the screening for TBI, there would not
    be any stigma attached to it, and yet, you might be able--I
    mean, we all want to eliminate that stigma, but we have to
    recognize that it exists--as part of that review, identify
    those with problems or at risk. That's just something I'd like
    the panel to consider.
        Senator Collins. Finally, Mr. Chairman, I really think the
    issue of the handoff to the VA is absolutely critical because
    that's the case of the young soldier who lost his leg, who
    tried to commit suicide; he was living in rural Maine, in a
    very small community, very far from the VA hospital. He was
    having problems with this prosthesis. He couldn't get the
    answers he needed. He became depressed and frustrated. We just
    have to find a way to reach people like that, and the VA system
    has to be part of the solution.
        Thank you for your indulgence.
        Senator Ben Nelson. Thank you, Senator. The effort to make
    the transition from Active Duty or from Guard/Reserve
    deployment to the VA, to make that as seamless as possible, is
    a wonderful exercise and recognizes the importance of having it
    be a continuum, as opposed to dropping off the cliff.
    Obviously, it's very difficult to make it happen in rural
    areas, as much as we would like, but it's obviously very
    important to have it extended into the rural areas, as well.
    So, I would agree with you and I hope that the panel would look
    for that, as well as the pre- and post-screening. I think
    there's a great deal of benefit to be gained from doing it that
    way.
        Thank you, Senator.
        Senator Collins. Thank you.
        Senator Ben Nelson. General Fraser, I have a question. It
    was in your written testimony, you indicated that the medical
    record reviews of many of the recent victims indicate that a
    majority of the suicide victims had utilized some form of
    mental health services for issues ranging from alcohol abuse to
    marriage counseling.
        While it's clear that they reached out for some help, as
    their medical records would indicate, they still committed
    suicide. I suppose it's easy to say that the mental health
    services are ineffective even, as a result, that's what
    happened. But, I don't know that that's a conclusion we want to
    draw, necessarily. What are your thoughts on that fact? Prior
    use of mental health services, and yet, it was not or may not
    have been sufficient; it also could be something else that came
    along.
        General Fraser. Thank you, Sir. That is something that we
    are trying to understand better. Because of that, anyone who
    was participating or receiving any kind of help, mental health
    assistance, counseling, or things of that nature, is reviewed
    after suicide. We have instituted and that we are now doing, is
    also a medical incident investigation. So, there's a follow-on
    investigation that's going to take place, so that our mental
    healthcare providers can understand that better. Was there
    something that happened in their care, in the runup to it, or
    other things that they may have missed, was there a seam? So,
    we are working this, not only when there's a suicide that's
    actually committed; there's the normal investigations that we
    do--normal, in the sense that we bring in a team, it's
    investigated. Our Office of Special Investigations and our
    security forces do that and give feedback to the commander. If
    it is found that they've had some care given, we also launch
    off on one of these other investigations to better understand
    that so that we can then input that into the system to try and
    shore that up even better. So, we're continuing to work it,
    sir. There's no one seam through that, either.
        Senator Ben Nelson. It's obvious that we've gotten pretty
    good at following the physical health of individuals, being
    able to document injuries, recovery, with complete medical
    records. We don't have the capability yet to be able to do that
    on the mental health side, for a variety of reasons. We've
    already indicated, stigma and identification, and perhaps even
    the identification by the soldier, by the airman, by the
    marine, by the sailor. So, hopefully we'll be able to be as
    effective with mental health records and support to be able to
    do that as we are on the physical side, ultimately.
        One other question I have is--I think it was General
    Chiarelli, you said ``learning to cope,'' trying to identify,
    at the time that you bring individuals in, that you identify,
    in your own minds, the ability of that person to cope with the
    strains, the stress, and everything that would come along in
    their military career. Are the other branches focused more on
    mental health upfront to determine the ability of the recruit
    to cope, not just simply with basic training, but to just cope
    with life's challenges that are obviously going to affect them:
    the breakup of a romantic relationship or financial problems
    that might develop?
        Admiral Walsh?
        Admiral Walsh. Coping for the recruits is a very important
    part of the program; however, empirically the data suggests to
    us that the 63 percent of those who commit suicide in the Navy
    are in the E4 to E6 category. These are our mid-grade petty
    officers. When we look further at it, what this suggests to us
    is that, what we really need to be looking at is, Who's looking
    after supervisors, who's looking after leaders, who's giving
    them the outlet that they need? We look at this by rating; we
    find corpsmen have a statistically high number, an unacceptable
    number. When we talk about mental health professionals, we also
    have to think about their dwell time and how much stress is on
    them because who looks after the providers is not a common
    question, and it's one that leaders need to ask.
        Senator Ben Nelson. General Amos?
        General Amos. Sir, General Chiarelli and I were meeting
    last week on TBI with General Sutton, working our way through
    how we can continue to provide a focus on that. One of the
    things that came out of that was the reality of most of the
    referrals and most of the folks that actually can put their
    fingerprints on a young man or young woman in distress really
    aren't necessarily the front-line mental health providers. Now,
    we say that, but really, in many cases, I think somewhere
    around 60 percent are the standard primary healthcare folks. In
    other words, it's your battalion surgeon, it's your doctor,
    your corpsman or medic, it's the chaplain. So, for us, our
    focus for the next little bit is going to make sure it's the
    whole body, it's everybody paying attention, taking care of one
    another, understanding that we don't leave anybody behind.
    Everybody plays an important part in this. That's where we're
    headed, sir.
        Senator Ben Nelson. General Fraser?
        General Fraser. Sir, we think that it begins at the
    accession, and we begin, right away, assessing those young
    airmen and understanding where they are. We also are
    institutionalizing our Wingman Program from the very beginning,
    even in the basic military training. We see that down there
    nowadays, even as we've expanded basic military training.
    They're working more together as a team. As you see them out
    running, as you see them out running the obstacle course, doing
    things, if one gets ahead, they're falling back, they're
    helping the others along. So, institutionalizing that from the
    beginning in those wingmen, and helping each other, we think
    that's going to pay great dividends.
        These assessments that we're doing are telling us a lot,
    though. The annual Physical Health Assessments, but also the
    pre-, the post-, and then the follow-on reassessments that are
    going on, we're learning a lot from that, and that's how we're
    able to follow up. Then we begin to get a history, and then you
    can understand the individual and where they are.
        The other thing is working with the families, working with
    the families through a key spouse program, working through the
    issues that they may have, to help us understand where they are
    because maybe we'll be able to see that there's a relationship
    problem there that we are able to address and help earlier on.
        The other thing is training the supervisors, the leaders,
    the flight commanders at every single level to understand and
    look for indicators. We've formalized that training, also, so
    that they have the tools in their kitbag that they can utilize
    to take care of their airmen. So, it's a holistic approach,
    again. But, it does begin on day one with the accession.
        Thank you, sir.
        Senator Ben Nelson. Senator Graham?
        Senator Graham. I know we want to get to the next panel.
    Gentlemen, just one quick question. I want to make sure I have
    your testimony right. Do you believe there's a shortage of
    mental health counselors in the military?
        General Chiarelli. There is in the Army, sir. Senator,
    there is in the Army, both on mental healthcare providers--
    although we have raised that number by some 250, there's no
    doubt in my mind we are short--and also substance-abuse
    counselors.
        Senator Graham. Right.
        Admiral Walsh?
        Admiral Walsh. Yes, sir. For the Navy, we're asking for
    more.
        Senator Graham. Okay.
        Admiral Walsh. We are at 88 percent of the fill that we
    need.
        Senator Graham. Okay.
        General Amos. Senator, you know we don't have medical in
    our Corps, but we rely on the Navy, and we are significantly
    short.
        Senator Graham. Right. You have the Navy folks.
        General Fraser. Sir, we are short in our active duty
    authorizations. We do not have them all filled.
        Senator Graham. My question is, is there anything this
    subcommittee can do, in terms of bonuses, you name it, to help
    recruit more people into this area?
        General Chiarelli. I can't tell you that at this time. I
    can tell you that we have a rough time. We have the resources
    out there to hire right now, but when you go to places like
    Fort Drum, Fort Campbell, Fort Hood, TX, in a specialty that is
    short already across the country, it is difficult, even with
    the money, to hire what you need.
        Admiral Walsh. Sir, we're aware of the nationwide shortage
    in mental health professionals, but the concept that we think
    works, in terms of operations with mental health, is to have
    them deploy with us. So, they need to come along and preferably
    serve in uniform the way the Assistant Commandant of the Marine
    Corps, General Amos, described.
        Senator Graham. Yes, well, we stand ready, if you think of
    something down the road, General. What I've gotten from this,
    it seems like the deployment activity of the Marine Corps and
    the Army obviously are putting more stress on servicemembers. I
    mean, that makes sense when you think about the missions of the
    Marine Corps and the Army in this particular war, and the Navy
    and the Air Force have done things never envisioned for the
    Navy and the Air Force, in terms of ground commitments. I can
    understand why the numbers are higher for the Army and the
    Marine Corps because deployments are longer and it's the nature
    of your work. So, I know you're on top of it, doing the best
    you can. All I can say is that, where this subcommittee can
    help inform the committee, as a whole, about how to make up for
    the shortage, we stand ready. If it's money, and that will
    help, I think we're ready to help with money.
        Thank you.
        Senator Ben Nelson. Thank you, gentlemen. Thank you,
    particularly, for waiting and being patient with the delayed
    start. Thank you for your service to our country. For the men
    and women who serve under you, we thank them as well.
        In our final panel, we welcome Lieutenant General Benjamin
    C. Freakley, who is the Commanding General of the United States
    Army Accessions Command. We all appreciate that recruiting is
    one of the most demanding, challenging jobs in any military
    service. In addition to the long hours, many recruiters work in
    remote areas, without the traditional support structures in
    place to help deal with stress, including the residual effects
    of prior deployments. General Freakley is charged with
    overseeing all Army recruiters and is here to discuss the
    results of his investigation into the recent suicides in the
    Houston Recruiting Battalion and actions taken throughout the
    entire Army to reduce the risk of suicide among recruiters.
        We welcome you.
        We also have with us Major General David A. Rubenstein,
    Deputy Surgeon General of the Army. He's here to discuss the
    role of the Army Medical Command in suicide, mental health, and
    substance abuse prevention, research, and treatment.
        Brigadier General Loree K. Sutton is the Director of the
    Defense Centers of Excellence for Psychological Health and
    Traumatic Brain Injury. She'll discuss the role of the Defense
    Centers of Excellence for Psychological Health and Traumatic
    Brain Injury in suicide prevention, and, as a piece of that,
    will address the status of DOD's establishment of the task
    force to examine matters relating to prevention of suicide by
    members of the Armed Forces required by the National Defense
    Authorization Act for Fiscal Year 2009.
        Also with us today is Brigadier General Michael S.
    Linnington. He is the Commandant, U.S. Corps of Cadets at the
    United States Military Academy. He's here to address the recent
    suicides and suicide attempts at West Point and specific
    actions that have been directed to prevent suicide at the
    Academy.
        Finally, we are honored to have a representative from the
    civilian sector, Ms. A. Kathryn Power, who is the director of
    the Center of Mental Health Services within the SAMHSA, which
    is under the HHS. Ms. Power has a long career of outstanding
    public service, including participation in the DOD Task Force
    on Mental Health, whose report we all consider a valuable
    resource. She will share views from the public health
    perspective. Her testimony will address suicide rates and
    causal factors in comparable U.S. civilian population groups.
    She'll also discuss best practices in suicide prevention from
    the civilian community that could be effectively applied in a
    military environment and ongoing and potential Federal agency
    collaboration efforts that could prevent suicides among members
    of the Armed Forces.
        We thank you all for taking time to be here today, and we
    look forward to hearing from you. Thank you.
        General Freakley?

    STATEMENT OF LTG BENJAMIN C. FREAKLEY, USA, COMMANDING GENERAL,
       U.S. ARMY ACCESSIONS COMMAND, DEPUTY COMMANDING GENERAL,
                       INITIAL MILITARY TRAINING

        General Freakley. Chairman Nelson, Ranking Member Graham,
    and distinguished members of the subcommittee, thank you for
    the opportunity to appear before you today.
        The subject we address is a tragic one. Suicide is a
    national problem, one to which the Army is not immune. When a
    soldier, civilian, or family member commits suicide, we, the
    Army at large, lose a brother or sister, a comrade in arms, a
    member of our Army family. Each loss is a tragedy, with any
    number of people asking how they could have done something
    differently to prevent this death.
        The motivation to commit suicide is rarely simple and often
    complicated by medical issues, family and personal
    relationships, job stress, and financial concerns. Army
    recruiters have particularly stressful jobs, and we are looking
    at their circumstances to determine how we provide them
    additional support.
        Between January 2005 and September 2008, there were four
    suicides within the United States Army Recruiting Battalion at
    Houston, TX. I directed an Army regulation 15-6 investigation
    to look into the factors existing with each suicide, and I
    appointed Brigadier General Frank D. Turner III, U.S. Army
    Accessions Command, Deputy Commanding General and Chief of
    Staff, to conduct this external investigation. The
    investigation thoroughly examined personal, organizational, and
    institutional factors that might have impacted the four
    soldiers.
        General Turner's investigation concluded that there was no
    single cause for these deaths. Relevant factors included
    stress, personal matters, and medical problems. Additionally, a
    poor command climate was perpetuated by a few individuals
    within the battalion, compounded by an artificially inflated
    mission placed on each recruiter. The command climate and
    inflated mission manifested in long hours and unpredictable
    schedules.
        United States Army Recruiting Command leads over 7,000
    full-time soldiers to recruit for the regular Army and over
    1,700 Reserve soldiers to recruit for the United States Army
    Reserve. Maintaining the All-Volunteer Force is a challenging
    task. Engaged, caring, and compassionate leadership is
    necessary to maintain the proper balance between mission
    accomplishment and ensuring the well-being of our recruiters
    and their families.
        Approximately 70 percent of the United States Army
    Recruiting Command personnel live in areas that are considered
    geographically dispersed. That means they live away from
    military installations and do not have ready access to care and
    peer support networks that they have come to expect, to include
    military medical facilities. Peer support networks are often
    difficult to maintain in recruiting, as most personnel live in
    surrounding communities, not on installations where soldiers
    can easily socialize.
        The investigation made several recommendations that we are
    addressing across Recruiting Command, Accessions Command, and
    the United States Army. General Turner's investigation found
    that there is nothing inherently problematic with combat
    veterans being assigned to recruiting duty after returning from
    a deployment, as compared to a wide range of other challenging
    Army assignments. Although post-deployment screening was not
    found to be a factor for any of the suicides in the Houston
    Battalion, improvements are required in reintegration policy
    compliance, post-deployment continuity of care, and ensuring
    assignment policies consider the special needs of soldiers and
    families, especially those assigned to communities away from
    military installations.
        In addition to the actions that we're taking, Accessions
    Command, the Army G-1, the Surgeon General, have adopted
    procedures to ensure compliance with recruiter screening and
    the selection process, the provisions of care for soldiers who
    require mental healthcare, Army-wide suicide training, and
    access to care in peer-support networks for geographically
    dispersed soldiers. The Army and the Command are taking very
    specific action to prevent future suicides. Leadership has
    changed in the Houston Battalion, and Recruiting Command has
    conducted an initial inspection that showed the command climate
    and morale is much improved. A formal Inspector General
    investigation will be conducted in the Houston Battalion in
    June of this year.
        At my request, the Department of the Army Inspector General
    is conducting a command-wide inspection of the recruiting work
    environment. The Secretary of the Army, the Honorable Pete
    Geren, directed a stand-down day, and this one was conducted
    across Recruiting Command on February 13, to address the
    complex issue of suicide and leadership to enforce a positive
    climate for our soldiers and their families.
        Additional suicide prevention training is being conducted
    across the Army as we work to change perceptions regarding
    mental health, increase awareness of suicide, and improve
    leadership.
        The Army G-1, through the Human Resources Command, is
    adapting screening and selection processes for prospective
    recruiters. The Army's Office of the Surgeon General and the
    Recruiting Command are developing recruiter-specific mental-
    health screening tools to be used in those processes.
        The Recruiting Command is revising its regulation to remove
    any ambiguity about mission assignment procedures.
    Additionally, we are implementing training programs at the
    Recruiting and Retention School to improve recruiter
    resiliency.
        Additionally, across Cadet Command over 4,600 gun cadets,
    who will be this year's new lieutenants, are being trained in
    suicide awareness so that they reduce the stigma and are aware
    of the young soldiers joining their formations.
        To address care and peer network support, we are developing
    a pilot program to assess the feasibility of mobilizing Reserve
    soldiers in their hometown as regular Army recruiters, under
    the premise that Reserve soldiers are already actively engaged
    in their community and have a well-established support network.
        We have received significant support from the Army
    leadership. The Secretary of the Army, the Honorable Pete
    Geren, has taken personal interest in this matter at every
    step, and offered support within his authority, as has the
    Chief of Staff of the Army and the Vice Chief of Staff. Losing
    soldiers to suicide is intolerable. Army senior leaders have
    acted swiftly to support recruiters and soldiers Armywide in
    laying the groundwork for understanding that there is no stigma
    attached to seeking mental healthcare and improving the
    education to all of our soldiers to be self-aware and aware of
    their buddies with suicide awareness. We expect that our focus
    on these issues, along with additional training and concerned
    leadership throughout our command, that our soldiers will seek
    the help they need before considering a tragic act.
        We thank you, sir, and the committee, for all of your
    attention to this matter, your continuing support to our Army,
    our command, and to our soldiers and their families.
        [The prepared statement of General Freakley follows:]
              Prepared Statement by LTG Benjamin C. Freakley, USA
                                  introduction
        Chairman Nelson, distinguished members of the subcommittee, thank
    you for the opportunity to appear before you today. The subject we
    address today is a tragic one. Suicide is a national problem, one to
    which the Army is not immune. When a soldier, civilian, or family
    member commits suicide, we--the Army at large--lose a brother or
    sister, a comrade in arms, a member of our Army family. Each loss is a
    tragedy, with any number of people asking how they could have done
    something differently to prevent this death. The motivation to commit
    suicide is rarely simple and often complicated by medical issues,
    family and personal relationships, job stress, and financial concerns.
    Army recruiters have particularly stressful jobs, and we are looking at
    their circumstances to determine how we provide them additional
    support.
                                houston suicides
        Between January 2005 and September 2008, there were four suicides
    within the U.S. Army Recruiting Battalion at Houston, TX. I directed an
    Army Regulation 15-6 investigation to look into the factors existing at
    the time of each suicide, and I appointed Brigadier General Frank D.
    Turner III, U.S. Army Accessions Command Deputy Commanding General and
    Chief of Staff, to conduct the investigation. The investigation
    thoroughly examined personal, organizational, and institutional factors
    that might have impacted the four soldiers. General Turner's
    investigation concluded that there was no single cause for these
    deaths. Relevant factors included stress, personal matters, and medical
    problems. None were diagnosed with Post-Traumatic Stress Disorder.
    Additionally, a poor command climate was perpetuated by a few
    individuals within the battalion, compounded by an artificially
    inflated mission placed on each recruiter. This command climate and
    inflated mission manifested in long hours and unpredictable schedules.
                               recruiting command
        The U.S. Army Recruiting Command employs over 7,000 full-time
    soldiers to recruit for the Regular Army and approximately 1,700
    Reserve soldiers to recruit for the U.S. Army Reserve. Maintaining the
    All-Volunteer Force is a challenging task. Engaged, caring, and
    compassionate leadership is necessary to maintain the proper balance
    between mission accomplishment and ensuring the well-being of our
    recruiters and their families.
        Approximately 70 percent of the U.S. Army Recruiting Command
    personnel live in areas that are considered ``geographically
    dispersed.'' That means they live away from military installations and
    ready access to the care and peer support networks they have come to
    expect, to include military medical facilities. Peer support networks
    are often difficult to maintain in recruiting, as most personnel live
    in surrounding communities, not on an installation where soldiers can
    easily socialize.
                                lessons learned
        The investigation made several recommendations that we are
    addressing across the Recruiting Command and the Army. General Turner's
    investigation found there is nothing inherently problematic with combat
    veterans being assigned to recruiting duty after returning from a
    deployment, as compared to a wide range of other challenging Army
    assignments. Although post-deployment screening was not found to be a
    factor for any of the suicides in Houston Battalion, improvements are
    required in reintegration policy compliance, post-deployment continuity
    of care, and ensuring assignment policies consider the special needs of
    soldiers and families, especially those assigned to communities away
    from military installations.
        In addition to the actions that we are taking, Accessions Command,
    the Army G1, and the Surgeon General have adopted procedures to ensure
    compliance with the recruiter screening and selection process, the
    provisions of care for soldiers who require mental health care, Army-
    wide suicide training, and access to care and peer support networks for
    geographically dispersed soldiers.
                                   way ahead
        The Army and the command are taking very specific action to prevent
    future suicides. Leadership has changed in Houston Battalion, and the
    Recruiting Command has conducted an initial inspection that showed
    command climate and morale is much improved. A formal Inspector General
    inspection will be conducted in the Houston Battalion in June of this
    year. At my request, the Department of the Army Inspector General is
    conducting a command-wide inspection of the recruiting work
    environment. The Secretary of the Army-directed ``stand-down day'' was
    conducted across the Recruiting Command on February 13 to address the
    complex issues of suicide. Additional suicide prevention training is
    being conducted across the Army, as we work to change perceptions
    regarding mental health.
        The Army G1, through its Human Resources Command, is adapting
    screening and selection processes for prospective recruiters. The
    Army's Office of the Surgeon General and the Recruiting Command are
    developing a recruiting-specific mental health screening tool to be
    used in those processes.
        The Recruiting Command is revising its regulation to remove any
    ambiguity about mission assignment procedures. Additionally, we are
    implementing training programs at the Recruiting and Retention School
    to improve recruiter resiliency.
        To address access to care and peer network support, we are
    developing a pilot program to assess the feasibility of mobilizing
    Reserve soldiers in their hometown as Regular Army recruiters, under
    the premise that Reserve soldiers are already actively engaged in their
    community and have a well-established support network.
        We have received significant support from Army leadership. The
    Secretary of the Army, the Honorable Pete Geren, has taken a personal
    interest in this matter at every step and offered all support within
    his authority.
                                   conclusion
        Losing soldiers to suicide is intolerable. Army senior leaders have
    acted swiftly to support recruiters and soldiers Army-wide in laying
    the groundwork for understanding that there is no stigma attached to
    seeking mental health care. We hope with our focus on these issues,
    along with the additional training and concerned leadership from all
    levels, all soldiers will seek the help they need before considering a
    tragic act. Thank you for your attention to this matter and your
    continuing support to the Army.

        Senator Ben Nelson. Thank you.
        General Rubenstein?

       STATEMENT OF MG DAVID A. RUBENSTEIN, USA, DEPUTY SURGEON
                      GENERAL, UNITED STATES ARMY

        General Rubenstein. Chairman Nelson, Senator Graham,
    Senator Thune, thank you for bringing us together to discuss
    this very complex and very difficult issue of suicide in our
    ranks.
        I'd like to tell you a story about a 33-year-old soldier at
    one our largest Army posts. He's married. He lives at home with
    his wife and his three children. He's assigned to the Warrior
    Transition Unit (WTU) of his post because of a motorcycle
    accident 2\1/2\ years ago that left him with a TBI. He is a
    model patient in every regard.
        He's been treated by the same psychiatrist for the past 2
    years and 1 month. He saw that psychiatrist on Friday of last
    week. On Monday, he saw his primary care doctor. He also saw
    his nurse case manager, and he had a group life-skills
    appointment. On Tuesday, he apparently committed suicide.
        We lost a soldier yesterday. We have a hole in our
    formations. We have a devastated family. We have a devastated
    unit. We have a TBI Clinic which is absolutely devastated. This
    soldier was used as a motivational speaker once a week in the
    TBI Clinic, talking to other soldiers for the past 2 years. Of
    course, we have individual healthcare providers who are
    devastated.
        This soldier was treated, was compliant, and was supported
    in every way, and yet, he's dead today.
        Thank you, again, for bringing us together to talk about
    this very complex, very difficult problem that causes all of us
    to scratch our heads and wonder how we stop the next one.
        I look forward to your questions, sir.
        [The prepared statement of General Rubenstein follows:]
               Prepared Statement by MG David A. Rubenstein, USA
        Chairman Nelson, Senator Graham, and distinguished members of the
    Personnel Subcommittee, thank you for the opportunity to discuss the
    Army Medical Department's efforts to support suicide prevention efforts
    across the Army. The increased operational demand of our military force
    to fight overseas contingency operations has stressed our Army and our
    aamilies. Despite our varied efforts over the last several years,
    suicide rates continue to rise. The Army and the Army Medical
    Department (AMEDD) are extremely concerned about this trend and we are
    committed to doing whatever it takes to prevent suicide. The AMEDD is
    contributing medical expertise to the suicide prevention task force
    recently established by the Army Vice Chief of Staff, General Pete
    Chiarelli, to address suicide and suicide prevention. This multi-
    disciplinary task force, led by Brigadier General Colleen McGuire, will
    integrate all of the diverse suicide efforts ongoing across the Army;
    build on these efforts; and develop a comprehensive strategy for
    suicide prevention that involves screening/surveillance, suicide
    prevention training, risk assessments, and treatment.
        The Army Medical Department supports the Army's multidisciplinary
    approach in many ways. Our most significant contributions are in the
    arenas of surveillance and treatment. We have made recent improvement
    in each of these areas.
                            surveillance in theater
        The Army's groundbreaking Mental Health Advisory Teams (MHATs) have
    shown that longer deployment, multiple deployments, greater time away
    from base camps, and combat frequency and intensity all contribute to
    higher rates of post-traumatic stress disorder, depression, and marital
    problems. All of these factors can contribute to increasing suicide
    rates. MHAT V findings show that rates of mental health problems rose
    significantly with each deployment, reaching nearly 30 percent among
    soldiers on their third deployment to Iraq. The 2007 effort also showed
    that soldiers in brigade combat teams deployed to Afghanistan are now
    experiencing levels of combat exposure equivalent to levels in Iraq,
    and that the rate of mental health problems is comparable between these
    two countries as well.
        The data from all the MHAT assessments have led to a number of
    important policy changes. The data have been used to improve the
    training and distribution of behavioral health personnel in theater.
    They have assured that sufficient mental health personnel (credentialed
    providers and mental health technicians) are deployed in theater and
    are providing support to soldiers at remote locations. The MHAT
    findings were the impetus for revising the Combat and Operational
    Stress Control doctrine and training for behavioral health personnel.
    All behavioral health professionals deploying to theater are now
    mandated to take the new Army Medical Department Combat and Operational
    Stress Control Course. Additionally, MHAT findings have resulted in
    improved training in battlefield ethics and suicide prevention.
        The MHAT assessments further led to the implementation of Army-wide
    mental health training, called Battlemind, for all soldiers and
    leaders. Prior to the conflicts in Iraq and Afghanistan, there were no
    empirically-validated training strategies to mitigate combat-related
    mental health problems. Our behavioral health professionals at Walter
    Reed Army Institute of Research used their MHAT experiences to develop
    the Battlemind training program, a strengths-based approach
    highlighting the skills that helped soldiers survive in combat instead
    of focusing on the negative effects of combat. The Army incorporated
    Battlemind training into the Deployment Cycle Support program in 2006
    and is integrating it into the new Comprehensive Soldier Fitness
    program led by Brigadier General (Dr.) Rhonda Cornum. The intent of the
    Comprehensive Soldier Fitness Program is to increase the resiliency of
    soldiers and families by developing the five dimensions of strength--
    physical, emotional, social, spiritual, and family.
                             surveillance army-wide
        Before 2004, the Army collected data on completed suicides using a
    variety of methods which were not always consistent. Beginning in 2004
    we began the Army Suicide Event Report, where we collected data on both
    completed suicides and serious suicide attempts. This report has
    yielded valuable data which we issue every year in an annual report.
    Now all the Services are using this format, which is called a DOD
    Suicide Event Report (DODSER).
        We have experienced difficulty integrating all of the different
    data sources and providing useful information to commanders. For this
    reason, in the fall 2008, we stood up the Strategic Analysis Cell under
    the Army's Center for Health Promotion and Preventive Medicine (CHPPM)
    to provide actionable intelligence to the Army G-1, the General Officer
    Steering Committee, and leaders Army-wide in an effort to reduce
    suicidal behavior in the Army. CHPPM will obtain non-medical data such
    as command investigations, Criminal Investigation Command reports, and
    Line of Duty reports to integrate with the DODSER and other medical
    data. In addition, they will evaluate nontraditional social outcomes
    data from Army installations (such as incidence of domestic violence,
    behavioral health diagnoses, utilization of mental health resources and
    substance abuse data, as well as other outcomes) for utility in
    generating a broader assessment of community health and resiliency.
        The Post-Deployment Health Reassessment, which does surveillance of
    individual soldiers following deployment, is identifying but failing to
    refer soldiers with alcohol problems to the Army Substance Abuse
    Program; this is something we are seeking to improve, because multiple
    studies have identified alcohol and depression as the major medical
    risk factors for suicide. In an effort to increase early intervention
    in soldiers with alcohol problems, Army senior leadership is examining
    all possible options to increase soldier self-identification and
    referral for alcohol treatment by ensuring confidentiality while
    maintaining good order and discipline in the force.
                                   treatment
        In the area of treatment we have instituted post-traumatic stress
    training for our healthcare providers so that they can accurately
    diagnose and treat combat stress injuries; we are dedicating time and
    energy toward provider resiliency training; and we have hired 250 more
    behavioral healthcare providers and over 40 marriage and family
    therapists to work in our military treatment facilities. We also have
    numerous longer-term efforts to enhance recruitment and retention of
    uniformed behavioral health providers.
        In an effort to provide far-forward treatment, the Services
    collectively deploy 200 behavioral health personnel in support of
    Operation Iraqi Freedom, and about 30 in support of Operation Enduring
    Freedom. We are also seeking to leverage the front end of the medical
    system. The medical asset which knows the average soldier best is the
    platoon medic; the medic is in a position to notice changes in an
    individual Soldier even before he or she presents for medical care. We
    have incorporated a CPR-like training for behavioral health issues into
    every medic's initial training and ongoing certification. Although
    suicides in theater rose from 2003 to 2007, they declined in 2008, we
    believe due in part to implementation of MHAT recommendations and the
    aggressive efforts of medics, providers, and leaders.
        Some experts feel that the best way of reducing population suicide
    rates is better recognition and treatment of depression/anxiety in
    primary care. On average, Soldiers visit primary care about 3.4 times
    annually (not counting specialty visits, vaccines, or dental visits),
    presenting an opportunity for screening. Studies of civilian suicides
    show that more than half of the individuals who commit suicide see a
    primary care provider in the month before taking their life. In 2006
    the Army Medical Command piloted a program at Fort Bragg, intended to
    reduce the stigma associated with seeking mental health care. The
    RESPECT-Mil pilot program integrates behavioral healthcare into the
    primary care setting, providing education, screening tools, and
    treatment guidelines to primary care providers. RESPECT-Mil leads to
    early contact and low stigma intervention options for soldiers
    concerned about the ramifications of seeing a mental health
    professional. Finally, RESPECT-Mil insures that screening and
    recognition occur in a health care context where acceptable and
    effective assistance can be expected and obtained. Based on the success
    of the program at Fort Bragg, the AMEDD expanded implementation of this
    program to 15 sites last year and plans to implement at an additional
    17 sites in 2009.
                                   conclusion
        The challenge in addressing suicide is that, unlike other medical
    problems, those who are suicidal often do not present for care at the
    time when care is most needed.
        Our own data show that once a soldier has a behavioral health
    problem, he is twice as likely as other soldiers to have concerns about
    seeking behavioral health care. That is why our current approaches
    (Battlemind training, Comprehensive Soldier Fitness) educate the
    soldier and other key people in a soldier's life (such as junior
    leaders, buddies, and spouses) to recognize a soldier in need and take
    appropriate action to assist. It is also why efforts to bring the
    medical system to the soldier at key junctures (Post-Deployment Health
    Assessment, Post-Deployment Health Reassesment) and taking full
    advantage of the soldier's contact with primary care for routine health
    care (RESPECT-Mil) also make sense.
        There is no scientifically proven way of preventing suicide except
    in people who have attempted suicide in the past. Unfortunately there
    are multiple risk factors for suicide and no simple solutions. However,
    the Army is moving out on multiple fronts in a coherent and integrated
    approach with General Chiarelli and Brigadier General McGuire leading
    the way. We appreciate the support of Congress and this subcommittee as
    we aggressively work through this difficult problem. Thank you for
    holding this hearing and for your enduring support of our soldiers and
    families.

