[Senate Hearing 111-716]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-716
 
   HEARING ON MENTAL HEALTH CARE AND SUICIDE PREVENTION FOR VETERANS

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


                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 3, 2010

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate



                  U.S. GOVERNMENT PRINTING OFFICE
58-333                    WASHINGTON : 2010
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001


                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Roger F. Wicker, Mississippi
Jim Webb, Virginia                   Mike Johanns, Nebraska
Jon Tester, Montana                  Scott P. Brown, Massachusetts\1\
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director



----------
\1\ Hon. Scott P. Brown was recognized as a minority Member on March 
24, 2010.


                            C O N T E N T S

                              ----------                              

                             March 3, 2010
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     2
Johanns, Hon. Mike, U.S. Senator from Nebraska...................     3
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     4
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     5
    Prepared Statement...........................................     5
Begich, Hon. Mark, U.S. Senator from Alaska......................     6
Murray, Hon. Patty, U.S. Senator from Washington.................    59

                               WITNESSES

Hanson, Daniel J., Operation Iraqi Freedom Veteran...............     7
    Prepared statement...........................................     9
    Response to post-hearing questions submitted by:
      Hon. John D. Rockefeller IV................................    10
      Hon. Mark Begich...........................................    10
Rudd, M. David, Ph.D., ABPP, Dean, College of Social and 
  Behavioral Science, University of Utah.........................    11
    Prepared statement...........................................    12
    Response to post-hearing questions submitted by:
      Hon. Daniel K. Akaka.......................................    14
      Hon. John D. Rockefeller IV................................    15
Jordan, Clarence, Member, National Board of Directors, National 
  Alliance on Mental Illness.....................................    16
    Prepared statement...........................................    18
        Attachment...............................................    22
    Response to post-hearing questions submitted by:
      Hon. Daniel K. Akaka.......................................    23
      Hon. John D. Rockefeller IV................................    25
Cross, Gerald, M.D., Acting Principal Deputy Under Secretary for 
  Health, U.S. Department of Veterans Affairs; accompanied by 
  Janet Kemp, R.N., Ph.D., VA National Suicide Prevention 
  Coordinator; Caitlin Thompson, Ph.D., Clinical Care 
  Coordinator; Antonette Zeiss, Ph.D., Associate Deputy Chief 
  Consultant and Chief Psychologist, Office of Mental Health 
  Services; Theresa Gleason, Ph.D., Deputy Chief, Mental Health 
  Services, Office of Research and Development; and Alfonso 
  Batres, Ph.D., MSSW, Director for Readjustment Counseling for 
  Vet Centers....................................................    30
    Prepared statement...........................................    32
    Chart presented to the Committee.............................    36
    Response to post-hearing questions to Dr. Cross submitted by:
      Hon. Daniel K. Akaka.......................................    36
      Hon. John D. Rockefeller IV................................    37
      Hon. Mark Begich...........................................    38
    Response to post-hearing questions submitted by Hon. Daniel 
      K. Akaka to Caitlin Thompson, Ph.D.........................    45
    Response to post-hearing questions submitted by Hon. Daniel 
      K. Akaka to Antonette Zeiss, Ph.D..........................    45
        Response to additional post-hearing questions............    48
    Response to post-hearing questions submitted by Hon. Daniel 
      K. Akaka to Theresa Gleason, Ph.D..........................    49
    Response to request arising during the hearing by Hon. Patty 
      Murray.....................................................60, 66

                                APPENDIX

Burris, Hon. Roland W., U.S. Senator from Illinois; prepared 
  statement......................................................    69
Lautenberg, Frank R., U.S. Senator from New Jersey; prepared 
  statement......................................................    69
Three Wire Systems, LLC and Health Net, Inc.; prepared statement.    70


   HEARING ON MENTAL HEALTH CARE AND SUICIDE PREVENTION FOR VETERANS

                              ----------                              


                        WEDNESDAY, MARCH 3, 2010

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:32 a.m., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Brown, Begich, Burris, 
Burr, Isakson, and Johanns.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. The Senate Committee on Veterans' Affairs 
will come to order.
    I want to say aloha and welcome to our panelists as well as 
other who are here and, of course, our Members and staff who 
have been working hard to prepare for this hearing. Today, we 
will address mental health issues confronting veterans with a 
particular emphasis on the risk of suicide.
    These are grave and troubling matters that I fear are 
becoming more prevalent as we send servicemembers into combat 
zones on repeated occasions. When we send men and women in 
uniform into battle, we seek to provide them with equipment to 
protect them from physical dangers. Too often, however, we do 
not provide sufficient protection and preparation for the 
equally serious mental dangers they will face.
    Mental illness is prevalent among today's veterans, which 
include PTSD, depression, and substance use disorders. 
Unfortunately, many of those suffering from such disorders do 
not seek proper help. The rising rate of suicide among these 
men and women is especially heartbreaking.
    The best information available suggests that about 18 
veterans kill themselves every day. In December 2009, the Army 
reported 17 suicides of active duty members. In January, the 
Army reported 27 confirmed or suspected suicides. These are 
very troubling and sobering numbers.
    I mention these statistics to open a broader discourse on 
mental health care issues affecting veterans and the need for 
focused and increased attention to effectively address these 
matters. As a Nation at war, it is our responsibility to fully 
explore ways to help those suffering from mental health 
disorders and to develop preventive measures to safeguard 
against the risks of suicide.
    We have made a promise to care for the invisible wounds of 
veterans and we must be vigilant ensuring we keep that promise. 
This obligation is not limited just to the time after a veteran 
separates from service. We must ensure we prepare deploying 
servicemembers for what they might experience and make sure 
that resource are available during deployment to help them cope 
with it.
    We must ensure that returning servicemembers are screened 
carefully, that those who need assistance are provided 
appropriate mental health care, and that all those leaving the 
military have a seamless transition to VA. It is also vitally 
important that family members be involved throughout these same 
stages.
    As a Senior Member of the Armed Services Committee and as 
Chairman of this Committee, I know that VA is a leader in 
providing mental health care and suicide prevention services. 
It is my strong hope that VA and DOD will work together to 
provide the best care to those in need.
    I continue to believe that it is very difficult to provide 
effective mental health care to someone still in active 
service. For that reason, I encourage VA and DOD to increase 
cooperation so that resources are used to their fullest 
potential and no veterans or servicemembers are overlooked or 
ignored.
    We had a productive hearing on mental health issues in 
April 2007. That hearing contributed to the passage of mental 
health care legislation dedicated to Justin Bailey, a veteran 
who overdosed while receiving treatment from VA for PTSD and 
substance use disorder. I hope to learn about how VA is 
implementing the provisions of the Bailey bill.
    VA has made great strides in improving the care and 
services available to veterans, but there is always more that 
can be done. I hope that our witnesses today can help us have a 
constructive discussion on what VA is currently doing, what VA 
can do better, and what VA needs to start doing. I look forward 
to hearing more about what the latest research is telling us 
and how we can implement these findings to keep VA on the 
cutting edge of mental health care delivery. While it is never 
possible to prevent all suicides in all cases, that must not 
stop us from trying.
    I thank the witnesses for being here this morning and look 
forward to hearing your testimony.
    May I now call on Senator Isakson for his statement.

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Aloha, Mr. Chairman.
    Chairman Akaka. Aloha.
    Senator Isakson. Thank you very much for calling this 
hearing today. I was there 2 years ago at our first hearing, 
because we had a rapid spike in suicides in the First Blended 
Air Force Wing stationed at Warner Robins, GA, where I will be 
this coming Saturday. It was an alarming statistic. It was an 
alarming occasion, and I took an interest in mental health in 
all of our military personnel.
    I think it should be noted that following that hearing in 
2007, the implementation of the Warrior Transition Centers was 
expedited. I have toured the one at Fort Stewart, GA, which is 
the DOD's attempt to have these transition centers ready for 
diagnosiswhen our soldiers are coming back, both for wounds 
that you can see as well as those that you cannot see. I think 
we are making progress, but there is a long way for us to go.
    I also want to thank the Chairman for referencing the 
seamless transition from DOD to Veterans health care. That is a 
significant area where we need improvement. The Uptown VA in 
Augusta and the Eisenhower Medical Center at Fort Gordon have 
developed a great seamless transition where the veterans don't 
end up falling in this black hole when they leave active duty 
and go into veteran status. I think it is an example of what 
can be done in our medical centers to see to it that our 
veterans have that continuum of contact with mental health and 
with physicians to help us reduce this problem of a high rate 
of suicide.
    So, your hearing 2 years ago has paid a dividend in a 
higher level of attention, and from what I have been able to 
see in my State, both at Fort Gordon as well as Fort Stewart, 
the military is addressing it quickly and decisively. 
Hopefully, with our continued pressure, we can get help to 
those that need it and we can get diagnosis of those that have 
not been diagnosed so they can get help before it is too late.
    So I want to thank the Chairman for his calling of this 
hearing today, but in particular note the success that has 
taken place since the 2007 hearing. Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Isakson.
    Senator Johanns, your statement, please.

                STATEMENT OF HON. MIKE JOHANNS, 
                   U.S. SENATOR FROM NEBRASKA

    Senator Johanns. Mr. Chairman, let me just say thank you 
for holding this hearing today on what all of us regard as an 
enormously important topic.
    I certainly know that mental health and suicide are 
challenges that servicemembers and veterans are struggling with 
very intensely. If my numbers are correct here, last year, the 
active Army alone reported 160 actual and suspected suicides 
for 2009, and it is my understanding that that is the worst 
year on record. It is enormously troubling. I know that the DOD 
and the VA are making an effort to stem this tide, but we all 
hope that more can be done and sooner.
    There are a couple of pieces of legislation that I just 
want to mention that I was proud to be a part of, which I hope 
will help. The first, with Senators Baucus and Tester, 
increased PTSD screening before and after deployments. The 
other, with Senator Shaheen, expanded Yellow Ribbon suicide 
prevention efforts for Guard and Reserve servicemembers.
    We do have a responsibility to care for our servicemembers 
not only while they are in the military, but also when they 
leave. That responsibility begins with oversight and making the 
efforts that I hope will bear some fruit.
    Now, I want to acknowledge that I am very aware that the VA 
is working on a solution, as Dr. Cross notes in his testimony. 
VA is allocating more financial and staff resources toward 
mental health in fiscal year 2011. That is a good step. Solving 
the problem probably, though, needs more than just additional 
brute force, if you will. Some of the nongovernmental people 
and organizations here today are doing groundbreaking work in 
helping loved ones support veterans with mental health 
disorders.
    On Friday, I was here for a hearing on the budget. I was 
very impressed by Secretary Shinseki's promotion of innovative 
pilot projects to reduce the disability claims backlog. My hope 
is that that kind of spirit of outside-the-box thinking will be 
applied to dealing with mental health disorders.
    So I look forward to the testimony today. I applaud the 
efforts, but I think we all have to acknowledge it is just such 
a heartbreaking problem. My hope is that we will continue to 
find ways forward to deal with this very important issue.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Johanns.
    Senator Brown?

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Aloha, Mr. Chairman----
    Chairman Akaka. Aloha.
    Senator Brown [continuing]. And thank you for holding this 
important hearing. I appreciate your leadership. And I want to 
thank even more than normal the witnesses for coming in. These 
are hard issues to discuss and thank you for joining us and 
applaud your willingness to talk about this.
    I am reminded that we have such a stigma attached to 
suicide. The President historically--Presidents of both 
parties, have typically not sent letters as they do when 
servicemen and women are killed. They have not sent letters out 
to families when someone commits suicide and that is a, if not 
a policy, a practice that clearly needs to change.
    Several veterans every day kill themselves. We know that. 
The rate of young veterans committing suicide continues to rise 
at alarming rates. We know that when young veterans return, 
when young soldiers, marines, sailors, airmen and women return 
from Iraq or Afghanistan or from the service and go back to 
Coshocton, St. Clairesville, Finley, or Dayton, OH, that so 
often the veterans service organization doesn't even know that 
young returning soldier or airwoman is even in town and then is 
less likely to get the counseling, the testing, the screening 
for PTSD, the support groups from peers and all that so often 
can save that young man or woman from continuing persistent and 
worse behavior later in their lives. That is why it is so 
important that we are here.
    The VA's residential PTSD program at Cincinnati Medical 
Center is an example of the extraordinary work VA is doing, not 
only treating PTSD, but helping veterans suffering from all 
kinds of mental illness and how important that is. My office is 
inundated with casework-related PTSD claims by Vietnam-era 
veterans. The question becomes, what can we do to help older 
veterans? What can we do to help younger veterans just 
returning?
    The Cincinnati VA is leading the Nation in providing vital 
and cutting-edge services in mental health, yet we have so much 
more to do.
    I am also concerned, Mr. Chairman, with veterans and 
military personnel self-medicating with drugs or alcohol. I 
hear from so many veterans' advocates who tell stories of 
veterans seeking help, but since they were discharged from the 
military on drug or alcohol abuse or some other manifestation 
of mental illness, rather than for the service-connected mental 
illness, they are essentially shut out of care from the VA. 
That is inhumane. It is bad public policy. It is morally wrong.
    I have introduced legislation and offered amendments to 
previous Defense Authorization bills to put important 
safeguards in place so that servicemembers can understand the 
ramifications of accepting a discharge that could prohibit them 
from receiving VA benefits later on.
    And last, I want to commend Secretary Shinseki, who was at 
the Vet Center, the Chillicothe Medical Center, 2 weeks ago. 
They are a national leader in treatment and care for homeless 
veterans. I want to commend him and the VA for their bold 
homelessness initiative. We have much to do.
    I want to thank those, again, who are testifying today.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator.
    Now, we will receive the opening statement of our Ranking 
Member, Senator Burr.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Aloha, Mr. Chairman. My apologies for my 
tardiness. I am going to ask unanimous consent that my opening 
statement be a part of the record, and I would like to 
specifically welcome Mr. Hanson and Mr. Jordan. I thank both of 
you for your willingness to share your experiences with us, 
many of which I know are painful to recount. This country owes 
both of you a debt of gratitude for your service and your 
continued service.
    Mr. Chairman, 3 years ago, this Committee held a hearing to 
examine VA's efforts to address the mental health needs of our 
veterans. At that hearing, we heard from family members of 
veterans and servicemembers who had taken their own lives 
following combat service. Only days after that hearing, a 
National Guard unit headquartered in Boone, NC, returned home 
from Iraq. Within 18 months of their return, four of the unit's 
175 soldiers had taken their own lives. This problem is real.
    With that said, Mr. Chairman, VA cannot be expected to do 
this alone. The Department of Defense has a critical role to 
play, but so do community organizations, veterans groups, 
nonprofits, churches, and others. This has to be an effort 
where we use every available source to help us end this quest. 
And I thank the Chair.
    [The prepared statement of Senator Burr follows:]
       Prepared Statement of Hon. Richard Burr, Ranking Member, 
                    U.S. Senator from North Carolina
    Good morning, Mr. Chairman, and a warm welcome to our panelists 
today, particularly you, Mr. Hanson and Mr. Jordan.
    We are truly grateful for your willingness to share your 
experiences with us, many of which are no doubt painful for you to 
recount. This country owes you both a debt of gratitude for your 
sacrifice and continued service to the Nation.
    Three years ago, the Committee held a hearing to examine VA's 
efforts to address the mental health needs of veterans. At that 
hearing, we heard from family members of veterans and servicemembers 
who had taken their own lives following combat service. They told us of 
a mental health care system that was too reactive, often only making 
services available when it was too late to be effective.
    Only days after that hearing, a National Guard unit headquartered 
in Boone, North Carolina, returned home from Iraq. Within 18 months of 
their return, four of the unit's 175 soldiers had taken their own 
lives.
    I hope to hear today that we have, in fact, put more emphasis on 
outreach, early intervention, and prevention. Legislation was enacted 
out of this Committee giving VA the authority it needs to do this; I'm 
anxious to hear about the progress being made, although the statistics 
we do have remain sobering.
    According to Congressional Quarterly, more American servicemembers 
took their own lives in 2009 than were killed in the wars in 
Afghanistan and Iraq combined. With that said, VA can't be expected to 
do it alone. The Department of Defense has a critical role to play, but 
so do community organizations, veterans' groups, non-profits, churches 
and others.
    The reasons which lead a young man or woman to contemplate ending 
their life are complex. So, too, are the solutions to prevent that from 
happening. We must continue to reach out on a general level to provide 
help for veterans with PTSD, depression, anxiety disorder, and other 
mental illness.
    The goal is to be sure that those with mental illness can return to 
live, work, learn, and participate fully in their communities.
    That means we must identify unmet needs and barriers to services. 
We must identify innovative treatments and services that are 
demonstrably effective. We must improve coordination among case 
managers and providers.
    These are tough goals, and they require that we ask tough 
questions. Questions such as whether our servicemembers are prepared to 
manage the stresses of combat before they set foot on the battlefield, 
and whether we are setting appropriate benchmarks to evaluate the 
effectiveness of prescribed treatment.
    As I said, these remain difficult questions. But the price of not 
addressing them is too high.

