[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 [email protected]. 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\
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    \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.]

                                 
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