        Senator Ben Nelson. Thank you.
        General Sutton?

    STATEMENT OF BG LOREE K. SUTTON, USA, DIRECTOR, DEFENSE CENTERS
      OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND TRAUMATIC BRAIN
                                 INJURY

        General Sutton. Chairman Nelson, Ranking Member Graham, and
    other distinguished members of the committee, thank you so much
    for the opportunity to bring you up to date on what DOD is
    doing to address the increase in suicides in such cases as
    Major General Rubenstein and General Freakley have described
    and to discuss our current initiatives to support the Services
    in reducing suicides and saving lives.
        We are committed to ensuring that every warrior receives
    standard-of-care treatment across the continuum of resilience,
    prevention, diagnosis, treatment, recovery, and reintegration.
    Our overarching goal is to do whatever it takes to prevent
    individuals from ever reaching that point of helpless and
    hopeless despair that can lead to suicide. It's about
    strengthening the connections, connections to one's selves,
    one's buddies, one's families, one's leaders, one's community,
    one's nation--mind, body, heart, and spirit.
        To enhance outreach and coordination among DOD, Federal
    agencies, and civilian partners, Centers of Excellence were
    created, thanks to Congress, to address psychological health
    issues and TBI for DOD. In coordination with the VA, academia,
    and many others, DOD established the Defense Centers of
    Excellence for Psychological Health and TBI in November 2007.
    Today, this is better known as DCOE, serving as DOD's open
    front door for all issues related to psychological health and
    TBI, including suicide prevention.
        I would like to tell you about several of our initiatives
    as they relate to preventing the tragedy of suicide.
        In August 2008, we established AfterDeployment.org, an
    interactive Web site for servicemembers and their families to
    explore behavioral health information and to readjust
    successfully to life, returning from deployment. This tool is
    being developed with Web 2.0, 3.0 interactive tools. It's
    currently getting 6,000 hits per month and that is continuing
    to grow. We will build on that tool.
        In November 2008, DCOE sponsored the first Warrior
    Resilience Conference, attended by 300 line warriors and health
    professionals. We brought in former Vietnam veterans, like
    Sergeant Andy Brandy, from New Mexico, who has continued to
    reach out to our warriors, marines, soldiers. He addressed, 2
    weeks ago, 4,000 returning soldiers at Fort Polk. Three
    sergeants in that formation came up to him after the
    presentation and said, ``Sarge, thanks so much for sharing your
    story. I was there. I'm returning from three tours. I thought
    it was me. I thought I was alone. I was going to kill myself
    this weekend.''
        We also brought in Lieutenant Colonel Dave Grossman,
    introduced an innovative community-immersion Philoctetes
    Project, which brings to light the lessons from 2,500 years
    ago, the Trojan Wars, the writings of Sophocles, as well as
    rolled out the resilience-stress continuum, a tool developed by
    warriors--marines, soldiers, Canadian armed-force soldiers--for
    marines, for leaders.
        We also, in January of this year, opened an outreach center
    to answer questions about psychological health and TBI, 24
    hours a day, with members of the military Services, veterans,
    families, healthcare providers, military leaders, and
    employers. We have already received numerous desperate calls.
    We've coordinated closely with the SAMHSA-VA Lifeline to ensure
    that we keep our arms around everyone who contacts us, wherever
    they happen to contact us from. The center can be reached at 1-
    866-966-1020 or by e-mail, at DCOEoutreach.org.
        DCOE recently spearheaded the historic joint effort between
    DOD and VA in cosponsoring the 2009 Suicide Prevention
    Conference, in part to align the efforts of the Suicide
    Prevention Programs across government agencies, healthcare
    professions, and communities. We also, thanks to Bonnie
    Carroll, Executive Director of the Tragedy Assistance Program
    for Survivors, we were able to connect with those families of
    suicide victims and learn from their experiences, to ensure
    that their losses are not in vain.
        The DOD Suicide Prevention and Risk Reduction Committee
    (SPARRC) provides expert support for DOD systemwide
    initiatives, including suicide surveillance, metrics, and
    common nomenclature. Timely, accurate reporting, monitoring,
    and analysis of suicide data is vital. DCOE and SPARRC rely on
    two complementary data sources for this: the Mortality
    Surveillance Division of the Office of the Armed Forces Medical
    Examiner (OAFME) and the National Center for TeleHealth and
    Technology (T2). By standardizing data and reporting, OAFME and
    T2 allow the Services to track and analyze suicide data and
    contributing risk factors to improve prevention, intervention,
    and treatment services. We will also be working very closely
    with the National Institute for Mental Health as they begin
    their study this coming year.
        DOD is committed to transforming its culture by emphasizing
    that seeking treatment is an act of courage and strength. To
    this end, with the support from the service Vice Chiefs and the
    surgeons general, we are formally launching the Real Warriors,
    Real Battles, Real Strength Campaign, a public-health
    educational campaign nationwide to be formally launched this
    next month promoting the vital message that stigma is an
    unacceptable, deadly, toxic workplace hazard, and to harness
    the power of individual stories, family members, warriors,
    communities, scientists, faith leaders, employers, members of
    our Nation, and members of generations of warriors that extend
    beyond our current generation.
        To help prevent combat operational stress injuries, DOD is
    working with the Services to implement psychological resilience
    programs that better prepare servicemembers for the stresses of
    combat in all stages of deployment. Further, we are
    implementing programs that embed mental health consultation and
    treatment services in the primary care setting. In addition,
    DOD is supporting ongoing studies that evaluate programs to
    identify best practices, innovative resources, and practical
    tools.
        In accordance with the National Defense Authorization Act
    for Fiscal Year 2009, as you mentioned, Mr. Chairman, DOD
    recognizes that opinions from multiple disciplines foster
    innovation. Thus, we are working to establish the DOD Suicide
    Prevention Task Force that will report to the Defense Health
    Board and the Secretary of Defense. Currently, we have fielded
    34 nominations from leading experts across the country. We have
    suicide prevention program managers who have selected these
    leaders for consideration and final selection from Dr. Cassells
    that will be announced later this month. That group then will
    move forward, without delay, to come up, within 6 months, with
    a set of recommendations, a report, and then a plan to follow.
    Time is not our friend.
        Finally, we must embolden leaders and the entire military
    community to foster a strength-based, holistic strategy.
    Through our continued and relentless efforts, we can make a
    change for the better, provide our warriors and families
    immediate care when they need it, intervene early, and prevent
    tragic losses. It takes a nation to embrace our warriors and to
    help them heal and reintegrate as they return from the
    adversity of combat.
        DOD greatly appreciates the committee's strong support of
    America's Armed Forces and your concern for their health and
    well-being. Thank you for the opportunity to address these
    vital issues. I look forward to your questions, Mr. Chairman.
        [The prepared statement of General Sutton follows:]
              Prepared Statement by BG Loree K. Sutton, M.D., USA
        Mr. Chairman, members of the committee, thank you for the
    opportunity to bring you up to date on what the Department of Defense
    (DOD) is doing to address the increase in suicide rates among
    servicemembers, and to discuss our initiatives to reduce suicides and
    save lives. We share your sense of urgency to take swift and effective
    action on this critical problem.
        In the military, the unprecedented pace of deployments to Iraq and
    Afghanistan has put pressure on servicemembers, particularly in the
    Army and Marines, sent to war zones in multiple deployments to defend
    our Nation under harsh and stressful conditions. Sustained high
    operational demands may be diminishing the breadth of psychological
    health resources and social supports that mitigate suicide. However,
    there is insufficient evidence at this time to identify a conclusive
    relationship between operational tempo and suicides. Only careful
    longitudinal studies of these factors will be able to reliably assess
    this relationship. Existing research suggests that there are common
    strains that many servicemembers who commit suicide face. Common issues
    are: relationship problems, marital problems, legal and/or
    disciplinary, substance abuse, and financial problems. Suicide expert
    Thomas Joiner, PhD, demonstrates in his book, Why People Die by
    Suicide, that there are three fundamental factors: feeling ineffectual
    and burdensome to others, lack of belongingness and sense of isolation,
    and hardening to self-deprivations, injuries, and learned ability to
    hurt oneself. These factors may come into play for servicemembers
    resulting in isolation and hopelessness. Increasing sensitivity to such
    signs is critical to identify and refer those who need help.
        Building resilient communities and looking out for our
    servicemembers and families is our sacred privilege and responsibility.
    The Department is actively engaged in providing and improving care,
    tools, and resources for all, while simultaneously addressing cultural
    barriers that prevent individuals from seeking care.
        We are firmly committed to ensuring that every warrior receives
    excellent care across the continuum of resilience, prevention,
    diagnosis, treatment, recovery, and reintegration. The programs in
    place also span the education and deployment life-cycle to ensure
    warriors and leaders are able to help themselves and others. In
    addition, the DOD provides tools and resources for families and
    communities. No individual, family, leader, or community is omitted
    from the suicide prevention equation; it is only through a holistic and
    comprehensive strategy that we will be optimally successful.
                         defense centers of excellence
        In an effort to enhance outreach and coordination among DOD,
    Federal agencies, and civilian partners, a center of excellence was
    created by Congress to address psychological health issues and
    traumatic brain injury (TBI) for the DOD. In collaboration with the
    Department of Veterans Affairs (VA), academia, and others, DOD
    established the Defense Centers of Excellence (DCoE) for Psychological
    Health and TBI in November 2007.
        DCoE's mission focuses on the full continuum of care and prevention
    for psychological health concerns and TBI. In this effort, we strive to
    provide opportunities for warriors and families to thrive through
    collaborative global networks promoting resilience, recovery, and
    reintegration.
        Today's society is immersed in social media tools and interactive
    Web sites. In an effort to leverage technology, Congress mandated an
    interactive Web site for servicemembers and their families to explore
    behavioral health information. An important DCoE initiative,
    afterdeployment.org, is a mental wellness resource for servicemembers,
    veterans, and military families--and can help warriors in their
    successful readjustment to life after returning from deployment.
    Through a user-friendly platform, entrants may find videos by veterans,
    spouses, and others about their real-life stories of overcoming the
    stresses of war. In addition, links on different educational topics are
    provided for those interested in more information. Afterdeployment.org
    has been well received due to the privacy afforded to the user.
    Visitors to the site can benefit from the wide variety of available
    resources without registering or providing any identifying information.
        The DCoE also opened an Outreach Center this year to answer
    questions about psychological health and traumatic brain injury, 24
    hours a day, from members of all the military Services, veterans,
    families, health care providers, military leaders, and employers. The
    Outreach Center can be reached at 1-866-966-1020 toll-free and via
    email at resources@dcoeoutreach.org. We work in coordination with the
    National Suicide Prevention Lifeline (1-800-273-TALK) as well as
    Military OneSource, the National Resource Directory, and the Service-
    specific hotlines.
        The DCoE recently organized the joint effort between DOD and VA in
    cosponsoring the 2009 Suicide Prevention Conference. This was the first
    time that the two Departments had officially co-sponsored this event,
    and the conference was aptly titled, ``Building Community Connections:
    Suicide Prevention for the 21st Century.'' An important goal of the
    conference was to align the efforts of suicide prevention across
    government agencies, healthcare professions, and communities.
    Psychological health and TBI experts, representatives of
    nongovernmental organizations, community leaders, mental health
    clinicians, military officers and noncommissioned officers, chaplains,
    relatives of servicemembers who had committed suicide and others
    participated in the conference. Plenary sessions featured powerful
    contributions from suicide-attempt survivors and family members of
    individuals who took their own lives. The conference provided four
    focused tracks: Clinical Intervention; Multi-Disciplinary Approaches;
    Practical Applications and Tools; and Research and Academics.
        Another critical type of collaboration in suicide prevention is the
    DOD Suicide Prevention and Risk Reduction Committee (SPARRC). This
    committee, which meets monthly and is chaired by a DCoE leader,
    includes a wide range of critical stakeholders. The membership includes
    the Suicide Prevention Program Managers from each Service and
    representatives from the National Guard Bureau, Reserve Affairs, Office
    of Armed Forces Medical Examiner (OAFME), National Center for
    TeleHealth and Technology, VA, Substance Abuse and Mental Health
    Services Administration, and others. This membership provides both
    expert and comprehensive support for the committee's goals of
    addressing DOD system-wide policy initiatives consistent with DOD
    readiness requirements and the Military Health System Strategic Plan of
    a ``Fit and Ready Force,'' program and implementation instructions,
    suicide surveillance metrics, and use of common nomenclature in suicide
    reports.
        It is especially important to highlight timely and accurate
    monitoring and analysis of suicide data across the DOD. DCoE and SPARRC
    rely on two complementary data sources in this effort. For the number
    of suicides and suicide rates, the Mortality Surveillance Division of
    the Office of the Armed Forces Medical Examiner and the Service Suicide
    Prevention Program Managers aggressively scrutinize suicides and
    suspected suicides in real time. Similar to the protocol of the Centers
    for Disease Control and Prevention which reports when there is 90
    percent of cause-of-death determinations completed. DOD makes estimates
    of suicides after 90 days utilizing standing DOD resources of the
    Medical Examiner and Service investigative services. It requires 2-3
    years for 90 percent of cause-of-death determinations to be completed
    in the civilian sector.
        The second source is the National Center for TeleHealth and
    Technology (T2), which is one of DCoE's six component centers. T2
    manages the DOD Suicide Event Report (DODSER) system, which provides
    over 250 data-points per suicide with details, summaries and analysis
    of a wide range of potential factors contributing to suicide attempts
    and completions. The DODSER data includes specific demographics,
    suicide event details, treatment and military history. The variables
    are designed to map directly to the Centers for Disease Control and
    Prevention's National Violent Death Reporting System to support direct
    comparisons between military and civilian populations. T2 is
    responsible for integrating and maintaining DODSER data, as input by
    the Services, and for preparing an annual DOD suicide report. The
    annual report, accomplished no later than July 31 each year, will
    include aggregated DODSER data. Services will produce corresponding
    standardized and comparable Service Suicide Event Reports resulting
    from their inputs.
        By standardizing data and reporting in the near future, the SPARRC,
    OAFME, and T2, will allow the Services to track and analyze suicide
    data and contributing risk factors proactively to improve prevention,
    intervention, and treatment services. No other organization or
    mechanism other than the SPARRC has existed to develop, formally
    require and monitor compliance across DOD for standardized suicide data
    (via diligently-developed collaborations). In addition, the data will
    facilitate the review and evaluation of the effectiveness of suicide
    prevention initiatives and their execution over time.
        DOD is actively committed to transforming its culture by
    emphasizing that seeking treatment is an act of courage and strength.
    This endeavor requires the direct engagement of leaders at all levels
    to provide leadership characterized by transparency, accountability,
    candor, respect and strength. To this end, DCoE, with the support from
    the Service Vice Chiefs, is formally launching the ``Real Warriors,
    Real Battles, Real Strengths'' campaign this spring. The campaign will
    catalyze constructive dialogue by harnessing the power of individual,
    family, unit, and community stories around the Nation.
                   suicide prevention efforts across the dod
        We know that preventing suicide in the Armed Services requires an
    integrated and united effort. In addition, a more resilient force must
    be established. To prevent the onset of combat operational stress
    injuries, DOD is implementing psychological resilience programs that
    better prepare servicemembers for the stresses of combat and all stages
    of deployment, as well as for the sustained increased demands in-
    garrison that occur during periods of conflict.
        It is essential for DOD to continually evaluate its current efforts
    and continue to deliver the most timely and relevant information to
    best inform our decisionmakers, families, and warriors. As such, DOD
    has many ongoing studies that evaluate programs to identify best
    practices, innovative resources, and practical tools. Multiple research
    studies on suicide prevention and resilience programs focus on
    reviewing, cataloguing, and identifying potential enhancements for
    current programs, while others are conducting longitudinal analyses.
    DOD-wide initiatives address stigma, provide guidelines for leaders,
    and ensure that psychological health issues are integrated throughout a
    warrior's career.
        DOD also recognizes that bringing together different opinions from
    multiple disciplines fosters innovation in program implementation and
    problem solving. The DOD Suicide Prevention Task Force, under the
    Defense Health Board, is a 14-member panel that will include
    representation from the Services, family advocates, civilian
    communities, and academic advisors. They will provide advice and
    recommendations on matters relating to operational programs, health
    policy development, and health research programs. The mission
    objectives of this group focus on promotion of health, treatment, and
    prevention of disease and injury.
        We must embolden leaders and the entire military culture to
    encourage help-seeking behaviors. The many programs and efforts across
    the DOD and throughout the Services will continue to provide critical
    solutions to help our servicemembers and families overcome the many
    stressors associated with service in a war time environment.
        Finally, we are in a position where, through our united and
    concerted efforts, we can make a change for the better; provide our
    warriors and families immediate care when they need it, to intervene
    early and prevent unnecessary losses. We are all devoted to this effort
    and will not leave any one behind.
        DOD greatly appreciates the committee's strong support of America's
    Armed Forces and your concern for their health and well being. We have
    made great progress thus far in meeting the challenges related to the
    stressors of waging war in this era of persistent conflict. With the
    committee's continued help and support, we will do even more.
        Thank you for the opportunity to address these vital issues. I look
    forward to your questions.

        Senator Ben Nelson. Thank you.
        Commandant?

     STATEMENT OF BG MICHAEL S. LINNINGTON, USA, COMMANDANT, U.S.
            CORPS OF CADETS, UNITED STATES MILITARY ACADEMY

        General Linnington. Chairman Nelson, Ranking Member Graham,
    and Senator Thune, thank you for the opportunity to testify
    today representing the United States Military Academy at West
    Point on the important topic of suicide.
        West Point remains one of the world's preeminent leader-
    development institutions and a top-tier college. The young men
    and women that attend West Point are the best our Country has
    to offer, and our staff and faculty are dedicated to developing
    them into effective leaders of character upon graduation as
    lieutenants in the United States Army.
        West Point is not easy. It requires dedication, discipline,
    and a thorough commitment to excellence in order to be
    successful. Cadets also require support from a variety of
    sources; most importantly, our staff and faculty and from
    parents and loved ones back home. Unfortunately, over the past
    year, two cadets and two members of our staff and faculty
    committed suicide, and we've had two suicide gestures. Although
    the circumstances of these deaths were all different, these
    suicides were largely the result of significant personal
    challenges in the soldiers' and cadets' lives, such as stress
    from broken relationships, and, in the case of one of the
    cadets, a pre-existing mental condition traced back many years
    which Academy officials did not know about at the time of his
    admission. None of those soldiers or cadets that committed
    suicide at West Point over the past year had deployed to a
    combat zone. Given that suicides at the U.S. Military Academy
    over the past several decades have been rare, these four
    suicides are not only troubling, they are unacceptable. The
    loss of any soldier is a tragedy, and West Point remains
    absolutely dedicated to the safety, health, welfare, and well-
    being of all of our cadets, as well as our staff and faculty.
        As the Commandant of Cadets, I am the steward of the United
    States Corps of Cadets, and I take that responsibility very
    seriously. Based on these incidents, we have reenergized our
    preventative measures and are doing everything in our power to
    preclude their reoccurrence.
        West Point has always had a robust mental health education
    and treatment program that includes mental health professionals
    in the Cadet Counseling Center located right in the cadet
    living area, assigned chaplains and tactical officers who are
    directly responsible for cadet well-being, and mental health
    professionals available from the on-post hospital for
    everyone's use. We are working hard to encourage everyone to
    take advantage of these resources and eliminate any stigma that
    may be present with anyone seeking professional help. Based on
    the significant increase in the number of cadets, staff and
    faculty, and family members seeking help in recent years, we
    think we are making progress in this important area.
        The superintendent addressed the issue of suicide head-on
    shortly before the December holidays, and, as a result of these
    suicide episodes, he directed all units complete suicide
    prevention training by the end of January and directed
    participation by all personnel in the Army's Suicide Prevention
    Stand-down, which you've heard about this afternoon. We also
    ordered suicide prevention handouts for every cadet, soldier,
    and civilian employee on post, which were received and
    distributed in mid-January.
        The superintendent reiterated to all leaders that suicide
    prevention and response is clearly a command program. Our
    overarching goal is educating soldiers, families, and civilians
    about the world-class suicide prevention programs, training,
    and resources available to create greater awareness about the
    warning signs of suicide and the appropriate responses that can
    save a person's life.
        We are committed to providing these resources to help our
    cadets, soldiers, civilians, and their families overcome
    difficult times. We are equally committed to training and
    educating America's future leaders to deal with these issues in
    their units when they graduate. By showing cadets what
    ``right'' looks like, removing the stigma of seeking help, and
    understanding the individual unit and environmental factors
    contributing to suicide, West Point continues to provide
    leaders of character for our Nation.
        I would like to emphasize that your tremendous support
    continues to prove absolutely essential in taking care of our
    soldiers in the Academy. You continue to nominate to West Point
    great young men and women of the highest caliber whose
    willingness to serve portends another great American century.
    With your continued leadership and support for the Army and
    West Point, we look forward to meeting the challenges ahead.
    Together we will continue to make a difference.
        Thank you, Mr. Chairman.
        [The prepared statement of General Linnington follows:]
                Prepared Statement by BG Michael Linnington, USA
        Chairman Nelson, distinguished members of this committee, thank you
    for the opportunity to testify today on behalf of West Point. West
    Point remains the world's preeminent leader-development institution and
    a top tier college. Recent independent rankings have named West Point
    as the best public college in the country. We are proud of that, and of
    the record of our graduates, the Long Gray Line. However, this winter,
    two cadets committed suicide, and last summer we lost a faculty member
    and a staff noncommissioned officer to suicide. Although the
    circumstances of these deaths were all different, and suicides at the
    United States Military Academy over the past several decades have been
    rare, this is very troubling. The loss of any soldier is a tragedy, and
    we remain dedicated to suicide prevention. We are committed to the
    well-being of all the soldiers.
        I am the steward of our cadets--sons and daughters of America--and
    I take that responsibility very seriously. Let me assure you that
    everyone at West Point is re-energizing our preventive measures, and
    investigating any patterns regarding these incidents.
        West Point is, of course, a college, not an Infantry Division, and
    we have found that none of these soldiers or cadets had deployed to a
    combat zone. Furthermore, we found that one of the cadets who committed
    suicide had a pre-existing mental health condition that he did not
    reveal during his medical screening for entrance to the U.S. Military
    Academy.
        The Department of Defense accessions screening process has remained
    relatively unchanged over the last two decades. The candidate completes
    a medical history that asks specific medical questions, including
    questions about the candidate's mental condition. Throughout the
    medical exam, the examining physician conducts a mental health
    assessment evaluating the individual's affect; orientation to time,
    space, and event; mood; anxiousness; and any other markers of abnormal
    behavior.
        We do believe that every candidate deserves an opportunity to be
    fully considered for admission--and prior mental health conditions
    often turn out to be a transient reaction to a stressful situation, for
    example, parents' divorce. However, our medical community as well as
    the admissions committee, is scrutinizing waivers for these conditions
    more closely, and we are less likely to grant a waiver for a mood or
    anxiety disorder than we have in previous years. For the class of 2013,
    we approved waivers for only three candidates in comparison to previous
    years in which we approved approximately eight such waivers each year.
        One data point we use as we analyze our situation is how we compare
    to other colleges and universities across America. An American College
    Health Association (ACHA) survey showed that 9.5 percent of college
    students have seriously contemplated suicide and 1.5 percent have made
    a suicide attempt. About 95 percent of students who commit suicide are
    clinically depressed.
        Data also shows that the national college student suicide rate is
    7.5 per 100,000 students. We are well below that--we have had only
    seven cadet suicides in the past 3 decades. This works out to about 6
    suicides per 100,000. Of course, those numbers are no comfort to us
    because our goal is to prevent all suicides.
        To that end, West Point has, and has had, a robust mental health
    program that includes Mental health professionals in the cadet
    counseling center, the Center for Personal Development (CPD), located
    directly in the cadet area. The CPD, a personal counseling and
    leadership center for cadets, is staffed by trained professional
    counselors and psychologists who operate under very strict
    confidentiality policies.
        Mental Health Professionals at Keller Army Community Hospital, on
    post. It is interesting to note that the number of cadet appointments
    with a psychiatrist has increased significantly in the past 5 years. We
    do not believe this means we have an increase in cadet psychopathology,
    but, rather, a reduction in the stigma associated with seeking help and
    a greater willingness to do so.
        An academy-wide focus on intellectual, physical, ethical, social,
    and spiritual well-being.
        A voluntary and rich religious program of all faiths that includes
    involved chaplains; several chapels, including a mosque; and
    religiously-oriented organizations and clubs, such as the Gospel,
    Jewish, and Catholic choirs and cadet-led Sunday School for our
    families.
        Close supervision of and interaction with all cadets by their
    tactical officers and NCOs, their cadet chain of command, their
    professors and coaches, and their sponsors. This personal coaching,
    teaching and mentorship is one of the hallmarks of West Point, and it
    is what separates us from all other universities and colleges in
    America.
        As you can see, we make every effort to maintain a robust mental
    health program, but after the second cadet committed suicide while he
    was on a medical leave of absence and under psychological care, we
    quickly redoubled our efforts. Immediately upon their return from
    winter leave, I spoke to all cadets about suicide prevention and
    ensured all of them received a formal suicide prevention briefing.
        The superintendent also addressed the issue of suicide head on. He
    directed all units to complete suicide prevention training by the end
    of January. In addition, we convened a multi-functional Mental Health
    Team from organizations across the post to address this issue,
    specifically the issue of information-sharing between mental health
    professionals and unit chains of command. We also ordered suicide
    prevention handouts for every cadet, soldier, and civilian employee on
    post, which were received and distributed by mid-January.
        General Hagenbeck also re-iterated to all leaders that suicide
    prevention and response is clearly a command program, and there should
    be no stigma associated with seeking help. His commentary was published
    in our post newspaper, as a reminder to everyone to seek help when it
    is needed.
        We also requested assistance from the Department of the Army Office
    of the Surgeon General (OSTG). We believed, and this was confirmed by
    the OTSG team's initial review, that our programs were sound and there
    is not a significant stigma associated with seeking help when it is
    needed among our cadets. Specifically, the OTSG team found that our
    mental health professionals have been providing appropriate treatment;
    and, aside from a friendship between a cadet who had committed suicide
    and another who later made a suicide gesture, there is no evidence of
    suicide contagion. Despite these positive findings, we remain concerned
    that, after 10 years without a cadet suicide, two occurred just a month
    apart. As a result, we are continuing to improve our program, and
    participate fully in the Army's education and information programs over
    the coming months.
        As directed by the Vice Chief of Staff of the Army to all Army
    units, we conducted a suicide prevention stand-down day and training
    between February 15 and March 15. Additionally, we will complete the
    chain-teaching program focused on suicide prevention that allows
    leaders to communicate with every soldier by 15 June.
        I also would like to address an allegation in a recent Washington
    Post story. The reporter inaccurately used the term ``hazing'' to
    describe what she later called ``teasing.'' Hazing is specifically
    prohibited by Army regulation, and the days of hazing are long gone at
    West Point. If a cadet is found to have engaged in inappropriate
    behavior, appropriate disciplinary action will be taken against the
    cadet based on the facts and circumstances of the cadet's individual
    case. West Point is, and should be stressful, but there is no hazing.
        The Superintendent has emphasized that leaders must vigilantly
    watch for suicide indicators. Leaders must communicate to those under
    our charge that there is no problem we cannot help them through, and no
    problem that should result in their not seeing the sun rise the next
    day.
        The over-arching goal is educating soldiers, families, and
    civilians about the world-class suicide prevention programs, training,
    and resources available to create greater awareness about the warning
    signs of suicide and the appropriate responses that can save a person's
    life. We are committed to providing the resources for awareness,
    intervention, prevention, and follow-up necessary to help our cadets,
    soldiers, civilians, and their families overcome difficult times.
        I would like to emphasize that your tremendous support has proven,
    and will continue to prove, absolutely essential to taking care of
    soldiers. You continue to nominate to West Point young men and women of
    the highest caliber whose willingness to serve portends another great
    American century. With your continued leadership and support for the
    Army and West Point, we look forward to meeting the challenges ahead.
    Together, we will continue to make a difference.

        Senator Ben Nelson. Thank you.
        Ms. Power?