    Thank you, Mr. Chairman, and thank you to all of our witnesses.

    Chairman Akaka. Thank you very much, Senator Burr. Your 
full opening statement will be included in the record, without 
objection.
    The Senator from Alaska, Senator Begich.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you very much, Mr. Chairman. I will 
be very brief. I have a meeting in Commerce at 10:15 for a 
budget presentation, but I am going to first say I appreciate 
you all being here. I am anxious for your comments.
    I have a series of questions which I am going to submit for 
the record to have you respond to of which some are very 
parochial. Alaska is a very rural State and how we deliver 
services and so forth; some commentary from that perspective 
and your thoughts in that arena; how do we use telemedicine; 
how do we use other avenues?
    But again, for this panel as well as the second panel who 
might be in the audience, I have a series of questions, Mr. 
Chairman, that I will just submit to the Committee, if that is 
OK, for response. I apologize for having to leave early, but I 
do want to hear the first panel's commentary. Thank you.
    Chairman Akaka. Thank you very much, Senator Begich.
    I want to welcome the witnesses on our first panel, all of 
whom bring a different perspective to this issue which will 
help to broaden our dialog of mental health care and suicide 
prevention for veterans. We have Daniel J. Hanson, an Operation 
Iraqi Freedom veteran; David Rudd, Dr. David Rudd, Dean of the 
College of Social and Behavioral Science at the University of 
Utah; and last, Clarence Jordan, a member of the National Board 
of Directors of the National Alliance on Mental Illness.
    I thank you all for being here this morning. Your testimony 
will appear in the record.
    Mr. Hanson, will you please begin with your testimony.

            STATEMENT OF DANIEL J. HANSON, VETERAN, 
                    OPERATION IRAQI FREEDOM

    Mr. Hanson. Good morning. My name is Daniel Hanson and I am 
27 years old. I joined the U.S. Marine Corps in 2003. Shortly 
after, I was assigned to Second Battalion, Fourth Marines, and 
we were deployed to Ar-Ramadi, Iraq. It was a deployment that 
started out with one of our Marines committing suicide. Shortly 
after, the funerals seemed to become a regular thing. It was 
pretty difficult to know that you had just talked to someone 
the day before and now you are saluting a pair of empty boots 
and an upside down M-16 and a set of dog tags. We lost 35 
total.
    After we got back from the deployment, we had a few classes 
and then we went on leave and that was that. Shortly after, 6 
months later, we deployed to Okinawa, Japan. After Okinawa, I 
got out of the Marine Corps, and just before getting out, I had 
a good friend, also a Marine, who went to the VA to get 
services, but they were booked at the time and he ended up 
hanging himself the next day, and that was hard for me. I was 
trying to get things back--my life was getting a little out of 
control--so I was trying to get things back in order.
    Shortly after, I lost another friend. He was killed in 
combat, buried at Arlington Cemetery here, and it kind of got 
me sliding again, as well. On March 23, 2007, my best friend 
and my brother was--he hung himself--he was also a Marine--in 
the basement of his home. After that day, I pretty much lost 
it. I was drinking every day, doing drugs, anything I could do 
to get away from the pain.
    I worked with the VA medical center. They were helpful. I 
did therapy and things like that. Eventually, I started getting 
DUIs and I went to the Dual Diagnosis Program at the St. Paul 
VA medical center. I did 30 days of treatment. I got out, and 
though it was informative, it wasn't something very applicable 
to my life. I kind of felt like just a number going through a 
revolving door. I have had doctors kind of deal, just do their 
things.
    About a month after I got out of the program, I attempted 
suicide. I woke up at the St. Cloud VA medical center on a 72-
hour lock-up. After that, I was released back to work. I think 
I got a phone call or two to make sure I was all right, to make 
sure that I had my life together. I was pretty much a monster. 
I was drinking all the time. I was lying all the time. I 
thought about dying every day. I got a divorce. I also just 
left my kids aside. I didn't want to live every day. I thought, 
I have got to kill myself before my kids know what a loser 
their dad is. I didn't know what to do.
    Eventually, after my last DUI, I just gave up and I knew I 
was either going to kill myself or I was going to do something 
for myself, for my kids. So, finally I had enough--I don't know 
what it was. I just gave up and I went to a program called 
Minnesota Teen Challenge. It is a 13- to 15-month faith-based 
rehabilitation program. I graduated a week ago, actually. For 
once in my life, I have a purpose. I don't wake up every day 
wanting to kill myself.
    I know if I did a 3-month program, a 6-month program, a 9-
month program, I would still be in the same boat I was. But 13 
to 15 months is what I needed to be able to get through, not 
just scratch the surface, but get down to the deep, the root 
issues that I was dealing with. And I know that going on an 
outpatient or going on a 30-, 60-, 90-day inpatient program 
wasn't going to do it. I needed much more, and I would be dead 
or in prison right now if I hadn't gone to Minnesota Teen 
Challenge. I mean, the problems I picked up over the years 
weren't going to go away in just a matter of months.
    I know a lot of veterans still that need it. They are kind 
of going through the outpatient program. I have friends that 
still just don't know what to do. Their everyday, once-a-week 
counseling isn't doing anything for them. They are going out 
drinking 10 minutes after they leave.
    For me, if I could suggest anything, it would be that there 
is more long-term care. I know in Minnesota the only thing that 
they really offer is the Dual Diagnosis Program, and I believe 
there is one at the Minneapolis VA, but it is outpatient only 
and I believe it is 5 or 6 weeks. For someone like me who hated 
myself, hated everything, wanted to die every day, I just 
needed way more. I was sick and nothing else was going to do it 
except for getting away from that environment for a long, long 
period of time.
    And the second, I would say there was really no 
accountability. I mean, it wasn't too long after I attempted a 
suicide and I was doing a once-a-week thing at the VA medical 
center where it was, you know, like everything was all right, 
but it wasn't all right. Sure, it was my part, too. I didn't 
want to--I was embarrassed. I thought, what kind of loser would 
kill himself? There is no reason for it. But there was never a 
feeling that someone really cared for me, really cared what 
happened to me when I left out that door. Maybe that hour we 
were together, but after that, it was done. There was no 
connection. There was no feeling that I needed--that they cared 
about me, that there was something, that if I died that day, 
that someone would care. And that is part of the reason why I 
was angry for so long.
    And then, also, I would suggest that--I think the VA has 
great programs, but programs like Minnesota Teen Challenge that 
can offer a 13- to 15-month stay and have been doing it for a 
long time would be great organizations to have relationships 
with, not just keep it internal in the VA, but be able to 
branch out to some of the nonprofit organizations, branch out 
to some of the non-government places to help these veterans so 
nobody is left behind and so that nobody commits suicide, 
because I have seen too many great men take their own life and 
I just would do anything to prevent it--anything. Anything.
    And that is all I have. Thank you very much for letting me 
share.
    [The prepared statement of Mr. Hanson follows:]
 Prepared Statement of Daniel J. Hanson, Operation Iraq Freedom Veteran
    My name is Daniel Joseph Hanson and I am 27 years old. I joined the 
United States Marine Corps in January 2003. I was eventually was 
assigned to 2d Battalion, 4th Marines and in February 2004 was deployed 
to Ar-Ramadi Iraq. The deployment started with one of our Marines 
shooting himself in the head and killing himself. It was not long 
before we started losing men and funerals seemed to become a regular 
thing. It was hard to know that you had just talked to someone the day 
before and now you were saluting an empty pair of combat boots, an 
upside down M-16 and a pair of dog tags. When it was all over in 
October 2004 we lost a total of 35 Marines.
    On our ``cool down'' period before returning we had a few classes 
discussing what each person had seen and how they were dealing with it. 
For me it was very difficult to talk about anything that bothered me 
because I was not an infantryman and felt as if I did not have the 
right to raise my hand because of it. I felt as if I was subpar because 
the other people in my battalion had been through much worse and I was 
weak if I couldn't handle the things that I went through. After a few 
classes we all returned from the deployment and shortly after went on 
leave. That is all that we went through in regards to post-deployment, 
a few classes to make sure that if we had any traumatic events we made 
sure we let somebody know.
    I was deployed a second time to Okinawa Japan in 2005. At this 
point I was married and had a child on the way. Upon returning from 
Okinawa I had my son and began preparations to get out of the Marine 
Corps. I was drinking almost every single day, getting in fights and 
was very depressed. I got out of the Marine Corps in January 2007 and 
decided I was out of control and needed to get help.
    Before I was released from active duty a friend and fellow Marine 
hanged himself in the basement of his home with an electrical wire. He 
had gone to the Saint Cloud VA Medical center seeking help, but was 
turned away. A couple weeks later (February 7th, 2007) my good friend 
and father figure SgtMaj J.J. Ellis was killed in combat. His funeral 
at Arlington National Cemetery got me to start drinking just a few 
short weeks after I was trying to get things together again. Then on 
March 23, 2007 my brother and best friend, who was also a Marine, 
hanged himself in the basement of his home. Travis was working with the 
VA Medical Center, but was not willing to open up to them about his 
internal struggles.
    At that point I really went off the deep end. I started working 
with the VA Medical Center on an outpatient basis. I struggled with 
anxiety and depression which eventually lead to a lot of destruction. 
In August 2007 I separated from my wife and eventually got divorced, 
after I got another woman pregnant while I was still married. I started 
racking up DUI after DUI and spent some time in jail. I went to the 
Saint Cloud VA Medical Center and went through the Dual Diagnosis 
Program. There was good content and it was very informative. However, 
it lacked any sort of discipline and there was a gentleman that was 
smoking meth in the stairwell at one point in time. It seemed more like 
something that would be to teach people about what drugs and alcohol 
can do to a person, but there was not a whole lot of real life 
application. Also, there was no aftercare so once I was cut loose I was 
pretty much on my own. I still did follow up at the Minneapolis VA 
Medical Center, but I was so far gone outpatient would not suffice.
    About a month after I completed the Dual Diagnosis Program I am 
attempted to kill myself by swallowing a large amount of prescribed 
pills. I woke up in the Saint Cloud VA Medical Center and was put up in 
the psych ward. I was put on a 72 hour hold and then released. There 
was almost no follow up after my departure from my 72 hour hold and 
then I was just thrown back into my life again. I continued to drink, 
cheat, and live a life of anger. I started using drugs again because 
the alcohol was not doing enough to help me cope during the day. I got 
another DUI and found myself in jail yet again. A week after my last 
DUI I found myself looking at a lot of jail time. I was scared, broken 
and wanted to die yet again. One week later I checked myself into 
Minnesota Teen Challenge, which is a 13-15 month faith based program.
    The Minneapolis VA Medical Center does not offer anything close to 
a 13-15 month long inpatient treatment program. I was walking around 
wanting to die every single day, month after month, and no 30, 60, or 
90 day program would have been able to get me to where I needed to be. 
A year removed from the world that had just become too much for me and 
that I hated seemed like way too much to commit to, but it has saved my 
life. Minnesota Teen Challenge changed me more than I ever thought 
possible. I have completely changed my thoughts, actions, and attitude 
over the last year. It was a struggle and I considered leaving many 
times, but that is because I have always been a person that always took 
the easy way out. I now want to live and I want to live a successful 
life free of any chemicals.
    While at Minnesota Teen challenge one of the biggest struggles that 
I dealt with was not having the funds to complete the program. I was 
not able to get the VA to fund the program while I was attending so I 
put in a claim to have my disability raised. I fell behind in child 
support, bills and eventually my payments to MnTC. It made things very 
difficult in the midst of me trying to get my life straightened out. I 
finally got my claim completed one day after my graduation and up until 
then I thought I was going to have to sleep in my car to come out to 
Washington D.C. to testify.
    In my working with the VA the three biggest things that I noticed 
was through my experiences at the VA Medical Center. First, they do not 
provide any long term care at all. The longest program that I know 
about is the Dual Diagnosis Program at the Saint Cloud VA Medical 
Center and I believe that it is only 90 days at the most. The problems 
that I picked up over the years of bad living were not going to go away 
in a matter of months. There are a lot of veterans I know that walk 
around in constant pain and depression because they have never been 
able to overcome the root of their problems. A program that lasts for a 
year or more is much more likely to help a person, and help them not 
just cope with their problems, but get rid of them all together. 
Minnesota Teen Challenge has changed my life from wanting to die every 
day to wanting to get up every day because I finally have a passion to 
live. Second, there was never any accountability in my experiences with 
the VA system. If I missed appointments or just stopped calling all 
together it did not seem to really matter to anyone. I felt like I was 
just another number going through the revolving door of head doctors 
that had to talk to me. I had the opportunity to work with a lot of 
great VA employees over my time there, but I never really felt 
connected. Never thought anyone really cared. Third, there are a lot of 
great organizations that are not connected to the Government, but are 
not being utilized because it may be more expensive. The VA cannot 
possibly take care of all the hurting veterans on their own and I 
believe that being able to utilize the resources of organizations not 
connected to the VA is necessary to help all of them.
    I would not be where I am now without the help from the Department 
of Veterans Affairs, but I could have gotten here a lot sooner. I have 
watched my friends and family who are veterans suffer through many of 
invisible wounds and there is no reason for it. Being able to get 
outside programs funded, keeping accountability of veterans and opening 
up to long term rehabilitation programs will save lives. I appreciate 
your time and the opportunity to share my testimony.
                                 ______
                                 