       STATEMENT OF A. KATHRYN POWER, M.ED. DIRECTOR, CENTER FOR
       MENTAL HEALTH SERVICES, SUBSTANCE ABUSE AND MENTAL HEALTH
        SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN
                                SERVICES

        Ms. Power. Mr. Chairman, Mr. Ranking Member, and members of
    the subcommittee, good afternoon. I'm pleased to offer
    testimony today on behalf of Dr. Eric Broderick, Assistant
    Surgeon General and Acting Administrator of SAMHSA, an agency
    of the U.S. HHS.
        This topic has a very special meaning for me. As a retired
    captain in the United States Navy Reserve, I'm intimately
    familiar with the duty, the courage, and the commitment that
    our servicemembers exhibit even under the most extreme
    conditions. We owe these men and women a debt of gratitude for
    their service to our country, but we owe them much more than
    that.
        As a mental health professional, I am keenly aware of the
    tragedy of suicide among all segments of our population. Every
    day in this country, there is one suicide every 16 minutes.
    Clearly, suicide is a public health crisis in America, and it
    demands a public health response. Within the public health
    context, all individuals in a community, whether that community
    is a school, a neighborhood, a military unit, or an entire
    base, are affected by the health of its individual members. Our
    mission at SAMHSA is to promote mental health, to prevent and
    treat mental and substance-use conditions, and to build
    resilience in individuals and communities throughout our
    Nation. We provide national leadership for suicide prevention,
    leading a broad group of Federal partners, including the DOD
    and VA, to implement the National Strategy for Suicide
    Prevention within the transformation of our Nation's health
    system.
        SAMHSA has three major suicide initiatives. Number one, our
    Garrett Lee Smith Youth Suicide Prevention Grant Program has
    funded more than 43 States and 18 tribes and tribal
    organizations, as well as more than 68 colleges and
    universities, on youth suicide prevention activities. We
    encourage all of our campus suicide prevention grantees to
    welcome active duty military and veterans onto their campuses
    and to provide specialized services.
        Number two, we support the Suicide Prevention Resource
    Center.
        Number three, our third major initiative is the National
    Suicide Prevention Hotline and Lifeline, which is a network of
    137 crisis centers throughout 48 States that receives calls
    from the national toll-free suicide prevention number, 1-800-
    273-TALK. All calls are free, confidential, answered 24/7.
    Today, the Lifeline averages 1,500 calls every day.
        As a result of the collaboration between SAMHSA and the VA,
    the Lifeline now serves as the front end for the Veterans
    Suicide Prevention Hotline. Today, when an individual calls the
    Lifeline number, they hear, ``If you are a U.S. military
    veteran or if you calling about a veteran, please press 1
    now.'' Callers are immediately routed to the VA Call Center in
    Canandaigua, New York. In its first year of operation, the Call
    Center in Canandaigua responded to more than 67,000 callers;
    calls from veterans led to nearly 6,000 referrals to the VA
    suicide prevention coordinators and more than 1,700 rescues--
    that is, actual calls to police and emergency personnel--for
    immediate responses to those individuals who were judged to be
    at immediate risk.
        Of special interest to this committee: In fiscal year 2008,
    780 callers identified themselves as active duty military. They
    received the same expert services as any veteran or family
    member who called. Thus far this fiscal year, 434 callers to
    the hotline, nearly 3 a day, identified themselves as being on
    active duty.
        Our soldiers, sailors, airmen, and marines deserve the best
    knowledge and practice we have to offer in suicide prevention.
    Several effective suicide prevention practices can be, and may
    already have been, adopted for use with Active Duty personnel.
    They include, first, gatekeeper training. This trains community
    members to understand the warning signs of suicide, talk about
    it, and how to arrange for a person who needs help who might be
    at risk. A second approach involves systematic followup in the
    critical time following an acute suicidal crisis. SAMHSA has
    awarded six grants to implement and evaluate effective followup
    to individuals who call the National Suicide Prevention
    Lifeline.
        Finally, ``postvention'' is the term for a promising
    approach that helps suicide survivors cope with the difficult
    feelings that follow such a sudden catastrophic loss.
    Postvention has been recognized by the Center for Disease
    Control (CDC) as an important strategy for preventing suicides
    among those who are left behind. In collaboration with our
    Garrett Lee Smith grantees, this approach is currently being
    used at Fort Campbell, KY, and by the New Hampshire National
    Guard.
        To promote the success of these and other suicide
    prevention programs, we work very closely with CDC and the
    National Institute of Mental Health (NIMH), our sister agencies
    in HHS. The data that CDC collects and the research that NIMH
    conducts help shape the suicide prevention initiatives that
    SAMHSA promotes and manage. In turn, our programs provide the
    field with critical science-to-service data and key research
    questions.
        At SAMHSA, we have ongoing partnerships with DOD and VA in
    two large Federal workgroups. One, on returning veterans and
    their families, and the other on suicide prevention. Those
    collaborative relationships and partnerships are not codified
    in law, nor do they receive any special funding. We meet
    together as concerned citizens, as mental health professionals,
    as members of the Armed Forces, all supporters of our Nation's
    military. Our goal is to improve the health and well-being of
    all Americans, particularly those who fight and die for us.
        The poet John Donne wrote, ``Any man's death diminishes me
    because I am involved in mankind.'' We must build on the esprit
    de corps in the military that can serve as a source of
    strength, resilience, and hope to protect the members of our
    Armed Forces from psychological distress, from substance abuse,
    and from suicide. We look forward to continued collaborations
    with Members of Congress, with DOD and VA, and the American
    people as we stem the tide of suicides among the brave men and
    women in our Armed Forces.
        Thank you very much for the opportunity to address you, and
    I look forward to your questions.
        [The prepared statement of Ms. Power follows:]
                 Prepared Statement by A. Kathryn Power, M.Ed.
        Mr. Chairman, Mr. Ranking Member, and members of the committee,
    good afternoon. I am Kathryn Power, Director of the Center for Mental
    Health Services (CMHS) within the Substance Abuse and Mental Health
    Services Administration (SAMHSA). I am pleased to offer testimony this
    morning on behalf of Dr. Eric Broderick, Assistant Surgeon General and
    Acting Administrator of SAMHSA, an agency of the U.S. Department of
    Health and Human Services (HHS).
        Thank you for asking me to testify at this hearing about the role
    that the mental health community in general, and HHS in particular, can
    play in helping prevent suicides among the young men and women who
    proudly serve our country in the Armed Forces.
        This topic has special meaning to me. As a retired captain in the
    United States Naval Reserve, I am intimately familiar with the courage
    and commitment our servicemembers show, even under the most extreme
    conditions. We owe these men and women a debt of gratitude for their
    service to our country.
        But we owe them much more than that. As a mental health
    professional, I am keenly aware of the tragedy of suicide among all
    segments of our population. In 2005, the most recent year for which we
    have national data, suicide resulted in 32,637 deaths, according to
    HHS's Centers for Disease Control and Prevention (CDC). Sadly, suicide
    was the third leading cause of death among young people aged 15 to 24.
    Rates of suicide are higher among males than among females, but studies
    indicate females have higher rates of suicidal thoughts and nonfatal
    suicidal behaviors than males. Although suicide is problematic
    throughout the lifespan, overall rates of death from suicide are
    highest among those aged 80 or older, followed by those aged 45 to 49.
        However, the number of suicides reflects only a small portion of
    the problem. Many more people are hospitalized due to nonfatal suicidal
    behavior than are fatally injured--and an even greater number are
    treated for injuries from suicidal acts in ambulatory settings or not
    treated at all. For example, in 2006, there were 594,000 visits for
    self-harm injuries seen in U.S. emergency departments. Further,
    research indicates that over 50 percent of people who engage in
    suicidal behavior never seek health services.\1\
    ---------------------------------------------------------------------------
        \1\ Crosby, A.E., Cheltenham, M.P., & Sacks, J.J. (1999). Incidence
    of suicidal ideation and behavior in the United States, 1994. Suicide
    and Life-Threatening Behavior, 29, 131-140.
    ---------------------------------------------------------------------------
        Clearly, suicide is a major, preventable public health problem in
    America and it demands a public health response. Within the public
    health context, all individuals in a community--whether that community
    is a school, a neighborhood, a military unit, or an entire base--are
    affected by the health of its individual members. As a public health
    agency, our mission at SAMHSA is to promote mental health; prevent and
    treat mental health and substance use problems; and build resilience in
    individuals, in communities, and in the Nation as a whole. A new report
    by the Institute of Medicine and the National Research Council, which
    was commissioned by SAMHSA and HHS's National Institutes of Health
    (NIH), recommends that we make the mental, emotional, and behavioral
    well-being of our young people a national priority.
        Many of our young people are active duty military, and their mental
    and emotional well-being is equally important. I was pleased to serve
    as a member of the Department of Defense Task Force on Mental Health.
    In its final report, called ``An Achievable Vision,'' the Task Force
    concluded, ``Maintaining the psychological health, enhancing the
    resilience, and ensuring the recovery of servicemembers and their
    families are essential to maintaining a ready and fully capable
    military force.'' In order to foster a prevention-oriented, public
    health approach to maintaining psychological health in the military and
    in the country as a whole, we must act to prevent the ultimate act of
    hopelessness--the taking of one's life.
        At SAMHSA we provide national leadership for suicide prevention,
    leading a broad group of Federal partners--including the Department of
    Defense (DOD) and the Department of Veterans Affairs (VA)--to implement
    the National Strategy for Suicide Prevention.
        Within the CMHS, we have three major suicide prevention
    initiatives. One of these initiatives is the Garrett Lee Smith Youth
    Suicide Prevention grant program. As of October 1, 2008, 43 States and
    18 Tribes and Tribal organizations, as well as more than 68 colleges
    and universities, are receiving funding for youth suicide prevention
    through this program.
        A second cornerstone initiative is the Suicide Prevention Resource
    Center, a national resource and technical assistance center that
    advances the field by working with States, Territories, Tribes, and
    grantees and by developing and disseminating suicide prevention
    resources.
        The third major initiative is the National Suicide Prevention
    Lifeline, which is a network of 137 crisis centers in 48 States that
    receives calls from the national, toll-free suicide prevention hotline
    number, 1-800-273-TALK. When a caller dials the hotline, the call is
    routed to the nearest crisis center, based on the caller's area code.
    The crisis worker listens to the individual, assesses the nature and
    severity of the crisis, and links or refers the caller to services,
    including emergency medical services when necessary.
        Routing calls to an individual's community links him or her to
    resources close to home; if the nearest center is unable to pick up,
    the call automatically is routed to the next nearest center. All calls
    are free and confidential and are answered 24 hours a day, 7 days a
    week. Every month, more than 46,000 individuals call the National
    Suicide Prevention Lifeline, an average of 1,500 individuals every day.
        Early in 2007, SAMHSA and VA--both members of the Federal Working
    Group on Suicide Prevention--began exploring strategies for a potential
    collaboration. It quickly became apparent that using the National
    Suicide Prevention Lifeline as a front end for a Veterans Suicide
    Prevention Hotline would offer numerous advantages. We knew that on the
    very first day of operation, by using a number that had already been
    heavily promoted for several years, more than 1,000 callers in crisis
    would hear the following message when they dialed 1-800-273-TALK: ``If
    you are a U.S. military veteran or if you are calling about a veteran,
    please press `1' now.'' Callers who press ``1'' are routed to the VA
    call center in Canandaigua, NY, staffed by VA professionals. On the
    very first day of operation, 73 callers pressed ``1.''
        In fiscal year 2008, the Call Center in Canandaigua responded to
    more than 67,000 callers. Calls from veterans led to more than 6,000
    referrals to VA Suicide Prevention Coordinators and more than 1,700
    rescues--calls to police or emergency medical personnel for immediate
    responses for callers judged to be at imminent risk. There have been
    only 2 known suicides among the 6,000 referrals.
        Of special interest to this committee, during fiscal year 2008, 780
    callers identified themselves as active duty military. They received
    the same expert services as any veteran or family members who called,
    including several times when the Call Center coordinated with the
    servicemember's base to arrange an emergency rescue. Thus far this
    fiscal year, 434 callers to the hotline--nearly 3 a day--identify as
    being on active duty.
        Possibly as a result of the newly expanded GI Bill, one of our
    Garrett Lee Smith grantees at Kansas State University discovered that
    distance learners in the military from Pakistan, Afghanistan, and Iraq
    have visited one of their Web sites (http://universitylifecafe.org/),
    which features a set of topics on mental well-being. As a result,
    Kansas State added items tailored for the military, including a suicide
    prevention video produced by DOD that features Major General Mark
    Graham, who commands the Army's Division West and Fort Carson in
    Colorado and who lost a son--an ROTC cadet--to suicide. At SAMHSA, we
    are encouraging all of our Campus Suicide Prevention Grantees to
    welcome active duty military and veterans onto their campuses and to
    provide specialized services for them.
        Our soldiers, sailors, airmen, and marines deserve the best
    knowledge we have to offer in suicide prevention. I am pleased to share
    with you several innovative practices that we know are effective in
    preventing suicides. These can be and already have been adapted for use
    with active duty personnel.
        Indeed, we are learning more about what leads to suicide and,
    therefore, what can be done to prevent it. We know that what leads an
    individual to take his or her own life is usually complex, involving a
    number of risk factors and warning signs, such as depression, substance
    abuse, and hopelessness. Suicide does not usually come out of the blue,
    as an impulsive act in a moment of crisis. Rather, suicide risk can
    build over time, bringing a person closer and closer to the brink of
    tragedy. Usually, individuals who die by suicide have spent some time
    thinking about suicide and may have even communicated, directly or
    indirectly, to someone else--such as a friend, family member,
    colleague, or fellow soldier--they are thinking about suicide or are
    feeling hopeless or desperate.
        Because people who die by suicide have often communicated about it
    with others, or might be willing to talk about it if asked, a promising
    approach to suicide prevention is called gatekeeper training. In this
    type of program, community members are taught the warning signs of
    suicide, along with instruction on how to arrange help for a person who
    is at risk for suicide. The best evidence suggests that suicide
    prevention is most likely to be effective when everyone in a community
    is involved and when everyone knows what to do when encountering this
    kind of crisis. The first step, which is at once simple and agonizingly
    difficult, is asking ``Are you thinking of killing yourself?''
        Examples of these kinds of gatekeeper training approaches include
    Question, Persuade, Refer, and Applied Suicide Intervention Skills
    Training (ASIST). These approaches are being implemented and evaluated
    in SAMHSA's Garrett Lee Smith Youth Suicide Prevention grants program.
    We are also working together with the National Institute of Mental
    Health (NIMH), part of NIH, to study the effectiveness of ASIST
    training with crisis telephone workers at the lifeline.
        Just as suicide risk does not usually appear for the first time at
    a single overwhelming moment of crisis, neither does it disappear as a
    crisis begins to lessen. Recent research has shown that the period
    after an acute suicidal crisis is also a high risk time for suicide. A
    study conducted by VA found high rates of suicide among individuals
    receiving depression treatment in the 12 weeks following discharge from
    inpatient hospitals, a finding also documented in other countries.
    Similar results have been found among those discharged from emergency
    departments.
        Fortunately, there is some evidence that providing systematic
    contact and follow-up in the time following an acute suicidal crisis
    can save lives. A study recently published by the World Health
    Organization found a significant reduction in deaths by suicide among
    those who received such follow-up contacts after being discharged from
    an emergency department. SAMHSA is working to promote follow-up to
    individuals who call the National Suicide Prevention Lifeline and has
    awarded six grants to implement and evaluate this approach. We are also
    closely collaborating with VA in its extensive efforts to provide
    follow-up to veterans who call the suicide hotline.
        Finally, we know that suicide deaths adversely affect those who are
    left behind. When a servicemember dies, his or her family and friends
    are affected, but so too are fellow servicemembers, commanding
    officers, first responders, chaplains, behavioral health staff, and
    others. In many ways, a suicide death is more difficult to deal with
    than a combat death. As a unit commander told one of our Garrett Lee
    Smith grantees, ``When my unit lost a soldier in Iraq in an IED attack,
    it was difficult but we dealt with it. It was painful returning home
    from deployment without him, but I was relieved that the rest of my
    unit was safe. When one of my soldiers killed himself 10 weeks after we
    returned, it was absolutely devastating and had a profound impact on
    our unit. Personally, I felt like I had failed him, his family, and the
    other soldiers in my unit.''
        In addition, we know that survivors of suicide are at risk for
    killing themselves, a phenomenon termed ``cluster'' suicides. This is
    what happened in Houston where four Army recruiters from one battalion
    died by suicide in a 3-year period. As a result of the increased risk
    to survivors, a critical part of suicide prevention work is called
    ``postvention,'' which is an intervention conducted after someone dies
    by suicide. Postvention helps survivors cope with the many complicated,
    difficult feelings that naturally occur following such a sudden,
    catastrophic loss. An active suicide postvention program that addresses
    the needs of all individuals who have been impacted by suicide is an
    essential component of any community's suicide prevention activities
    and can help stem the tragic tide of future loss. Postvention has been
    recognized by CDC as an important strategy for preventing cluster
    suicides.
        NAMI New Hampshire, one of SAMHSA's Garrett Lee Smith grantees,
    developed a postvention model called Connect/Frameworks, which is
    recognized as a best practice by the Suicide Prevention Resource
    Center's Best Practice Registry. Originally developed for civilians,
    the program has been adapted by the New Hampshire National Guard to
    build resilience, promote healing, and reduce risk in the aftermath of
    a suicide. This training ensures consistent and appropriate response in
    the aftermath of a suicide and helps survivors--including family,
    fellow soldiers, chaplains, and the entire National Guard community--
    with grieving and healing.
        Also, in January 2008, Major General Jeffrey J. Schloesser,
    commanding officer at Fort Campbell, KY, and its 45,000 service
    personnel invited Tennessee's Garrett Lee Smith grantee to provide
    guidance in the aftermath of several suicides on and off base,
    involving both Service personnel and family members. Beginning with
    presentations on post-traumatic stress disorder for troops and the
    development of a task force, the collaboration now includes ongoing
    debriefings of all suicide incidents, postvention and support for
    survivors and fellow warriors, and the implementation of base-wide
    awareness campaigns. The grantee credits the commitment of General
    Schloesser with the program's success, noting that leadership at the
    top is required for a base to engage fully in suicide prevention
    efforts.
        Leadership at the top is critical, as evidenced by the witnesses at
    this hearing. But no one individual, agency, or military branch can
    solve this problem alone. As former Surgeon General Dr. David Satcher
    said, ``Because its effects are societal in scope and tragic in their
    consequences, suicide prevention is everyone's business.''
        At SAMHSA, we work closely with two of our sister agencies in HHS--
    CDC and NIMH. The data and evaluation information that CDC collects and
    the research that NIMH conducts help shape the suicide prevention
    services SAMHSA provides. In turn, our Services offer data and key
    research questions.
        CDC is working with DOD and VA on combining relevant data from
    CDC's National Violent Death Reporting System, which collects data on
    violent deaths within the civilian population, with DOD's Suicide Event
    Report. This effort is designed to characterize more comprehensively
    those factors that contribute to suicide incidents among current and
    former military personnel. Having a better understanding of the most
    common contributing factors could help focus military suicide
    prevention initiatives. CDC is also working with the U.S. Army Center
    for Health Promotion and Preventive Medicine to develop an evaluation
    of its Ask, Care, Escort (ACE) suicide intervention program. CDC has
    proposed several options to evaluate and enhance the U.S. Army's ACE
    Program and their online interactive video, ``Beyond the Front.''
        NIMH and the U.S. Army have entered into a memorandum of agreement
    to conduct research that will help the Army reduce the rate of
    suicides. This research study will: (1) examine the mental and
    behavioral health of soldiers, with particular focus on the multiple
    determinants of suicidal behavior; (2) identify modifiable risk and
    protective factors and moderators of suicide-related behaviors; and (3)
    identify specific interventions for reducing suicide risk by addressing
    empirically identified risk and protective factors. The Funding
    Opportunity Announcement, ``Collaborative Study of Suicidality and
    Mental Health in the U.S. Army,'' was released on January 5 at http://
    grants.nih.gov/grants/guide/rfa-files/RFA-MH-09-140.html.
        Ultimately, the key to effective suicide prevention for all
    Americans, including members of the armed services, is found in
    collaboration among each and every one of us who has a stake in the
    outcome. At SAMHSA, that has meant ongoing partnerships with DOD and VA
    in two Federal workgroups, one on Returning Veterans--chaired by
    Brigadier General Loree Sutton and co-chaired by Dr. Antonette Zeiss
    from VA--and the other on Suicide Prevention--chaired by Commander
    Aaron Werbel from DOD and co-chaired by Dr. Richard McKeon from SAMHSA.
    The Federal Working Group on Suicide Prevention has prepared a complete
    compendium of suicide prevention efforts across participating Federal
    agencies--including DOD and VA. Our collaborative activities are
    further exemplified by such activities as The National Behavioral
    Health Conference and Policy Academy on Returning Veterans and Their
    Families, a conference we cosponsored with DOD and VA in 2007 and 2008.
    In these collaborative partnerships, we meet together as concerned
    citizens, mental health professionals, and members of the Armed
    Forces--all proud supporters of our Nation's military. Our goal is to
    improve the health and well-being of all Americans, particularly those
    who fight and die for us. No one--least of all members of our Nation's
    fighting forces--should ever die by his or her own hand.
        The poet John Donne once wrote, ``. . . any man's death diminishes
    me, because I am involved in mankind.'' So, too, is each and every one
    of us here today. We must do all that we can, individually and
    collectively, to restore a sense of community that helps protect
    individuals from psychological distress, substance abuse, and suicide.
    In many ways, America is losing the spirit of community that was
    previously fostered by extended families, religious organizations, and
    community centers. Today, we are more likely to eat alone, study alone,
    and even, as author Robert Putnam pointed out, to bowl alone.
        But there is an esprit de corps in the military that bodes well for
    reconnecting individuals to a source of strength and hope that will
    protect them during difficult times. While young people may no longer
    congregate in the town square, they meet in virtual town squares on
    such sites as MySpace and Facebook. SAMHSA is taking full advantage of
    these social networking sites to get the word out about the National
    Suicide Prevention Lifeline. We know that every time we actively
    promote the Lifeline, calls go up and more individuals are saved from
    an untimely death.
        We look forward to continued collaboration with Members of
    Congress, DOD and VA, and the American people as we strive to stem the
    tide of suicides among the brave men and women in our Armed Forces.
        Thank you for the opportunity to address you today. I would be
    happy to answer any questions you may have.

        Senator Ben Nelson. Thank you.
        Senator Graham.
        Senator Graham. Thank you, Mr. Chairman. I'll be brief.
        I appreciate the information you provided the committee
    about ongoing programs. Major General Rubenstein, I think your
    example shows that there are some things that you just can't
    prevent, no matter how much you stay on top of it. This example
    you gave is one where I don't know what more you could have
    done. But, what you're telling us, Ms. Power, is that there are
    a lot of people that, if we get early enough, we can turn it
    around.
        If an active duty member calls this hotline, is the
    military commander notified?
        Ms. Power. I'm sorry, if the active duty member calls the
    hotline?
        Senator Graham. Right.
        Ms. Power. They have just identified themselves as an
    active duty member, and they get the same service from either
    the crisis center locally or we can, in fact, connect them to
    the VA, if they want. But when they identify themselves as
    active duty members, it's generally in the conversation with
    the local crisis center with whom they've been connected.
        Senator Graham. But do we, as a matter of routine, inform
    the military, ``You have a problem here''?
        Ms. Power. A matter of routine for when we talk to them?
        Senator Graham. Yes. When you talk to the person, when the
    person calls the hotline, are they identified?
        Ms. Power. It depends on the conversation. Some individuals
    voluntarily put forward the fact that they are on active duty;
    and generally either those individuals will say that they do
    not want to talk to anyone else other than the local crisis
    center with whom they are connected.
        Senator Graham. Okay. So, there is no way to get that
    person's name and contact the military?
        Ms. Power. Well, we're having some conversations with DOD,
    actually, as we've garnered these statistics and we've become
    more knowledgeable about how individuals who are back in their
    local communities are connecting with those crisis centers,
    we're starting some conversations with DOD about how we may be
    able to make some connections, similarly to what we've done
    with the VA.
        Senator Graham. Ms. Powell, how many active duty people
    identified themselves when they called the hotline?
        Ms. Power. Last year?
        Senator Graham. Yes.
        Ms. Power. It was 780 callers, and thus far this year, 3
    per day.
        Senator Graham. Okay. Major General Rubenstein and
    Brigadier General Sutton, is that disturbing?
        General Sutton. In one sense, it is, Senator Graham.
        In another sense, it's heartening to know that folks who
    are having difficulties are calling. What's disturbing about it
    is, as our Outreach Center coaches work with the National
    Lifeline coaches we've established a network that is used
    daily.
        Senator Graham. How many people contacted your system about
    suicidal thoughts?
        General Sutton. I don't have an exact number for you, at
    this point. I will tell you, we just started our Outreach
    Center in January. It is not a lifeline, which is why, when
    they call us, if they need the services of the National
    Lifeline, we make sure that we have a warm handoff.
        What is disturbing about the individuals that we speak with
    is the proportion of active duty callers who say, ``I don't
    want my chain of command to know about this.'' It points to the
    issues that still linger, in terms of stigma and transforming
    the culture.
        We have identified this issue in our work with the Service
    Vice Chiefs, and we have currently developed standard operating
    procedures which will be formalized into a memorandum of
    agreement with the VA and with SAMHSA to ensure that anyone
    that can develop a relationship of trust that will then enable
    us to link them back to their home community or their chain of
    command, we absolutely are committed to doing that. But, we
    cannot violate the confidence, if an individual prefers that
    that not be the case.
        Senator Graham. Major General Rubenstein, do we have any
    numbers to compare to, how many active duty people are on base
    and calling?
        General Rubenstein. We'll get you the numbers for the
    record, Senator.
        General Rubenstein. It is disturbing, if those active duty
    soldiers who live on or in the immediate vicinity of a military
    base feel they have to call a third party.
        Senator Graham. That's the point. I mean that is an
    astonishing number, to me, if you had 780 contacts last year.
        General Rubenstein. The issue of stigma is not normally the
    issue of the relationship between the caller or the soldier and
    his healthcare provider, but rather the relationship with the
    soldier and his leadership. It's the leadership that we have to
    work with so hard in order to ensure the leadership is taking
    the issue seriously.
        Senator Graham. Right. I know this is hard, but that's the
    most overwhelming evidence I've heard that there is a real
    stigma problem here, if 780 people have to go outside the
    military chain. I understand. I mean, this is not easy. I've
    been a judge advocate most of my life, and I understand exactly
    how reluctant people are to identify themselves with having any
    problem because you're worried about being promoted, not
    eligible for a particular career path. If you could talk, that
    would be helpful. Find out exactly what's going on here, all I
    can say, that's just a big number. I've heard your testimony
    about what you're trying to do in the Recruiting Command. You
    had a cultural problem there. At West Point, it's an
    aberration, and I know you're on top of it. But, this is the
    first evidence I've heard, from both panels, that there's a
    systematic problem here, there is a large number of people
    apparently going outside of all the programs that you've
    created. The programs seem to be very robust, and you're doing
    a lot with a limited resource. But, this stigma problem now is
    put in perspective for me.
        One last question, and I'll have to leave. In terms of
    mental health counselors, the resource problem the other panel
    testified to, what can we do, from a committee point of view,
    to help find more people to go into mental health counseling in
    the military?
        General Rubenstein. From the Army's perspective, there are
    two things. One is to continue the resources that we do need in
    order to hire our military and civilian and contract providers;
    but, number two is our delegated hiring authority, which is an
    action, not from this committee, but is an action from Congress
    that allows us to very rapidly hire someone when they show up
    and say, ``I'd like to apply for a job.'' It allows the
    hospital commander, the clinic commander, to hire the person
    without going through the long and laborious processes in
    place.
        So, continue the resources, as the committee has done, and
    as Congress has done for hiring actions.
        Senator Graham. General Sutton?
        General Sutton. I would just add to the points that General
    Chiarelli brought up earlier, in terms of the importance of
    establishing a robust T2 network, which we are in the process
    of doing, working with the VA, working with the National Guard,
    and working with the States. We know that even if we were able
    to have perfect ease in hiring the individuals that we need and
    want to bring onto our team, we still have individuals in
    remote locations who will not benefit from those services
    unless we can connect them.
        We are also working very closely right now on what we're
    calling a SimCoach. This is a project linking up with DARPA and
    the Institute for Creative Technology, which will harness the
    best of artificial intelligence, with voice recognition
    technology, with expert learning and neuroscience and simulated
    conversation. These technologies all exist at this point; they
    haven't been put together in a single tool that will allow our
    servicemembers and their loved ones to access, in the privacy
    of their own home, their own smart phone, or their laptop.
        Senator Graham. Well, can this committee help? I mean, do
    you need something from this committee?
        General Sutton. Sir, you've already gotten us launched, so
    we'll keep you posted on the progress.
        Senator Graham. Okay. Mr. Chairman, thank you for letting
    me go first, and thank you for having this hearing. I think
    it's been very instructive in sort of putting the puzzle
    together, and I think what we have is a resource problem, but,
    more than anything else, we have a holdover of stigma that
    we're going to have to keep fighting because the proof is in
    the pudding, here. When you have this many people feeling they
    can't talk to someone within the system, then that's a problem.
    I know you're all on top of it the best you can be.
        Thank you.
        Senator Ben Nelson. Thank you.
        In that regard, assuming that we had enough mental health
    providers within the system, do they become part of the
    problem, in terms of the person not wanting to talk to them for
    fear that will get communicated to their chain of command,
    which would raise the question of whether or not maintaining a
    civilian relationship for these providers would that give them
    an independence that would be outside the chain of command to
    overcome the stigma and the fear of reprisal and fear of
    nonpromotion?
        Dr. Rubenstein?
        General Rubenstein. Mr. Chairman, the soldier who doesn't
    want to see the psychological health provider on post, for fear
    of his command finding out about it, is the same soldier who
    doesn't want to be seen downtown, for the very same reason, the
    concern that somehow he or she is going to be found out as
    needing psychiatric help for a stress-related issue, and
    because of that, will fear for the ability to advance in his
    job in the military. I don't think this is limited to our
    providers who are on post versus our providers who might be
    downtown. We have 2,500 psychologists, psychiatrists, and
    social workers in the military. We use a network of 54,000
    civilian providers that are under the TRICARE networks in our
    communities around the United States. The patient who doesn't
    want to go on post is the same patient who's not going to want
    to be seen downtown, although they may sneak downtown in order
    to pay out of their pocket to receive care.
        Senator Ben Nelson. Or they call the hotline to avoid
    detection, perhaps.
        General Rubenstein. Perhaps so.
        Senator Ben Nelson. General Rubenstein, if you had to look
    at the example that you gave us today of the soldier who
    committed suicide this week, and you look back over everything
    that was done, and you could recreate the situation to try to
    get a different result, is there anything that you could see
    there that would stand out to you that was missed or perhaps
    was done ineffectively?
        General Rubenstein. Yeah, that's a fascinating question. As
    a private pilot, I read aviation safety magazines, and if
    there's an accident, they start going backwards through time
    and they start to find something that started to go amiss. This
    soldier was a low-risk soldier, had been seen by the same
    psychiatrist for over 2 years, and was being used as a
    motivational speaker for other patients in the area of TBI. The
    question comes down to how closely the healthcare team and the
    leadership team work together. What makes the military
    community unique from the general population, and the reason
    we're concerned that 20.2 suicides per 100,000 is larger than
    19.5 in the civilian sector, in the military we pride ourselves
    on putting our arms around our soldiers and looking into our
    eyes and having battle buddies. We don't have the same thing in
    the civilian sector. So when you ask about, ``Could we have
    done something?''--we could always do something.
        Senator Ben Nelson. Sure.
        General Rubenstein. The question is, with this soldier who
    has 2\1/2\ years of history under his belt in the WTU, being
    used as a motivational speaker, gets a piece of bad news and,
    to everyone's surprise, reacts by putting a pistol to his
    chest.
        Senator Ben Nelson. Ms. Power, in your prepared statement
    you discuss a phenomenon that you referred to as ``cluster
    suicides,'' and you state that this is what happened in
    Houston, where the four Army recruiters from one battalion died
    over that 3-year period. Can you give us a little bit more
    information about what you call ``cluster suicides''?
        Ms. Power. I think in the testimony we were trying to get
    out the point, Senator, that the deaths by suicide are always
    very complex cases, and there are typically a variety of risk
    factors that play a role in each death. SAMHSA, of course, has
    not conducted any review of any of the deaths that were
    mentioned, and I certainly wouldn't presume to identify any one
    specific cause for those particular tragic deaths, but
    certainly we know that overwhelming stress and pressure can
    play a role in suicide, and, in combination with other risk
    factors, it can become quite fatal.
        SAMHSA's intent, in my written testimony, was basically to
    highlight the potential role for the strategy of postvention,
    where you can bring in appropriate support and assistance to
    those who were close to, or who knew, the individual who died
    by suicide, and thus, helping to prevent other future suicides.
    That was really the intent, to emphasize the fact that, when
    there are commands or communities in which there are multiple
    suicides, we've found that the postvention strategies can be
    very effective in reducing that potential.
        Senator Ben Nelson. Commandant Linnington, did you, in
    response to what has occurred at the Academy, take that
    approach, to try to get ahead of it with other individuals
    through post-counseling?
        General Linnington. Yes, sir. In fact, one of the things we
    did well before the Army's program was, when we had the two
    suicides earlier in the year, we started an aggressive
    education program, and we really worked hard on the reduction
    in stigma required to go seek help. Of course, in a young
    population, a college population, that's the battle buddies,
    the peers, are the ones that really are the first line of
    defense, in terms of identifying those at risk. So, we really
    went after that aspect of it hard. As we've looked at it over
    the last several months, our numbers have really gone up,
    significantly up, in terms of the number of cadets that are
    seeking help. So, we look at that as good news. Unfortunately,
    when that happens, you identify more folks that are at risk
    than you originally thought, which then leads to follow-on
    treatment, and, in some cases, inpatient treatment. But, that's
    good news, also, I think, in that we identified them before it
    takes place.
        Senator Ben Nelson. So, do you believe there was a
    reduction of the stigma concerns?
        General Linnington. Yes, sir, I do. In fact, we were so
    concerned about that, that in January we asked the Army, the
    Office of the Surgeon General, to send a team to West Point to
    look at our program comprehensively and look specifically look
    at the stigma aspect of it, to see if we had a stigma. Their
    findings were quite the opposite, that there was not a large
    stigma at the Academy. I think that goes to what we do with our
    cadets from when they first enter the Academy. They start as
    freshman in college. We talk to them about the facilities
    available, and we talk to them about seeking help. We also have
    cadet peer counselors identified for them in their first
    summer, so they see them all the time, they see chaplains at
    all the training events. We have full-time tactical officers
    responsible for their health and welfare; they speak to them,
    required, quarterly. So, because they have those multiple
    opportunities to engage with other folks, we think the stigma
    is low compared with the rest of the Army and those where
    seeking help may be viewed negatively.
        Senator Ben Nelson. Thank you.
        Senator McCaskill.
        Senator McCaskill. In my background, I worked with
    substance abuse significantly, as the prosecutor in Kansas
    City. We had a local tax that allowed us to spend significant
    monies on prevention and treatment, and I was very involved in
    the drug court movement in this country. So, I'm pretty well
    versed on the issues of substance abuse, based on my
    background.
        I went over to Walter Reed after the scandal. First, let me
    compliment you on the changes and the improvements that have
    been made at Walter Reed; they're significant, and I
    acknowledge that, and I think you have done well in addressing
    many of them. But, one of the things that struck me as I went
    over there, at that point in time, as I walked around, was in
    every room I looked in there were bottles and bottles of pills,
    and bottles and bottles of liquor, and a whole lot of brave,
    wonderful men and women who were there and kind of in limbo, in
    terms of what their future held. Many of them were waiting for
    a variety of reasons. I saw nothing anywhere about substance
    abuse. There was a bar you could go in, and drink, but there
    was nothing anywhere about substance abuse counseling. Then you
    add to that what we have had, in terms of the problems that
    we've seen at Fort Leonard Wood, as it's related to the
    substance abuse program there. I don't know how aware you all
    are that I've introduced a piece of legislation dealing with
    substance abuse in the military, to try to look at this more
    carefully. I don't need to tell you that we have some
    challenges here, in terms of culture.
        I would like you all to take a moment and address your view
    of confidentiality as it relates to someone stepping forward
    and wanting treatment, versus the culture that exists now,
    which is more focused on the discipline of the unit and combat
    readiness, and whether or not, if someone steps forward and
    wants treatment, whether that's something that their commander
    needs to know about.
        I think it's a real challenge in the military, and I know
    all of you, as medical professionals, and certainly, Ms. Power,
    you understand. I'm willing to bet that just about all of those
    suicide cases, if you look, probably had some kind of substance
    abuse issue that was also going on there at the same time. It's
    just highly unusual that people don't try to self-medicate,
    that are suffering from a mental illness, and that alcohol, and
    particularly now with all the injuries we're having, the
    prevalence of a lot of the drugs that are out there. If you all
    would address that, I would appreciate it.
        Ms. Power. I'll start with the issue, since I can't address
    the military issues, but I can certainly address the fact that
    substance abuse is one of the conditions. We certainly talk
    about co-occurring conditions and co-occurring disorders. In
    those co-occurring conditions, the presence of substance use
    and substance abuse is quite high, relative to the presence in
    completed suicides. So we are aware of the very deep and very
    serious connection between mental health status and substance
    use and substance abuse.
        In fact, the combination of trauma, the combination of
    depression, and the combination with substances often are some
    of the present and triggering factors for suicide. So, from the
    perspective of SAMHSA, we know that we have to address both
    mental health status and substance use, and substance use
    environment, and substance abuse. If we don't address them--
    that's why we actually promote the notion of integrated
    treatment--from a prevention standpoint to an intervention
    standpoint to an integrated standpoint. I know that several of
    the military programs have really focused on an integrated
    treatment approach in a way that I think is quite superlative.
    I will defer to my military colleagues to talk about that.
        General Rubenstein. Ma'am, I'll address this from the
    Army's perspective, and that is, we have far too few soldiers
    who voluntarily go to our Army Substance Abuse Program (ASAP),
    and enroll in order to receive help. The Army is, very shortly,
    going to be releasing a new policy that allows a soldier to
    self-refer to ASAP for training and education, and then, at the
    call of the counselor, into treatment, without the chain of
    command being notified of that.
        Tied to that, of course, is ensuring that our ASAP programs
    are not in buildings that are off in parking lots that are not
    surrounded by anything else so it's not the only reason you
    would walk in the building and those kinds of things.
        So, both from the physical standpoint, but also, most
    importantly, when a soldier self-identifies, the commander does
    not get told about it. It's been that age-old problem of
    balancing the need for the soldier's health with the need for
    good order and discipline of the military. We're very excited
    about this new proposal. The policy will be released very
    shortly, and we're looking forward to great results out of
    this.
        Senator McCaskill. I'm so glad I got here. That's terrific
    news.
        General Rubenstein. Yes.
        Senator McCaskill. I do believe that, in many ways, it
    might be easier for a soldier to say, ``You know, maybe I need
    to think about this drinking,'' or ``I have a drinking issue''
    than ``I have a mental health issue,'' understanding the kind
    of pride and the kind of atmosphere that is so important to our
    military, that everybody drinking is not something that is
    weird.
        General Rubenstein. You're absolutely right. As I said, as
    we pilot this and bring it out, we're looking for good results,
    we're looking to be able to show commanders, ``It's okay for
    your soldier to say, `I have a problem,' and you not knowing
    about it. If the soldier is at risk to himself or to others,
    we'll let you know.''
        Senator McCaskill. Now, that soldier is probably more
    healthy than some of the ones that aren't going to step
    forward, and the commander will never know about that.
        General Rubenstein. Starting point, though.
        Senator McCaskill. Yes. Starting point. Yes, it's good.
        General Rubenstein. Thank you very much.
        Senator McCaskill. Good. That's terrific.
        Do we think we have enough people that are qualified to be
    substance abuse counselors, that are actively working now in
    the military? First of all, I don't mean to pick on Fort
    Leonard Wood. I'm proud of the Fort. My father has a history
    there, and it's close to home, and I know a lot about it. But,
    we're anxiously looking at all of the military bases because I
    have a feeling that Fort Leonard Wood's not the only place
    where they don't have sufficient personnel in place to actually
    provide the counseling for the folks who needed it and wanted
    it.
        General Rubenstein. Right, we have a little over 250
    counselors today. We have over 70 open hiring actions. The
    problem that we have put ourself into is that we are going for
    master's-prepared counselors. What we have to do, and what we
    are doing, is rewriting our own policies so that we have a mix
    of the master's-prepared counselor and the paraprofessional.
    The paraprofessional, as in the civilian sector, works very
    well under the supervision of an independent licensed
    practitioner. We're fully convinced that if we go to a mix of
    master's-degreed and paraprofessional counselors, we will have
    a much broader range of population to recruit from and be able
    to fill, not only those 71 holes that we have, but more, as
    well.
        Senator McCaskill. Has there been any talk about whether or
    not it would be a good idea to look at some of the members of
    the military who have been through substance abuse counseling
    and are recovering, and to pull them in to the counseling
    process? I know that it's hard to go to a successful drug
    treatment facility and not find former users that have become
    counselors and are very, very good at it, because nobody can
    look at them and say, ``Well, you don't understand,'' because
    they can say, ``Well, you know what, yup, I just definitely can
    understand.'' I think, in the military, that would be
    particularly helpful because you would have that recognition
    that someone who has been in exactly the same position has
    struggled with this issue and come out the other side whole.
        General Rubenstein. By broadening the potential population
    to other than the master's-degreed counselors, I think we're
    going to reach into that pool who are successful graduates, if
    you will, have gone through the program, but haven't gone out
    and pursued a full-blown academic preparation resulting in a
    master's degree with certification; the paraprofessional that
    we're talking about. Yes, ma'am.
        Senator McCaskill. I thank you all. On the issue of the
    confidentiality, there's nothing better than realizing that
    part of the legislation you're pushing may not even be needed
    anymore. That happened with Walter Reed, too. So many of the
    things that then-Senator Obama and I originally put in that
    legislation that was filed that very next week, the military
    acted carefully and quickly to fix many of those problems
    before we ever had a chance to get the bill off the printing
    press, almost. So, thank you all very much.
        Thank you, Mr. Chairman.
        Senator Ben Nelson. One final question, here, recognizing
    the time.
        General Sutton, obviously we've heard from each of the
    Services today about the various suicide prevention programs,
    the policies, the initiatives, and what could be better, and
    what everyone is attempting to do to improve them. Do the
    Defense Centers of Excellence for Psychological Health and TBI
    assess service-level suicide prevention programs, do an
    assessment of programs, as well as the research? Or, are the
    centers more responsible for creating DOD-wide programs?
        General Sutton. Actually, sir, both.
        Senator Ben Nelson. You do both.
        General Sutton. As of January of this year, as we've grown
    into our potential, we accepted the responsibility, across the
    Department, for suicide prevention, and that includes working
    with the Services. We're putting outcome metrics against number
    of the programs. We're also working at the Samueli Institute
    and the RAND Corporation. We have a number of promising
    practices that are across installations, such as yoga,
    mindfulness, acupuncture, as well as, for example, Senator
    McCaskill, you had mentioned whether we could use
    servicemembers who have successfully gone through substance
    abuse programs--one such individual, a 1st sergeant--who's a
    1st sergeant of the WTU at Fort Lewis, he traveled with me to
    Germany last month to address the senior leaders under General
    Hamm's leadership, and he was able to tell his story. He's
    given me permission to give his name, 1st Sergeant Creed
    McCaslin. He was able to talk about how, after his multiple
    tours in Iraq, with, as his command sergeant major described
    it, possibly the most trauma-exposed individual he knows of in
    this conflict, and as he came back from that, he was
    experiencing very severe post-traumatic stress, started to
    self-medicate, as you mentioned, ma'am, got himself into
    trouble, was relieved from his position for a DWI; he had gone
    to a buddy's house that night and didn't want his buddy to know
    what he was experiencing, woke up at 3 o'clock in the morning
    with dreams, flashbacks, severe post-traumatic stress, got
    himself into trouble, and now has been able to, through that
    experience, talk about his journey to claiming post-traumatic
    growth, and to talk to young soldiers, sailors, airmen,
    marines, and troops, leaders, to let them know that, yes, you
    can make a mistake, you can go get treatment, and you can come
    back, and you can still lead. So, I think it's a very powerful
    example that we will continue to build upon.
        We also know, Mr. Chairman, that there are some effective
    suicide prevention practices that have been established in the
    literature. One such program is called the Caring Letters
    Project. Now, we have not yet implemented this within DOD, but
    it's something that I'm working closely on, now I'm going to be
    reaching out within our priority working group for
    reintegrating veterans, warriors, and their families, Ms.
    Power, as well as working with Matt Friedman, who's the
    Director of the National Center for PTSD, because this project
    is a very simple project, but what it involves is writing a
    letter, a supportive, caring motivational letter, to
    individuals at risk who have been discharged from psychiatric
    units in the past year, a letter that comes from the staff,
    that have a relationship with that individual, every quarter
    for the next year. That practice has shown itself to actually
    prevent suicides.
        So, there are things that we know, in addition to all that
    the Services are doing right now, to get the providers and the
    care networks and the identification and the gatekeepers, all
    of those things, the community-based efforts, primary-care
    treatment, awareness, cultural transformation, but we know it
    also boils down to such simple things as human connection.
        I'm an Army psychiatrist. I recently got a letter from a
    senior NCO with whom I had worked, actually, at Fort Leonard
    Wood several years ago, Senator McCaskill, when I was the
    deputy commander there. This sergeant major sent me a copy of a
    tattered e-mail that I had shared with him several years ago.
    Unbeknownst to me, he had been carrying it in his wallet for
    these last almost 9 years. He said, ``Ma'am, with all of the
    talk right now and the crisis having to do with suicide, I want
    you to know that having this note from you from 8 years ago.
    I've carried in my letter, I have taken out, on more than one
    occasion, and it has kept me from a very, very desperate
    decision.''
        So, I think there are some things there that we can learn,
    both formal programs, as well as informal ways of, as we
    transform the culture, to help individuals connect. Just as
    health is much more than the absence of disease, resilience is
    much more than the presence of destructive behavior, such as
    suicide. It has to do with proper rest, nutrition, friends,
    family, love, faith, hope, and growth. Those are all things
    that, as we, yes, work to prevent that individual who's at that
    desperate point, that we also move to the left to build
    resilience from day number one of accession.
        I would say, when it comes to the screening question that
    was mentioned earlier, we already know that, as important as
    screening is, we cannot screen our way out of this challenge.
    When only 3 out of every 10 Americans aged 18 to 24 are even
    eligible to put on this uniform, we have a national resilience
    crisis, and that's something that I look forward to in our
    position with the Defense Centers of Excellence and the
    Services and working across the government, around the country,
    and, yes, around the world. I really look forward to continuing
    this journey of identifying best practices and putting them to
    use where they will count for our troops and their loved ones
    and our Nation at large.
        Thank you, Mr. Chairman.
        Senator Ben Nelson. Before we conclude, is there anything
    that we didn't ask and should have, or anything that we didn't
    touch on that you would identify that would be helpful for us
    as we continue this journey together?
        [No response.]
        If not, thank you very much. I appreciate your wisdom and
    your service. We hope, as a result of this and the days ahead,
    we will see improved results.
        Thank you.
        [Questions for the record with answers supplied follow:]
               Questions Submitted by Senator E. Benjamin Nelson
                               reserve component
        1. Senator Ben Nelson. General Chiarelli, Admiral Walsh, General
    Amos, and General Fraser, National Guard and Reserve members who do not
    live in close proximity to a military installation, or who live in very
    remote locations, can experience their own set of issues when it comes
    to access to health care and family support programs that may be needed
    following a deployment. Are there any specific programs in place in
    each of the Services to address the unique needs of National Guard and
    Reserve members and their families, to ensure there are no gaps in
    access to help and support for the National Guard and Reserve when it
    comes to suicide prevention?
        General Chiarelli. From February 15 to March 15, 2009, the Army
    conducted a service-wide Suicide Prevention Stand Down and Chain
    Teaching, a first according to the Center for Military History. During
    the stand down, the Army trained every soldier on suicide risk
    identification and intervention, and addressed the stigma associated
    with behavioral health counseling, using an interactive video titled
    ``Beyond the Front.'' Feedback from soldiers about the video was so
    positive that new, similar videos are being created for families and DA
    civilians; and the Army National Guard and Reserve plan to tailor these
    videos for their soldiers as well. Also during the stand-down, the Army
    distributed thousands of Ask, Care, Escort (ACE) wallet cards to
    soldiers; these cards provide a quick reference on how to identify and
    care for a potentially suicidal buddy. Follow-up to the stand down
    included chain teaching on suicide prevention tactics. Chain teaching
    remains underway through July 1.
    Army Reserve
        The Army Reserve is taking a proactive approach to the Suicide
    Prevention Program by coordinating workshops to train personnel as
    Applied Suicide Intervention Trainers and Train-the-Trainers who will
    assume responsibilities for conducting Applied Suicide Intervention
    Skills Training (ASIST) from LivingWorks Education, Inc workshops in
    their region.
        The Army Reserve is also placing emphasis on suicide prevention
    through its Yellow Ribbon Reintegration Program (YRRP), which includes
    loved ones as well as fellow soldiers. The Army Reserve has an
    initiative to include suicide awareness training to its units' Family
    Readiness Groups (FRGs). The more people in a soldier's life who are
    aware of signs and symptoms associated with a soldier contemplating
    suicide, the more likely we will be able to work to prevent these
    tragedies.
        The Army Reserve stays in touch with soldiers and family members
    throughout the deployment cycle through events outlined in the YRRP.
    YRRP activities are conducted at 30-, 60-, and 90-day intervals prior
    to mobilization and deployment, while deployed, and at 30-, 60-, and
    90-day intervals after re-deployment. YRRP topics of discussion,
    informational briefings, and training activities focus on services and
    support directly affecting the well being of soldiers and their family
    members. Army Reserve leaders also have periodic town halls and
    information-sharing sessions, supplemented by recurring training on
    suicide prevention, during the deployment cycle.
        The Army Reserve is coordinating with the National Guard Bureau and
    others to pursue the development of a suicide prevention training
    package for families. The ultimate plan for the Army Reserve Family
    Suicide Prevention Training is to have a Reserve component-family
    unique interactive video, Reserve component-family unique intervention
    tools, and family facilitator/training guide.
        The Army Reserve Command has implemented new required training for
    the commander, First Sergeant, Family Readiness Liaison/Rear Detachment
    Commanders, FRG leaders, and key volunteers of alerted and/or deployed
    units (the ``Family Readiness Team''). This training, called Army
    Reserve-Family Readiness Education for Deployment training was formerly
    known as Deployment Cycle Support training. The objective is to provide
    information for family members and soldiers affected by mobilization,
    deployment, sustainment, and reunion. The intent is to develop a
    network of informed personnel associated with the Army Reserve Family
    Program to help alleviate concerns by family members and/or soldiers
    trying to find answers to deployment-related questions. Family Program
    Academy (FPA) training is divided into three parts: fundamental,
    developmental, and resource. Fundamental FPA training includes the
    basics required to establish and maintain a viable, functioning FRG at
    the unit level. Developmental FPA training builds on those basics and
    enhances the participant's capability to sustain and enhance unit
    family programs. Resource training is provided at the unit.
        Operation Resources for Educating about Deployment and You (READY)
    is a series of training modules, videotapes, CDs, and resource books
    published for the Army as a resource for staff to train Army families
    who are affected by deployments. Operation READY materials include:
    pre-deployment and ongoing readiness, Family Assistance Centers,
    Homecoming and Reunion, the Army FRG Leader's Handbook, and the Army
    Leader's Desk Reference for Soldier/Family Readiness. The training is a
    train-the-trainer program for instructors and senior volunteer resource
    instructors to take back to units and show how information and
    materials are accessed and utilized. Chain of command training is
    designed to familiarize unit leadership with the scope of family
    programs within the Army Reserve. Briefings are provided on all aspects
    of family programs, such as mobilization training, volunteer
    management, and the Army Family Action Plan.
        Finally, the Army Reserve encourages its soldiers to participate in
    the ``Strong Bonds'' program to help rebuild relationship skills with
    loved ones. These events typically occur on a weekend and are funded by
    the Army Reserve at a non-military site.
    Army National Guard
        The Army National Guard has a suicide prevention program at the
    National Guard Bureau level and in the States. The Army National Guard
    Suicide Prevention Program Management team trains State Suicide
    Prevention Program Managers in intervention skills so that they can
    intervene when they encounter someone in crisis. Depending on their
    issues, someone in crisis would be referred to a counselor, taken to
    the hospital, connected with a chaplain, etc. The Army National Guard
    policy requires annual ACE Suicide Prevention for Leaders training and
    annual ACE Suicide Prevention for Soldiers training. Additionally, the
    unit-level Suicide Intervention Officers receive the ACE Suicide
    Intervention Training, and gatekeepers, like chaplains and behavioral
    health workers, attend ASIST. The Army National Guard relies heavily on
    families as our first line defenders against suicide. While the State
    Suicide Prevention Program Managers have the training to intervene in a
    crisis, they are often limited in the amount of help they can render.
    Specifically, unless a citizen-soldier or a family member contacts the
    State military leadership, there may not be an opportunity for the
    Suicide Prevention Program Manager to intervene when the citizen-
    soldier who is in a citizen status is having suicide ideations. As a
    result, the United States Army Center for Health Promotion and
    Preventive Medicine has produced a training program geared to increase
    suicide awareness for families. We have provided that training package
    to our States.
    Family Support Programs
        The Army OneSource (AOS) provides a multiagency approach for
    community support and services to meet the diverse needs of soldiers
    and families, regardless of where they reside. The AOS connects
    soldiers and their family members to support services using both
    personal and web-based (www.armyonesource) means. AOS provides
    information on 14 baseline services at 87 Army Community Service (ACS)
    centers, 249 enduring Guard Family Assistance Centers, Army and Child
    and Youth Programs, Operation Military Kids in 42 States and Operation
    Military Child Care in 50 States, Reserve Readiness Centers, and
    recruiting battalions.
        To augment existing military support services, DOD established the
    Military Family Life Consultant (MFLC) program to provide non-medical,
    short term, situational, problem-solving counseling services to address
    issues that occur as a result of the military lifestyle and help
    servicemembers and their families to cope with the reactions to the
    stressful/adverse situations created by deployments and reintegration.
    The MFLC works directly with ACS, National Guard Headquarters, and
    Reserve Regional Commands to provide support to servicemembers and
    their families.
        Military OneSource supplements existing Army family programs by
    providing a 24/7 toll free information and referral through telephone
    and web-based services. One of the many services available is up to six
    face-to-face counseling sessions for active duty, National Guard,
    Reserve soldiers; deployed civilians; and their families worldwide.
    Military OneSource provides information ranging from every day concerns
    to deployment and reunion issues. Additionally, if there is a need for
    face-to-face counseling, Military OneSource will provide referrals to
    professional civilian counselors for assistance in the continental
    United States, Alaska, Hawaii, Puerto Rico, and the U.S. Virgin
    Islands. Outside these areas, face-to-face counseling is provided via
    existing medical treatment facility services.
        In addition to face-to-face counseling and short-term-telephonic
    consultation, Military OneSource is now providing e-consultation for
    those who prefer communicating online. This option uses instant-
    messaging, with the consultant and participant communicating online in
    real time; however, online consultations are not appropriate for
    children under 18, for people with complex issues, or for situations
    that require a group setting (couples and family counseling).
        As part of the DOD Joint Family Support Program, Military OneSource
    has hired State-based consultants to work at State Joint Force
    headquarters. These consultants assist the State family program
    directors and other joint headquarters staff in integrating Military
    OneSource into operations around the deployment cycle and identifying
    resources that support the well-being of Service and family members at
    the State level.
        Admiral Walsh. To specifically address the psychological health
    (PH) needs of Navy reservists, two programs were funded by the PH/TBI
    supplemental. Both are non-installation based programs that address the
    unique circumstances of Reserve component members and their families.
    We know improvement in the overall PH of the Navy Reserve will be
    achieved by quickly identifying members with stress disorders, helping
    them secure appropriate and timely care, identifying long-term
    strategies to improve PH and resiliency, and by providing PH education
    and training to leadership down to the deck plates.
    Navy Reserve Psychological Health Outreach Program
        The Navy Reserve Psychological Health Outreach Program was
    implemented in 2008, and has facilitated the assignment of two
    Psychological Health Outreach Coordinators and three outreach Team
    members to each of the five Reserve Component Commands (RCC). They are
    licensed clinical social workers who provide initial mental health
    clinical assessment of Reserve component servicemembers and provide
    appropriate care referral, if needed, and subsequent follow-up. The
    Outreach team members make visits to two to three Navy Operational
    Support Centers (NOSC) per month in their respective Reserve Regions
    where they provide PH education including the Operational Stress
    Control Awareness and Suicide Prevention briefs to NOSC staff and
    Reserve unit members. The Psychological Health Outreach Team is also
    available upon request by the NOSC to make special visits for PH
    assessment of unit members affected by suicides and suicide attempts.
    Reserve Returning Warrior Weekends
        The Returning Warrior Workshop (RWW) is a ``five-star event''
    conducted on weekends and attended by up to 200 sailors, marines, and
    family member or spouse. It is the signature event of the Navy Reserve
    Reintegration program. Attending participants have the opportunity to
    address personal, family, or professional situations experienced during
    deployment and receive readjustment and reintegration support from a
    network of counselors, PH outreach coordinators, chaplains, and Fleet
    and Family Support Center (FFSC) representatives. Throughout the
    weekend, participants benefit greatly from considerable counseling
    opportunities to educate and support the Navy family and to assist
    sailors re-acclimating to their families and civilian lives.
        Both of these programs will be extended in the summer 2009 to
    provide support to the USMC Reserve.
        General Amos. The Selected Marine Corps Reserve (SMCR), Navy
    Selected Reserve (SELRES) assigned to SMCR units, Active Reserve (AR),
    and Active component (AC) personnel are advised by their leaders that
    the help offered by Military OneSource is only a phone call away at any
    time of the day or night and is available anytime to all servicemembers
    and their families. Marines, sailors, and family members are briefed
    that this organization can provide immediate telephonic intervention,
    can alert hands-on providers as needed, and can provide on-line or
    face-to-face counseling by licensed clinicians for up to 12 sessions
    per year. Additionally, they are advised of the services provided by
    the nearest Veterans Administration (VA) facility and the Veteran
    Center. Information on local hotlines, mental health facilities,
    community agencies, internet sites, and governmental resources is also
    provided.
        Programs of the YRRP specifically address PH/wellness during Pre-
    deployment, Mid-deployment, and Post-deployment events-both for
    marines, sailors, and their families. Combat Operational Stress Control
    (COSC); physical, behavioral, and spiritual health issues; relationship
    sustainment and reconciliation; financial management; compulsive
    behavior prevention; substance abuse; and societal reintegration topics
    are all covered. Though suicide is not specifically addressed as a
    topic in this setting, these presentations address the top five most-
    common stressors associated with suicide.
        In addition to the annual Suicide Awareness and Prevention training
    provided to all marines and sailors, unit leaders at all levels within
    the SMCR units receive additional training and have access to a
    leader's guide on dealing with suicidal ideations, statements, and
    behaviors. Real-life events and challenges that lead some to entertain
    suicidal thoughts are discussed. Licensed clinicians, available through
    the MFLC program that is provided through an Office of the Secretary of
    Defense (OSD) contract, are available to units for their pre- and post-
    deployment events. These consultants provide short-term, non-medical,
    solution-focused counseling to members and their families on issues
    arising from the military lifestyle.
        General Fraser. Yes. In addition to training requirements, that are
    the same for the Active Duty members, Reserve component members are
    part of the YRRP. It pays for servicemembers and several family members
    to attend events at 30, 60, and 90 days post-deployment. As part of
    this program, the Post-Deployment Health Assessment (PDHA) and Post-
    Deployment Health Reassessment (PDHRA) are tools to identify members
    that may have suicidal tendencies. If geographically separated from
    their unit of assignment, members can also register and attend another
    Service's YRRP events.
        Additionally, VA mental health and medical services are available
    to all military members that deployed. The member needs only to show a
    copy of their orders to receive care. Transitional Assistance Advisors
    provide a person in each State/territory to serve as the statewide
    point of contact to assist members in accessing Veterans Affairs
    benefits and healthcare services.
        Military OneSource also provides support to members and their
    families. Members and families are briefed on these programs/resources
    before deploying and after redeploying.
    Air National Guard:
        In addition to YRRP, each Air National Guard Wing has a Family
    Readiness person and a Medical Unit that provides help and support. The
    Air National Guard Readiness Center has a Director of Psychological
    Health on staff and 40 out of 56 Directors of Psychological Health have
    been hired for each of the States and territories. Military Health Net
    assists redeploying ANG members and their families in personal
    interviews and re-interviews. There is a TRICARE provider network who
    can refer members for financial management assistance, mental health
    assistance and care, family and individual counseling, anger
    management, etc.
    Air Force Reserve:
        The Air Force recently stood up four regional Psychological Health
    Advocate (PHA) teams and hired a Director of Psychological Health
    (DPH). There are plans for an additional four teams. These teams will
    develop and implement population-based PH at each wing within their
    respective region, ensure access to quality mental healthcare at Air
    Force Medical Treatment Facilities for eligible Air Reserve component
    beneficiaries, and follow-up, as necessary to ensure positive outcomes.
        Air Force reservists are currently required to complete (in person)
    an in-processing checklist with their unit/wing upon return from
    deployment. Reserve unit deployment managers and full time unit
    personnel maintain contact with Reserve members during deployment,
    post-deployment, while on leave, and during downtime. The PDHRA
    screening is being accomplished 90-180 days after returning from
    deployment and any positive response results in contact with the member
    for further assessment and possible referral for services.
        Other programs and resources already in place to address the needs
    of Air Force reservists and their families: YRRP, Joint Family Support,
    routine screenings (Physical Health Assessment (PHA), PDHA and PDHRA,
    Expanded benefits such as Tricare Reserve Select, increased
    collaboration between DOD and the VA on medical issues, Landing Gear,
    annual suicide prevention training, MFLCs, Military OneSource, ESGR,
    Transition Assistance Advisors, Childcare for personnel on extended AD
    orders, family care plans, chaplain support, and financial counseling.

        2. Senator Ben Nelson. General Chiarelli, Admiral Walsh, General
    Amos, and General Fraser, is anything being done to reach out to
    members of the Individual Ready Reserve (IRR), who are not required to
    drill or check in with units?
        General Chiarelli. IRR soldiers who have recently returned from a
    deployment or attended a muster event are screened and/or received
    information regarding reintegration/coping techniques from the
    Department of Veterans Affairs (VA).
        The US Army Human Resources Command (HRC) began a pilot program in
    2007 to muster IRR soldiers; 29,000 IRR soldiers were sent orders to
    muster, with over 8,000 completing muster duty. Of these, 7,500
    completed a Personnel Accountability Muster (PAM), a one-on-one event
    with an Army Career Counselor at one of over 200 Army Reserve centers.
    An additional 600 IRR soldiers completed a Readiness Muster, a full
    spectrum medical and mobilization validation event, conducted at four
    Pilot Army Reserve locations. Since 2007, the muster program outreach
    continues to expand and regularly sends muster orders to 35-40,000 IRR
    soldiers each year; with 11-13,000 mustering. IRR soldiers can now
    complete a PAM at over 400 locations; anywhere there is an Army Reserve
    Career Counselor. This year nearly 1,300 soldiers will muster at 13
    Readiness Muster locations, 5 which occur at a Veteran Affairs Medical
    Center. They initiate the Army Periodic Health Assessment (PHA), Post-
    Deployment Health Reassessment, validate their readiness for continued
    service, receive vital information regarding veteran's benefits, and
    guidance regarding Federal and local employment opportunities. With
    sustained funding, the projection for 2010 is to expand the
    collaborative partnership with Veterans Affairs to maximize the
    opportunity for more IRR soldiers to complete a full spectrum Readiness
    Muster screening.
        HRC facilitates the participation of IRR soldiers who have recently
    returned from deployment in the YRRP. IRR soldiers (and a family
    member) on a voluntary basis may attend an event hosted either by the
    Army Reserve, the Army National Guard, or another military Service.
    Soldiers normally attend an event that is nearest their home, but
    consideration is given, upon request, to send them to the events hosted
    by the unit with whom they deployed.
        The Human Resources Command initiates contact with newly assigned
    IRR soldiers through an IRR Welcome Letter and Orientation Handbook.
    This information is mailed about 30 days after assignment to the IRR
    and explains general requirements, expectations, training
    opportunities, and annual muster duty.
        There are three kinds of musters. Approximately 5 months after
    entering the IRR a soldier is ordered to a PAM at a local Army Reserve
    center for a one-on-one event with a career counselor. In following
    years, some soldiers will be ordered to a Readiness Muster at a local
    Army Reserve center or Veterans Affairs Medical Center. This event is a
    full spectrum medical screening to identify any challenges they may be
    experiencing and educate them on a wide variety of veteran benefits
    available. Soldiers who cannot attend a centralized Readiness Muster
    are ordered to visit a unit visit muster in their local area focused on
    orientating IRR soldiers on the camaraderie and esprit-de-corps
    available in Army Reserve units. At all musters, soldiers are screened
    for completion of the Post-Deployment Health Reassessment, which based
    on answers provided in the screening, can alert a medical professional
    of suicide ideations. Additionally, all soldiers complete an online PHA
    as required.
        Admiral Walsh. The Navy Reserve Psychological Health Outreach
    program is available to assist with providing outreach services to the
    IRR--this is a natural extension of services already being provided. In
    addition, IRR members are encouraged to attend a RWW and other
    reintegration events if they have been recently deployed. Names of
    recently deployed IRR personnel have been forwarded to the Navy's YRRP
    leader, and future lists are available on request. Accordingly, the
    principal intent is to forward IRR sailors' names to the RCC
    coordinating the RWW to facilitate invitations to the appropriate
    upcoming RWW. Additionally, IRR members participate in the Navy's PDHRA
    program to follow up on their physical and PH. The first PDHRA occurs
    within 90-180 days following re-deployment. Finally, IRR members are
    required to complete an annual virtual muster questionnaire, part of
    which addresses any health concerns or changes in health status. If
    members bring up concerns or changes, IRR counselors are present 5 days
    per week to follow up with members and provide advice and assistance
    when necessary.
        General Amos. Marines in the IRR are managed by Marine Forces
    Reserve's Mobilization Command (MOBCOM). In addition to a full-time
    Family Readiness Officer (FRO) and a specially-trained Religious
    Ministry Team, other members of the command's Marine Corps Family
    Readiness Team (MCFRT) contact IRR marines within 60 to 90 days after
    their discharge from the Active component. Marines who have been
    mobilized from the IRR are asked to complete a PDHRA. Any responses
    indicating a need for referrals receive a personal telephone call and
    follow-up action. RWWs are used as the Yellow Ribbon 60-day
    Reintegration Event. The comprehensive event provides a safe and open
    environment for Service and family members to openly discuss issues
    ranging from reintegration difficulties to past combat traumas. A
    psycho-educational model is used to help attendees realize they are
    having normal reactions to abnormal events. The setting provides a
    sense of commonality and helps individuals realize they are not alone.
    Though geographically isolated they come connected to a larger
    community. Chaplains and counselors are readily available to provide
    counseling as required. Follow-up for individuals is obtained through
    the use of mental health resources near the member's residence.
        General Fraser. Members of the Participating IRR have the same
    annual requirements as members of the Selected Reserve. These members
    receive the same Suicide Prevention briefings and are afforded the same
    access to resources like the YRRP and Military OneSource. Non-
    participating members of the IRR do not have the same annual
    requirements, but they are afforded some access to those resources.