     Response to Post-Hearing Questions Submitted by Hon. John D. 
  Rockefeller IV to Daniel J. Hanson, Operation Iraqi Freedom Veteran
    First, I want to thank you for your compelling testimony. Sharing 
your difficulties has to be hard, but it is brave of you to speak out 
about what you think needs to change to help other veterans. I 
understand your points about the need for a longer program--over 90 
days--and the importance of follow up.
    Question. What do you think about a mandatory training course or 
mental health program for all veterans as a way to eliminate the 
stigma? Do you think this would be helpful? How long should such course 
be?
    Response. I think that is a great idea and the more training the 
better, but I just feel it is of the utmost importance to have the 
right people in charge of a program like that. I also think that it 
would be a great idea for some of the non VA programs to get training 
for how to handle veterans with problems. A program that would really 
be able to help, in my opinion, would be a lot more beneficial if it 
was at least a few months long.
                                 ______
                                 
  Response to Post-Hearing Questions Submitted by Hon. Mark Begich to 
             Daniel Hanson, Operation Iraqi Freedom Veteran
    Question 1. Long term care, was it available for you?
    Response. None. The longest care that I was offered was the Dual 
Diagnosis Program and that is 90 days at the most. I went through the 
program in 30 days and was no better than the day I started. There is 
not even an inpatient program offered in Minneapolis.

    Question 2. What type of follow-up aftercare by the VA was 
available for you?
    Response. I did weekly 1 hour therapy sessions and the occasional 
group therapy through the VA, but it was very hands off.

    Question 3. Did the VA give you a choice of outside treatment 
facilities and Faith-Based programs?
    Response. No. I had to pay for Minnesota Teen Challenge out of my 
own pocket and was told the VA would not pay for the program. That made 
things much more difficult for me and for trying to support my 
children.

    Question 4. What type outreach and follow-up did you receive from 
the VA?
    Response. Weekly counseling sessions. The occasional phone call was 
all I received even after I attempted suicide.

    Chairman Akaka. Thank you very much, Mr. Hanson.
    Dr. David Rudd?

   STATEMENT OF M. DAVID RUDD, Ph.D., ABPP, DEAN, COLLEGE OF 
       SOCIAL AND BEHAVIORAL SCIENCE, UNIVERSITY OF UTAH

    Mr. Rudd. Mr. Chairman, Mr. Ranking Member, and Members of 
the Committee, as a veteran and a psychologist, I appreciate 
the opportunity to appear today and discuss the Department of 
Veterans Affairs efforts to address the mental health needs of 
America's veterans. I would like to thank Mr. Hanson for his 
testimony. It is the kind of strength and courage that he 
demonstrates that is exactly what we need: for people to step 
forward, talk about their experiences, and offer unique insight 
and input into the process.
    There is no disagreement that the mental health demands on 
the VA will continue to grow over the course of the next 
decade. Given the duration of Operation Enduring Freedom and 
Operation Iraqi Freedom, current mental health demands are 
unprecedented. In addition to grappling with anticipated 
problems like depression, Post Traumatic Stress Disorder, and 
substance abuse, the VA is struggling to address the tragic 
loss of veterans to suicide. I have absolutely no hesitation to 
endorse the recent efforts of the VA, but will certainly 
encourage the VA to explore non-traditional approaches and 
public-private partnerships in an effort to undermine the 
devastating impact of stigma, an issue that oftentimes gets 
very little discussion and debate.
    As you will hear from other witnesses, the VA has 
implemented a range of programs and initiatives all geared 
toward meeting the growing mental health demands of today's 
veterans. With respect to suicide, the VA has launched an 
intensive suicide prevention program, one that includes an 
innovative Suicide Prevention Hotline, an Internet chat line--
and let me say, these two programs are cutting edge. They are 
unlike any that have ever been implemented and they are having 
great success, and I would certainly applaud those efforts.
    As you know, there are 18 deaths per day due to suicide 
among American veterans with approximately five per day among 
those in active treatment. The numbers are nothing short of 
heartbreaking. These numbers reveal several challenges, 
including the simple reality that the majority of veterans are 
not accessing much-needed care during moments of crisis. I 
think that is the critical point--that we are not reaching the 
veterans that are at highest risk, and that is the primary 
concern that I personally have.
    Data is emerging to suggest that recent changes in the VA 
delivery system are proving more effective with OEF and OIF 
veterans, with a reduction in soldier risk for those in active 
treatment. We have good treatments today for suicidality. There 
are a number of treatments that are effective and can be 
effective in a number of settings. They are not difficult to 
implement. The problem is getting people to actually access the 
treatment, and getting people to stay in treatment once they 
start.
    Scientifically, we know that there are a number of 
treatments and inventions that prove effective. The effective 
elements of these treatments are simple and straightforward, 
they are very concrete, and they result in hope, which is what 
we need to help overcome the issue of suicidality. Despite the 
availability of effective treatments, it is important to 
remember that not only will many of our veterans face acute 
problems, but just as Mr. Hanson has demonstrated, they will 
continue to face chronic problems. This is an issue that is not 
going to go away. Part of my concern personally and 
scientifically is that this is going to require long-term care, 
far more than short-term care that we have conceptualized to 
this point.
    In addition to what the VA is currently doing, efforts that 
certainly should be applauded, I would like to emphasize the 
need for the VA to think outside of the box, to experiment with 
non-traditional approaches and consider that the existing data 
point to the undeniable truth that we simply are not reaching 
the larger portion of veterans in need. This is a problem for 
both the VA and the Department of Defense.
    I would suggest to you that stigma and the nature of the 
military culture are at the heart of the problem. The military 
culture is one that appropriately is dedicated to developing 
warriors, a culture that treasures strength, courage, and 
sacrifice, all admirable qualities.
    As OEF and OIF have demonstrated, psychiatric casualties 
are much larger than originally anticipated. Prolonged and 
repeated exposure to combat takes a considerable psychological 
toll. Our soldiers and veterans struggle to understand their 
health--they continue to struggle to understand the health 
consequences of killing, the exposure to combat, what it means 
to be in combat, and what the normal trajectory of response to 
combat is. It is an issue that we need to think very seriously 
about and we need to look beyond traditional mental health 
approaches when we are doing that.
    Traditional mental health approaches talk almost 
exclusively in the language of illness, contrary to the very 
core of what we know about a warrior mentality. For many of our 
veterans, the notion of illness and disorder is synonymous with 
personal failing and weakness, and it only serves to compound 
the existing shame and guilt that they experience. We need to 
move away from this traditional language of pathology and talk 
about the issues of optimal performance and resilience. We need 
to do this early in the experience of training soldiers. We 
need to look at unique programs and alternatives for helping 
soldiers understand early in the process about potential 
problems in terms of adjustment to combat.
    It is critical for the Department of Defense and the VA to 
reach veterans by normalizing the combat experience and 
subsequent adjustment. This can take a number of forms, but it 
is essential that early in training, all soldiers be exposed to 
training targeting the consequences of killing, talking in 
specific terms about post-combat adjustment.
    It is important for the VA to recognize that they fight a 
longstanding image as an inflexible and unresponsive 
bureaucracy. There is a need to stretch existing boundaries and 
explore public-private partnerships that provide new experience 
and alternatives for our veterans.
    As an example, given an estimated 500,000 veterans will 
transition to college campuses over the course of the next 
decade, I would strongly encourage the VA to look at partnering 
with university campuses. They need to go where the veterans 
are, and a large portion of those veterans are going to be on 
our college campuses. We need to look at partnering in very 
specific ways. I can tell you, we would welcome the opportunity 
to partner with the VA system in terms of providing care and 
assessing and responding to veterans on campuses.
    The problems experienced by today's veterans demonstrate an 
undeniable truth. Traditional approaches do not reach those in 
greatest need. We need to think outside of the box, experiment 
with non-traditional approaches, set aside the language of 
mental illness and pathology, and put our veterans first.
    Thank you very much. I would welcome the opportunity to 
answer questions.
    [The prepared statement of Mr. Rudd follows:]
  Prepared Statement of M. David Rudd, Ph.D., ABPP, Dean, College of 
 Social & Behavioral Science, University of Utah; Scientific Director, 
        National Center for Veterans Studies, University of Utah
    Mr. Chairman, Mr. Ranking Member, and Members of the Committee, I 
appreciate the opportunity to appear today to discuss the Department of 
Veterans' Affairs (VA) efforts to address the mental health needs of 
America's Veterans.
    There is no disagreement that the mental health demands on the VA 
will continue to grow over the course of the next decade. Given the 
duration of Operation Enduring Freedom (OEF) and Operation Iraqi 
Freedom (OIF) current mental health demands are unprecedented. In 
addition to grappling with anticipated problems like depression, Post 
Traumatic Stress Disorder, and substance abuse, the VA is struggling to 
address the tragic loss of veterans' to suicide. I have no hesitation 
to endorse the recent efforts of the VA, but will offer encouragement 
for the VA to explore non-traditional approaches and public-private 
partnerships in an effort to undermine the devastating impact of 
stigma.
    As you will hear from other witnesses, the VA has implemented a 
range of programs and initiatives, all geared toward meeting the 
growing mental health demands of today's Veterans. With respect to 
suicide, the VA has launched an intensive suicide prevention program, 
one that includes an innovative suicide prevention hotline and Internet 
chat line. As you know, there are eighteen deaths per day due to 
suicide among America's Veterans, with approximately five per day among 
those in active treatment with the VA. These numbers are nothing short 
of heartbreaking.
    These numbers reveal several challenges, including the simple 
reality that the majority of Veterans' in need are not accessing much 
needed services at moments of crisis. Data is emerging to suggest that 
recent changes in the VA delivery system are proving more effective 
with OEF and OIF Veterans', with a reduction in suicide risk for those 
in active treatment. Scientifically we know that there are a number of 
treatments and interventions proven effective for suicidality. The 
effective elements of these treatments are simple and straightforward, 
inspiring hope and recovery in concrete fashion. Despite the 
availability of effective treatment, it is important to remember that 
not only will many of our Veterans face acute problems a large 
percentage will struggle for many years requiring intensive and 
enduring care. This is not a short-term issue.
    In addition to what the VA is currently doing, efforts that 
certainly should be applauded, I would like to emphasize the need for 
the VA to think outside of the box, to experiment with non-traditional 
approaches and consider that the existing data point to one undeniable 
truth, we simply are not reaching the larger portion of those in need. 
This is a problem for both the VA and the Department of Defense. Stigma 
and the military culture are at the heart of the problem.
    The military culture is one appropriately dedicated to developing 
warriors, one that treasures strength, courage and sacrifice. As OEF/
OIF have demonstrated, psychiatric casualties are much larger than 
originally anticipated. Prolonged and repeated exposure to combat takes 
a considerable psychological toll. Our soldiers and Veterans struggle 
to understand their experiences and the consequences of killing. 
Traditional mental health approaches are simply not effective at 
reaching our soldiers and Veterans, an outcome that is not particularly 
surprising. Traditional mental health approaches talk almost 
exclusively in the language of illness, contrary to the very core of 
military training. For many of our Veterans the notion of illness and 
disorder is synonymous with personal failing and weakness, only serving 
to compound existing shame and guilt. We need to move away from the 
traditional language of pathology and talk about the issue of optimal 
performance and resilience.
    It is critical for both the Department of Defense (DOD) and VA to 
reach Veterans by ``normalizing'' the combat experience and subsequent 
adjustment. This can take many forms, but it is essential that early in 
training all soldiers be exposed to training targeting the consequences 
of killing, talking in specific terms about post-combat adjustment. Not 
a single soldier comes out of combat the way that they went in; combat 
is a life altering experience. We can do a better job of helping our 
warriors understand the normal adjustment problems experienced 
following combat, eliminating the possibility that subsequent 
psychological problems will be attributed to personal failings and 
weakness. As the Air Force Suicide Prevention Program demonstrated, the 
impact of high-ranking leaders cannot be underestimated. Nothing is 
more powerful to a struggling enlisted man or woman, hesitant to seek 
care, than to see a commander talk openly and honestly about his or her 
own difficulties following combat.
    Similarly, it is important for the VA to recognize that they fight 
a longstanding image as an inflexible and unresponsive bureaucracy. 
There is a need to stretch existing boundaries and explore public-
private partnerships that provide new service alternatives for our 
Veterans. As an example, given that an estimated 500,000 Veterans will 
make their way to college and university campuses over the next decade, 
the VA should consider the placement of providers on campuses around 
the country. The VA will need to go to where the Veterans are in order 
to reach the seventy percent hesitant to seek care. We would certainly 
welcome such a partnership. Similarly, expansion of the existing VA 
system may not be the most effective expenditure of available funds. As 
is well known among suicide researchers, a large percentage of those 
that take their own lives see primary care providers in the month prior 
to their death. Although the VA has improved training for primary care 
providers within their system, why not explore other potential 
partnerships with private medical centers?
    The problems experienced by today's Veterans demonstrate an 
undeniable truth, traditional approaches do not reach those in greatest 
need. We need to think outside of the box, experiment with non-
traditional approaches, set aside the language of mental illness and 
pathology, and put our Veterans first.
                                 ______
                                 
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
  M. David Rudd, Ph.D., ABPP, Dean, College of Social and Behavioral 
                      Science, University of Utah
    Question 1. Especially in terms of research and emerging opinions 
on most effective treatment methods, what was not discussed in the 
hearing that needs to be?
    Response. It should be mentioned that, according to the empirical 
literature, there are only two effective treatments for PTSD, including 
cognitive processing therapy and prolonged exposure therapy. There 
needs to be more effort to make sure that these are the 
psychotherapeutic treatments offered to veterans, including the 
necessary clinical training for VA providers.
    With respect to suicidality, there are only a handful of effective 
treatments. As with PTSD, it is important for the VA system to offer 
these psychotherapeutic options and make sure their providers are 
appropriately trained.
    The VA system should also be making a concerted effort to implement 
interventions in Emergency Departments that work to do two things: 1) 
reduce the rates of ED presentations for suicide attempts and 2) 
facilitate transition into treatment and improved compliance with 
ongoing treatment.

    Question 2. We recently heard from veterans in Hawaii that they do 
not want to utilize tele-mental health options, whereas many younger 
veterans like this form of care delivery. What studies have been done 
to compare needs and preferences of the different generations with 
respect to delivery or type of care? How should that be integrated into 
VA's care delivery?
    Response. There are a number of options for integrating online 
treatment options. The majority view online options as adjunctive in 
nature, i.e. used as a resource to traditional approaches. In net gain 
is a reduction in demand for face-to-face sessions, something 
particularly important for veterans in rural areas with limited access 
to major medical centers and clinics. We are in the process of testing 
an online ``toolkit'' for suicidal veterans with the goal of reducing 
the need for face to face contact. The most effective tele-mental 
health/online options utilize a combination of online and face to face 
contact.

    Question 3. In addition to veterans severely injured and those 
returning from combat zones, do any of you have any recommendations for 
identifying less obvious groups of veterans who might be at an 
increased risk for suicide?
    Response. The VA and DOD have both launched fairly extensive 
efforts to identify high-risk veterans struggling with mental health 
problems. I would suggest (and empirical data supports the idea) that 
there is far greater need to identify at risk veterans in primary care 
settings (i.e. family medicine, internal medicine). A considerable 
number of high risk patients appear in primary care and refuse mental 
health care. They can more effectively be identified, treated and 
maintained in primary care settings.

    Question 4. We know that the stigma associated with mental health 
problems is a serious barrier to veterans seeking treatment. What else, 
in addition to VA's current efforts to overcome stigma, would be 
beneficial?
    Response. Far greater coordination is needed between DOD and the 
VA. The problem with stigma is generated while on active duty. If 
greater steps are not taken by DOD the problem will persist. We need 
those in the upper echelon of command (both officers and NCO's) to 
openly discuss mental health problems and talk about the effectiveness 
of their own treatment, all the while emphasizing that it has not 
limited their careers. Additionally, more attention needs to be focused 
on the transition from active duty status, particularly for National 
Guard and Reserves. These two groups in particular need to be the 
target of stigma reductions campaigns.

    Question 5. Have male and female veterans differed much in their 
treatment outcomes for various models of mental health services? If so, 
how well do you believe VA has factored such differences into its 
treatment programs?
    Response. There are not particular differences in response rates to 
care. However, there are differences in the types of trauma that 
precipitate care. For example, sexual assault among female veterans has 
not received the attention it deserves. The same can be said for 
vicarious trauma, i.e. among health care providers (e.g. nurses) in 
combat zones.
                                 ______
                                 
     Response to Post-Hearing Questions Submitted by Hon. John D. 
 Rockefeller IV to M. David Rudd, Ph.D., ABPP, Dean, College of Social 
               and Behavioral Science, University of Utah

    Question 1. In your testimony, you mention the need to change 
traditional language about mental health for the military and veterans. 
Can you explain that idea in more detail?
    Response. DOD and the VA can do a better job ``normalizing'' post 
traumatic stress by ``relabeling'' the problem. We need to talk about 
how to effectively adjust to post combat environment. As long as we 
continue to use diagnostic labels like depression, PTSD, and substance 
abuse we'll see a large percentage of soldiers unwilling to receive 
care. If we talk about building and maintaining ``resilience'' and 
``optimal performance'', something that should be started in basic 
training, we'll have more soldiers involved. We'll also have to go to 
the soldiers and stop asking them to come to clinics and hospitals for 
care. The facilities themselves stop soldiers from accessing care since 
they don't want to be ``seen'' in those settings.

    Question 2. You mention partnerships with other health providers, 
but how would this work with your other idea of changing the 
traditional language about mental health for the military?
    Response. We should partner with primary care providers. The 
integration of mental health professionals in primary care settings 
carries far less stigma. Soldiers are willing to willing to be seen for 
``medical'' problems and related injuries. Providing mental health care 
in that context helps get around the traditional problem of going to a 
specialty mental health clinic.

    Question 3. How could we educate or make the entire private sector 
sensitive to this issue?
    Response. I believe we have to start talking in consistent fashion 
about the emotional and psychological consequences of combat, 
normalizing the experience. Not one single soldier goes to war and 
returns home without having to address emotional or psychological 
issues in some form or fashion, whether it's grieving the loss of 
friends or more complex issues. The issue of the Purple Heart is a 
great example. We honor those with physical wounds but not those with 
psychological ones. Until we are willing to take on that problem, 
psychological problems following combat will continue to be viewed as 
``weakness'' and ``failure.''

    Chairman Akaka. Thank you very much, Dr. Rudd.
    Mr. Clarence Jordan, your statement, please.