                                   dwell time
        3. Senator Ben Nelson. Brigadier General Sutton, we know that
    deployments put great stress on servicemembers and their families.
    While deployment and exposure to combat are not the sole reasons a
    member may kill himself or herself, and in many cases the member has
    never deployed, they can contribute to other stressors such as
    financial or marital instability. In your view, would increased dwell
    time, for the Army in particular, help to ease these stressors?
        General Sutton. Suicide risk factors are related to the number of
    stressors and demands on the individual balanced by the ability to cope
    with multiple stressors at the same time. To the extent that some of
    those demands can be alleviated by more time at home to clear away
    problems, there may be a benefit. In addition, given the increased
    level of health and fitness that comes with increased time to pay
    attention to health, resilience in the face of stress can be enhanced
    as well. Lack of social support or loss of important relationships in
    an individual's life significantly increases suicide risk. Long
    deployments and multiple deployments within a short time of each other
    can lead to deterioration in relationships, especially marriages and
    close intimate relationships. When the individual comes home without a
    strong social network, risk of self-harm, to include reckless behavior,
    self-injurious behavior, and more extreme suicidal behavior can result.
    In addition, mental health conditions, especially depression and
    substance abuse, add to those risks and may be associated with
    deteriorated coping and prolonged exposure to stress. Sleep problems,
    fatigue, and overall feelings of inability to cope with probably
    without enough energy also contribute to overall risk levels. These
    problems are often associated with both deployments and with suicidal
    behavior. Clearly, any measure that reduces the stress to individuals,
    while building individual strength and protective factors, such as
    strong social networks, will help to minimize the risk.

        4. Senator Ben Nelson. Brigadier General Sutton, have you derived
    from the Defense Centers of Excellence's studies or collaborative
    efforts with other agencies or outside groups a recommended length of
    time a servicemember should have between deployments to recover from
    the stresses incurred during their time in theater?
        General Sutton. The Defense Centers of Excellence (DCoE) for PH and
    Traumatic Brain Injury (TBI) has not identified a recommended length of
    dwell time for servicemembers. Additional research is needed to better
    understand the effect of deployment stressors on individuals and
    variables unique to the individual Services. Length of deployment may
    be just as important, or more important, as dwell time to reduce all
    signs of distress. In addition, optimal dwell time may vary based on
    length of deployment, number of previous deployments, and nature of
    combat exposure during deployments. We have learned that the British
    Forces have standardized dwell time based on a ratio of time away in a
    combat environment. Their experience may help to inform our research
    efforts and, ultimately, our policies.

      research funding for psychological health and traumatic brain injury
        5. Senator Ben Nelson. Brigadier General Sutton, over the past 2
    years a great deal of money, to the tune of at least $600 million, has
    been put towards PH and TBI. Could you please explain how you have
    allocated the funds authorized to the Defense Centers of Excellence for
    PH and TBI, what mechanisms you have in place to vet and execute
    contracts to conduct research, and describe the timelines you have in
    place for actionable results?
        General Sutton.
    Fiscal Year 2007/Fiscal Year 2008:
        While well over $600 million was provided for PH and TBITBI
    efforts, $300 million was assigned to fund RDT&E projects specifically
    focused on PH and TBI, $45 million of which was assigned to support
    specific DCoE for PH and TBI RDT&E priorities. The remaining $255
    million was assigned to the United States Army Medical Research and
    Material Command (USAMRMC) for execution. Recommendations for
    investment of these funds were provided by key stakeholders, which
    included representatives from the Armed Services Biomedical Research
    Evaluation and Management Secretariat (Army, Navy, Air Force, the OSD/
    Office of Health Affairs); Uniformed Services University of the Health
    Sciences; Director of Defense Research and Engineering; the VA; the
    National Institute of Health (NIH); clinical consultants from each of
    the Services, and the DCoE.
        In regard to mechanisms in place to vet and execute contracts to
    conduct research, program management responsibility for the full $300
    million RDT&E appropriation was administered by the USAMRMC in
    collaboration with DCoE as applicable. The program execution model for
    the fiscal year 2007 PH/TBI research program was conducted according to
    the USAMRMC two-tier review model, which includes scientific peer
    review and programmatic review, recommended by the National Academy of
    Sciences Institute of Medicine. The USAMRMC Acquisition Activity was
    responsible for negotiation of awards. Program execution through award
    can take up to 12 months.
        About $5 million of the $45 million assigned to the DCoE for PH and
    TBI was directed toward Complementary and Alternative Medicine research
    proposals. The remaining funds, assigned to the USAMRMC Congressionally
    Directed Medical Reach Program (CDMRP), were distributed across
    preclinical studies, clinical research, and clinical trials addressing
    research focused on five critical research gap areas for both PH and
    TBI. Among the 201 projects funded, three were multidisciplinary
    consortia, including a $60 million Clinical Consortium focused on Post-
    Traumatic Stress Disorder (PTSD) and TBI and two $25 million research
    consortia, one each for PTSD and TBI. The DCoE has visibility on these
    consortia through participation on External Advisory Boards for each.
        The USAMRMC, in collaboration with the DCoE as applicable, will
    provide full lifecycle management for all projects supported via the
    $300 million assigned in fiscal year 2007 to support PH and TBI RDT&E
    efforts. These efforts make possible a dynamic continuum of scientific
    knowledge between basic research and clinical observation. Actionable
    outcomes for these research projects are expected over the next 1-5
    year range. Abstracts for all of these awards can be viewed at http://
    cdmrp.army.mil/search.aspx.
        Additionally the DCoE was instrumental in providing expertise on
    the panel which recommended the fiscal year 2008 Deployment Related
    Medical Research Program (DRMRP) awards. Of the DRMRP awards
    recommended, ten targeted PH for approximately $30 million and ten
    targeted TBI for approximately $9 million. Abstracts for these awards
    will be posted at the CDMRP site listed above upon completion of award
    negotiations.
    Fiscal Year 2009:
        Again, significant funding has been appropriated for PH/TBI
    research, but the DCoE only had responsibility to make recommendations
    for $90 million. Since the granting process is not yet complete, the
    information remains procurement sensitive. However, the approved
    execution plan is in compliance with the guidance provided in the
    language that accompanied the appropriation as well as incorporates
    some emerging priorities. The DCoE continues to enhance its
    relationship with USAMRMC and to leverage and participate in their
    proposal review process as well as their contracting and management
    capabilities.

    role of the defense centers of excellence for psychological health and
                             traumatic brain injury
        6. Senator Ben Nelson. Brigadier General Sutton, we have heard from
    each of the Services today about various suicide prevention programs,
    policies, and initiatives. Do the Centers of Excellence for PH and TBI
    assess Service-level suicide prevention programs and research, or are
    the Centers only responsible for creating Department of Defense (DOD)
    programs?
        General Sutton. The DCoE for PH and TBI has undertaken program
    evaluation responsibilities for all programs, including suicide
    prevention. It is one of the DCoE's core responsibilities to assist the
    Services in conducting their own program evaluations using subject
    matter experts as consultants to enable effective evaluation protocols.
    This function is not yet available within the DCoE, but it is in
    development. DCoE does not establish DOD policy or create new programs
    just for informing policy offices of the best research and practice in
    the area. The Services are all members of the DOD Suicide Prevention
    and Risk Reduction Committee and coordinate their programs through that
    joint forum to share best practices. DCoE assumed the Chair of that
    committee in October 2008. The Air Force has proven to have the most
    effective model for suicide prevention through its community-based
    suicide prevention program and 11 program components. This program has
    been cited as a model for the Nation and often cited in the
    professional literature for its effectiveness. In addition, DCoE will
    provide support to the DOD Task Force on Suicide Prevention, responsive
    to the NDAA for Fiscal Year 2009, section 733. This task force will
    assess suicide education and prevention programs of each military
    Service.

        7. Senator Ben Nelson. Brigadier General Sutton, what is the
    Defense Centers of Excellence doing to coalesce the projects being
    performed by other agencies and entities, such as the VA and other
    Federal agencies, State and private universities, and non-governmental
    organizations to identify gaps in research or treatment, as well as to
    avoid duplication of efforts?
        General Sutton. The DCoE for PH and TBI established a Research
    Directorate to oversee the coordination across DOD and other Federal
    and non-Federal agencies. In addition, DCoE engages in activities to
    identify gaps in research and to avoid duplication of effort,
    including:

          Coordinating development of recommended PH and TBI
    research strategies, requirements and priorities jointly across
    multiple agencies;
          Creating common data elements, definitions, metrics,
    outcomes, and instrumentation standards;
          Conducting comprehensive scan for current research
    activities related to PH and TBI, and integrating research efforts of
    component centers, DOD including Blast Injury Research Program
    coordination, VA, Federal agencies, and civilian organizations;
          Performing gap analysis using the Joint Process
    Integration Panel to define requirements and priorities as inputs to
    the overarching Health Affairs biomedical research, development
    testing, and evaluation (RDT&E) portfolio, joint development of
    requests for proposals, and both programmatic and peer reviews;
          Developing PH and TBI research and clinical practice
    clearinghouse capabilities;
          Consolidating and disseminating best practices and
    monitoring clinical investigations (non-RDTE); and
          Translating research into practical tools, technologies,
    protocols, and clinical practices.

        The following is a selected (not comprehensive) list of agencies
    and institutions with whom DCoE actively collaborates:
    DOD Agencies:

          Bureau of Medicine and the Office of Naval Research
          U.S. Army Medical Research and Materiel Command
          Armed Forces Health Surveillance Center
          Armed Forces Institute of Regenerative Medicine
          Uniformed Services University of the Health Sciences
          Center for Neuroscience and Regenerative Medicine
          Joint Improvised Explosive Device Defeat Organization
          Defense Advanced Research Projects Agency

    Other Federal Agencies:

          Department of Veterans Affairs
          National Institutes of Health
          National Institute on Disability and Rehabilitation
    Research
          Centers for Disease Control and Prevention
          Department of Health and Human Services

    Non-Federal Institutions:

          University of California San Diego Medical Center
          University of Southern California--Institute for Creative
    Technologies Sesame Workshop
          Medical University of South Carolina
          University of Cincinnati
          University of Washington
          Dartmouth College
          University of Maryland Baltimore
          Spaulding Rehabilitation Hospital
          Massachusetts General Hospital
          Duke University
          Brigham and Women's Hospital
          RAND Corporation
          National Military Family Association
          Purdue University
          Massachusetts Institute of Technology
          Laurel Highlands Neuro-Rehabilitation Center, Johnstown,
    PA
          Lakeview Virginia NeuroCare, Charlottesville, VA

                             oversight of services
        8. Senator Ben Nelson. General Sutton, what is DOD doing to
    understand what programs the Services are undertaking and what works?
        General Sutton. The DCoE for PH and TBI works with the Services and
    external partners to understand and track suicide prevention programs.
    In addition to DCoE research studies, the Suicide Prevention and Risk
    Reduction Committee provides a venue for the Services to discuss their
    current efforts. Also, DCoE will provide support to the DOD Task Force
    on Suicide Prevention. This task force augments DOD efforts to capture
    Service-level prevention and intervention efforts. It will establish
    and update suicide education and prevention programs conducted by each
    military department based on identified trends and causal factors.

        9. Senator Ben Nelson. General Sutton, is DOD overseeing a best
    practices model, taking into account the differences of the Services
    and incorporating those things and treatments that could work DOD-wide?
        General Sutton. One of the core functions of the DCoE for PH and
    TBI is to assess programs across the Services as measured against a set
    of core principles to find best practices and pockets of excellence.
    The goal is to feed evidence-based information to the Service
    leadership to take appropriate action as they implement and shape
    programs for their Services as well as to the Assistant Secretary of
    Defense for Health Affairs to establish policy that will proliferate
    best practices across the enterprise. Of course, we are cognizant of
    the fact that Service-unique cultures must be taken into consideration
    as well as Service-unique requirements.
        An example of a product from our process is the publication of the
    guideline for Clinical Management of Mild TBI in Theater. We gathered
    our best clinicians from the Services who had treated patients in
    theater and developed a standardized guideline for use by our providers
    in Iraq and Afghanistan. To improve the quality of care, we established
    clinical standards, which incorporated lessons learned and best
    practices, and introduced evidence-based care as the enterprise
    standard for acute stress disorder and PTSD, depression, and substance
    use disorders.

        10. Senator Ben Nelson. General Sutton, if we are not doing this,
    how can we do this and who should oversee the overall mental health and
    wellness of our armed services?
        General Sutton. For prevention methods to work, building protective
    factors and reducing risk factors at the early stages of distress are
    effective. This cannot be done solely from a medical point of view
    because if only medical or mental health intervention is used, the
    intervention is too late. Ideally, prevention takes a community
    approach. First-line supervisors, family members, and friends are in
    the best position to identify behaviors that might indicate an
    individual is experiencing distress far in advance of that distress
    resulting in suicidal behaviors. Educating supervisors, commanders, and
    peers in identification of distress and sources of support can help.
    Working from a positive perspective, creating a strong, supportive
    community that fosters well-being is our best approach to PH, strong
    social networks, and overall well-being of the force. The DOD will
    establish more resources for use by line commanders to foster well-
    being rather than relying solely on last-minute identification of
    suicidal members. Clearly, a full continuum of care is needed and the
    mental health community will be an important link in the chain.
    Increased focus on positive strength building in the organization and
    community will prove critical to our prevention efforts in the future.

                           health care professionals
        11. Senator Ben Nelson. General Chiarelli, Admiral Walsh, General
    Amos, and General Fraser, throughout the hearing, we heard a consistent
    concern about the shortage of healthcare professionals. Please address
    the shortage of healthcare professionals, including those who are
    specialized in the treatment of mental health matters, by noting the
    shortage in billets authorized and the shortage in billets assigned or
    filled. The goal is to develop a clear picture as to whether this is a
    billet problem or a fill problem. Please note the percentage of fill
    with regard to the number of authorized positions. Additionally, please
    provide the retention rate associated with each health care career
    specialty.
        General Chiarelli. Army requirements for mental health providers
    include psychologists, social workers, psychiatrists, and psychiatric
    registered nurses. Current inventory as of March 2009 totaled 2,579
    assigned personnel against 2,501 billets, for a fill rate of 103
    percent against documented military authorizations and civilian
    requirements. However, our manning documents do not yet reflect the
    needs of a force stressed from 7 years of combat operations. We believe
    we have a need for at least 3,072 military, civilian, and contract
    behavioral health providers. This represents a shortage of 493
    behavioral health providers. When compared to current on hand
    behavioral health assets, the Army has an 84 percent fill rate.
        Despite increasing behavioral health assets by almost 40 percent
    since 2007, the Army recognizes additional needs and is trying to hire
    or contract approximately 87 psychiatrists, 146 psychologists, 222
    social workers and 38 psychiatric nurses.
        The Army Medical Department military force is monitored by use of
    continuation rates. These rates depict the number of individuals who
    continue from 1 year of service to the next and have proven to be a
    reliable indicator of force behavior. For the last 3 years, the overall
    continuation rates for mental health specialties ranged from 86.6
    percent to 94.1 percent.
        The Army Medical Command (MEDCOM) has identified some medical
    professional specialties to monitor closely based on concern about fill
    rates (percent inventory against military authorizations or civilian
    requirements), distributable inventory, deployment frequency, and
    historic ability to recruit, hire, and retain individuals in these
    positions. The top four of these specialties of concern are
    Neurosurgeon (70 percent fill rate), Nurse Anesthetist (77 percent fill
    rate), Dentist (77 percent fill rate) and Family Medicine Physician (96
    percent fill rate).
        In response to the National Defense Authorization Act prohibition
    on medical or dental military to civilian conversions, the Army
    afforded MEDCOM the flexibility to reshape restored structure as
    necessary to support Grow the Army and to meet emerging medical
    requirements. Documented increases in military structure included 25
    psychiatrists; 15 psychiatric nurses; 20 social workers; 12 clinical
    psychologists and 103 enlisted mental health specialists. Even with
    these increases, as the operational tempo of the force leads to growing
    psychological stress, the actual need for behavioral health providers
    exceeds the manpower requirements currently documented on MEDCOM
    manning documents. MEDCOM will continue to assess the demand for
    services in this dynamic environment to keep manning documents as
    current as possible. The Army is committed to addressing any shortfalls
    in mental health support for our soldiers.
        Admiral Walsh and General Amos. Healthcare professional retention,
    although improving, still remains below the rate needed to meet
    inventory requirements by specialty skill mix. While incentives and
    bonuses have contributed to reduced loss trends, in the attached charts
    we highlight select specialties that continue to require attention.
        The attached charts display the percentage of fill to the number of
    billets authorized for each Navy medical community. Additionally, the
    attachment depicts retention by specialty in the form of a 5-year
    average loss rate. Loss rates are used to identify recruiting and
    training demand for individual designators and specialties.

        General Fraser. Our consultant for mental health indicates the
    current billets would be adequate to meet Air Force needs if we could
    fill them all. The following data reflects the number of authorizations
    and members assigned to corps and specific career fields/AFSCs. The
    data reflects Duty AFSCs for the billets and the assigned personnel.
    The numbers include training billets and members in training status
    (Graduate Medical Education residents). The data source is the Fiscal
    Year 2008 Health Manpower Statistics report, published by the Defense
    Manpower Data Center (DMDC) from information compiled by the automated
    Health Manpower and Personnel Data System (HMPDS).

                     TABLE 1. OVERALL AFMS MANNING BY CORPS
    ------------------------------------------------------------------------
       AFMS Corps (including training                               Percent
                  billets)                Authorized   Assigned     Manned
    ------------------------------------------------------------------------
    Medical Corps.......................       3,371       3,459       102.6
    Dental Corps........................         971         922        94.9
    Nurse Corps.........................       3,501       3,276        93.6
    Biomedical Sciences Corps...........       2,345       2,182        93.0
    Medical Service Corps...............       1,049       1,029        98.1
    Enlisted Corps......................      20,924      21,551      103.0
    ------------------------------------------------------------------------
    Table taken from 2008 HMPDS Report.

                                            TABLE 2. CRITICAL AFMS SHORTAGES
    ----------------------------------------------------------------------------------------------------------------
                                                                                                   Retention Rate\1\
                      Specialty                     AD Authorized    AD Assigned   Percent Manned  at mid-career (10
                                                                                                     YOS) (Percent)
    ----------------------------------------------------------------------------------------------------------------
    General Surgery..............................              78              57            73.1                 22
    Pharmacist...................................             258             219            84.8                 12
    Public Health Officer........................             199             176            88.4                 39
    Family Practice Physician....................             448             399            89.0                 21
    Operating Room Nurse.........................             236             212            89.8                 25
    ----------------------------------------------------------------------------------------------------------------
    Table taken from 2008 HMPDS Report.
    \1\ Retention Rate added by AF/A1I based on current data. Mid-career (10 year point) used as commonality among
      career fields with differing educational obligations and requirements.

                                           TABLE 3. MENTAL HEALTH SPECIALTIES
    ----------------------------------------------------------------------------------------------------------------
                                                                                                      Retention Rate
                                                                                                        \1\ at mid-
                Specialty             Civilian Auth/     Civilian       Active Duty     Active Duty     career (10
                                         Assigned     Percent Manned   Auth/Assigned  Percent Manned       YOS)
                                                                                                         (Percent)
    ----------------------------------------------------------------------------------------------------------------
    Psychologist....................           18/18             100         256/205          80.1 6
    Social Worker...................         168/165            98.2         199/209           105.0              53
    Psychiatrist....................             1/1             100           87/94           108.0              25
    Mental Health Nurse \2\.........             1/1             100           47/55           117.0              39
    Mental Health Technician........           11/12             109         763/695            91.1             22
    ----------------------------------------------------------------------------------------------------------------
    Table taken from 2008 HMPDS Report.
    \1\ Retention Rate added by AF/A1I based on current data. Mid-career (10 year point) used as commonality among
      career fields with differing educational obligations and requirements.
    \2\ Mental health Nurse: Due to small population size, Retention Rate may have high error rate.

        Regarding Clinical Psychologists, we have a fill problem due to
    retention issues. Special Pays will be of significant help in retaining
    psychologists. Regarding accessions, we bring most psychologists on to
    active duty through one of three Air Force internship programs.
    Historically they have been successful in filling their training
    authorizations (though some difficulties this year, and 2 years ago).
    We have increased the number of Health Professions Scholarship Program
    scholarships for psychologists in an effort to help fill our internship
    slots.
    Retention Rates
        The average career length (ACL) for mental health providers is as
    follows:
          (Time is in Commissioned Years of Service (CYOS))

              ACL - Social Worker - 12.78 CYOS
              ACL - Mental Health Nurses - 11.22 CYOS \1\
    ---------------------------------------------------------------------------
        \1\ Mental Health Nurse (46P) auths are extremely small (<100);
    data based on 3-year average (Fiscal Year 2006-Fiscal Year 2008)
    ---------------------------------------------------------------------------
              ACL - Psychiatrists - 8.78 CYOS
              ACL - Psychologists - 5.47 CYOS

        The decision point is where all military and educational
    obligations have been fulfilled and the individual is first able to
    separate. Based on historical data, retention for Mental Health
    Providers is as follows:

              Clinical Psychologists - 20 percent after their military
            obligation is complete (4 years).
              Mental Health Nurses - 58 percent after their military
            obligation is complete (4 years).
              Psychiatrists - 25 percent after their military obligation is
            complete (9 years).
              Social Worker - 88 percent after their military obligation is
            complete (4 years).
                                     ______

                 Questions Submitted by Senator Lindsey Graham
                         suicide prevention in the army
        12. Senator Graham. General Chiarelli, we all share your view that
    the current numbers of suicides in the Army are unacceptable. What are
    your expectations for the initiatives that you have described?
        General Chiarelli. Several events have occurred since my March 2009
    testimony, which have shaped my expectations. First, I have gathered
    information and made important observations during an 8-day, six-
    installation visit. Second, the Army Suicide Prevention Task Force has
    completed a multidisciplinary review of Army doctrine, policies,
    organizations, training, materiel, leadership, personnel, and funding.
    As a result of these events, approximately 250 action plans were
    developed to form one part of the overall prevention effort: the Army
    Campaign Plan for Health Promotion, Risk Reduction, and Suicide
    Prevention, issued in April 2009. Additionally, I convene a senior
    level council that regularly meets to vet and refine those action plans
    for my approval. I expect this process of vetting and review to
    continue for several months as the council develops recommendations for
    long-term, large-scale changes Army-wide, to include increasing the
    number of behavioral health personnel and Chaplains Corps personnel.
    Meanwhile, Army leaders and medical treatment facilities will optimize
    existing policies and resources in the short term to prevent suicides
    and set the stage for the longer-term changes. I have already alerted
    commanders to begin that optimization and preparation immediately.
        The YRRP, already adopted by the Army Reserve and National Guard as
    a model and implemented in many States, will be implemented in all
    States.
        On-line mental health services (via web-based or video-
    teleconference) will be expanded and made available on an Army-wide
    basis, both in theater and in the continental United States. The
    interactive video ``Beyond the Front'' will continue to be available to
    soldiers and their families online.
        A mechanism for ensuring continuity of treatment will be developed
    to ensure appropriate transfer of care from professional officer filler
    information system (PROFIS) care providers to state-side behavioral
    health care providers upon soldiers' return from theater.
        Bottom line for expectations: it will ultimately be soldiers taking
    care of soldiers. Soldiers will be the first to recognize another
    soldier in need; feel empowered to get his or her buddy the help he or
    she needs; and will know where to go to get it.

        13. Senator Graham. General Chiarelli, what are the metrics you
    will use to gauge the success of these programs?
        General Chiarelli. The overall metric for the success of Army
    programs is a reduction in the rate of suicides by Army soldiers.
        For the Army Suicide Prevention Task Force and Council, I would
    measure their success by the institutionalization of the Task Force's
    functions and the perpetuation of the Council process to ensure that
    the Army is continually re-examining itself to find new ways to reduce
    the number of suicides.
        The success of the YRRP will be its implementation rate by State
    National Guards, and with appropriate modifications, by the Army
    Reserve.
        The success of on-line mental health services (via web-based or
    video-teleconference) will be increased access to, and use of, those
    services and the success of the ``Beyond the Front'' video would be its
    review by all soldiers, Army-wide.
        The success of changes to the PROFIS system would be the seamless
    handoff of behavioral health care from PROFIS providers to state-side
    behavioral health care providers.
        Finally, the success of soldiers taking care of soldiers is when a
    soldier can recognize the symptoms or behavior of a soldier in need
    just as he or she would recognize the symptoms of a heat or cold
    injury.

        14. Senator Graham. General Chiarelli, do you anticipate reducing
    dwell times as part of this strategy?
        General Chiarelli. The Army's suicide prevention strategy does not
    rely on increasing dwell time as part of our approach to reducing
    suicides. Increasing dwell time is critical to bringing our Army back
    into balance and is a top priority for us. So while it is not part of
    our suicide prevention strategy per se, reducing dwell time should have
    a beneficial impact on a host of behavioral health issues and make our
    suicide prevention efforts more effective.

        15. Senator Graham. General Chiarelli, what are you goals for the
    program in the next 6 months? In 1 year?
        General Chiarelli. Overall, my goal in the next 6 months is due
    diligence and regimented enforcement of all institutional processes
    that exist to take care of soldiers with an ultimate goal being
    significant reduction in the number of suicides. The heightened state
    of awareness of the suicide problem has caused our commanders to widen
    their aperture and get back to the basics in caring for soldiers.
        At 6 months, the Task Force should be dissolved, with the transfer
    of its functions to an appropriate proponent on the Army Staff, and the
    continued evaluation of the Army's efforts to combat suicide and risky
    behavior utilizing the Council process.
        The YRRP should be increased in the Guard and Reserve. Within 1
    year, I would like to see this program implemented throughout the Guard
    and Reserve.
        My goal for the use of on-line mental health services is removal of
    any legal or policy impediments to expand use of such services, and
    increased implementation of those services. At 1 year, I would like to
    see additional expansion of those services and increased use of those
    services. Additionally, the ``Beyond the Front'' video should be viewed
    and internalized by every soldier and that we continue to exploit its
    learning methods.
        My goal for the success of the changes to PROFIS is improvement in
    the continuity of care being provided to soldiers returning from
    theater.

                    command leadership and suicide reduction
        16. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, let's talk about command climate and the importance
    of that as a contributor or as a protective factor in suicide, as well
    as holding leaders accountable for climate within their commands. Is
    command climate routinely studied when a suicide occurs, as it was in
    the Houston Recruiting Battalion?
        General Chiarelli. Any significant serious event within a unit,
    i.e., suicide, AWOL/desertion, domestic abuse, should send a signal to
    the leadership that potential unit morale and welfare issues are
    creating risky behaviors and impacting the readiness of the unit. The
    command climate survey is one of many tools the command can utilize to
    obtain a better perspective of what is happening within their units.
        The Command Climate Survey is anonymous and briefly addresses 20
    climate areas including: officer leadership, NCO leadership, immediate
    supervisor, leader accessibility, leader concern for families, leader
    concern for single soldiers, unit cohesion, counseling, training,
    racist materials, sexually offensive materials, stress, training
    schedule, sponsorship, respect, unit readiness, morale, sexual
    harassment, discrimination, and reporting harassment/discrimination
    incidents.
        The Command Climate Survey is one of many tools in the command;
    others include unit climate, observations, personal interviews,
    reports, and other unit data. Combined, these can be effective in
    determining where potential problem areas are, and where to focus
    priorities. Army values will compel the command group to take action in
    the areas where soldiers are most vulnerable.
        Admiral Walsh. The Navy Operational Stress Control program
    emphasizes the role of leadership in fostering resilience and
    mitigating stress reactions, in part through positive command climate
    and unit cohesion.
        Navy assesses command climate at the unit level in multiple ways to
    include use of Command Assessment Teams and command climate surveys as
    part of a long standing Navy Equal Opportunity Program.
        Additionally, the Navy monitors organizational climate through a
    variety of Tone of the Force Metrics and multiple questionnaire and
    survey instruments.
        Navy assesses behavioral health needs, and associated command
    climate factors, for ground deployed sailors using the Behavioral
    Health Needs Assessment. This tool has enabled corrective action, when
    climate concerns have arisen associated with behavioral health needs,
    before waiting for suicides to occur.
        Each suicide in the Navy is investigated to identify contributing
    factors. Any misconduct, on the part of individuals or the command,
    identified in the course of JAGMAN Line of Duty Investigation or NCIS
    investigation is referred to the adjudicating authority for
    disposition.
        The NCIS death investigation process is aimed at ruling out
    criminal causality. Therefore, careful examination, documentation and
    processing of the death scene, forensic analysis of recovered evidence,
    and extensive interviews are conducted in order to garner a full
    picture of the deceased, their mindset, and their environment. In
    addition to command climate, other factors that are taken into
    consideration as part of the NCIS investigation may include the level
    of security clearance and whether the deceased had access to classified
    information, financial hardship, marital/relationship problems,
    substance abuse, job satisfaction and if there is a history of previous
    suicide attempts.
        The DOD Suicide Event Report includes questions that relate to
    command climate (for example Q. 90 ``Prior to the event was there
    evidence of unit or workplace hazing?''). However, a formal command
    climate assessment is not automatically triggered by a suicide death.
        General Amos. Global command climate is not always a significant
    factor in assessing stressors related to a specific suicide. Specific
    issues of local command climate may play a role and are assessed
    through questions on the DOD Suicide Event Report (DODSER), the use of
    command interviews associated with the DODSER, command investigations,
    and NCIS investigations. The Marine Corps has not found instances of
    suicide clustering that would indicate a unique command climate
    condition. Were we to see indicators of that, we would investigate to
    examine possible causal or contributing factors.
        General Fraser. The Air Force agrees that a positive command
    climate is essential to unit cohesiveness and readiness, and it serves
    as a protective factor to prevent suicides. Because of this, Wing
    Commanders initiate an investigation after every suicide and all
    contributing factors are examined. The lessons learned are shared with
    the MAJCOM, commanders and unit leaders.
        Additionally, the Air Force regularly assesses command climate in
    all units through Unit Climate Assessments. Additionally, Community
    Action Information Boards (CAIBs) at each base identify and address
    vulnerabilities that may exist in the community. CAIBs are cross
    functional and provide senior leaders visibility on suicide risk
    factors such as marital/relationship problems, substance abuse, legal/
    disciplinary actions, financial, et cetera. This awareness combined
    with rapid notification of suicides allows senior leaders to identify
    cases where leadership issues may contribute to increased risk for
    suicide.

        17. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, what systems are in place to identify a command in
    which there may be leadership problems which contribute to an increased
    risk of suicide?
        General Chiarelli. For a healthy command environment to exist there
    must be proactive actions on the part of the commander and all of his
    or her leadership. Conducting a climate assessment in accordance with
    Army Regulation 600-20 (Army Command Policy) provides the leadership
    with the basis to know where the unit stands, and what, if any actions
    will be required to improve the climate. Leaders at all levels within
    any command are responsible for assisting the commander in the conduct
    of assessments.
        Unit ``climate'' factors such as leadership, cohesion, morale, and
    the human relations environment have a direct impact on the
    effectiveness of each unit. The requirement to assess the environment
    is within 90 days of taking command and once annually thereafter.
        The Command Climate Survey is anonymous and briefly addresses 20
    climate areas including: officer leadership, NCO leadership, immediate
    supervisor, leader accessibility, leader concern for families, leader
    concern for single soldiers, unit cohesion, counseling, training,
    racist materials, sexually offensive materials, stress, training
    schedule, sponsorship, respect, unit readiness, morale, sexual
    harassment, discrimination, and reporting harassment/discrimination
    incidents.
        The Command Climate Survey is one of many tools in the command;
    others include unit climate, observations, personal interviews,
    reports, and other unit data. Combined, these can be effective in
    determining where potential problem areas are, and where to focus
    priorities. Army values will compel the command group to take action in
    the areas where soldiers are most vulnerable.
        Admiral Walsh. The Navy proactively assesses command climate at
    command and unit level in multiple ways, to include use of Command
    Assessment Teams (CAT-Teams), command climate surveys, and cultural
    workshops as part of a long standing Navy Equal Opportunity and Naval
    Safety Center programs and policies.
        Further, the Navy monitors organizational climate through a variety
    of ``Tone of the Force'' Metrics and multiple questionnaire and survey
    instruments. Commanding Officers are provided direct feedback from CAT-
    Team leadership and workshop/survey facilitators, enabling
    instantaneous visibility of where leadership intervention is required.
        In addition to the many positive programs and systems in place that
    are utilized to proactively prevent suicide incidents, the Navy also
    thoroughly investigates each incident. These investigations help
    identify contributing casual factors, and the navy applies the lesions
    learned to prevent similar incidents in the future. If any misconduct
    is discovered during the course of the JAGMAN Lind of Duty
    Investigation or NCIS investigation, on the part of individuals or the
    command/unit, the adjudicating authority is called upon for
    disposition.
        General Amos. The Marine Corps has both internal and external
    systems in place to assess commands in which problems may exist.
    Commanders continuously assess the leadership environment within their
    unit and subordinate units. They assess mission performance,
    disciplinary issues, and morale, among a multitude of indicators. Our
    senior enlisted marines provide another source of information. We also
    have Request Mast procedures whereby any marine can bring issues up the
    chain of command for resolution. These procedures are reviewed by our
    command inspection process to ensure they are not only in place but
    working. The Marine Corps conducts command climate assessments; QOL
    surveys; command chaplain assessments; mental health liaison with
    commanders; and IGMC inspections. For non-hostile deaths in add,
    commanding generals conduct back-briefs with the unit leadership and
    associated staff officers to understand what happened in context and
    see if there are lessons learned that can prevent future losses.
    Additionally for non-hostile deaths not in a medical facility, NCIS
    conducts an independent investigation.
        General Fraser. The Air Force utilizes the Air Force Climate
    Survey, the Unit Climate Assessment (UCA), and the CSAF's weekly
    suicide report to identify commands that may be experiencing leadership
    problems that contribute to an increased risk of suicide.
        The Air Force conducts two climate surveys on a recurring basis.
    The Air Force Climate Survey is conducted every 2 years to assess Air
    Force organizational climate and provide feedback to leaders to improve
    their units. It focuses on leadership support and job satisfaction. The
    UCA measures unit effectiveness and the unit's human relations
    environment. The CSAF's weekly suicide report provides a brief
    description of any suicide that has occurred. This description includes
    the unit the member was assigned to, providing senior leadership timely
    visibility on issues and where they are occurring.

                  limited privilege suicide prevention program
        18. Senator Graham. General Fraser, please elaborate on the Limited
    Privilege Suicide Prevention Program described in your written
    testimony. Please articulate the way in which you believe your programs
    have been effective and how that reconciles with increased levels after
    implementation?
        General Fraser. The objective of the Limited Privilege Suicide
    Prevention (LPSP) program, initiated in 1999, is to identify and treat
    those Air Force members who, because of the stress of impending
    disciplinary action under the Uniform Code of Military Justice (UCJM),
    pose a genuine risk of suicide. In order to encourage and facilitate
    treatment, the LPSP program provides limited confidentiality under
    specific circumstances. Air Force members enrolled in the LPSP program
    are granted limited protection with regard to information revealed in,
    or generated by their clinical relationship with mental health
    providers. Such information may not be used in the existing or any
    future UCMJ action or when weighing the characterization of their
    service during the separation process.
        The Air Force Suicide Prevention Program (AFSPP) is a leadership
    driven, cross-functional program that relies on ongoing reassessment
    and reinvigoration. The AFSPP is comprised of 11 initiatives and takes
    a community wide approach. The Air Force Community Action and
    Information Board (CAIB) and Integrated Delivery System (IDS) work at
    each installation, and at the Air Force level, bridging communication
    between helping services and leadership providing community level
    support and action. Prior to adopting the AFSPP in 1998, the pre-AFSPP
    suicide rate from 1987 to 1996 was 13.5 suicides per 100,000. Since
    adoption of the AFSPP, the post-AFSPP suicide rate average from 1997 to
    2008 is 9.8 suicides per 100,000, resulting in a 28 percent rate
    reduction.

                            mental health providers
        19. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, you have all testified that more mental health
    providers are needed in your Service. Please identify the authorities
    that you have to provide incentives to mental health providers for both
    Active and Reserve military Service and civilian service.
        General Chiarelli. Each category of personnel (Active, Reserve and
    civilian) has multiple incentives to support both recruitment and
    retention. For the Active component, the full array of Physician
    Special Pays (Variable Special Pay, Medical Additional Special Pay,
    Incentive Special Pay/Multiyear Incentive Special Pay, Multi-Year
    Special Pay) and the Critical Wartime Skills Accession Bonus are
    available to Psychiatrists/Child Psychiatrists. Additionally,
    psychiatrists are eligible for Board Certification Pays and the active
    Duty Health Professions Loan Repayment Program (ADHPLRP). Psychiatric
    nurses are eligible for both Incentive Special Pay if they have
    completed an approved graduate program, and for Non-Physician Board
    Certification (NPBC) pay while on active duty. Fully qualified
    psychiatric nurses are also eligible for the Nurse Accession Bonus and/
    or ADHPLRP as a recruitment incentive. Licensed Clinical Psychologists
    and Licensed Social Workers are eligible for ADHPLRP and NPBC. Clinical
    psychologists are additionally eligible for the Critical Skills
    Accession Bonus. Under the new Consolidation of Health Professions
    Special Pays (section 335, title 37, U.S.C.), Social Work officers and
    Clinical Psychologists will be offered both Incentive Pays and a
    Retention Bonus in addition to Board Certification Pay. Implementation
    is pending with the OSD.
        Incentives for the Reserve Forces are only available to specialties
    listed on the Army Reserve Critical Wartime Specialty List in
    accordance with DOD Instruction 1205.20. Psychiatrists are authorized
    to receive the Accession and Retention Special Pays (provided they have
    completed an approved graduate program and are board certified) and to
    participate in the Selected Reserve Health Professions Loan Repayment
    Program. Those in training are eligible for the Medical/Dental School
    Stipend Program. Fully qualified Clinical Psychologists in the Selected
    Reserves are authorized the same incentives as the fully qualified
    Psychiatrist.
        There are two separate authorities granting direct hire authority
    for civilians, allowing MEDCOM to streamline traditional hiring
    processes and make on-the-spot selections to reduce hiring times. These
    authorities are legislated in the Defense Appropriations Act for Fiscal
    Year 2009 and the National Defense Authorization Act for Fiscal Year
    2009. The Appropriations Act for Fiscal Year 2008, for the first time,
    granted direct hire authority for an additional 12 occupations, for a
    total of 24 occupations, including social workers, social services
    assistants, psychologists, and psychology technicians. The challenge is
    that this authority expires at the end of the fiscal year, creating a
    lapse period until the next year's authority is delegated to management
    officials. The direct hire authority granted initially under the NDAA
    for Fiscal Year 2008, and extended until 2012 under the NDAA for Fiscal
    Year 2009, was to provide uninterrupted appointment coverage through 30
    September 2012. However, this authority has not been delegated from the
    OSD to the Services. OSD is withholding delegation pending review of
    the implications of the Gingery v. Department of Defense case regarding
    veterans' preference for excepted service positions. Meanwhile MEDCOM
    continues to use the direct hire appointment authority under the
    Appropriations Act for Fiscal Year 2009.
        Admiral Walsh.
    Federal Civilians:
        Recruitment, relocation, and retention incentives, each up to 25
    percent of annual adjusted base salary, may be given in a multi-year
    package up to a total of 4 years as allowed at 5 U.S.C. 5753. Federal
    Student Loan Repayment Program up to $10,000 per year up to a total of
    $60,000 as allowed at 5 U.S.C. 5379.
    Military Personnel:
        Currently DOD has authorized the payment for all Services the
    following special pays:

             Medical Corps: Title 37, Chapter 5,

                     Section 301d, Multi-year Special Pay (MSP).
                    Psychiatry, $43,000/$28,000/$17,000 annually for 4/3/2
                    years of obligation.
                     Section 302, Psychiatry, Incentive Special Pay (ISP),
                    $20,000 with or without MSP. Variable Special Pays
                    (VSP), Additional Special Pays (ASP) and Board
                    Certified Pays (BCP) which vary by individual by years
                    of creditable service.

    Medical Service Corps:
        Currently Navy authorizes a clinical Psychologist Critical Skills
    Retention Bonus of $15,000 per year for a 4 year agreement. Section
    302c authorizes Clinical Psychologist and Social Workers Board
    Certified Pay (BCP) which vary by individual by years of creditable
    service. Awaiting Assistant Secretary of Defense (Health Affairs)
    (ASD(HA)) authorization for a Clinical Psychologist Retention Bonus,
    Incentive Pay and Accession Bonus and an accession bonus for Social
    Workers as authorized in National Defense Authorization Act 2008
    Section 335.
    Nurse Corps:
        Title 37, Ch5, Sec 302e, ASD(HA) authorizes payment of Incentive
    Special Pay for Mental Health Nurse Practitioners and Mental Health
    Nurses of $20,000/$15,000/$10,000/$5,000 annually for 4/3/2/1 years of
    obligation.
        General Amos. The USMC does not have the responsibilities or
    authorities for maintaining adequate numbers of Mental Health
    providers. Rather, in our unique relationship with Navy Medicine the
    Marine Corps establishes validated requirements for providers of all
    types that Navy Medicine uses its authorities and tools to meet the
    requirements. The Marine Corps concern is that although Navy Medicine
    has filled all of our validated requirements to date, there appears to
    be the potential in the not to distant future for Navy Medicine for the
    first time ever not being able these requirements. We are in
    coordinated and constructive dialogue at this time to meet this
    challenge.
        General Fraser. Active Component Accession Bonuses: Under title 37,
    U.S.C. 302, in January 2009 we offered a psychiatrist accession bonus
    of $272,000 for a 4-year contract. We also offered a nurse contract of
    $30,000 for 4-years or $20,000 if they take the Health Professions Loan
    Repayment Program (HPLRP) assistance of up to $40,000. HPLRP and Health
    Professions Scholarship Program (HPSP) authority is granted by title
    10, U.S.C., and implementation guidance of DODI 6000.13. HPSP provides
    tuition and a monthly stipend for Medical Corps, Dental Corps, Nurse
    Corps, or Biomedical Sciences Corps officers. In general quotas are
    based on specialty with quotas specifically set aside for Clinical
    Psychologists.
        Active Component Retention Bonuses: Under title 37, U.S.C. 301, and
    302, psychiatrists are offered up to $92,000 per year based on the pay
    tables published annually by Health Affairs. This includes $15,000 in
    Additional Special Pay; up to $12,000 in Variable Special Pay based on
    years of service; up to $6,000 for Board Certification based on years
    of service; Incentive Special Pay of up to $20,000, up to $43,000 in
    Multi-year Special Pay for a 4-year contract; and $39,000 for a 4-year
    commitment, for those with a completed residency, but still have 18-
    months educational commitment remaining. Psychiatrists receive
    additional special, variable, and board certification pay of up to
    $57,500 over regular officer salary.
        Mental Health Nurses and Psychiatric Nurse Practitioners: Under
    title 37, U.S.C. 302, up to $20,000 for a 4-year contract and up to
    $5,000 per year for certified nurses is offered.
        The National Defense Authorization Act of 2008, Consolidation of
    Special Pays, allows special pays including board certification pay for
    careers previously excluded from Special Pays incentives programs.
    Implementation is funded for fiscal year 2009, but is in coordination
    at USD/DOD level. Under the consolidation authority, we hope to offer
    an Accession Bonus of $20,000 per year for a 4-year contract and allow
    up to $31,000 per year to retain Clinical Psychologists.
        Since fiscal year 2007, Clinical Psychologists have been offered a
    Critical Skills Retention Bonus (CSRB) of $30,000 for a 3-year contract
    at 3 to 6 years of service, under authority of title 37 U.S.C. 355.
    Most psychologists separated at the 4-year point.
        Reserve Component Accessions: The Reserve Component Wartime Health
    Care Specialties with Critical Shortages list is published every 2
    years. Bonuses are offered per title 37, U.S.C., section 302. Accession
    Loan Repayment: The HPLRP is for members not taking or not eligible for
    the Wartime Health Care Specialties incentive pay program.
        Civilian Component: Available accession and retention tools for
    civilian employees include recruitment bonuses of up to 25 percent of
    base salary, retention allowances of up to 25 percent of base salary,
    credit for non-Federal and Uniformed Service experience for annual
    leave accrual for new employees, and Student Loan Repayment of $10,000
    per year with $60,000 maximum payment. Superior Qualification
    Appointments (for GS employees only) provides an advance in-hire rate
    up to Step-10 of assigned grade.

        20. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, what authorities are being used today?
        General Chiarelli. Each category of personnel (Active, Reserve and
    civilian) has multiple incentives to support both recruitment and
    retention. For the Active component, the full array of Physician
    Special Pays (Variable Special Pay, Medical Additional Special Pay,
    Incentive Special Pay/Multiyear Incentive Special Pay, Multi-Year
    Special Pay) and the Critical Wartime Skills Accession Bonus are
    available to Psychiatrists/Child Psychiatrists. Additionally,
    psychiatrists are eligible for Board Certification Pays and the active
    Duty Health Professions Loan Repayment Program (ADHPLRP). Psychiatric
    nurses are eligible for both Incentive Special Pay if they have
    completed an approved graduate program, and for Non-Physician Board
    Certification (NPBC) pay while on active duty. Fully qualified
    psychiatric nurses are also eligible for the Nurse Accession Bonus and/
    or ADHPLRP as a recruitment incentive. Licensed Clinical Psychologists
    and Licensed Social Workers are eligible for ADHPLRP and NPBC. Clinical
    psychologists are additionally eligible for the Critical Skills
    Accession Bonus. Under the new Consolidation of Health Professions
    Special Pays (section 335, title 37, U.S.C.), social work officers and
    clinical psychologists will be offered both Incentive Pays and a
    Retention Bonus in addition to Board Certification Pay. Implementation
    is pending with the OSD.
        Incentives for the Reserve Forces are only available to specialties
    listed on the Army Reserve Critical Wartime Specialty List in
    accordance with DOD Instruction 1205.20. Psychiatrists are authorized
    to receive the Accession and Retention Special Pays (provided they have
    completed an approved graduate program and are board certified) and to
    participate in the Selected Reserve Health Professions Loan Repayment
    Program. Those in training are eligible for the Medical/Dental School
    Stipend Program. Fully qualified Clinical Psychologists in the Selected
    Reserves are authorized the same incentives as the fully qualified
    Psychiatrist.
        There are two separate authorities granting direct hire authority
    for civilians, allowing MEDCOM to streamline traditional hiring
    processes and make on-the-spot selections to reduce hiring times. These
    authorities are legislated in the Defense Appropriations Act for Fiscal
    Year 2009 and the National Defense Authorization Act for Fiscal Year
    2009. The Appropriations Act for Fiscal Year 2008, for the first time,
    granted direct hire authority for an additional 12 occupations, for a
    total of 24 occupations, including social workers, social services
    assistants, psychologists, and psychology technicians. The challenge is
    that this authority expires at the end of the fiscal year, creating a
    lapse period until the next year's authority is delegated to management
    officials. The direct hire authority granted initially under the NDAA
    for Fiscal Year 2008, and extended until 2012 under the NDAA for Fiscal
    Year 2009, was to provide uninterrupted appointment coverage through 30
    September 2012. However, this authority has not been delegated from the
    OSD to the Services. OSD is withholding delegation pending review of
    the implications of the Gingery v. Department of Defense case regarding
    veterans' preference for excepted service positions. Meanwhile MEDCOM
    continues to use the direct hire appointment authority under the
    Appropriations Act for Fiscal Year 2009.
        MEDCOM spent $27.3 million in fiscal year 2007 for recruitment,
    relocation, and retention (3Rs) incentives to attract and retain
    civilians across MEDCOM. Spending on 3Rs in fiscal year 2008 increased
    by 44 percent to $39.2 million, with $48 million earmarked for fiscal
    year 2009. At the end of first quarter fiscal year 2009, spending for
    the year on 3R incentives totaled $11.3 million.
        During fiscal year 2008, MEDCOM undertook a major initiative to
    review and update special salary rates for civilians. As a result, over
    15 special salary rate tables were updated, predominately for nurses
    and pharmacists, at a cost of $11 million. Currently MEDCOM has over
    5,500 civilians receiving special salary rates, which represents 25
    percent of our Army civilian healthcare force.
        Additionally, MEDCOM allocates $1.5M annually for student loan
    repayment for registered nurses.
        Throughout MEDCOM, managers have used the Direct Hire Authority
    (DHA) for medical occupations to expedite the hiring process. Since May
    2002, 900 physicians and over 5200 registered nurses were hired using
    DHA. Since December 2007, when additional occupations were added to the
    DHA, MEDCOM managers used DHA to hire over 100 psychologists and almost
    200 social workers.
        Admiral Walsh. Current authority by Assistant Secretary of Defense
    (Health Affairs) (ASD(HA)) is Title 37, Chapter 5, Sections 301d
    (Medical Multiyear Special Pay (MSP), 302 (Medical Variable Special Pay
    (VSP), Additional Special Pay (ASP), Incentive Special Pay (ISP), and
    Board Certification Pay (BCP)); Section 302c MSC Psychologist BCP and
    Navy Critical Special Retention Board (CSRB); Section 302c also
    authorizes Social Workers BCP. Section 302e Special Pay Nurse
    Anesthetists authorizes the Secretary of Defense to extend authority to
    any nurse designated as critical with ``post-baccalaureate'' education
    and training. ASD(HA) is processing new pay authority Section 335 for
    Medical Service Corps Clinical Psychology Retention Bonus, Incentive
    Pay and Accession Bonus and an accession bonus for Social Workers.
        General Amos. My understanding is that for Navy Medicine all active
    duty Medical Professional Corps (Medical Corps, Nurse Corps, Medical
    Service Corps and Dental Corps) met recruiting goals for fiscal year
    2008 and are on track to meet fiscal year 2009 targets. Civilian health
    care professional recruiting is done locally as individual medical
    commands recruit to meet their specific requirements. For some medical
    specialties in less population dense geographic locations civilian
    health care professional recruiting is more challenging, but no more of
    a challenge than seen by the private sector in those regions.
    Additionally, the reversal of the military-to-civilian medical billet
    conversion has helped ease requirements to find civilian medical
    professionals for hard to fill assignments.
        General Fraser. AF Active Duty and Reserve/Guard components are
    using all authorities established by title 37, U.S.C., chapter 5, in
    addition to title 10, U.S.C., chapter 105, and title 10, U.S.C.,
    section 16302, for the Health Professions Scholarship Program and
    Health Professions Loan Repayment Program. The Active component also
    uses DODI 6000.13 for implementation guidance for many of the accession
    and retention programs.
    Civilian Component:
        Multiple tools are available for civilian employees for both
    accession and retention purposes:

          Recruitment bonuses for new accessions (up to 25 percent
    of base salary)
          Retention allowances to sustain high caliber employees
    (up to 25 percent of base salary)
          Credit for non-Federal and Uniformed Service experience
    for annual leave accrual for new employees
          Student Loan Repayment for new accessions ($10,000 per
    year with $60,ooo max payment)

        Superior Qualification Appointments (for GS employees only)
    provides an advance in-hire rate up to Step-10 of assigned grade

        21. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, how much money was allocated by component in fiscal
    year 2008, and fiscal year 2009 to attract and retain mental health
    professionals both in uniform and as civilian?
        General Chiarelli. The Health Professions Special Pays are not
    apportioned specifically to mental health providers but encompass all
    health care providers. In fiscal year 2008, the budget to support
    active duty health professional special pays (both retention and
    incentive) was $206.1 million. The fiscal year 2008 budget to support
    Reserve duty health professional special pays (both retention and
    incentive) was $22.3 million. In fiscal year 2009, the current budget
    is $225 million for the Active component and $32.4 million for the
    Reserve component. In fiscal year 2009, $770,000 has been paid out to
    support Registered Nurse incentive special pay for Psychiatric Nurses.
    Additionally, $1.408 million has been expended to support the Critical
    Skills Retention Bonus for Clinical Psychologists.
        Using a risk assessment tool to determine necessary funding levels
    for civilian hiring needs, MEDCOM programmed $48 million for 3Rs
    funding for fiscal year 2009. At the end of first quarter fiscal year
    2009, spending for recruitment, relocation, and retention was $11.3
    million of the $48 million programmed for fiscal year 2009.
        Admiral Walsh. The following funding applies to military mental
    health professionals only. No funds were secured to for the purpose of
    acquiring civilian (GS) mental health providers.
        Fiscal Year 2008:

             Medical Corps -

                     Multiyear Special Pay (MSP): $1.425 million
                     Incentive Special Pay (ISP): $1.0 million

             Medical Service Corps -

                     Critical Skills Retention Bonus (CSRB): $1.2 million

             Nurse Corps -

                     $0

        Fiscal Year 2009:

             Medical Corps -

                     MSP: $1.821 million
                     ISP: $1.76 million

             Medical Service Corps -

                     CSRB: $120,000, Retention Bonus: $1.55 million
                     ISP: $.5 million
                     Accession bonus: $.48 million

        The CSRB is being phased out and replaced by accession, retention
    and incentive pays in accordance with title 37, section 335, approved
    in the 2008 National Defense Authorization Act.

             Nurse Corps -

                     $.835 million

        General Amos. The USMC does not have the responsibilities or
    authorities for maintaining adequate numbers of Mental Health
    providers. Rather, in our unique relationship with Navy Medicine the
    Marine Corps establishes validated requirements for providers of all
    types that Navy Medicine uses its authorities and tools to meet the
    requirements. As such, I must defer to my Navy Medicine colleagues to
    answer this question.
        General Fraser. Active component: Because of limitations imposed by
    law, accession and retention pays of mental health providers were
    restricted to physicians and nurses. All other mental health providers
    were precluded from participating in special pays programs. Because of
    this limitation, beginning in fiscal year 2007, the Air Force used the
    Critical Skills Retention Bonus (CSRB) under authority of title 37,
    U.S.C., section 355, to focus retention pay to targeted year groups of
    Clinical Psychologists in order to retain them past their first
    historical separation point. We have budgeted money against the new
    Consolidation of Special Pays authority for mental health providers.

    ------------------------------------------------------------------------
                                                Fiscal Year     Fiscal Year
                                                   2008            2009
    ------------------------------------------------------------------------
    Active (Mental Health Only).............
      Accession.............................              $0    $2.1 million
      Retention.............................    $9.1 million   $12.4 million
      HPLRP.................................    $7.8 million    $9.5 million
      HPSP..................................        $129,000         pending
    Reserve (Total Medical Budget)..........
      Retention.............................    $5.2 million    $9.8 million
      HPLRP.................................    $2.8 million    $1.7 million
    Civilian (Total Medical Breakout).......
      Relocation............................         $12,900          $9,000
    ------------------------------------------------------------------------
    HPLRP: Health Professions Loan Repayment Program
    HPSP: Health Professions Scholarship Program

        Civilian component: In fiscal year 2008, there was $12,899 utilized
    for relocation incentives for civilian mental health providers, and
    $9,000 for relocation incentive in fiscal year 2009. There were no
    recruitment or retention incentives used.

        22. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, how much is required in fiscal year 2010?
        General Chiarelli. The total requirement identified for health
    professions special pays in fiscal year 2010 is $297.9 million for the
    Active component and $19 million for the Reserve component. This
    increased requirement recognizes the expansion of special pays under
    section 335 of title 37, which now includes Clinical Psychologists and
    Social Work Officers.
        The requirement to fund 3R incentives (recruitment, relocation, and
    retention) for civilian hires in fiscal year 2010 is $73.1 million.
        Admiral Walsh. ASD(HA) and all three Services have agreed to not
    increase rates in fiscal year 2010 due to conversion to consolidated
    special pays as authorized in NDAA for Fiscal Year 2008, section 335;
    however, fiscal year 2010 DOD budget formulations are being finalized
    and once the President's budget is completed further details may be
    submitted.
        General Amos. The USMC does not have the responsibilities or
    authorities for maintaining adequate numbers of Mental Health
    providers. Rather, in our unique relationship with Navy Medicine the
    Marine Corps establishes validated requirements for providers of all
    types that Navy Medicine uses its authorities and tools to meet the
    requirements. As such, I must defer to my Navy Medicine colleagues to
    answer this question.
        General Fraser. The Air Force will fully support the President's
    2010 budget. We stand behind the Secretary of Defense's commitment to
    recognize the critical and permanent nature of wounded, ill and
    injured; TBI; and PH programs and to improve the efforts to care for
    wounded servicemembers and to treat their mental health needs.

        23. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, do you believe the programs and authorities in
    place have maximized their potential or are new programs and
    authorities needed?
        General Chiarelli. Once the authorities contained within Section
    335 of title 37, U.S.C., are fully implemented by the DOD, sufficient
    flexibility will exist to offer accession, incentive and retention pays
    to all categories of health care providers. While these authorities
    exist, there will be a need to insure that adequate appropriations are
    made available as we seek the most effective funding level to attract
    sufficient individuals to support the existing force structure.
        Current programs in place have contributed to MEDCOM's ability to
    attract and retain high quality medical professionals, including mental
    health providers. The National Security Personnel System (NSPS) has
    provided much needed pay flexibilities, especially for physicians,
    dentists and registered nurses. For example, the current provisions
    allow MEDCOM to offer competitive compensation for new graduate nurses.
    The ability to set pay within pay bands and use enhanced recruitment
    incentives when needed for new hires, allows management to more readily
    attract new employees. Earnings by physicians, such as psychiatrists,
    under NSPS are no longer restricted by the annual pay cap of $196,700
    and may be as high as $400,000. The new DOD Physicians and Dentists
    ``Hybrid'' Pay Plan will provide the same level of compensation for
    general schedule (GS) physicians and dentists that cannot be converted
    to NSPS. This hybrid pay plan will grant these the same amounts of
    annual pay, will use the same medical specialty tables and will also
    raise the pay cap to $400,000. Implementation of this new pay plan must
    be expedited within DOD. MEDCOM believes that current title 38
    authorities delegated to OSD are sufficient to address changes in
    qualifications and compensation for registered nurses. During mid-March
    2009, the three Services conducted a 3-day Registered Nurse Workshop to
    seek changes by recognizing higher levels of education within the
    nursing community and seek market sensitive pay. MEDCOM also endorsed
    the DOD review to determine whether a civilian mental health
    scholarship program is necessary to meet future hiring needs. In terms
    of new program needs, MEDCOM needs the authority and flexibility to
    quickly offer market sensitive pay for our GS health care
    professionals. As an example, approximately 1,900 registered nurses are
    currently paid using special salary rates based on the current pay rate
    at the VA. In reality, MEDCOM's ability to increase salary rates for
    nurses, pharmacists, and other occupations is dependent on the VA
    updated pay schedules and is further limited to pay no more than VA
    rates. The DOD needs the authority and flexibility to set market
    sensitive pay on its own to be able to offer a competitive labor market
    salary rate for health care professionals.
        Admiral Walsh. The Navy believes current and expected programs
    under the new consolidated special pays authority title 37, chapter 5,
    section 335 will be sufficient to meet Navy's accession and retention
    incentive requirements. However the Navy will be exploring a change to
    the maximum age to be accessed into the Navy from 42 to 48 for Nurse
    Corps and Medical Service Corps officers. This change will allow Mental
    Health providers who are seeking a career change or received their
    degree later in life the ability to be accessed on to active duty.
        General Amos. The Department is performing well overall currently
    on the recruiting front, with encouraging trends the past 2 years.
    According to Navy Medicine most significantly, the recruitment of
    Medical and Dental students via the Health Professions Scholarship
    Program has dramatically reversed its 3 year trend of failing to meet
    recruiting goals. Retention is also on the upswing throughout the Navy
    Medicine. The Department has launched several initiatives in the last
    12-18 months that have provided leaders with additional tools to aid in
    recruiting and retention. These efforts are paying off and the
    Department will examine these initiatives closely to determine which
    are especially successful and which are less so in order to best focus
    future resources.
        General Fraser. Active and Reserve components: The programs now in
    place are in their first year of execution. Further study is required
    to determine if they are having an effect in accessing and retaining
    medical specialties.
        The new authorization under Consolidation of Special Pays (title 37
    U.S.C. 335) has been funded by the Services. We anticipate that it will
    take at least 2 fiscal years to determine if this new authority will
    meet our future accession and retention demands for mental health
    professions.
        Civilian component: Air Force Medical Group Commanders use of
    existing civilian pay incentives to attract and retain qualified
    employees while maintaining fiscal responsibility.

        24. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, what additional authorities would be helpful to
    attract and retain more mental health providers to military and
    civilian service?
        General Chiarelli. Full implementation of section 335 of title 37,
    U.S.C., should provide sufficient statutory authorities to address all
    Active component requirements. Title 27, section 302 and title 10,
    chapter 1608, U.S.C., should provide sufficient statutory authorities
    to address all of the Reserve component requirements.
        A major change is needed to grant DOD civilian healthcare providers
    the same benefits, entitlements, and pay flexibilities that are granted
    to the VA. Civilian employees of the VA and Army Medical Command
    (MEDCOM) work side by side at a number of our medical treatment
    facilities, where compensation differences are discussed and noted
    among employees. Currently, title 38 appointment, pay and other
    authorities are delegated to DOD through an Office of Personnel
    Management Delegated Agreement. A revised Delegated Agreement is
    reissued by OPM to DOD each time the VA is granted new civilian
    personnel provisions through legislation. Recommend that DOD be granted
    the identical VA legislative provisions directly by Congress, instead
    of relying on an OPM Delegated Agreement. Additionally, it would
    benefit MEDCOM to partner directly with the VA to align compensation,
    grade structure, and other personnel program provisions. Also, as many
    of the current Office of Personnel Management qualification and
    classification standards are outdated, MEDCOM would also benefit by
    using standards to similar to those used by the VA.
        Admiral Walsh. The Navy believes that a change in the maximum
    accession age for Medical Service Corps and Nurse Corps is needed to
    increase mental health provider accessions. The Navy will be proposing
    a change to the maximum age to be accessed into the Navy from 42 to 48
    for Nurse Cops and Medical Service Corps officers. This is the same age
    limit authority that the Medical Corps and Dental Corps presently have.
    This change will allow Mental Health providers who are seeking a career
    change or received their degree later in life the ability to be
    accessed on to active duty.
        General Amos. The Navy Medical Department has launched several
    initiatives in the last 12-18 months that have provided leaders with
    additional tools to aid in recruiting and retention. These efforts are
    paying off and the Department plans to examine these initiatives
    closely to determine which are especially successful and which are less
    so in order to best focus future resources.
        General Fraser. Active and Reserve component: Current military
    special pay authorities are in place or coming on line soon with our
    educational accession programs. Additional time is needed to determine
    if they are having an effect in accessing and retaining medical
    specialties.
        The Health Professional Scholarship Program does appear to
    contribute to attracting people with critically needed specialties. We
    are executing more scholarships than at anytime in the past and thanks
    to the $13.0 million congressional add for fiscal year 2008, we will
    fully execute 100 percent of our funded quotas this year.
        Civilian component: Existing DOD Direct Hire Authority for medical
    occupations is a valuable recruiting tool and appears to be making a
    positive impact on medical occupation accessions.