    STATEMENT OF CLARENCE JORDAN, MEMBER, NATIONAL BOARD OF 
         DIRECTORS, NATIONAL ALLIANCE ON MENTAL ILLNESS

    Mr. Jordan. Thank you. Chairman Akaka, Ranking Member burr, 
and Members of the Committee, on behalf of the National 
Alliance on Mental Illness, NAMI, thank you for inviting me 
today to share my views.
    I am privileged to serve on the National Board of Directors 
of NAMI, the Nation's largest grassroots mental health consumer 
organization. We are dedicated to improving the lives of 
individuals and families affected by mental health in adults 
and in children.
    Mr. Chairman, NAMI is deeply concerned about the newest 
generation of repatriated war veterans, whether they remain on 
active duty, serve in the Guard and Reserve, or return to 
civilian life following service. We want to see the VA take a 
more relating posture in coordinating both intergovernmental 
and public-private arrangements that would do a better job at 
outreach, screening, education, counseling, and care of 
veterans who fought and are still fighting these wars and to 
help their families recover from these experiences.
    NAMI is very proud that the VA in 2008 recognized that we 
can play an important role within the VA in helping families of 
veterans cope with and recover from mental illness. NAMI's 
signature program, Family-to-Family, is dedicated and designed 
to meet the needs of family members who have questions relative 
to whether or not their loved one, the veteran home from 
deployment and war, is experiencing not only from the 
standpoint of what the illness is, but the treatment, the 
various medications, the prognosis, and what they can expect in 
supporting and caring for those loved ones and gaining the 
ultimate goal of recovery.
    Mr. Chairman, I am a 15-year veteran of the world's finest 
Navy. I know how combat situations and military life in general 
put unique stresses on these individuals. In my case, while the 
signs and symptoms of a problem were there and more than one 
person tried to point them out to me, I completely denied the 
problem at the time. I mean, after all, an individual with 
mental illness isn't sent to the Naval War College or given a 
scholarship to Naval Post-Graduate School in Monterey.
    With the clarity of hindsight now, I can say that I 
struggled for years with mental illness, and when I was on 
active duty, I know that I was not alone. Following the Navy, I 
wandered literally in the wilderness for nearly two decades. 
This lifestyle ultimately led to getting me into deep kimchi. I 
owe a debt of gratitude to the judge who gave me a choice of 
going to treatment or going to jail. I chose treatment. It was 
the push that I needed to start turning my life around.
    I stayed in treatment at a local community mental health 
center for 12 months and I continue to be a consumer today. I 
believe I have achieved recovery to enable me to live a better 
life. I am living proof that a mental illness does not mean 
that one cannot live happy, productive lives. Since leaving 
that initial treatment, I have not only held responsible jobs, 
but I have become actively involved in NAMI, where I train 
others to do advocacy work and to help others achieve their 
ultimate goal of recovery.
    It is important for people, veterans and non-veterans, to 
realize that there are different types and levels of mental 
illness and that, most importantly, the things they can do to 
stop forward is to talk to mental health professionals to find 
out the essence of their problems.
    When I served in the Navy, I had no basis of experience or 
knowledge about mental illness that would have led me to 
believe I had a problem. Furthermore, my personal image of 
someone with a mental illness when I was in the Navy was 
definitely not me. I knew next to nothing about the VA and its 
mental health programs. I believe I share this experience with 
thousands of military servicemembers, veterans who could 
benefit from VA services but may not be getting them. I believe 
that the VA must do a better job of reaching out and making its 
services known to larger shares of the veterans' population who 
serve.
    Given our experience to date in the wars in Afghanistan and 
Iraq, plus the overlay of combat experience of prior 
generations of veterans, more veterans need readjustment and 
mental health counseling and other mental health services than 
those who are appearing at the VA facilities to seek these 
services. I believe much insight about veterans who do not use 
VA health care should be obtained from serving those veterans 
who have called 273-TALK, the National Suicide Prevention 
Hotline, and I would urge this Committee to consider requiring 
such a study to determine how much VA is aiding these callers.
    Make no mistake, NAMI deeply appreciates the existence of 
273-TALK. We have committed and commended to VA's Office of 
Mental Health Services for having established this vital link 
to VA counseling and who have saved the lives of thousands of 
veterans, but we believe a large group of veterans still are in 
need and are not being reached. We are proud that our members, 
despite these problems, actively participate in consumer 
counsels and our Family-to-Family education programs in VA 
facilities.
    The VA and NAMI executed an important Memorandum of 
Understanding in 2007 formally committing to our signature 
Family-to-Family education program within the VA facilities. At 
100 VA medical centers, Family-to-Family is a formal 12-week 
NAMI education program. It enables families living with mental 
illness to learn how to cope and better understand it. Also, 
Family-to-Family focuses on care for caregivers and how 
caregivers can cope with worry, stress, and the emotional 
overload that attends mental illness in families. Based on the 
success of Family-to-Family, we have a goal of introducing more 
NAMI signature programs, such as Peer-to-Peer and NAMI 
Connection program within the VA mental health care.
    Mr. Chairman, our Grade the States Report last year 
revealed that very few States offered mental health or 
readjustment programs for returning members of the National 
Guard and Reserve from Iraq and Afghanistan. However, we 
learned that States like Massachusetts and Vermont are good 
models of programs that provide peer outreach and direct 
delivery of services to their Guardsmen.
    We call your attention also to similar efforts in 
California, Connecticut, Maine, Maryland, New Hampshire, and 
New Jersey, New Mexico, New York, and North and South Carolina. 
Of special note, the State of Montana launched an ambitious 
program of post-deployment screening and referrals for Montana 
National Guardsmen home from Afghanistan and Iraq.
    NAMI is committed to recovery. In the case of our 
professional military service, we want to ensure that those 
serving in these regular forces are well cared for by the DOD 
when they return from active duty; by both DOD and the VA for 
those in the National Guard and Reserve components when they 
return to their garrisons. NAMI believes that many tailored 
approaches need to be made for those new veterans, that all 
civilian efforts should be led by VA in coordination with 
agencies, including DOD, SAMHSA, the Public Health Services, 
Indian Health Services, the National Guard Bureau, the State 
Guard leadership, and leaders of State public mental health 
agencies, as appropriate as needed. In some cases, private 
mental health providers should be enlisted and coordinated by 
VA to ensure they can provide the quality of care veterans may 
need.
    NAMI also urges this Committee to expand the establishment 
of diversionary courts for veterans. I mentioned my personal 
experience with that judge in Nashville who gave me an 
opportunity to turn my life around, and I believe that many 
military experiences like mine can be helped if provided an 
opportunity.
    NAMI urges the Committee to support the development of 
diversionary courts for veterans, especially combat veterans, 
to make sure that the VA reaches out and coordinates with 
existing court systems in cities and States to ensure post-
deployment veterans receive the most timely and effective care 
possible rather than allowing sick and disabled veterans 
suffering with mental illnesses consequences to their war 
service to be convicted and sent to jail.
    Finally, NAMI endorses the organization of the Independent 
Budget for fiscal year 2011. In that budget and policy 
statement, AMVETS, Disabled Veterans, Paralyzed Veterans, and 
American Veterans of Foreign Wars in the United States 
recommend a series of good ideas that would further improve 
VA's mental health programs. I ask the Committee to consider 
these recommendations and to ensure, either through oversight 
or legislation, the Department of Defense carries out these 
intents and the spirits of these recommendations.
    This concludes my testimony, Mr. Chairman.
    [The prepared statement of Mr. Jordan follows:]
   Prepared Statement of Clarence Jordan, Member, National Board of 
         Directors, National Alliance on Mental Illness (NAMI)
    Chairman Akaka, Ranking Member Burr, and Members of the Committee: 
On behalf of the National Alliance on Mental Illness (NAMI), please 
accept NAMI's collective thanks for this opportunity to provide 
testimony at today's oversight hearing to assess the Department of 
Veterans Affairs' (VA) mental health programs.
    I am privileged to serve on the national Board of Directors of 
NAMI, the Nation's largest grassroots consumer organization dedicated 
to improving the lives of individuals and families affected by mental 
illness. Through NAMI's 1,100 chapters and affiliates in all 50 states 
NAMI supports education, outreach, advocacy and research on behalf of 
persons with schizophrenia, bipolar disorder, major depression, severe 
anxiety disorders, Post Traumatic Stress Disorder (PTSD), and other 
chronic mental illnesses that affect both adults and children. In my 
opinion what NAMI does best as an organization is to advocate for, 
train and educate family members of persons living with mental illness. 
In recent years NAMI began to realize that the lives of our newest 
veterans and the experiences that they've had while serving our country 
in combat necessitate not only that they receive post-deployment 
services essential to get well afterward, but also that their families 
have needs that must be addressed to ensure that a family recovers from 
the experience.
    NAMI is very proud that the VA has recognized that NAMI can play an 
important role within VA mental health in helping families of veterans 
cope with, and recover from, mental illness, whether acute or chronic. 
One NAMI signature program in particular, Family-to-Family, is designed 
to meet the needs of family members who have questions relative to what 
their loved one--the veteran home from deployment in war--is 
experiencing, not only from the standpoint of what the illness is, but 
the treatment protocol, the various medications and prognosis, and what 
they can expect in supporting and caring for their loved one in gaining 
the ultimate goal of recovery.
    As a case in point, I am a 15-year veteran of U.S. Navy aviation. I 
know how combat situations, as well as other more basic tenets of 
military life, put unique stressors on those of us who have served, as 
well as on our families. In my case, while the signs of a problem were 
there, and more than one person tried to point them out to me, I 
completely denied the problem at that time. With the clarity of 
hindsight now, I can say that I struggled for years with mental illness 
when I was on active duty in the United States Navy. I know now that I 
was not alone.
    My struggle with mental illness ultimately led me to leave military 
service, and for nearly a decade afterward I bounced from one job to 
another and from city to city. In 1998 I finally had to face the fact 
that I had a problem. At the time, I was using alcohol and other drugs 
to keep me from dealing with the realities of my life, and that 
approach ultimately led me to trouble with the law. I owe a debt of 
gratitude to a judge who gave me a choice of going to jail or going 
into mental health treatment. It was the push I needed to start turning 
things around. In my case I went to a local community mental health 
center in Nashville, Tennessee, and met with several doctors who 
evaluated my condition. I ultimately was diagnosed with major 
depression.
    I stayed in treatment at that health center for 12 months to work 
through the issues I was experiencing. I believe I have achieved 
recovery to enable me to live a better life. I believe I am living 
proof that a mental illness does not mean that one cannot live a happy, 
productive life. Since leaving that initial treatment, I have not only 
held responsible jobs but I've become actively involved in NAMI, where 
I now train others and do advocacy work to help those with these 
problems achieve their potential.
    It's important for people, veterans and non-veterans, to realize 
that there are different types and levels of mental illness and that 
the most important thing they can do if they think they have a problem 
is to step forward and talk to a mental health professional to find 
out.
    When I served in the Navy, I personally had no base of experience 
or knowledge about mental illness that would have led me to believe I 
had a problem. Furthermore, my personal ``image'' of someone with a 
mental illness when I was in the Navy was definitely not me. I knew 
next-to-nothing about the VA and its mental health programs. I believe 
I share this experience with thousands of military servicemembers and 
veterans who could benefit from VA services but may not be getting 
them.
    I believe that the VA must do a better job of reaching out and 
making its services known to a larger share of the veteran population 
(both those recently discharged-demobilized and older generations), and 
work more cooperatively with the military service branches, other 
Federal agencies, state governments, and private mental health 
providers. Today, we have over 23 million living veterans, yet VA sees 
only a quarter of them in its health care programs, and even a smaller 
fraction in its mental health services. Given our experience to date in 
the wars in Afghanistan and Iraq, plus the overlay of combat 
experiences of prior generations of veterans, it is obvious that more 
veterans need readjustment and mental health counseling and other 
mental health services than those who are appearing at VA facilities to 
seek these services.
    No one to my knowledge is studying what happens to veterans after 
combat if they do not enroll in VA health care. VA participates in the 
national suicide hotline program, 273-TALK, and recently reported that 
over 60,000 veterans had contacted that resource since it was 
established. I believe much insight about veterans who do not use VA 
health care could be gleaned from surveying those veterans who have 
called 273-TALK, and would urge this Committee to consider requiring 
such a study by VA or the Substance Abuse and Mental Health Services 
Administration (SAMHSA) to determine how much VA is aiding these 
callers. Make no mistake: NAMI deeply appreciates the existence of 273-
TALK. We have commended VA's Office of Mental Health Services for 
having established this vital link to VA counselors who have saved the 
lives of thousands of veterans, but we believe a larger group of 
veterans still is in need and is not being reached.
    Despite our concerns about the need for broader outreach, not only 
to prevent suicides but to ensure that more veterans can become aware 
of VA services, NAMI has enjoyed a long-term interest and involvement 
in mental health programs within the VA. For 30 years NAMI has served 
as an advocate for veterans under care in VA programs, because VA is 
caring for our family members. NAMI and its veteran members formally 
established a Veterans Council in 2004 to assure close attention is 
paid to mental health issues and policies in the VA, especially within 
each Veterans Integrated Services Network (VISN) and programs at 
individual VA facilities. Council membership includes veterans who live 
with serious mental illness, family members of these veterans, and 
other NAMI supporters with an involvement and interest in the issues 
that affect veterans living with and recovering from mental illness. 
The Council members serve as NAMI liaisons with their VISNs; provide 
outreach to veterans through local and regional veterans service 
organization chapters and posts; increase Congressional awareness of 
the special circumstances and challenges of serious mental illness in 
the veteran population; and work closely with NAMI's State and 
affiliate offices on issues affecting veterans and their families.
    Our members are directly involved in consumer councils at more than 
one-third of VA medical centers and we advocate for even more councils 
to be established throughout the VA system. Also, VA and NAMI executed 
an important memorandum of understanding in 2007 formally promoting our 
signature ``Family to Family'' education program within VA facilities. 
As I mentioned above, Family to Family is a formal twelve-week NAMI 
educational program that enables families living with mental illness to 
learn how to cope with and better understand it. The program provides 
current information about schizophrenia, major depression, bipolar 
disorder (manic depressive illness), Post Traumatic Stress Disorder 
(PTSD), panic disorder, obsessive-compulsive disorder, borderline 
personality disorder, co-occurring brain disorders and addictive 
disorders, to family members of veterans suffering from these 
challenges. Family to Family supplies up-to-date information about 
medications, side effects, and strategies for medication adherence. 
During these sessions participants learn about current research related 
to the biology of brain disorders and the evidence-based, and most 
effective, treatments to promote recovery from them.
    Family members of veterans living with mental illness gain empathy 
by understanding the subjective, lived experience of a person with 
mental illness. Our Family to Family volunteer teachers provide 
learning in special workshops for problem solving, listening, and 
communication techniques. They provide proven methods of acquiring 
strategies for handling crises and relapse. Also, Family to Family 
focuses on care for the caregiver, and how caregivers can cope with 
worry, stress, and the emotional overload that attends mental illness 
in families. We at NAMI are very proud of Family to Family, and we were 
especially pleased that former VA Under Secretary Michael Kussman and 
VA's Office of Mental Health Services saw the wisdom of formally 
bringing NAMI resources like Family to Family into VA mental health 
programs at the local level.
    I believe I can fairly report that this effort has been a great 
success to date, functioning in about 100 VA medical centers. We at 
NAMI are hoping to continue building on that success, including 
renewing the existing Family to Family memorandum of understanding with 
VA, and to introduce more of NAMI's signature programs, such as our 
Peer to Peer and NAMI Connections programs, into VA mental health care.
    Mr. Chairman, in March of last year NAMI issued its biennial Grade 
the States report, an effort to survey state mental health program 
directors on the types and scope of mental health programs available 
within their states for all residents.
    I hope the Committee's professional staff will take the opportunity 
to review the results. NAMI found that while 14 States had improved 
their grades since NAMI's 2006 survey, 12 fell backwards, and that the 
national average grade for state-sponsored public mental health 
programs still remained unchanged, a grade of ``D.'' You can see the 
full Grade the States report at www.nami.org/grades09.
    For the first time ever, the Grade the States report last year 
asked a series of questions about whether states offered any 
readjustment or other mental health programs for servicemembers and 
family members of the state National Guard units returning from 
deployments in Afghanistan and Iraq. Very few states responded in the 
affirmative, but we have learned that the states of Massachusetts and 
Vermont are two good models of programs that effectively provide peer-
outreach and direct delivery of coordinated services to their returning 
Guardsmen. These appear to be state-funded efforts, but in the case of 
Vermont they are subsidized by a VA cooperative funding agreement. This 
is good information that might encourage some States to look to 
Massachusetts and Vermont for ideas. We call your attention also to 
similar efforts in California, Connecticut, Maine, Maryland, New 
Hampshire, New Jersey, New Mexico, New York, North Carolina and South 
Carolina. Of special note, the State of Montana launched an ambitious 
program of post-deployment screening and referrals for Montana National 
Guard members home from Afghanistan and Iraq. NAMI commends Congress 
for including Senator Tester's bill, modeled on the Montana program and 
based on advocacy by NAMI Montana, in last year's National Defense 
Authorization Act (NDAA). That new law requires the Department of 
Defense (DOD) to conduct three face-to-face mental health screenings of 
every servicemember returning from a contingency operation. NAMI is 
also pleased that Congress included Senator Shaheen's legislation based 
on a New Hampshire NAMI suicide prevention training initiative, the 
``Yellow Ribbon Reintegration Program,'' also called ``Yellow Ribbon 
Plus,'' in the NDAA. Unfortunately, while Congress authorized these two 
new programs, it did not provide designated funding for them. We hope 
directed funding to support these efforts will be provided in the next 
DOD appropriations act, in Fiscal Year 2011.
    Mr. Chairman, as you can see from some of these examples, NAMI is 
deeply concerned about the newest generation of repatriated war 
veterans, whether they remain on active duty, serve in the Guard or 
Reserves, or return to civilian life following service. We want to see 
the Department of Veterans Affairs take a more leading posture in 
coordinating both inter-governmental and public-private arrangements 
that would do a better job at outreach, screening, education, 
counseling and care of the veterans who fought and are still fighting 
these wars, and to help their families recover from these experiences. 
NAMI is committed to recovery, whether from transitional readjustment 
problems coming to a family that welcomes an Army or Marine infantryman 
back from war, or one dealing with chronic schizophrenia in a young 
adult who never served in the military. In the case of our professional 
military services, we want to ensure that those serving in the regular 
force are well cared for by DOD when they return to their duty stations 
after combat deployments; by both DOD and VA for those in the National 
Guard or Reserve components when they return to garrison in their 
armories; and, by VA for those who become veterans on completion of 
their military service obligations and return to their families--
whether in urban or rural areas.
    NAMI believes many tailored approaches will need to be made for 
these new veterans, but that all of the civilian efforts should be led 
by VA, in coordination with other agencies (including DOD, SAMHSA, the 
Public Health Service and the Indian Health Service), the National 
Guard Bureau, State Guard leaderships, and the leaders of State public 
mental health agencies, as appropriate to the need. In some cases, 
private mental health providers should be enlisted and coordinated by 
VA to ensure they can provide the quality of care veterans may need, 
and are trained to do so in the case of Post Traumatic Stress Disorder 
and other disorders consequent to combat exposure and military trauma, 
including military sexual trauma. We realize that finding qualified 
private mental health providers in highly rural areas is an extreme 
challenge and will require VA and other public agencies to be creative. 
Nevertheless, we believe these unmet needs can be dealt with if VA 
establishes a firm will to do so.
    NAMI also urges this Committee and other relevant groups in 
Washington and in state capitals, to expand the establishment of 
diversionary courts for veterans. I mentioned my personal experience 
with a judge who gave me an opportunity to turn my life around, and I 
believe that my military experience was part of that judge's 
consideration in diverting me to treatment rather than sending me to 
jail. In the few instances where veterans courts exist, they have 
become effective tools to get veterans who are struggling with mental 
illnesses the help that they need. NAMI urges the Committee to support 
the development of diversionary courts for veterans, and especially 
combat veterans, and to make sure that VA reaches out and coordinates 
with the existing courts systems in cities and States to ensure post-
deployment veterans receive the most timely and effective care 
possible, rather than allowing sick and disabled veterans suffering 
with mental illnesses consequent to their war service to be convicted 
and sent to jail or prison.
    Mr. Chairman, the National Alliance on Mental Illness is committed 
to supporting VA efforts to improve and expand mental health care 
programs and services for veterans living with serious mental illness. 
Until recently, forward motion had been stalled on VA's ``National 
Mental Health Strategic Plan,'' to reform its mental health programs--a 
plan that NAMI helped develop and fully endorses. NAMI wants to see VA 
stay on track to provide improved access to mental health services to 
veterans returning from Iraq and Afghanistan today, as well as to other 
veterans diagnosed with serious mental illness--all important 
initiatives within the VA strategic plan. In 2008 VA announced its 
establishment of a ``Uniform Mental Health Service'' benefits package, 
one that NAMI supports as beneficial to ensuring VA progress toward 
full implementation, and will provide help to the newest war veteran 
generation and all veterans who live with mental illness.
    Finally, NAMI is an endorser organization of the Independent Budget 
for Fiscal Year 2011. In that budget and policy statement, AMVETS, 
Disabled American Veterans, Paralyzed Veterans of America and Veterans 
of Foreign Wars of the United States recommend a series of good ideas 
that, if implemented would further improve VA's mental health programs. 
I ask the Committee to closely consider these recommendations and to 
ensure, either with oversight or legislation that VA (and the 
Department of Defense in some instances) carries out the intent and 
spirit of these recommendations. For the benefit of the Committee, I am 
attaching these Independent Budget recommendations to this testimony.
    This concludes my testimony on behalf of NAMI, and I thank you for 
the opportunity.
Attachment
                                 ______
                                 