                               suicide prevention
        25. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, what is your Service providing now in leadership
    training for noncommissioned officers (NCOs) regarding suicide
    prevention and how is it different than what has been provided
    historically?
        General Chiarelli. At every echelon of leadership, the Army has
    heightened command emphasis on suicide prevention and Comprehensive
    Soldier Fitness and Resiliency. From February 15 to March 15, 2009, the
    Army conducted a service-wide Suicide Prevention Stand Down and Chain
    Teaching, a first according to the Center for Military History. During
    the stand down, the Army trained every soldier on suicide risk
    identification and intervention, and addressed the stigma associated
    with behavioral health counseling, using an interactive video titled
    ``Beyond the Front.'' Feedback from soldiers about the video was so
    positive that new, similar videos are being created for families and DA
    civilians; and the Army National Guard and Reserve plans to tailor
    these videos for their soldiers as well. Also during the stand-down,
    the Army distributed thousands of ACE wallet cards to soldiers; these
    cards provide a quick reference on how to identify and care for a
    potentially suicidal buddy. Follow-up to the stand down included chain
    teaching on suicide prevention tactics. Chain teaching remains underway
    through July 1.
        In the past, suicide prevention training was PowerPoint slide-
    based, individual soldier focused, and failed to highlight sensitivity
    to the leading causative factors of failing personal relationships,
    financial problems, and/or professional setbacks. Today's program has
    evolved into a holistic approach that develops leaders at the lowest
    echelons who are focused on knowledge and signs, and are capable of
    providing direct intervention. Suicide prevention is also reinforced in
    Stress Management/PTSD, mild TBI, Health Promotion Awareness, and
    Fratricide prevention training programs. We have codified suicide
    prevention and resiliency training in the Noncommissioned Officer
    Education System (NCOES) to include 10 total hours of suicide
    prevention training during Warrior Leader, Basic NCO-Common Core, and
    Sergeants Major courses.
        The newest and emergent program that the Army is undertaking
    attempts to prevent suicide by way of improving soldier resiliency
    through a program of Comprehensive Soldier Fitness. The vision of this
    program is an Army of balanced, healthy, self-confident soldiers,
    families, and civilians whose resilience and total fitness enables them
    to thrive in an era of high operational tempo and persistent conflict.
    This program will increase the resilience of soldiers and families by
    developing the five dimensions of strength and fitness: physical,
    emotional, social, spiritual, and family. Several Training and Doctrine
    Command (TRADOC) Advanced Individual Training (AIT) platoon sergeants
    will participate in a program with the University of Pennsylvania this
    spring to develop a program of instruction in order to train, educate,
    and experience our TRADOC NCOs so that they can integrate soldier
    resiliency program into future basic training and AIT.
        The bottom line, however, is that soldiers have always taken care
    of soldiers. The Army team is an unbroken chain from the Chief of Staff
    to the newest recruit, and the team has been mobilized to help one
    another. I firmly believe that ultimately, it is our soldiers who will
    turn this problem around.
        Admiral Walsh. The Navy began Front-Line Supervisor Training in
    2008. The course, jointly developed by the DOD Suicide Prevention and
    Risk Reduction Committee, is a 3 to 4 hour interactive train the
    trainer seminar that includes case examples, discussion, and role play
    to improve supervisory skills and confidence in assisting personnel in
    distress. Once trained, these trainers will provide training to all NCO
    (petty officers) front-line supervisors within the command.
        General Military Training (annual suicide prevention training),
    required of all hands, is informational in nature and reviews warning
    signs, risk and protective factors, responsibilities for assisting a
    shipmate, and how to access assistance. The Front-Line Supervisor
    Training is more comprehensive, conducted live in small groups, and
    uses discussion and practice to improve suicide prevention knowledge
    and skills.
        Currently suicide prevention training is not a required part of
    petty officer leadership training. Suicide prevention training will be
    included in petty officer leadership training starting in late fiscal
    year 2009.
        General Amos. The Marine Corps is currently developing a half-day,
    evocative, peer-led, leadership training suicide prevention course
    which will be mandatory for all NCOs this summer. The training is being
    developed under contract and includes a 30 minute dramatic video, video
    interviews with suicide survivor spouses and marines; marines who have
    made suicide attempts; and marines who intervened to support those in
    distress. The course is designed specifically for NCOs and has been
    developed with a focus group of NCO marines. Evocative, NCO directed
    training such as this has not been offered in the past. Upon
    implementation, it will be studied for efficacy and improvement through
    a relationship with the Uniformed Services University of Health
    Sciences.
        Due to the unique nature of this training, it will not be available
    until the summer. In the interim, a 2-hour suicide prevention training
    was required of all marines during the month of March. All commanding
    officers (Colonel and higher) created 4-6 minute video taped messages
    for their marines and these were incorporated into the 2 hour training.
    This training was also a break from ``training as usual'' in that it
    highlighted the strong command senior leadership focus on suicide
    prevention and presented a ``case study'' of a stellar marine overcome
    by circumstances which led to a suicide. Resources were presented for
    those who needed help or for junior leaders who had marines they
    believed needed help.
        General Fraser. Enlisted Professional Military Education (EPME)
    courses address suicide prevention as one of the most serious
    leadership issues affecting the Air Force. Leadership lessons are
    embedded in all levels of EPME. Specific Stress Management lessons are
    developed at the Senior Enlisted Leader, NCO, and airman levels. At the
    Senior Noncommissioned Officer Academy (SNCOA), suicide is addressed as
    a leadership issue with a focus on knowing, recognizing, coping and
    dealing with pre- and post-deployment stressors. The SNCOA includes
    lessons on risk factors, warning signs, providing assistance, post-
    suicide actions, and impact on the mission. The NCO Academy (NCOA)
    curriculum covers information on risk factors, warning signs, providing
    assistance, post-suicide actions, and impact on mission as part of the
    Contemporary Supervisor Issues lesson. The Airman Leadership School
    (ALS) curriculum discusses how stress directly relates to suicide and
    how negative stress can lead to suicidal behaviors and even death.
    Students must be able to explain the differences, and discuss the need
    for supervisors to realize their own limitations and seek more
    appropriate sources of assistance to remedy a situation.
        Additionally the Air Force has implemented additional programs at
    the base level such as Front-Line Supervisor Training, introduced in
    2008. This half-day course is based on the motto that ``Good Leadership
    is Good Prevention'' and provides in-depth training on assisting
    personnel in distress, as well as suicide prevention.

        26. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, based on information provided to this subcommittee,
    the number of suicides by members of the Reserves is significantly less
    than for the Active component. Is that correct? Please explain.
        General Chiarelli. That is correct to the extent we are talking
    about the absolute number of activated Guard and Reserve soldiers. To
    the extent we are talking about Guard and Reserve soldiers who are not
    serving on active duty, it is unclear if that is correct because we do
    not have complete data on these Guard and Reserve soldiers, but we are
    trying to develop data to clarify this.
        To explain, we know that fewer completed suicides are observed
    among Guard and Reserve soldiers on active duty than among regular Army
    soldiers. Although the causes of suicide and risk factors for suicide
    are complex, we do know that those Guard and Reserve soldiers who die
    from suicide have a very different risk profile than what we typically
    see among Regular Army soldiers who die from suicide.
        As for Guard and Reserve soldiers not serving on active duty, our
    analysis is limited by the data available to us. We are unable to
    calculate and compare rates for Guard and Reserve soldiers because it
    has been difficult to obtain accurate denominator data (total force
    strength) for Guard and Reserve soldiers for the period 2004-2008. This
    makes it difficult to calculate the rate of suicides within the Guard
    and Reserve (as compared to the absolute number of suicides).
    Additionally, it has been difficult to obtain accurate numerator data
    because it is less likely that the suicide will be captured in our data
    systems when a non-activated Guard or Reserve soldier dies from
    suicide. The Army is working on strategies for capturing data for
    suicides among Guard and Reserve soldiers who are not on active duty to
    enable us to calculate the rates accurately for comparison with the
    active Army.
        Admiral Walsh. The numbers regarding Reserve component suicides may
    appear to be misleading since, in accordance with DOD data
    standardization agreement, suicides of reservists are only
    investigated/reported if the death occurs while the member is serving
    on active duty, during drill, training, or travel to or from drill or
    training. This represents only a limited segment of Reserve sailor
    deaths. reservists who commit suicide while not in a duty status as
    described above (i.e., in civilian status) are not captured in suicide
    statistics.
        Going forward, Navy is revising reporting requirements to capture
    all suicides and suicide behavior by Reserve component members, both on
    active duty and in civilian status. Incidents will be reported by
    DODSER beginning in 2009 so that Navy can capture a more accurate
    suicide rate for the Navy Reserve.
        General Amos. Yes, the number of suicides by reservists is lower
    than those of the Active component. It is important to note that the
    Marine Corps does not separate Reserve component from Active component
    marines when reporting and calculating overall active duty suicide
    numbers and rates. We are looking at ways to better capture and
    understand Reserve suicides as there may be different stressors that
    require different approaches. We are also considering the most
    effective method for tracking Selected Marine Corps Reserve suicide
    data.
        General Fraser. While the number of individual suicides committed
    by members of the Air Force Reserve is lower than that of our regular
    component counterparts, the rate per 100,000 is comparable. Risk
    factors for suicide are the same for Reserve, Regular Component, and
    civilian populations (relationships, marriage, finance, work, legal/
    disciplinary, and substance abuse).

        27. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, reaching reservists potentially at risk for suicide
    poses special challenges. Do you agree on that? Please explain.
        General Chiarelli. U.S. Army Reserve soldiers potentially at risk
    for suicide do pose special challenges. Army Reserve unit leadership
    typically will not be in contact with their soldiers outside of a
    weekend battle assembly (BA) or an annual training event. Army Reserve
    soldiers are geographically dispersed, with most of them not near a
    military installation or VA Medical Center, in the event care is
    needed. These challenges have made it even more important for Army
    Reserve leadership to get to know their soldiers while at BA and
    schedule activities that build unit cohesion; in essence, the key to
    addressing these challenges is through preventative measures. The Army
    Reserve relies heavily on battle buddies to keep in touch with each
    other outside of BA weekends and the Army Reserve senior leadership has
    placed extensive emphasis to ensure that unit commanders reduce the
    stigma associated with seeking behavioral/mental health. It is critical
    that leadership creates a comfortable command climate for soldiers to
    come forward seeking help. The Army Reserve is placing emphasis on
    suicide prevention through its YRRP. The Army Reserve keeps in contact
    with soldiers throughout any deployment through events outlined in the
    YRRP. YRRP activities are conducted at 30-, 60-, and 90-day intervals
    prior to mobilization and deployment, while deployed, and at 30-, 60-,
    and 90-day intervals after re-deployment. YRRP topics of discussion,
    informational briefings and training activities focus on services and
    support directly affecting the soldier's well-being (and that of their
    family members, as well). The Army Reserve is working an initiative to
    include suicide awareness training to its units' FRGs. The more people
    in a soldier's life aware of signs and symptoms associated with a
    soldier contemplating suicide, the more likely we will be able to head
    off this tragedy. The Army Reserve encouraged its soldiers to
    participate in the ``Strong Bonds'' program to help rebuild
    relationship skills with loved ones. These events typically occur on a
    weekend and are funded by the Army Reserve at a non-military site. Army
    Reserve soldiers who may not have immediate resources are encouraged to
    talk with their unit leadership, battle buddies, family members,
    friends, Military OneSource and the VA Hotline.
        Admiral Walsh. Until the fall of 2008, there had been many
    challenges in identifying and reaching all reservists who might be at
    risk for committing suicide due to the part-time visibility of Reserve
    unit personnel by their Reserve unit leadership. The establishment of
    the Navy Reserve Psychological Health Outreach program in August 2008
    now provides a means of providing proactive outreach and assessment of
    those reservists who are identified by unit commanding officers, family
    members, self-referral, or other unit members as being potentially at
    risk for harm to themselves. In addition, Outreach Team members are
    available to provide special site visits to NOSCs or to units that have
    dealt with a suicide in order to provide intervention and counseling
    for unit members and family members affected by the death. As the
    Outreach program has matured and become more visible through the Navy
    Reserve, identification and early intervention has increased
    exponentially; the Outreach coordinators are now working with over 400
    reservists who have sought assistance with various PH issues, including
    seven who have actually attempted suicide or expressed thoughts of
    suicide.
        General Amos. It is true that Reserve communities can pose some
    unique challenges due to limited contact and geographic distance from
    resources; however, we are committed to reaching all Reserve component
    marines with suicide prevention and psychological wellness resources.
    Marines in the IRR are managed by Marine Forces Reserve's MOBCOM. In
    addition to a full-time Family Readiness Officer (FRO) and a specially-
    trained Religious Ministry Team, other members of the command's MCFRT
    contact IRR marines within 60 to 90 days after theft discharge from the
    Active component. Marines who have been mobilized from the IRR are
    asked to complete a PDHRA. Any responses indicating a need for
    referrals receive a personal telephone call and follow-up action. RWWs
    are used as the Yellow Ribbon 60-day Reintegration Event. The
    comprehensive event provides a safe and open environment for Service
    and family members to openly discuss issues ranging from reintegration
    difficulties to past combat traumas. A psycho-educational model is used
    to help attendees realize they are having normal reactions to abnormal
    events. The setting provides a sense of commonality and helps
    individuals realize they are not alone. Though geographically isolated
    they come connected to a larger community. Chaplains and counselors are
    readily available to provide counseling as required. Follow-up for
    individuals is obtained through the use of mental health resources near
    the member's residence.
        The Marine Corps Suicide Prevention Program is in Manpower and
    Reserve Affairs and works with Marine Forces Reserves to ensure that
    all guidance and resources are relevant and available for the Reserve
    community. We have programs that reach out to all marines, including
    those currently inactive and geographically separated. These include
    the Marine for Life Hometown Links and the Wounded Warrior Regiment.
    The Wounded Warrior Regiment offers a call center that is available 24/
    7 to assist marines in their recovery regardless of their geographic
    location. In addition, the Marine Corps works with the Defense Centers
    of Excellence on PH and TBI which offers a 24/7 call center that is
    available for all Reserve marines and family members regardless of
    theft active or inactive status.
        General Fraser. Air National Guard: Yes, the ANG poses a unique
    challenge due to the nature of its mission and members' military
    status. Guard Airmen are covered by the same suicide prevention
    training requirements as our Active Duty force.
        Air Force Reserves: There are special challenges associated with
    reaching reservists potentially at risk for suicide. While our Citizen
    Airmen have volunteered in record numbers, a great deal of their time
    is spent in civilian status. In civilian status, privacy laws limit our
    ability to monitor their behavior and actions. It is very difficult to
    accurately investigate or review suicides of those reservists who
    commit suicide while they are in civilian status. These investigations
    are managed by local authorities who sometimes share results with
    family members, but are not obligated to collaborate with the military.
        The Air Force Reserve will continue to enforce programs like
    mandatory Suicide Prevention briefings. These briefings emphasize
    identification of suicide risks and the appropriate courses of action.
    Additionally, we will also continue to promote the ``Wingman'' concept
    of caring for our airmen both in and out of uniform and capitalize on
    all available YRRP efforts.

        28. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
    and General Fraser, how are you tailoring your prevention strategies to
    identify and stay in contact with Reserve members, especially following
    an extended period of Active Duty?
        General Chiarelli. It is critical that leadership in the U.S. Army
    Reserve develop a command climate where soldiers feel comfortable
    coming forward to discuss issues. When Army Reserve unit leadership is
    engaged and genuinely concerned about soldier well-being, many issues
    are identified and corrected before they become larger concerns. The
    Army Reserve keeps in contact with soldiers throughout any deployment
    through events outlined in the YRRP. YRRP activities are conducted at
    30-, 60-, and 90-day intervals prior to mobilization and deployment;
    while deployed; and at 30-, 60-, and 90-day intervals after re-
    deployment. YRRP topics of discussion, informational briefings and
    training activities focus on services and support directly affecting
    the soldier's well-being (and that of their family members, as well).
    Army Reserve leaders also have periodic town halls and information-
    sharing sessions supplemented by recurring training on suicide
    prevention and must conduct Post-Deployment Health Risk Assessments.
    The Army Reserve family programs staff is conducting several events
    that bring soldiers and families together to discuss these issues.
        The U.S. Army Reserve Command has implemented new required training
    for the commander, First Sergeant, Family Readiness Liaison/Rear
    Detachment Commanders, FRG Leaders, and key volunteers of alerted and/
    or deployed units (the ``Family Readiness Team''). This training was
    formerly known as Deployment Cycle Support Training and is now Army
    Reserve-Family Readiness Education for Deployment training. The
    objective of this training, conducted by the 88th Regional Readiness
    Command Family Readiness Division, is to provide information to key
    Army Reserve staff and volunteers who are likely to be asked questions,
    or offer assistance to family members and soldiers affected by
    mobilization, deployment, sustainment and reunion. The intent is to
    develop a network of informed personnel associated with the Army
    Reserve Family Program to help alleviate concerns by family members
    and/or soldiers trying to find answers to deployment-related questions.
    FPA training is divided into three parts: fundamental, developmental,
    and resource. Fundamental FPA training includes the basics to help
    establish and maintain a viable, functioning FRG at the unit level.
    Developmental FPA training builds on those basics and enhances the
    participant's capability to sustain and enhance unit family programs.
    Resource training is provided at the unit upon request for those that
    are more advanced in their family program.
        Operation READY is a series of training modules, videotapes, CDs,
    and resource books published for the Army as a resource for staff to
    train Army families who are affected by deployments. Operation READY
    materials include: pre-deployment and ongoing readiness, Family
    Assistance Centers, Homecoming and Reunion, the Army FRG Leader's
    Handbook, and the Army Leader's Desk Reference for Soldier/Family
    Readiness. The training is a train-the-trainer program for Instructors
    and senior volunteer resource instructors to take back to units and
    show how information and materials are accessed and utilized.
        Chain of command training is designed to familiarize unit
    leadership with the scope of family programs within the Army Reserve.
    Briefings are provided on all aspects of family programs such as
    mobilization training, volunteer management, and the Army Family Action
    Plan.
        Admiral Walsh. The Psychological Health Outreach Team members have
    been provided with the names of returning unit members and Individual
    Augmentee personnel, and Team members actively call these individuals
    as soon as they are released from active duty. Team members have also
    been actively engaged with Reserve component servicemembers assigned to
    Medical Hold, engaging with them to ease their transition back into
    civilian life and to ensure continuity of care by available local
    providers. Outreach team members visit the NOSC in their respective
    Regions on a routine basis, where they meet with unit members, NOSC
    staff personnel, and family members if they are available. During these
    visits, the Outreach team provides the Operational Stress Control brief
    as well as the Suicide Prevention brief. Team members are also
    available to meet with unit members and, if necessary, link them up to
    an Outreach Coordinator for care referral and follow-up.
        General Amos. Reserve communities can pose some unique challenges
    due to limited contact and geographic distance from resources; however,
    we are committed to reaching all Reserve component marines with suicide
    prevention and psychological wellness resources. Marines in the IRR are
    managed by Marine Forces Reserve's MOBCOM. In addition to a full-time
    Family Readiness Officer (FRO) and a specially-trained Religious
    Ministry Team, other members of the command's MCFRT contact IRR marines
    within 60 to 90 days after their discharge from the Active component.
    Marines who have been mobilized from the IRR are asked to complete a
    PDHRA. Any responses indicating a need for referrals receive a personal
    telephone call and follow-up action. RWWs are used as the Yellow Ribbon
    60-day Reintegration Event. The comprehensive event provides a safe and
    open environment for Service and family members to openly discuss
    issues ranging from reintegration difficulties to past combat traumas.
    A psycho educational model is used to help attendees realize they are
    having normal reactions to abnormal events. The setting provides a
    sense of commonality and helps individuals realize they are not alone.
    Though geographically isolated they come comiected to a larger
    community. Chaplains and counselors are readily available to provide
    counseling as required. Follow-up for individuals is obtained through
    the use of mental health resources near the member's residence.
        The Marine Corps Suicide Prevention Program is in Manpower and
    Reserve Affairs and works with Marine Forces Reserves to ensure that
    all guidance and resources are relevant and available for the Reserve
    community. We have programs that reach out to all marines, including
    those currently inactive and geographically separated. These include
    the Marine for Life Hometown Links and the Wounded Warrior Regiment.
    The Wounded Warrior Regiment offers a call center that is available 24/
    7 to assist marines in their recovery regardless of their geographic
    location. In addition, the Marine Corps works with the Defense Centers
    of Excellence on PH and TBI which offers a 24/7 call center that is
    available for all Reserve marines and family members regardless of
    their active or inactive status.
        General Fraser. The YRRP for members and families has proven to be
    a highly successful program. Deployment support and reintegration
    programs are being provided in all phases of deployment, including but
    not limited to pre-deployment, deployment, demobilization, and post-
    deployment and reconstitution phases. Reconstitution activities are
    being held at approximately 30-, 60-, and 90-day intervals following
    demobilization or deployment. Activities focus on reconnecting members
    and their families with the service providers to ensure that members
    and their families understand benefits and entitlements as well as the
    resources available to help them overcome the challenges of
    reintegration. Best practices from the most successful programs are
    being collected to populate other base YRRPs.
        Through the YRRP, the Air Force Reserve was able to develop and
    hire Regional Psychological Health Advocate teams (overseen by a
    Director of Psychological Health). These teams help identify and
    respond to PH needs of members of the Air Force Reserve. They help
    ensure that identified issues, such as a potential TBI or line of duty
    determinations, are processed in a timely manner. These actions ensure
    speedy referrals are accomplished and additional access to mental
    health and/or other appropriate services are provided to maximize
    positive outcomes. The PHA teams also consult with Air Force Reserve
    leadership on PH issues and respond to specific matters that may become
    more challenging if not addressed.

                       post-deployment health assessments
        29. Senator Graham. Major General Rubenstein, we often hear that
    although the post-deployment health assessments are performed by a high
    percentage of soldiers returning from combat, many who are referred for
    follow-up care never obtain it. What is the evidence on obtaining
    follow-up care in the Army?
        General Rubenstein. According to data obtained from the Defense
    Medical Surveillance System (6 April 2009), between 1 January 2003 to 6
    April 2009, 472,840 active duty soldiers completed the PDHA. Thirty
    percent of the soldiers received referrals. Of the 30 percent who
    received referrals, 97 percent of the referrals had a medical visit
    with a health care provider within 6 months after the referral (this
    includes either inpatient or outpatient visits).
        From 2005 through 2008, 190,742 active duty soldiers completed the
    PDHRA. Of the total number completing the PDHRA, 52,189 (27 percent) of
    the soldiers received referrals and 77 percent of the referrals had a
    medical visit with a health care provider within 6 months after the
    referral.
        The Army Reserve and Army National Guard do not maintain reliable
    data concerning referrals from the PDHA or PDHRA. They have each
    identified this as an issue and are currently in the process of
    developing automated solutions.

        30. Senator Graham. Major General Rubenstein, how do you track
    whether or not a soldier attains that care?
        General Rubenstein. Referral completions within the Military Health
    System are tracked by the installation military treatment facility
    (MTFs). The MTFs use the DOD's electronic health record for capturing
    referrals identified on the PDHA and PDHRA. Unfortunately, this
    tracking system is only effective for Active component soldiers. No
    formal tracking of PDHA/PDHRA referrals is in place for the Reserve
    component. The Army Reserve and Army National Guard have each
    identified this as an issue and are currently in the process of
    developing automated solutions.

        31. Senator Graham. Major General Rubenstein, does failure to
    obtain follow-up mental health care place a soldier at greater risk of
    suicide?
        General Rubenstein. Soldiers who are depressed or abusing
    substances or who have psychiatric pathology are at a higher risk for
    suicide. Soldiers who fail to receive treatment for these disorders may
    have an increased risk for suicide. However, most soldiers who commit
    suicide in the Army do not have a mental health diagnosis. Instead,
    many suicides appear to be related to recent life stressors, such as a
    relationship break-up or job difficulty.

        32. Senator Graham. Major General Rubenstein, how are we going to
    fix this problem?
        General Rubenstein. The Army has been vigorously pursuing suicide
    prevention and intervention efforts. Nevertheless, the number of
    suicides has continued to rise, which is an issue of great concern.
    Some of our recent efforts are outlined below.
        In March 2009, the VCSA established a new Suicide Prevention Task
    Force to integrate all of the efforts across the Army. A Suicide
    Prevention General Officer Steering Committee (GOSC) stood-up in March
    2008. The GOSC's efforts are ongoing, with a focus on targeting the
    root causes of suicide, while engaging all levels of the chain-of-
    command.
        From February 15, 2009 to March 15, 2009, the Army conducted a
    total Army ``stand-down'' to ensure that all soldiers learned not only
    the risk factors of suicidal soldiers, but how to intervene if they are
    concerned about their buddies. The ``Beyond the Front'' interactive
    video is the core training for this effort. It was followed by a chain-
    teach which focuses on a video ``Shoulder to Shoulder; No Soldier
    Stands Alone'' and vignettes drawn from real cases. The Army continues
    to use the ACE tip cards and strategy.
        The Army established the Suicide Analysis Cell at the Center for
    Health Promotion and Disease Prevention (CHPPM) in July 2008. This is a
    suicide prevention analysis and reporting cell that has epidemiological
    consultation-like capabilities. They will gather suicidal behavior data
    through numerous sources, including the Army Suicide Event Report
    (ASER), the U.S. Army Criminal Investigation Division Reports, AR 15-6
    investigations, and medical and personnel records.
        The GOSC and related efforts reaffirmed the Army Suicide Prevention
    overarching strategies and expanded them. They include: 1) raising
    soldier and leader awareness of the signs and symptoms of suicide and
    improving intervention skills; 2) providing actionable intelligence to
    Leaders regarding suicides and attempted suicides; 3) improving
    soldiers' access to comprehensive care; 4) reducing the stigma
    associated with seeking mental healthcare; and 5) improving soldiers'
    and their families' life skills.
        In the fall of 2008, the Army Science Board studied the issue of
    suicides in the Army. While their report has not been officially
    released, it reiterated the above strategies and the need for a
    comprehensive, multi-disciplinary approach. It did not find easy or
    simple solutions to the problem.
        The Army has also developed a Memorandum of Agreement with the
    National Institutes of Mental Health (NIMH), which was signed in the
    fall of 2008. This is an ongoing 5 year research effort to better
    understand the root causes of suicide and develop better prevention
    efforts. This NIMH effort is being coordinated with the CHPPM Suicide
    Analysis Cell mentioned above, as well as with suicide prevention
    efforts from the Walter Reed Army Institute of Research.
        The Army intends to roll out the Comprehensive Soldier Fitness
    Program this year. This program is designed to build resilience in all
    soldiers in the emotional, social, familial, and spiritual domains. The
    program as a whole will provide education that builds coping skills for
    soldiers to deal with challenges and adversity.

                            national suicide hotline
        33. Senator Graham. Brigadier General Sutton and Ms. Power, I am
    concerned that DOD does not appear to get feedback from the National
    Suicide Hotline about calls to that hotline by military members. Would
    it be beneficial to explore some means of sharing general information
    about the nature of calls by military members, specific issues that are
    identified, the number of such calls, or other trends and
    characteristics?
        General Sutton. DOD has been using the National Suicide Hotline for
    well over a decade. This is the same hotline that the VA uses. Suicide
    risk factors are generally consistent across the different populations.
    Aggregate data are of approximately equal value in identifying
    characteristics or demographics as population-specific data. However,
    the primary purpose of the hotline is intervention rather than
    surveillance. Having trained respondents on the line who have
    experience talking with individuals with urgent problems is a great
    service to the public. The value of the specific arrangement the
    suicide hotline has with the VA lies in the ability to target
    intervention benefits to the veteran population, not necessarily
    identifying characteristics of the callers. The VA can access the
    individual's medical records (given caller consent) and can assist the
    caller in understanding and accessing resources that are available only
    to veterans and that may be more effective in treating veteran specific
    conditions and concerns.
        The VA, which collects and maintains all data on Veteran Suicide
    Prevention Hotline callers, consistently shares general, non-
    identifiable data on active duty callers with both Substance Abuse and
    Mental Health Services Administration (SAMHSA) and DOD during various
    monthly meetings and conference calls, as well as upon request. When VA
    crisis counselors need to arrange an emergency rescue (for a
    servicemember at imminent risk of harm) on a military base, they always
    contact key base leaders. Callers not at imminent risk receive
    referrals for both military and non-military mental health resources,
    but a caller's confidentiality is not violated by disclosing this
    information to the chain of command in non-emergency situations.
        In addition to active duty servicemembers calling the Veterans
    Hotline, some also choose to connect to local crisis centers. Callers
    access the Veterans Hotline through SAMHSA's National Suicide
    Prevention Lifeline (800-273-TALK), a system that routes calls based on
    the area code, from anywhere in the United States to a network of more
    than 135 independent, certified crisis centers across the country.
    Veterans and their families are invited to ``press 1'' to be routed to
    the VA call center in Canandaigua, NY, which maintains its own
    database.
        Veteran and Active Duty callers who choose not to ``press 1'' are
    routed to the crisis center that is geographically closest to them.
    Following an assessment by the local crisis center, veterans and Active
    Duty military have the option of having their call ``warm transferred''
    to the VA call center in Canandaigua. Similarly, calls can be ``warm
    transferred'' from the DCoE for PH and TBI to the Veterans Suicide
    Prevention Hotline. A ``warm transfer'' is a process in which a crisis
    worker stays on the line with the caller until contact is made with the
    center to which the call is transferred, thereby reducing the
    likelihood that a caller at risk will ``fall through the cracks.''
        By the end of 2009, all of these independent crisis centers will be
    collecting and reporting to SAMHSA consistent, non-identifiable
    demographic data, including whether the caller has ever served in the
    U.S. military, but SAMHSA will not be able to determine how many of
    those callers are Active Duty.
        We also are working with the VA and SAMHSA to determine the
    effectiveness of having specific VA respondents who can access veteran
    information and resources as compared with general community resources.
    If the interventions appear to have value, DOD will work to determine a
    method to add military specific respondents in either VA call centers
    or in dedicated military call centers to provide targeted
    interventions. In addition, making a warm hand-off to a military
    specific referral source may be an alternative option for both
    community-based and VA-specific call centers.
        Ms. Power. The VA which collects and maintains all data on Veteran
    Suicide Prevention Hotline callers, consistently shares general, non-
    identifiable data on active duty callers with both SAMHSA and DOD
    during various monthly meetings and conference calls, as well as upon
    request. Also, when VA crisis counselors need to arrange an emergency
    rescue (for a servicemember at imminent risk of harm) on a military
    base, the base is always contacted. Callers not at imminent risk are
    given referrals for both military and non-military mental health
    resources, but callers' confidentiality is not violated by disclosing
    this information to the chain of command in non-emergency situations.
        In addition to active duty servicemembers calling the Veterans
    Hotline, some also choose to connect to local crisis centers.
        Callers access the Veterans Hotline through SAMHSA's National
    Suicide Prevention Lifeline (800-273-TALK), a system that routes calls,
    based on the area code, from anywhere in the United States to a network
    of more than 135 independent, certified crisis centers across the
    country. Veterans and their families are invited to ``press 1'' to be
    routed to the VA call center,in Canandaigua, NY, which maintains its
    own data base.
        Veteran and active duty callers who choose not to ``press 1'' are
    routed to the crisis center that is geographically closest to them.
    Following an assessment by the local crisis center, veterans and active
    duty military have the option of having their call ``warm transferred''
    to the VA call center in Canandaigua, Similarly, calls can be ``warm
    transferred'' from the-DOD Center of Excellence on PH and TBI to the
    Veterans Suicide Prevention Hotline. A ``warm transfer'' is a process
    in which a crisis worker stays on the line with the caller until
    contact is made with the center to which the call is transferred,
    thereby reducing the likelihood that a caller at risk will ``fall
    through the cracks,''
        By the end of 2009, all of these independent crisis centers will be
    collecting and reporting to SAMHSA consistent, non-identifiable
    demographic data, including whether the caller has ever served in the
    U.S. military, but SAMHSA will not be able to determine how many of
    those callers are active duty.

        34. Senator Graham. Brigadier General Sutton and Ms. Power, are
    there any discussions ongoing along these lines between DOD and the
    SAMSHA? If so, what is the intent?
        General Sutton. The DOD, VA, and Substance Abuse and Mental Health
    Services Administration (SAMHSA) meet regularly in a variety of venues
    to address suicide prevention, including the Federal Workgroup on
    Suicide Prevention, the Federal Workgroup on the Reintegration of
    Veterans and their families, and the DOD's Suicide Prevention and Risk
    Reduction Committee.
        The DOD, VA, and SAMHSA frequently discuss the appropriate role of
    hotlines for Active Duty military. SAMHSA provides consultation as
    requested and as appropriate. DOD and SAMHSA leverage the wealth of
    information available when talking with agencies that are already
    managing programs that may be best practices in the field.
    Opportunities range from implementing lessons learned from the
    experiences of the VA hotline and SAMHSA's National Suicide Prevention
    Lifeline, to developing interagency partnerships that use current
    infrastructures to conduct joint programming, to intervening with
    servicemembers at risk who may reach out to civilian resources.
        Ms. Power. The DOD, VA, and SAMHSA meet regularly in a variety of
    venues during which suicide prevention is addressed including the
    Federal Workgroup on Suicide Prevention, the Federal Workgroup on the
    Reintegration of Veterans and their families, and the DOD's Suicide'
    Prevention and Risk Reduction Committee. The DOD, VA, and SAMHSA
    frequently discuss the appropriate role of hotlines for active duty
    military. SAMHSA provides consultation, as requested and as
    appropriate.