               Attachment to Testimony of Clarence Jordan
                  Recommendations in VA Mental Health
                  Fiscal Year 2011 Independent Budget
    VA should provide frequent periodic reports that include facility-
level accounting of the use of mental health enhancement funds, and an 
accounting of overall mental health staffing, the filling of vacancies 
in core positions, and total mental health expenditures, to 
Congressional staff, veterans service organizations, and to the VA 
Advisory Committee on the Care of Veterans with Serious Mental Illness 
and its Consumer Liaison Council.
    Consistent with strong Congressional oversight, the Under Secretary 
for Health should appoint a mental health management work group to 
study the funding of VA mental health programs and make appropriate 
recommendations to the Under Secretary to ensure that VHA's allocation 
system sustains adequate funding for the full continuum of services 
mandated by the Mental Health Enhancement Initiative and UMHS handbook 
and remains in full commitment to recovery as the driving force of VA 
mental health programs.
    VA must increase access to veteran and family-centered mental 
health-care programs, including family therapy and marriage counseling. 
These programs should be available at all VA health-care facilities and 
in sufficient numbers to meet the need.
    Veterans and family consumer councils should become routine 
standing committees at all VA medical centers. These councils should 
include the active participation of VA providers, veteran health-care 
consumers, their families, and their representatives.
    VA and the DOD must ensure that veterans and servicemembers receive 
adequate screening for their mental health needs. When problems are 
identified through screening, providers should use nonstigmatizing 
approaches to enroll them in early treatment in order to mitigate the 
development of chronic illness and disability.
    VA and the DOD should track and publicly report performance 
measures relevant to their mental health and substance-use disorder 
programs. VA should focus intensive efforts to improve and increase 
early intervention and the prevention of substance-use disorder in the 
veteran population.
    VA should invest in research on effective stigma reduction, 
readjustment, prevention, and treatment of acute Post Traumatic Stress 
Disorder (PTSD) in combat veterans, increase its funding for evidence-
based PTSD treatment programs, and conduct translational research on 
how best to disseminate this state-of-the-art care across the system.
    VA should conduct an assessment of the current availability of 
evidence-based care, including for PTSD, identify shortfalls by the 
site of care, and allocate the resources necessary to provide universal 
access to evidence-based care. VA should conduct a rigorous study of 
the intensity of mental health care to determine if it has been reduced 
for older generations of veterans in order to generate the capacity to 
absorb newer arrivals (primarily veterans of Operations Enduring and 
Iraqi Freedom) with more acute needs. If the study finds results in the 
affirmative, VA should begin to address that trend.
    A task force--composed of experts from the Veterans Benefits 
Administration, Veterans Health Administration mental health staff, 
veterans service organizations, and disabled veterans--should be 
assembled to explore potential barriers and disincentives to recovery 
from mental health disabilities that may be created or influenced by 
VA's disability compensation system.
    VA should immediately correct case management program deficiencies 
and begin to treat psychological injury and mental illness in veterans 
with the same intensity that it treats serious physical injuries. VA 
and the DOD should move rapidly to develop health policy and research 
inquiries that are responsive to the recommendations published in the 
2007 IOM report, Gulf War and Health: Physiologic, Psychologic, and 
Psychosocial Effects of Deployment-Related Stress.
    VA needs to improve its succession planning in mental health to 
address the professional field shortages, recruitment, and retention 
challenges noted in this Independent Budget. VA should ensure that 
qualified women mental health counselors with expertise in military 
sexual trauma are available in all Vet Centers and that all 
professional staff are provided training on the current roles of women 
returning from combat theaters and their unique post-deployment mental 
health challenges.
    The VA Advisory Committee on the Care of Veterans with Serious 
Mental Illness should be replaced by a secretarial-level committee on 
mental health, armed with significant resources and independent 
reporting responsibility to Congress.
    Congress should ensure that the new mandatory, face-to-face mental 
health screening process for post-deployed combat servicemembers 
(including National Guard and Reserves) required by the National 
Defense Authorization Act of 2010 is conducted by personnel who are 
effectively trained to identify these hidden service-incurred wounds, 
and to treat them when found. This responsibility should be jointly 
embraced by both DOD and VA mental health-care programs in a shared 
effort under the authority of Public Law 97-174, ``VA/DOD Health 
Resources Sharing and Emergency Operations Act.''
                                 ______
                                 
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
Clarence Jordan, Member, National Board of Directors, National Alliance 
                           on Mental Illness
    Question 1. What are the members of NAMI's Veterans' Council 
finding are the most serious roadblocks to veterans or family members 
receiving the necessary care and services, and do you have any 
recommendations to remove those roadblocks?
    Response. Of primary concern is stigma, which continues to exert a 
tremendous amount of force on those in need of care. Ignorance and 
confusion over signs and symptoms are baffling resulting in prolonged 
periods of rationalization and denial. The resulting effect is 
individuals who present late in the disease state at which time any 
number of co-morbid conditions become apparent. Another critical 
roadblock for many is accessibility and an attending social and 
cultural norm that results in the prospective recipient of care 
isolating and resulting in self destructive behaviors.
    There is any number of roadblocks and depending upon the resilient 
nature of the veteran and/or family member, presenting lesser or 
greater degree of difficulty in overcoming them to include:

     Dual diagnosis of mental health and primary care have been 
co-located but not with substance abuse.
     Women's issues are still huge, with concerns over 
inconsistencies in care and apparent confusion over a no-fault process 
for obtaining gender preference therapists for military sexual trauma 
treatment. In previous generations we did not talk about military 
sexual trauma, and some women veterans going back as far as Vietnam and 
Korea are just beginning to tell their stories. There are no verifying 
records because there were no mechanisms to deal with the issue at that 
time.
     Treatment for PTSD claims for veterans who have either had 
no symptoms for years and are experiencing symptoms re-emerging or that 
were never addressed.
     Cultural competency on the part of health care providers 
is extremely problematic; veterans have expressed numerous concerns 
over the lack of a shared set of values and beliefs with their VA 
caregivers.
     Outreach to families including children (of deployed, 
returning troops) is still a great concern, despite recent reported 
improvement in the numbers over the past several months.
     Lack of a person-centered family first approach to care. 
In VA there is this ``assembly line'' approach; get them in, and get 
them out. Individual needs preference, hopes and aspirations are seldom 
heard resulting in a feeling of not being heard. There is not a sense 
of hope or expectation of recovery at the service level.

    On the plus side of the equation the VA Secretary has listed both 
substance abuse and homelessness as high priorities. As mentioned 
previously there is more family involvement than a year ago, but not 
enough. I do not think that the VA will go full bore on children's 
services, but a family therapy approach that includes the children both 
as a support system to a returning parent and for their own stability 
is needed. Maybe this could be a contract issue with children's or 
family services in the community.
    Secretary Shinseki in my opinion is really doing a good job. His 
T--21 Initiatives that include strategies to improve community 
partnerships, outreach and education and addition to supportive 
services, are strategies for the 21st century. His style as well as his 
content are highly respected but he alone cannot do it all. A 
collaborative approach with private and public service centers and 
support facilities could go a long way to dealing with many of the 
issues raised above. Employing the principles espoused in the SAMHSA 
Consensus Statement on recovery combined with the Secretary's T-21 
Initiative would help immensely. Borrowing from lessons learned in the 
public sector VA should use more web-based resources to provide 24-hour 
a day, seven days a week access to user information and connection to 
others through social networking. Also VA should use trained consumer 
experts in recovery to help shape and guide recovery services employed 
at higher levels within the VA system for greater continuity and 
oversight of recovery efforts and programs. Finally, the VA needs to 
find an innovative solution to engage over time with this latest cohort 
of returning veterans and family members that circumvents existing 
stigma and is designed to assist those less likely to ask for 
assistance in current traditional outreach ways. Mr. Chairman, a life 
filled with hope, pride of service and support of a grateful nation and 
community should be the end game for our returning warriors.

    Question 2. During your 12-month inpatient treatment, what do you 
believe was the most effective component of the program that motivated 
you to become more proactive in your own treatment and adhere to your 
program?
    Response. In a word, CONTACT; the development of an interpersonal 
relationship with a person who self disclosed they had a mental illness 
just like me. Gentlemen, we should never underestimate the power that 
stigma holds sway over the sufferer. In my case I was affected in three 
ways: self stigma, label avoidance and public stigma. My sense of self 
worth and self efficacy was all but eliminated. To avoid being labeled 
as someone with a mental illness I would rather had been labeled as an 
addict, alcoholic and yes, even as homeless, with all its connotations. 
For decades I wore a mask, too afraid of what I might really see if 
ever I took a good look in a mirror. Estranged from family and friends 
and everything that ever meant anything to me, I existed in a world of 
aberrant behavior whereas to hide my own bizarre behaviors. I paid 
tithes to the church of shame and despair, attending every sermon 
hoping and praying that one day I would be delivered from this hellish 
no-man's land of the self-exiled. This once proud Naval Officer 
willingly embraced all the negative stereotypes of what it meant to 
live on the fringes of society.
    Even after the diagnosis, or shall I say diagnoses, I believed that 
one day I would just be over it like a common cold.
    Like my descent, my rise from the depths of my despair took a slow, 
often fatuous journey of having to re-learn the simplest of executive 
functioning skills. I found the road of treatment to be fraught with 
disempowering practices and low expectations.
    Peer support for me was more than mentorship through a twelve-step 
process; it was about vicariously learning how to deal with decisions 
involving emotions and a fragile belief system. The weeks and months of 
treatment that preceded the acquisition of peer services could only do 
so much; I had learned that medication could have positive effects, I 
had learned the importance of journaling as a means of mood check; I 
had arrived at a state of enactive attainment. I was at a point 
persuasion, still being seduced by my illness, and my peer specialist 
provided the physical arousal needed to move beyond the symbiotic 
nature of our relationship and posed for a renewed self-efficacy. It 
was at this point that I appreciated all the more the values and 
beliefs I had learned in the Navy.
                                 ______
                                 
     Response to Post-Hearing Questions Submitted by Hon. John D. 
Rockefeller IV to Clarence Jordan, Member, National Board of Directors, 
                  National Alliance on Mental Illness
    Thank you for your testimony and the commitment of NAMI to the 
Family to Family program for education and support. I hope you will 
continue to work on this until every VAMC has a group.

    Question. Can you also share your thoughts on a mandatory training 
course or mental health program for all veterans as a way to eliminate 
the stigma? Do you think this would be helpful? How should such a 
course be structured?
    Response. Programs like the Illinois Warrior Assistance Program and 
the Real Warriors Campaign are very valuable. The developer and staff 
of these great efforts deserve to be commended; their scope is very 
comprehensive, offering a full array of social networking, information 
and referrals. They are packaged in very patriotic and eye popping web 
designs, and unique and return visitor numbers are very impressive. 
They, like our own NAMI web resources and so many other tremendous 
resources, depend on a ``pull'' methodology; they are built to bring 
those in who are seeking help and are willing to receive the much 
needed support.
    The real or more pressing question at hand is what programs exist 
for the more than two thirds of those eligible who are in need but do 
not seek help. And unless I miss my guess, there may be significant 
underserved segments of our Veterans population that have not yet come 
to rely upon the internet for their information.
    The warrior ethos, good order and discipline along with a sense of 
esprit-de corps goes to the heart of our military culture and structure 
on which Army, Navy, Air Force, Marine Corps and Coast Guard depend. 
Military culture is sometimes maligned as too rigid and involving too 
much discipline that nevertheless colors the environment in which the 
sailor, soldier, airman and marine must step forward and admit to an 
illness that for some invokes feelings of weakness and perhaps laziness 
or just being a plain slacker. Promoting and rewarding (at a minimum, 
not penalizing) help-seeking behavior is at odds with the public stigma 
both within military and civilian (for Guard and Reservists) worlds 
these service personnel compete and live in, and that is the dilemma. 
Some programs use a reverse logic approach depicting help-seeking 
behavior as consistent with a sense of operational readiness; some use 
an avoidance approach whereby mental illness and/or its many symptoms 
are simply looked upon as a natural consequence of military life. 
Research certainly suggests that education in and of itself, whether 
conducted at the unit or brigade level, whether single or multiple 
presenters, produces limited effects with most participants returning 
to their base line within a week. Public stigma and negative 
stereotypes return leaving those who responded to the affirmative 
without much support and worse yet, they may encounter outright 
discrimination.
    An approach that is designed to resemble more of a push or 
``mandatory approach,'' could speak to that. By its very nature a push 
approach wherein everyone participates could go a long way in avoiding 
personal stigma associated with help-seeking behaviors. Such an 
approach would also have a higher probability of neutralizing public 
stigma.
    A combination push/pull approach could increase significantly the 
number of veterans receiving care provided there is some incentive for 
individuals to participate fully and with anonymity. The use of 
technology that is not only personal but also employed to reach the 
masses with simultaneous messaging could be used to produce the desired 
push for participation. Innovative use of screening and incentives 
could enhance more timely and effective interactive between military 
servicemember and helpers. ValueOptions has designed an innovative 
solution that, in my opinion, addresses these cultural challenges 
inherent in asking for help and garnering access to care to existing 
programs.
    One other barrier exists that is directly associated with the 
stigma of label avoidance. Personnel policies and procedures exist 
which serve as a barrier to military servicemember participation in 
operational readiness programs, and must be silent on matters of 
servicemember's successful treatment. Stigma will be more difficult to 
battle as long as policies remain that penalize or limit future options 
or opportunities as a consequence of seeking behavioral health 
assistance. While there has been progress in this area, there is much 
work to be done before eliminating rational reasons for not seeking 
care. Additionally, the Uniform Code of Military Justice (UCMJ) can, by 
individual commanders, be misused to exorcise personnel deemed to be 
``odd balls'' or different following deployments and exposure to war. 
Such practices must be closely monitored.

    Chairman Akaka. Thank you very much, Mr. Jordan.
    My first question is to Mr. Hanson, and I want to thank you 
for sharing your story with us. We heard from Dr. Rudd that a 
large number of veterans will contend with mental health 
difficulties over the long term and may require treatment for 
years. Your experience seems to support that. Do you believe 
the VA program you completed was helpful as a stepping stone to 
your final recovery, or do we need to significantly revise the 
VA program?
    Mr. Hanson. Well, Mr. Chairman, I believe that the program 
I did was beneficial and that I was able to see what the drugs 
and alcohol were doing, that I did have a problem; but as far 
as treating my issues, I believe that it was little to no 
benefit for me. I mean, I drank the day after I got out of the 
program and I pretty much wasn't changed. It was something that 
I had to do because I knew I eventually had a court case coming 
up and I thought that treatment might look good, because it was 
a licensed program, to be honest with you, Mr. Chairman. As far 
as changing me the way I needed change, it did absolutely 
nothing, to be honest with you. Having no disrespect to the 
Department of Veterans Affairs, but I felt like it wasn't 
beneficial at all.
    Chairman Akaka. Mr. Jordan, I believe that involving family 
members in care is critical to a successful outcome and to 
getting a veteran seen in the first place. What lessons should 
VA take from NAMI's Family-to-Family program that would make 
mental health care more successful?
    Mr. Jordan. Thank you, Mr. Chairman. Several things. One, 
that recovery is possible.
    Number 2, that recovery is a process; it is not linear. 
That setbacks, such as those described by Mr. Hanson, do occur, 
and that love and support more than anything else is the key to 
supporting that member's recovery.
    Chairman Akaka. For all of our witnesses, significant 
resources have been allocated through VA over the last couple 
years for the purpose of improving mental health care. If you 
were to rate VA's progress over the past 8 years on a scale of 
one to ten, what score would you give VA's mental health 
services? Mr. Hanson?
    Mr. Hanson. I only have been really working with the VA for 
the last 3 years, Mr. Chairman. I would have to give it around 
a six, just because I feel, kind of like Mr. Jordan said, there 
is not a feeling of a lot of care or love and I think that is 
what I need. I understand that it is a professional 
environment, but there are a lot of times I felt like I was 
just another number and it left me feeling, you know, put off 
by it, really, to be honest, Mr. Chairman. So I would say a 
six. Thank you.
    Chairman Akaka. Thank you very much.
    Mr. Jordan?
    Mr. Jordan. I would agree, a five or a six. I mentioned the 
273-TALK. I think that is an excellent program. I think that 
there is a lot of research regarding peer-to-peer-type 
services, mutual support groups, that have not benefited the 
vast majority of individuals in care. There seems to be an 
absence of outreach and education that I think is very vital to 
a member obtaining full recovery.
    Chairman Akaka. Thank you.
    Dr. Rudd?
    Mr. Rudd. Well, I probably would rate it a little higher. I 
would say a seven or an eight. I think that they have been 
innovative, that they have tried some new things. There is 
evidence that some of these new things are working. Certainly, 
the hotline and Internet chat line are unique and there is 
evidence of success there. They are having much greater success 
in terms of reduction of suicide risk for those in active 
treatment.
    I think at the heart of the problem, though, that they face 
and that many other clinicians face is the difficulty of 
getting a certain portion of the high-risk population actually 
in for care, and that is where you have to think outside of the 
mental health scope, that perhaps there are other kinds of 
partnerships within primary care and other alternatives that we 
can look at to get that portion of the population to agree to 
come in for treatment.
    Chairman Akaka. Thank you. Thank you very much.
    Let me call on our Ranking Member for his questions.
    Senator Burr. Thank you, Mr. Chairman.
    Dean Rudd, I am sorry I overlooked your military service. 
Thank you for that.
    Dean, let me ask you, you expressed the importance for the 
VA to think outside the box to treat mental illness by 
experimenting with non-traditional approaches. The Department 
of Defense funds the Complementary and Alternative Medicine 
Research for Military Operations and Health Care Program, which 
does research non-traditional treatments, such as manipulation, 
bio-electromagnetic devices, and acupuncture. Are these 
examples of non-traditional approaches that you would recommend 
the VA take a look at or use?
    Mr. Rudd. Not necessarily. I think that when I talk about 
non-traditional, I am thinking more about how we reach out to 
veterans, and rather than identifying the presence or absence 
of a mental illness, telling someone that they have a mental 
illness is not necessarily a compelling reason for them to get 
care when they have been raised in a culture in which that 
mental illness is seen as a weakness. It is almost an 
affirmation of their failure----
    Senator Burr. Let me ask you----
    Mr. Rudd [continuing]. To say, you have PTSD. You need 
treatment.
    Senator Burr. Let me ask you from the standpoint of your 
professional experience, how important is it when we identify a 
servicemember who has been discharged and we think there is a 
likelihood of a mental health challenge there, that we 
immediately get them in treatment and keep them in treatment 
versus to wait a year for something to manifest itself to a 
different point?
    Mr. Rudd. I think, actually, Mr. Hanson's story kind of 
tells the tale. I think we need to get them in treatment, 
recognize and understand what the barriers are to keeping them 
in treatment, and then facilitate ongoing care; because once 
they step out of treatment, the problem becomes far more 
complex. And as he demonstrated, it goes from a difficulty of 
perhaps a post-traumatic stress problem to depression to 
substance abuse, a lot of comorbidity, a lot of clinical 
complexity, where it is very difficult to keep people in care 
at that point.
    I, frankly, think we need to do far more on the very front 
end when we bring people into basic training and start to talk 
to them about resilience and about how they can perform at 
their best and recognize when they are having difficulty to 
relabel, reframe that to a large degree to make it acceptable 
and understandable.
    I can tell you the most compelling thing I have ever seen, 
I was on a panel on Veterans Day and there was a one-star 
general, a Brigadier General. He spoke at that panel about his 
difficulty with PTSD after his experience in Iraq. After that 
panel, there was a cohort of young soldiers that came up to him 
to talk about that experience because he essentially said it is 
acceptable, it is OK, it is understandable that you are going 
to have these difficulties.
    I think we just--we need to think differently and not 
necessarily in terms of the clinical end, because we know what 
works clinically, but how do we convince people, how do we talk 
to people about the problem.
    Senator Burr. Mr. Hanson, as you know, the primary 
screening tool for returning combat servicemembers is the 
completion of a Post-Deployment Health Assessment, and then we 
do a Post-Deployment Reassessment several months after the 
separation. What is your view on the adequacy of those 
screening procedures?
    Mr. Hanson. Senator, kind of like what Dr. Rudd said, it 
was something where it is considered a weakness. Essentially, I 
recall ours was in a large setting. They said, if you have any 
problems, raise your hand or something like that. And, I mean, 
you know, no one is going to raise their hand. For me, it was a 
weakness kind of deal, especially for me. My primary MOS was in 
infantry, so I felt like, these guys aren't raising their hand. 
I have got absolutely no right to raise my hand, whether I saw 
something or not. So for me, it is just if it can be maybe on a 
more one-on-one basis where it is more personal, it would 
probably be a lot more effective, I would think.
    Senator Burr. Had yours been one-on-one, would you have 
raised your hand?
    Mr. Hanson. I definitely would have opened up, Senator, 
that is for sure. A little bit more, anyway. But it is hard to 
say, because I definitely thought I was a big, bad Marine, so I 
didn't really want to talk about anything.
    Senator Burr. And had you opened up and had the VA set out 
a treatment regime for you, would you have gone?
    Mr. Hanson. I highly doubt it.
    Senator Burr. So what would it take for you to have 
participated? I am asking more about the challenges you had in 
life that were competing with, should I take the time to go to 
this treatment.
    Mr. Hanson. I think for me, if they would have made it 
clear that, essentially, I have to. I mean, if I said that I 
had an issue and it had to be addressed, then maybe it would be 
something with my veterans' benefits, with a disability check. 
You are not going to get any--you have to go to this or there 
is going to be stuff held back, essentially. You have an issue. 
You need readjusting. You are not man enough to do it.
    Senator Burr. Daniel, at what point after you got back did 
the alcohol and drugs begin to play a role?
    Mr. Hanson. As soon as I went on leave, pretty much, 
Senator. Right away. I mean, the drinking was progressive, 
where I was on leave and I was drinking, and then slowly it got 
to where when I was happy I was drinking. Then when I was sad I 
was drinking. When I was bored I was drinking. So essentially 
it was to drink to celebrate and it was to drink when I was 
depressed and it just kind of slowly evolved into an everyday 
thing where I was abusing and I was neglecting my family and 
friends.
    Senator Burr. And the length of that time between your 
disengagement with the military and finding the program in 
Minnesota was what length of time?
    Mr. Hanson. It was about 2 years.
    Senator Burr. About 2 years? During that 2-year period, did 
you visit a VA facility?
    Mr. Hanson. Yes, sir, I did. I was doing outpatient therapy 
for some time. Also, I did the Dual Diagnosis Program.
    Senator Burr. So did you share with them your level of 
alcohol consumption and drug consumption?
    Mr. Hanson. Yes, I did.
    Senator Burr. And what was their course of treatment 
relative to that?
    Mr. Hanson. I mean, they knew that I--they told me that I 
had a problem, that I shouldn't be drinking, that I was 
depressed, and I was put on medication, and a follow-up where 
it was once-a-week therapy. Once I completed that program, I 
was told to take the anti-depressant, come in once a week, and 
keep your head up.
    Senator Burr. From the start of your association with VA or 
at any point while you exercised services from the VA, did you 
understand the full scope of benefits that were offered?
    Mr. Hanson. For me, I did. When I--a couple months after I 
got out of the Marine Corps, I worked for the Veterans' 
Benefits Administration, so I was familiar with what was 
offered. So, I knew on the grand scale of things what was 
offered, that is, as far as the benefits go. But as far as the 
VA hospital, there were a lot of things I wasn't aware of as 
part of----
    Senator Burr. Well, my next question was, did you 
understand the full array of services, as well.
    Mr. Hanson. No, sir.
    Senator Burr. At any point, did you look at the VA doctor 
that was treating you and say, what else can we do? Or were you 
just feeling OK that you had gone occasionally?
    Mr. Hanson. I mean, I work with a lot of really good 
doctors over there and they--I mean, there was definitely 
benefit there, but yes, Senator, I--we had a lot of 
conversations where I just said, I don't know what to do 
anymore, you know. Well, maybe you should do this other 
program. Well, do you feel like killing yourself? Yes, I kind 
of do. Well, do you have a plan to do it? No, not right now, I 
don't have a plan to do it. Well, you know, here is a card if 
you need it. You call this number if you are going to do that. 
OK, you know. And I said, I just can't get this thing right, 
and they made a lot of good suggestions. You can do this 
program and this program. But at 4, it was leaving time and, 
you know, you want to look at somebody in the eye when they are 
going to their vehicle kind of deal. So it was--I had some 
great conversations, but in the long run, it was kind of--I 
know they have got a lot of people, and I understand, but I 
just kind of felt like----
    Senator Burr. You needed the boot in the butt to get you in 
it?
    Mr. Hanson. Yes, sir. I did need the boot in the butt.
    Senator Burr. Good. Good. Thank you.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Burr, for your 
questions.
    I want to thank the panel for your testimony and also your 
responses to our questions. This is an issue and an area where 
we want to spend time in trying to help as much as we can, and 
you have been helpful this morning and you will be very helpful 
in what we are planning to do. So I want to thank you very much 
for coming and participating in this hearing. Thank you.
    Let me now introduce the second panel. I would like to 
welcome the witnesses of our second panel, Dr. Gerald Cross, 
Acting Principal Deputy Under Secretary for Health. Dr. Cross, 
welcome back to the Committee. He is accompanied by Dr. Janet 
Kemp, VA National Suicide Prevention Coordinator; Dr. Caitlin 
Thompson, Clinical Care Coordinator; Dr. Antonette Zeiss, 
Associate Deputy Chief Consultant and Chief Psychologist of the 
Office of Mental Health Services; Dr. Theresa Gleason, Deputy 
Chief of Mental Health Services at the Office of Research and 
Development; and Dr. Alfonso Batres, Director for Readjustment 
Counseling for Vet Centers.
    I want to thank you for being here. Your full testimony 
will appear in the record. Dr. Cross, will you please begin. I 
understand that Dr. Thompson will be making some remarks, as 
well. Thank you.

STATEMENT OF GERALD CROSS, M.D., ACTING PRINCIPAL DEPUTY UNDER 
  SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 
  DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JANET KEMP, 
   R.N., Ph.D., VA NATIONAL SUICIDE PREVENTION COORDINATOR; 
 CAITLIN THOMPSON, Ph.D., CLINICAL CARE COORDINATOR; ANTONETTE 
   ZEISS, Ph.D., ASSOCIATE DEPUTY CHIEF CONSULTANT AND CHIEF 
    PSYCHOLOGIST, OFFICE OF MENTAL HEALTH SERVICES; THERESA 
GLEASON, Ph.D., DEPUTY CHIEF, MENTAL HEALTH SERVICES, OFFICE OF 
  RESEARCH AND DEVELOPMENT; AND ALFONSO BATRES, Ph.D., MSSW, 
      DIRECTOR FOR READJUSTMENT COUNSELING FOR VET CENTERS