        35. Senator Graham. Brigadier General Sutton and Ms. Power, what
    are the opportunities and the parameters of such discussions from both
    DOD and SAMSHA perspectives?
        General Sutton. The DOD, VA, and the Substance Abuse and Mental
    Health Services Administration (SAMSHA) frequently discuss the
    appropriate role of hotlines for active duty military. SAMHSA provides
    consultation as requested and as appropriate. DOD and SAMHSA leverage
    the wealth of information available when talking with agencies that are
    already managing programs that may be ``best practices'' in the field.
    Opportunities range from implementing ``lessons learned'' from the
    experiences of the VA hotline and SAMHSA's National Suicide Prevention
    Lifeline, to developing interagency partnerships that use current
    infrastructures to conduct joint programming, to intervening with
    servicemembers at risk who may reach out to civilian resources.
        Ms. Power. As SAMHSA and the VA discovered in 2007 at the beginning
    stages ofplanning for the VA hotline, there is a wealth of information
    to be learned from talking with agencies that are already managing
    programs that may be ``best practices'' in the field. Opportunities
    range from implementing ``lessons learned'' from the experiences of the
    VA hotline, to developing interagency partnerships that use current
    infrastructures to conduct joint programming; to intervening with
    servicemembers at risk who may reach out to civilian resources.

                      suicide as a public health epidemic
        36. Senator Graham. Major General Rubenstein, Brigadier General
    Sutton, and Ms. Power, what is your definition of a public health
    epidemic?
        General Rubenstein. A public health epidemic is the occurrence of
    an illness, health-related event, or health outcome that occurs in
    excess of the normal or above baseline levels in a specific population
    or place.
        General Sutton. An epidemic generally refers to a rapidly
    spreading, widely prevalent outbreak or disease that affects many
    people more rapidly or more widely than would be normally expected.
    While suicide is a public health problem, it still remains a rare event
    and would not be considered an epidemic.
        Ms. Power. The Centers for Disease Control and Prevention define
    epidemic as ``the occurrence of more cases in a place (or population)
    and time than expected.''

        37. Senator Graham. Major General Rubenstein, Brigadier General
    Sutton, and Ms. Power, does the Army's and Marine Corps' current
    experience with suicide meet that definition? If so, what additional
    prevention and surveillance measures should be applied?
        General Rubenstein. I'll address the Army's experience with
    suicide. Using the definition described in the previous question, the
    Army is experiencing an epidemic of suicides. However, the term
    ``epidemic'' is broadly and variously defined and the present
    application of this term to suicides is more a reflection of the sense
    of urgency we all share in addressing this problem in the Army. These
    tragic losses represent the most visible form of the cumulative adverse
    health outcomes experienced by soldiers, families, and communities in
    association with enduring contingency operations. Using the definition
    above, one should note that Army health data would support that we are
    seeing epidemic levels of substance abuse, depressive disorders, PTSD,
    and behavioral health hospitalizations in the Army. For many of our
    soldiers, these occurrences lie in the causal pathway to suicide. The
    Army has recently established a Behavioral and Social Health Outcomes
    Program at CHPPM for the purpose of conducting systematic surveillance
    on suicides and other associated social outcomes in the Army, such as
    substance use, domestic violence, and behavioral health diagnoses. This
    program will assess for emerging trends in social epidemiology and
    consider their implications for behavioral health policy, programs, and
    research. It will strive to provide expert consultation to the Army as
    it develops and implements evidence-based, effective approaches to
    maximizing the psychological and social health of our soldiers,
    families, organizations, and communities. CHPPM is currently building a
    comprehensive social outcomes database which will relate numerous data
    sources from within the Army. The information from this database will
    serve as a foundation for supporting future work in suicide reduction,
    such as the Army-NIMH 5-year epidemiologic study of mental health,
    psychological resilience, suicide risk, suicide-related behaviors, and
    suicide deaths in the U.S. Army.
        As we learn more about those suicide risk factors that lie in
    association with combat experiences and the impact of lengthy overseas
    contingency operations on our soldiers, organizations, and communities,
    we will more readily be able to address the specific needs of these
    high-risk soldiers and their families. However, we do not have to
    identify individuals in order to save them. Most of our suicides will
    continue to come from the larger, lower-risk populations within our
    Army. For this reason, we will continue to move forward in supporting
    efforts to apply preventive strategies to the whole Army population;
    examples of such strategies include the recent stand-down, the ACE
    card, and the ``Beyond the Front'' and ``Shoulder to Shoulder; No
    Soldier Stands Alone'' interactive videos. This approach is also the
    intent of the Battlemind Training System and the Comprehensive Soldier
    Fitness program.
        General Sutton. Suicide rates have increased, but suicide remains a
    rare event. Fluctuations in rare events can sometime seem dramatic,
    simply because any increase in a rarely occuring event looks bigger
    than an increase in a frequently occurring event. Random variation is
    normal. Only by watching over time, can you determine if there is an
    increasing trend. A single spike would not indicate a ``rapidly
    spreading or prevalent'' epidemic. That does not mean that we should
    not take action. Every increase should be a signal for additional
    efforts. We take every increase seriously.
        In addition, we cannot compare current suicide rates for Active
    Duty with civilian populations because, while DOD compiles the
    statistics by the close of each quarter, national statistics for that
    same period are not available from Center for Disease Control (CDC)
    until approximately 3 years later. A sustained focus on and
    prioritization of suicide prevention is crucial regardless of whether
    the magnitude of the increase can be categorized as an epidemic. Losing
    even one member of the Armed Forces to suicide is not acceptable.
    Leadership continues to address this issue in a comprehensive, public
    health manner, putting to use the best practices from both civilian and
    military experts, while evaluating the effectiveness of programs.
        The DODSER was developed to examine the causes and circumstances of
    suicide related behaviors among servicemembers. It examines over 250
    data points to look at all contributing risk and protective factors.
    Several efforts are underway to improve the quality of data--for
    example working on the standardization of nomenclature and
    clarification between attempts and self-injurious behaviors. The DODSER
    standardizes the data collected on all suicide events and is an
    integral part of DOD's Suicide Prevention Program.
        Ms. Power. Based on the above definition, the yearly rates reported
    by the U.S. Army seem to qualify as above the expected occurrence.
    However, it should be noted that we cannot compare current suicide
    rates for active duty with civilian populations because while DOD is
    able to compile its statistics by the close of each month, national
    statistics for that same time period will not be available from CDC
    until about 3 years later. We have no way of knowing whether the
    suicide rate for the civil ian population is increasing at a comparable
    rate to that within the military because, for example, of the current
    financial crisis.
        While defining or establishing the.existence of an epidemic or
    disease cluster has an important role, a sustained focus on and
    prioritization of suicide prevention is crucial regardless of whether
    the magnitude of the increase can be categorized as an epidemic. Losing
    even one member of the Armed Forces to suicide is not acceptable.
    Leadership should continue to address this issue in a comprehensive,
    public health manner, putting to use the best wisdom from both civilian
    and military experts, while evaluating the effectiveness of programs
    that are being implemei1ted.
        Prevention and surveillance measures that focus on suicide attempts
    are also of great importance. Suicide attempts are the strongest single
    risk factor for later death by suicide, highlighting the importance of
    suicide attempt surveillance as well as prevention and intervention
    strategies focused on members of the Armed Services who have attempted
    suicide.

                         national institutes of health
        38. Senator Graham. Major General Rubenstein, Brigadier General
    Sutton, and Ms. Power, the Army has recently entered into an agreement
    with the NIH to study factors in Army suicides. Although I commend the
    Army for reaching out beyond its borders for solutions to suicide
    prevention that can be effectively applied to the military, $50 million
    sounds like a lot of money to me. Do you support that initiative?
        General Rubenstein and General Sutton. The Assistant Secretary of
    Defense for Health Affairs supports the study and has contributed
    funding as demonstrated in the answer to question #40. The DCoE for PH
    and TBI supports the Army's intention and commitment to examine suicide
    risk and take necessary action to prevent suicide among soldiers. At
    the moment, this is an Army effort with which the Marines have
    indicated interest. The results are expected to benefit the other
    Services' suicide intervention efforts as well. This 5-year
    longitudinal study will be the largest single study on the subject of
    suicide that National Institute of Mental Health (NIMH) has ever
    undertaken. The study is designed to provide a comprehensive evaluation
    of both risk and protective factors associated with suicides, and
    support the development of evidence-based prevention, assessment, and
    treatment services. The study's findings also will inform our general
    understanding of suicide in the U.S. population, and may lead to more
    effective interventions for civilian society.
        In addition, soldiers can and do access civilian health and mental
    health resources, highlighting the importance of the study's findings
    by civilian resources. This study is a collaborative effort between the
    Army and NIMH, and includes considerable oversight by both the Army and
    NIMH through dedicated program management resources by both government
    agencies, frequent reviews and reporting, joint oversight committees,
    and a funding mechanism that allows the research to be re-directed
    quickly should promising avenues be discovered.
        Ms. Power. This will be the largest single study on the subject of
    suicide that NIMH has ever undertaken. The project aims to strengthen
    the Army's efforts to reduce suicide among its soldiers by identifying
    risk and protective factors for suicidal thinking and behavior, and
    then utilizing this information to identify specific intervention
    options and practical suicide risk reduction efforts. The study's
    findings will also inform our understanding of suicide in the U.S.
    population overall, and may lead to more effective interventions for
    both soldiers and civilians. In addition, soldiers can and do access
    civilian health and mental health resources, highlighting the
    importance of the study's findings being utilized by civilian
    resources. SAMHSA stands ready to assist in that process.

        39. Senator Graham. Major General Rubenstein, Brigadier General
    Sutton, and Ms. Power, what are we getting for the investment?
        General Rubenstein and General Sutton. While currently this is an
    Army effort with which the marines have indicated interest, the results
    are expected to benefit the other Services' suicide intervention
    efforts as well. This 5-year longitudinal study will be the largest
    single study on the subject of suicide that National Institute of
    Mental Health (NIMH) has ever undertaken. The study is designed to
    provide a comprehensive evaluation of both risk and protective factors
    associated with suicides, and support the development of evidence-based
    prevention, assessment, and treatment services. The study's findings
    will inform our general understanding of suicide in the U.S.
    population, and may lead to more effective interventions for civilian
    sectors of society.
        In addition, soldiers can and do access civilian health and mental
    health resources, highlighting the importance of the study's findings
    being utilized by civilian resources. Rather than being a research
    grant in the conventional sense, this study is a collaborative effort
    between the Army and NIMH and includes considerable oversight by both
    the Army and NIMH through dedicated program management resources by
    both government agencies, frequent reviews and reporting, joint
    oversight committees, and a funding mechanism that allows the research
    to be re-directed quickly should promising avenues be discovered.
        Ms. Power. The Institute of Medicine's report, Reducing Suicide: A
    National Imperative, states, ``Despite the extensive knowledge that
    research has provided regarding risk and protective factors, we are
    still far from being able to integrate these factors so as to
    understand how they work in concert to evoke suicidal behavior or to
    prevent it.'' This initiative has potential for assisting us in
    understanding what is evoking suicidal behavior in the Army, and, of
    greater importance, using such information to prevent suicide in the
    Army and in the Nation.

        40. Senator Graham. Major General Rubenstein, Brigadier General
    Sutton, and Ms. Power, how will DOD maintain oversight for money that
    is transferred to the NIH?
        General Rubenstein and General Sutton. The $10 million was
    reprogrammed from the Defense Health Program to the Department of the
    Army to fund the Suicide Mitigation Study. The Department of the Army
    will allocate the funding to the NIH to conduct the study and will
    monitor the services rendered by the NIH to insure the funds are
    effectively used for the intended purpose.
        Ms. Power. We defer to DOD to respond to this procedural matter.

                          medical accession standards
        41. Senator Graham. Lieutenant General Freakley, Major General
    Rubenstein, and Brigadier General Linnington, previously Brigadier
    General Linnington testified that the DOD accessions screening process
    has remained relatively unchanged over the last 2 years. Is it
    appropriate to undertake a review of those standards in light of the
    increasing rate of suicide?
        Lieutenant General Freakley, General Rubenstein, and Brigadier
    General Linnington. The DOD Accession Medical Standards Work Group
    (AMSWG) reviews the accession standards every 4 years with the latest
    review due for publication later in 2009. In April 2009, the AMSWG has
    scheduled a conference with the psychiatric consultants from the three
    Services to review the accession standards and discuss current science
    as well as the feasibility of mental fitness prescreens applied to the
    accessions process. The DOD has explored psychological and mental
    health screening of applicants without success for many years.
    Unfortunately, no reliable screening tool has been developed. The
    Accession Medical Standards Analysis and Research Activity (AMSARA) at
    the Walter Reed Army Institute of Research is looking into the merits
    of conducting a case control study of suicide victims/attempters to
    identify whether accession risk factors exist, including medical
    (psychiatric) disqualifications and waivers as well as psychiatric
    morbidity while on active duty. If accession risk factors are found to
    exist, then a review of the accession standards and a possible change
    would be in order.

        42. Senator Graham. Lieutenant General Freakley, Major General
    Rubenstein, and Brigadier General Linnington, what changes or
    improvements could be made to reduce the risk of accessing an
    individual who is at risk for suicide?
        Lieutenant General Freakley, General Rubenstein, and Brigadier
    General Linnington. All potential recruits received a detailed physical
    with specific questions about whether or not they have received any
    psychiatric counseling. The current individual screening tools are
    self-reported instruments and rely largely on the knowledge and
    truthfulness of the applicant to disclose any disqualifying medical or
    psychiatric conditions. The current DOD self assessment screening tool
    (DD Form 2807-1) is under review for appropriate content. Additionally,
    the Accession Medical Standards Analysis and Research Activity (AMSARA)
    at Walter Reed Army Institute of Research has proposed using the Army's
    non-cognitive, executive function instruction, called the Assessment of
    Individual Motivation (AIM), to study it as a predictor of military
    success (6, 12, 24, and 36 months attrition) and to see if it can
    predict psychiatric morbidity, to include suicidal behavior (i.e.
    attempts, gestures). The AIM is a 27-item questionnaire available at
    all Military Entrance Processing Stations and administered currently to
    applicants without a high school degree to try and predict occupational
    success.

                            data on suicide attempts
        43. Senator Graham. Brigadier General Sutton and Ms. Power, is
    there scientific evidence that indicates a relationship between suicide
    attempts and completed suicides?
        General Sutton. Suicide attempts represent a risk factor category
    for later death by suicide especially when alcohol is involved,
    highlighting the importance of suicide attempt surveillance as well as
    prevention and intervention strategies for members of the Armed
    Services. Importantly, when a serious suicide attempt is met with
    treatment and increased social support, later risk of suicide death is
    reduced. It is therefore important to provide attention and targeted
    treatment for individuals with suicide attempts. Longitudinal research
    also indicates that attempted suicide is an important clinical
    predictor of suicide completion. The frequency of suicide attempts per
    year are positively correlated with the likelihood of eventual death by
    suicide, with an estimated 10 percent to 15 percent of all attempters
    eventually take their lives. There do appear to be gender differences
    among suicide attempters, as males who have attempted suicide have been
    found to be more likely to eventually end their lives than do female
    attempters. Attempts also appear to be age dependent, with about 100 to
    200 attempts for one suicide completion for young adults ages 15 to 24
    years old and four attempts for every one suicide completion among
    adults ages 65 years and older (Goldsmith et al., 2002). The Air Force
    data on suicide attempts and completed suicides suggests that the
    individuals who attempt may be very different from those who die by
    suicide on the first attempt. Nevertheless, any self-injurious behavior
    is a sign of distress and warrants our compassion and intervention.
        Ms. Power. The single strongest risk factor for later death by
    suicide is a prior suicide attempt. One of the seminal studies in this
    area indicated that over 40 percent of individuals who attempted
    suicide either re-attempted or died by suicide within 5 years.
    (Beautrais AL)
        Although there are no official national statistics on attempted
    suicides, it is generally estimated that there are 25 attempts for each
    death by suicide. Reports also indicate that there are three non-fatal
    suicide attempts among females for every one among males.
        For the first time this year, SAMHSA's National Survey on Drug Use
    and Health (NSDUH) queried adults about suicide attempts and an
    analysis, including national, and State-level estimates, will be
    available during calendar year 2009.

        44. Senator Graham. Brigadier General Sutton and Ms. Power, should
    DOD and the Services more carefully collect and analyze data on suicide
    attempts?
        General Sutton. Prevention and surveillance measures that focus on
    suicide attempts are of great importance. DOD and Services are
    committed to collecting and analyzing the best possible data on suicide
    and suicide attempts.
        Assessing suicide attempts and other self-injurious behaviors
    presents a complex challenge. These challenges are shared by the DOD,
    working to improve its capability to document attempts. The DOD Suicide
    Prevention and Risk Reduction Committee is currently addressing
    standardization in the nomenclature and is working towards cross
    Service standardization on suicide attempts and other self-injurious
    behaviors. In this effort, the DODSER database, overseen by the
    National Center for Telehealth and Technology, a component center of
    the DCoE for PH and TBI can capture and track trends and associated
    risk factors to better address the needs of our servicemembers.
        The DOD and the Services agree that we must do everything possible
    to collect and analyze data that may be helpful for preventing
    suicides, reducing distress, and improving overall mental health and
    well-being. There has been inconsistency in the types of data collected
    and measures used. The main inconsistencies are associated with what
    data the Services collect, how they collect data on non-fatal suicide
    behaviors, and whether Services use the DODSER as a uniform tool.
    Progress has been made with the Services who have not tracked this data
    or used the DODSER for non-fatal suicide behaviors. They are exploring
    opportunities to track these behaviors, initiate policy changes, and
    conduct preparatory training needed to begin collecting DODSER data.
        Ms. Power. As noted above, there are no national surveillance
    statistics on attempted suicides, however the DOD is in a unique
    position to be able to collect this data among active duty
    servicemembers.
        SAMHSA believes that surveillance on suicide attempts should be
    collected as soon as possible after an attempt to allow intervention
    efforts to commence as quickly as possible to prevent further self-
    harm. This would enable improved continuity of care for individuals at
    heightened risk for suicide following discharge from emergency
    departments and inpatient psychiatric hospitalizations for suicide
    attempts. Through its National Suicide Prevention Lifeline and Suicide
    Prevention Resource Center, SAMHSA is implementing initiatives to
    support that goal.

        45. Senator Graham. Brigadier General Sutton and Ms. Power, what
    additional metrics regarding attempted suicides are needed in order to
    tailor specific suicide prevention strategies to populations at risk in
    DOD?
        General Sutton. To tailor specific suicide prevention strategies to
    populations at risk in DOD, metrics regarding both completed suicides
    and attempted suicides are necessary in two areas. First, it is
    necessary to be able to predict who is at risk for suicide. To do this,
    it is necessary to collect comprehensive and reliable data on a variety
    of risk factors. Additional research is needed in this area to identify
    individuals at risk. Second, when high risk cases are identified,
    efficacious suicide prevention procedures must be available.
    Unfortunately, many suicide prevention approaches implemented at the
    point of actual suicidal behavior have only limited empirical support
    at this time. Additional randomized controlled trials are needed to
    improve our understanding of efficacious suicide prevention strategies.
    Again, our best opportunity for reducing suicide is relying on a
    community and organizationally based approach that seeks to reduce
    general distress and improve overall protective factors and coping
    behaviors in the face of the multiple stressors encountered by our
    military community. Only by implementing broad-based early prevention
    strategies can we hope to intervene early enough in the chain of events
    to prevent increasingly urgent problems.
        Ms. Power. We defer to DOD to respond to this question.

        46. Senator Graham. Brigadier General Sutton and Ms. Power, what is
    the source of data on suicide attempts within DOD?
        General Sutton. The Services collect available data on suicide
    attempts. Assessing trends within DOD is currently limited due to the
    difficulties detecting and documenting suicide attempts. The DOD and
    Services are committed to collecting and analyzing the best possible
    data on suicide and suicide attempts. Although this is a very
    challenging task, DOD is making great strides forward in this area.
    Some Services collect DODSERs on nonfatal suicide behaviors (e.g.,
    Army). Other Services are exploring the opportunity to initiate such
    efforts. The DODSER is overseen by the National Center for Telehealth
    and Technology, a component center of the DCoE for PH and TBI. It can
    capture and track trends to address better the needs of our
    servicemembers.
        The DOD and the Services agree that we must do everything possible
    to collect and analyze data that may be helpful for preventing
    suicides. There has been inconsistency in the type of data collected
    and measures used. The main inconsistencies are in whether the Services
    collect data, how they collect data on non-fatal suicide behaviors, and
    whether Services use the DODSER as a uniform tool. Progress has been
    made with the Services who have not tracked this data or used the
    DODSER for non-fatal suicide behaviors. They are exploring
    opportunities to track these behaviors, initiate policy changes, and
    conduct preparatory training needed to begin collecting DODSER data.
        Ms. Power. We defer to DOD to respond to this question.

        47. Senator Graham. Brigadier General Sutton and Ms. Power, is it
    collected centrally and by whom?
        General Sutton. By the end of fiscal year 2009, DODSER will store
    all Service information regarding suicide attempts.
        A cooperative plan to standardize suicide surveillance across DOD
    was established in July 2008 by the Suicide Prevention and Risk
    Reduction Committee. DODSER is a web software system that allows the
    military to capture detailed information about suicide events. The
    DODSER enables DOD-level data collection and reporting of suicide
    events and risk/protective factors. The National Center for Telehealth
    and Technology, a component center of the DCoE for PH and TBI, created
    the software to automate standardized data collection efforts. The
    software requirements were collaboratively developed with the Suicide
    Prevention Program Managers from the Army, Navy, Air Force, and Marine
    Corps. Historically, all the Services used idiosyncratic suicide
    surveillance systems. In January 2008, the DODSER was launched as a DOD
    solution to serve all the Services.
        Current functionality provides a secure website that collects a
    core of standardized DOD suicide surveillance items that differ by
    Service. Data collected includes detailed demographics, suicide event
    details (e.g., suicide method, substance use at the time of the event,
    sequence of events leading up to the suicide), decedent treatment
    history (e.g., mental health history, prior suicide attempts,
    diagnostic history), decedent military history (e.g., deployment, time
    in unit), and information about other risk factors (e.g., legal
    problems, relational problems, history of abuse).
        Ms. Power. We defer to DOD to respond to this question.

        48. Senator Graham. Brigadier General Sutton and Ms. Power, do
    military leaders routinely receive data on suicide attempts? If not,
    should they?
        General Sutton. The communication of information about suicides is
    inconsistent across Services and levels of leadership. This information
    is important for leaders to identify levels of distress and other
    indicators that prevention programs may need additional attention. The
    DOD Suicide Prevention and Risk Reduction Committee will address the
    issue of information flow in the coming meetings.
        Locally, commanders are informed of suicides that occur under their
    command. That information alone is important for prevention; however,
    with expanded information on this indicator as well as other indicators
    of distress and well being, our commanders will be better positioned to
    ensure their responsibility for taking care of people is fulfilled.
        Ms. Power. We defer to DOD to respond to this question.

                           substance abuse counseling
        49. Senator Graham. Major General Rubenstein, please provide
    clarification on the Army's proposal to do away with the requirement to
    inform commanders when a soldier seeks counseling for alcohol or drug
    abuse.
        General Rubenstein. Data from the PDHRA, a medical screening which
    occurs 3-6 months after a soldier returns from deployment, indicate
    that a significant number of soldiers screen positive for alcohol
    problems but very few are referred to the Army's alcohol treatment
    program (Journal of the American Medical Association, November 2007).
    When providers are asked about this, they indicate that the requirement
    for mandatory command notification, even when a soldier is self-
    referred, is a deterrent to seeking treatment for many soldiers-
    particularly for those who are career oriented. Army Substance Abuse
    Program enrollment data also show very few career oriented soldiers
    receive alcohol treatment.
        Data from anonymous surveys indicate that alcohol is a problem for
    many post-deploying soldiers (New England Journal of Medicine, July
    2004), and that these soldiers are also at a much higher risk for
    suicide, drinking and driving, riding with an impaired driver, and
    domestic violence. In addition, 50 percent of soldiers with Post-
    Traumatic Stress Disorder (PTSD) have alcohol problems. The latter
    occurs insidiously: many soldiers report using alcohol in an attempt to
    self-medicate early PTSD symptoms such as problems with sleep or
    irritability; however, it requires increasingly larger `doses' of
    alcohol to achieve the same effect. Thus, many soldiers with no
    previous history inadvertently slip into having alcohol problems.
        The change in policy would allow alcohol treatment to have the same
    confidentiality protections as other medical care, when a soldier
    accesses care for an alcohol problem voluntarily and proactively before
    there is an alcohol-related incident that has come to Command
    attention. The goal is to get more soldiers `through the door earlier'
    and to get them help before alcohol-related problems progress to
    career, relationship, health, or even life-impairing dimensions.

        50. Senator Graham. Major General Rubenstein, please provide
    additional information on the types of providers needed to increase
    availability of substance abuse counseling, the number of additional
    providers that are needed, and the cost of providing additional
    substance abuse counseling in 2010.
        General Rubenstein. The Army plans to staff the Army Substance
    Abuse Program (ASAP) clinics with a ratio of 1 ASAP provider per 2,000
    assigned troops. In addition, where installations have trainee
    populations, an augmentation formula is being developed to supplement
    the above staffing model. Select installations that have been
    identified to pilot an ASAP confidential self-referral program will
    receive additional providers to support the execution of that program.
    The ASAP requirement, based on the staffing model of 1:2000, equates to
    347 providers. Presently, ASAP has 241 clinical providers on hand,
    requiring the hire of an additional 106 providers to fully comply with
    the staffing model calculation. ASAP has identified an additional
    requirement of 18 providers for the confidential self referral pilot
    projects, for a total identified current shortfall of 124 clinical ASAP
    providers.
        Additionally, ASAP plans to intensify oversight and access by
    having 4 full-time Regional Medical Command (RMC) ASAP Coordinators who
    will oversee each Region in maintaining Joint Commission standards, not
    only ensuring timely evaluations and treatment, but actually serving as
    a provider when deployments/redeployments create inordinate surges in
    the number of referrals. We will need to add 21 ASAP-dedicated medical
    records/administrative positions to free providers from phone/
    receptionist functions, records management, and numerous other clerical
    duties. ASAP will also hire an independently licensed manager to
    implement a research pilot project in the use of Cranial-electro
    Stimulation (CES), a device which preliminary research indicates is
    beneficial in reducing cravings, anxiety, and stress. The total
    shortfall, when including support staff, clinicians and administrators
    equates to 150 current vacancies. I estimate the total cost of the 150
    additional personnel plus travel and supplies of the CES Manager and
    the regional coordinators will be approximately $14 million annually.
        As a result of the robust nationwide competition for social workers
    and psychologists, the Surgeon General recently approved a policy which
    will significantly increase the pool of providers eligible to be ASAP
    counselors. This policy allows employment of paraprofessional mid-level
    licensees, such as Licensed Professional Counselors (LPCs), Licensed
    Mental Health providers, and Licensed Masters in Social Work. These
    counselors will be supervised by the independently licensed Clinical
    Director (psychologist or social worker), in accordance with DOD
    policy. For those who choose to work toward independent licensure
    during this supervised employment period, they will have an opportunity
    to get promoted and become a part of the ASAP workforce as independent
    providers. This concept of ``growing our own'' has been used
    successfully by other agencies during periods of difficult recruiting
    and high turnover. Another aspect of this policy allows a grace period
    of 1 year for Masters level graduates of psychology and social work
    programs to obtain Substance Abuse Certification.
                                     ______

                 Questions Submitted by Senator Roger F. Wicker
                      side effects from prescription drugs
        51. Senator Wicker. Major General Rubenstein and Brigadier General
    Sutton, a case has come to my attention where a servicemember was
    prescribed a drug with a listed potential side effect of an increased
    risk of suicide. What are the Services doing to ensure that those
    service men and women who are prescribed drugs with these side effects
    are being properly monitored?
        General Rubenstein. All medications have both benefits and risks.
    Antidepressant medications have great benefits but also may have side
    effects in some individuals. Some of these side effects are mild and
    transient, such as nausea and dizziness. In rare cases there are more
    serious side effects and in some instances there may be increased
    suicidal ideation. Before a servicemember is prescribed a medication,
    he or she receives a clinical evaluation. They are informed of the
    benefits and risks of any treatment, to include medication. Soldiers
    receiving treatment for depression or PTSD are closely monitored by
    their providers, especially in the beginning of treatment.
        General Sutton. Standards of care include providing patient
    education about potential side effects of medications and counseling,
    especially for those with moderate to severe major depressive
    disorders. Prescription and monitoring considerations are built into
    the VA/DOD Clinical Practice Guidelines (CPGs) for treating outpatients
    with major depression and PTSD. The VA/DOD CPGs include guidance on
    when psychotropic medications are clinically indicated, as well as
    guidance on the selection of different types of medications, including
    mechanism of action, side effect profile, drug interactions, dosing,
    therapeutic blood levels (if applicable), ratings of quality of
    evidence, strength of recommendations, and follow up requirements. The
    follow up requirements are adjusted based on the severity of the
    condition.
        The CPGs also provide specific guidance on evaluating potentially
    suicidal patients. This guidance includes gathering information on risk
    factors for completed suicide as one of the main parts of the
    evaluation. The guidance also includes risk factors that are common
    across multiple disorders (e.g., a history of suicide attempts, or the
    presence of substance use disorders), as well as risk factors that are
    specific to each disorder (e.g., among veterans with PTSD, intensive
    combat-related guilt has been linked to suicidality). Patients with
    acute suicidality are usually hospitalized.
        Health Affairs' policy regarding deployment-limiting psychiatric
    conditions includes the admonition not to deploy servicemembers who
    have started on psychotropic medications, or whose medication regimen
    is significantly changed, within 3 months of deployment.

        52. Senator Wicker. Major General Rubenstein and Brigadier General
    Sutton, how is this different from steps being taken by the Services to
    monitor other service men and women?
        General Rubenstein. There is no difference. Prescribing healthcare
    providers monitor their patients whenever a new drug is prescribed.
        General Sutton. For servicemembers not on prescription medication,
    monitoring is conducted by the individual treatment facility and/or
    provider based on their individual guidelines.
        When Active Duty servicemembers call the National Suicide
    Prevention Lifeline, they are transferred to the VA Hotline. Callers
    not at imminent risk receive referrals for both military and non-
    military mental health resources, but callers' confidentiality is not
    violated by disclosing information to the chain of command in non-
    emergency situations.
        For servicemembers who have deployed, the post-deployment health
    assessment and post-deployment health reassessment identifies PH
    concerns following combat operations and refers the servicemember to
    the appropriate resource.
        The Caring Letter Project is a suicide prevention outreach program
    that involves sending brief letters of concern and reminders of
    treatment availability to inpatients at high risk for suicide following
    psychiatric hospitalization. This is a notable project because it has
    empirical support for preventing suicide completion. The National
    Center for Telehealth and Technology, a component center of the DCoE
    for PH and TBI, is currently piloting this intervention to tailor its
    use for a military setting.
        In addition, the DOD/Veterans Health Administration CPGs for
    initial treatment of major depressive disorders recommend follow-up 1
    to 2 weeks after initializing antidepressant treatment, irrespective of
    medications or psychotherapies used, to assess for compliance with
    recommended therapies or for side effects if medication is used.

        53. Senator Wicker. Major General Rubenstein and Brigadier General
    Sutton, is there any type of psychological screening given to
    individual service men and women before prescribing these drugs?
        General Rubenstein. Before a servicemember is prescribed a
    medication, he or she receives a careful clinical evaluation.
    Psychological screening may be used, if clinically indicated. All
    soldiers are evaluated for their risk of suicide, homicide, and other
    risky behaviors. All medications have both benefits and risks.
    Medications should only be used when the benefit outweighs the risk.
        General Sutton. The VA/DOD CPGs advise psychiatrists and primary
    care providers to perform a thorough evaluation before prescribing
    psychotropic medication to include obtaining a history (including
    psychiatric, marital, family, military, past physical or sexual abuse,
    and medication or substance use), conducting a physical examination and
    laboratory tests, performing a mental status examination, completing a
    drug inventory to include over-the-counter drugs and herbals, and
    assessing and documenting signs and symptoms of depression.
        As defined by the Diagnostic and Statistical Manual-IV TR,
    suicidality is one of the core symptoms and signs of depression (i.e.,
    recurrent thoughts of death, recurrent suicidal ideation without a
    specific plan, or a suicide attempt or a specific plan for committing
    suicide). For example, the VA/DOD Guidelines for Depression describe
    assessing suicidal ideation and intent as ``Direct and nonjudgmental
    questioning regarding suicidal ideation/intent is indicated in all
    cases where depression is suspected. A significant number of patients
    who contemplate suicide are seen by a physician in the month prior to
    their attempt. Direct assessment of suicidal ideation and intent does
    not increase the risk of suicide. Consider gathering collateral
    information from a third party, if possible.''

        [Whereupon, at 6:04 p.m., the subcommittee adjourned.]