    Dr. Cross. Chairman Akaka, Ranking Member Burr, and 
distinguished Members of the Committee, thank you for the 
opportunity to appear here today to discuss VA's response to 
the mental health care needs of America's veterans.
    I want to digress for a moment and say thank you to the 
previous panel. I listened closely and I found the stories 
compelling. That means a great deal to us. Particularly, I was 
compelled by the alternative court mechanism, an innovative 
approach that we are very interested in, as well, and we can 
talk more about that perhaps later.
    Thank you for the introductions of my team. I want to 
mention that Dr. Thompson, sitting next to me, is one of the 
counselors at our Suicide Prevention Hotline. She is on the 
front lines every day, and her work as well as that of Dr. Kemp 
and the other counselors on the hotline have saved countless 
lives of veterans and we deeply appreciate her time and thank 
her for her service to America's veterans.
    My written testimony provides greater detail about our 
mental health programs and policies. Right now, I want to make 
three points.
    First, VA's clinical programs are improving the lives and 
well-being of veterans with mental health conditions. I can 
point to several objective outcome measurements that support 
this claim. To begin with, the number of homeless veterans 
continues to decline. These data are gathered annually and show 
that those veterans most in need are receiving the care and 
services necessary to reestablish their lives.
    Another outcome measure is that veterans with serious 
mental illness who use VA services do not have the more 
challenging gap that is present elsewhere. In this and in other 
countries, individuals with serious mental illness have an 
average life expectancy of approximately 20 years less than 
those without mental illness. However, in VA, that has 
virtually disappeared. It is less than 2 years' difference. 
That is an 18-year benefit, approximately, to the veterans 
being treated for serious mental illness in VA.
    Yet another outcome measure is the soldier rate among 
veterans receiving VA care. It continues to drop. And as you 
can see on the chart, there has been a decline since 2001 
resulting in about 250 fewer suicides per year. This decrease 
was especially observed in our youngest veterans, those age 18 
to 24.
    Data obtained from the CDC confirms that young veterans 
receiving VA care are significantly less likely to commit 
suicide than those not receiving VA care. And based on these 
findings, we know that our programs are working and we will 
continue to improve them because we believe that we have much 
more that needs to be done. Any suicide of a veteran is an 
absolute tragedy, in my belief.
    To continue achieving these results, we need to bring more 
veterans into our facilities to deliver the care they need. We 
have a variety of outreach initiatives because we understand 
not all veterans are the same and there is no such thing as too 
much communication when it comes to letting veterans know that 
we are there for them.
    So my first main point was better mental health outcomes at 
the VA. My second main point is that VA is committed to a 
robust research program that identifies the causes and 
effective treatments for mental health conditions. Our current 
budget for this research portfolio is about $100 million, and 
we are using these resources to determine biologic and genetic 
factors that may increase a person's risk for developing mental 
health problems.
    We are also researching the best treatment protocols and we 
are using these results to improve care. For example, VA 
research has determined that it is imperative we closely 
monitor patients immediately following their inpatient stay, 
and so more and more we are requiring closer follow-up, weekly 
follow-ups, more periodic follow-ups, as necessary, after 
inpatient care is completed.
    The National Academy of Sciences Institute of Medicine 
found that VA-sponsored research provided sufficient evidence 
for prolonged exposure and cognitive processing therapy as key 
treatments for PTSD, and we have actively implemented those 
findings, those research findings, to guide our care for 
veterans with PTSD.
    My third point is that our suicide prevention efforts are 
having a real impact and saving lives every day. It is no 
exaggeration, sir, to say that our Suicide Prevention Hotline 
is one of the most successful programs we have ever 
implemented. In 2009 alone, we intervened to save more than 
3,300 veterans from suicide. Our hotline operators, like Dr. 
Caitlin Thompson right next to me, and suicide prevention 
coordinators have compelling stories to share with you about 
those encounters with veterans and how they bring them back 
from the very edge.
    Mr. Chairman and Ranking Member, this is work we can all be 
proud of and we thank you for your support of these initiatives 
and helping to make them possible.
    In conclusion, VA has aggressively increased the resources 
available to address the mental health needs of our veterans. 
We are working closely with our partners at DOD to improve the 
quality of care for veterans and for servicemembers alike. 
Since October, we have held two major conferences related to 
mental health care needs of veterans and servicemembers with 
DOD.
    We were also able to provide direct support to our 
colleagues at DOD within hours of the shootings at Fort Hood. 
We deployed staff, including four Mobile Vet Centers, to the 
Fort Hood community. They provided readjustment counseling 
services to more than 6,600 veterans, active duty 
servicemembers, and families.
    This concludes, sir, my prepared statement. Thank you again 
for the opportunity to appear, and sir, my colleagues and I are 
prepared to answer any questions.
    [The prepared statement of Dr. Cross follows:]
  Prepared Statement of Gerald M. Cross, MD, FAAFP, Acting Principal 
Deputy Under Secretary For Health Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Mr. Chairman, Mr. Ranking Member, and Members of the Committee: 
Thank you for the opportunity to appear today to discuss the Department 
of Veterans Affairs' (VA) response to the mental health needs of 
America's Veterans. I am accompanied today by my colleagues, Dr. 
Antonette Zeiss, Deputy Chief Consultant and Chief Psychologist, Office 
of Mental Health Services, Office of Patient Care Services, Veterans 
Health Administration (VHA); Dr. Theresa Gleason, Mental Health 
Research Portfolio Manager, Office of Research and Development, VHA; 
Dr. Alfonso Batres, Chief Readjustment Counseling Officer; and Dr. 
Janet Kemp, VA National Suicide Prevention Coordinator.
    VA has responded aggressively to address previously identified gaps 
in mental health care by expanding our mental health budgets 
significantly. In fiscal year (FY) 2010, VA's budget for mental health 
services reached $4.8 billion, while the amount included in the 
President's budget for FY 2011 is $5.2 billion. Both of these figures 
represent dramatic increases from the $2.0 billion obligated in FY 
2001. VA also has increased the number of mental health staff in its 
system by more than 5,000 over the last 3 years. During the past 2 
years, VA trained over 2,500 staff members to provide psychotherapies 
with the strongest evidence for successful outcomes for Post Traumatic 
Stress Disorder (PTSD), depression, and other conditions. Furthermore, 
we require that all facilities make these therapies available to any 
eligible Veteran who may benefit. In FY 2010 and FY 2011, we will 
continue to expand inpatient, residential, and outpatient mental health 
programs with an emphasis on integrating mental health services with 
primary and specialty care.
    VA is working closely with our colleagues at the Department of 
Defense (DOD) to improve the quality of care for Veterans and 
servicemembers alike. Since October 2009, VA and DOD have held two 
major conferences related to the mental health needs of Veterans and 
servicemembers.
    My testimony today will make three points: first, it will describe 
VA's approach to treating mental health conditions. It is our belief 
that treatment options should be widely available and uniquely tailored 
to the individual needs of each Veteran. Second, it will detail VA's 
policy and guidance to the field, as specifically identified in the 
Uniform Mental Health Services in VA medical centers and Clinics 
Handbook. This Handbook is being implemented across the VA health care 
system to expand access to necessary mental health services for 
Veterans. Finally, my testimony will conclude by providing evidence VA 
has gathered that our programs are successful and based upon the best 
available scientific basis; it will also detail the research VA 
conducts in this area. In sum, our programs are saving lives and 
improving the quality of life for Veterans with mental illness.
                  va's approach to mental health care
    With its emphasis on providing care management for depression and 
making evidence-based psychotherapy available for all Veterans who need 
it, VA is ensuring that planning for treatment of mental health 
conditions includes attention to the benefits as well as the risks of 
the full range of effective interventions. Making these treatments 
available responds to the principle that when there is evidence for the 
effectiveness of a number of different treatment strategies that can be 
effective, the choice of treatment should be based on the Veteran's 
values and preferences, as well as the clinical judgment of the 
provider.
    VA has been making significant enhancements to its mental health 
services since 2005, through the VA Comprehensive Mental Health 
Strategic Plan and special purpose funds available through the Mental 
Health Enhancement Initiative. VA's enhanced mental health activities 
include outreach to help those in need to access services, a 
comprehensive program of treatment and rehabilitation for those with 
mental health conditions, and programs established specifically to care 
for those at high risk of suicide. To reduce the stigma of seeking care 
and to improve access, VA has integrated mental health into primary 
care settings to provide much of the care that is needed for those with 
the most common mental health conditions. In parallel with the 
implementation of these programs, VA has been modifying its specialty 
mental health care services to emphasize psychosocial as well as 
pharmacological treatments and to focus on principles of rehabilitation 
and recovery.
    The focus on recovery for those with serious mental illnesses 
reflects major scientific advances in treatment and rehabilitation. 
Although it is still not possible to offer definitive cures for all 
patients with serious mental illness, it is realistic to offer the 
expectation of recovery. Veterans, often with their families, should 
collaborate with their providers in planning treatments, where the 
goals are to help the Veteran live the kind of life he or she chooses, 
in spite of any residual signs or symptoms of mental illness. To 
achieve this vision, VA has hired staff to provide peer support, 
trained clinicians in evidence-based strategies for treatment and 
rehabilitation, enhanced the care in residential treatment settings, 
and strengthened programs that involve families.
    In addition to the care offered in medical facilities and clinics, 
VA's Vet Centers provide outreach and readjustment counseling services 
to returning war Veterans of all eras. By the end of the current fiscal 
year, we anticipate having 299 Vet Centers in operation. It is well-
established that rehabilitation for war-related PTSD, Substance Use 
Disorder, and other military-related readjustment problems, along with 
the treatment of the physical wounds of war, is central to VA's 
continuum of health care programs specific to the needs of war 
Veterans. The Vet Center service mission goes beyond medical care in 
providing a holistic mix of services designed to treat the Veteran as a 
whole person in his or her community setting. Vet Centers provide an 
alternative to traditional mental health care that helps many combat 
Veterans overcome the stigma and fear related to accessing professional 
assistance for military-related problems. Vet Centers are staffed by 
interdisciplinary teams that include psychologists, nurses and social 
workers, many of whom are Veteran peers.
    Vet Centers provide professional readjustment counseling for war-
related psychological readjustment problems, including PTSD counseling. 
Other readjustment problems may include family relationship problems, 
lack of adequate employment, lack of educational achievement, social 
alienation and lack of career goals, homelessness and lack of adequate 
resources, and other psychological problems such as Depression and/or 
Substance Use Disorder. Vet Centers also provide military-related 
sexual trauma counseling, bereavement counseling, employment counseling 
and job referrals, preventive health care information, and referrals to 
other VA and non-VA medical and benefits facilities.
    To promote suicide prevention, VA established a strong partnership 
with the Department of Health and Human Services Substance Abuse and 
Mental Health Services Administration (SAMHSA) to operate a Veterans 
Call Center as part of the National Suicide Prevention Lifeline (1-800-
273-TALK). VA also has appointed suicide prevention coordinators and 
care managers at each VAMC and the largest community-based outpatient 
clinics. Altogether, VA employs over 400 staff members who focus 
specifically on suicide prevention. My colleague, Dr. Janet Kemp, 
discusses these programs in greater detail in her testimony.
                       va policy and requirements
    In 2009, VA approved the Handbook on Uniform Mental Health Services 
in VA medical centers and Clinics to define what mental health services 
should be available to all enrolled Veterans who need them, no matter 
where they receive care, and to sustain the enhancements made in recent 
years. One important set of requirements in the Handbook was to ensure 
that evidence-based psychotherapies are available for Veterans who 
could benefit from them and that meaningful choices between effective 
alternative treatments are available.
    Also, based on its Comprehensive Mental Health Strategic Plan, VA 
has enhanced access to mental health services by requiring that mental 
health services must be integrated into primary care services. To 
ensure Veterans are monitored appropriately while they are receiving 
mental health services, including treatment with psychotherapeutic 
medications, VA requires that these integrated care programs include 
evidence-based care management.
    Care management for depression includes repeated contacts with 
patients to educate them about depression, medications, and other 
treatment, as well as to provide evaluations of both therapeutic 
outcomes and adverse effects. The benefits of the frequent contact 
program relate to increased patient-engagement in care. Also, 
information from patient monitoring is translated into decision-support 
for providers about when they should modify treatment. Two programs 
that are used frequently in VA primary care settings are Translating 
Initiatives in Depression into Effective Solutions (TIDES) and the 
Behavioral Health Laboratory (BHL), both of which are evidence-based 
interventions supported by extensive research. Studies on care 
management for depression in primary care settings have demonstrated 
that these interventions can decrease both depression and suicidal 
ideation in older adults. This led to recognition of care management 
for late life depression as a best practice for suicide prevention.
    For several years, VA has provided training to clinical mental 
health staff to ensure that there are therapists in each facility who 
are able to provide evidence-based psychotherapies for the treatment of 
depression and PTSD as alternatives to pharmacological treatment or as 
a course of combined treatment. The initiative to make these 
psychotherapies broadly available within VA is relevant to concerns 
about medication safety, but the program was not developed as a result 
of those concerns. VA implemented the broad use of evidence-based 
psychotherapies in response to evidence that for many patients, 
specific forms of psychotherapy are the most effective and evidence-
based of all treatments. Specifically, the Institute of Medicine report 
on treatment for PTSD emphasized findings that exposure-based 
psychotherapies, including Prolonged Exposure Therapy and Cognitive 
Processing Therapy, were the best-established of all treatments for 
PTSD. Other specific psychotherapies included in VA's programs include 
Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for 
depression and Skills Training and Family Psycho-Education for 
schizophrenia. VA is adding other treatments such as Problem Solving 
for Depression, Cognitive Behavioral Therapy and Contingency Management 
for Substance Use Disorder, and behavioral strategies for managing both 
pain and insomnia.
                          va's accomplishments
    As stewards of the public interest and bearing the responsibility 
for caring for America's Veterans, VA conducts ongoing analyses of its 
programs and continually asks itself how they can be improved. VA's 
mental health enhancements were designed to implement evidence-based 
practices. Evidence led VA to adopt specific requirements for follow-up 
care after hospital discharge, and to require depression care 
management. Most generally, the findings support the conclusion that 
high quality mental health care can prevent suicide. The suicide rate 
for all Veterans who used VA health care declined significantly from FY 
2001 to FY 2007, as the attached chart indicates.
    Mental illnesses are among the most prevalent conditions affecting 
Veterans of all generations, wars or conflicts. VA research continues 
its commitment to defining the most effective mental health treatments. 
VA investigators have generated many major findings related to 
behavioral and psychiatric disorders such as schizophrenia, depression, 
substance use (including alcohol, illicit drugs, and nicotine), suicide 
prevention, and PTSD. From conducting large clinical trials to 
supporting center-based research programs to improving care delivery, 
mental health research continues to be a major priority for the VA 
research program.
    In one line of research, VA scientists are investigating factors 
related to improving adherence and compliance. This includes studies on 
anti-depressant adherence among older Veterans, reducing the impact of 
drug side effects, and a patient-centered approach to improve screening 
for side effects of second-generation antipsychotics. Efforts to 
improve the quality of care for persons with severe mental illness have 
focused on the inclusion of family members as active participants in 
the patient's treatment. VA researchers are also evaluating how to best 
implement an integrated health care approach for Veterans with serious 
mental illness. Combined with a number of other behavioral and 
psychological intervention studies, VA has been at the forefront of 
mental health research that seeks to improve treatment options for 
clinicians and patients dealing with mental health care needs.
    VA research is also striving to identify critical risk factors for 
major mental health disorders. One unique study is looking at Veterans 
who were deployed to Iraq as active duty Army, National Guard, or 
Reservists who had baseline physical and mental health assessments 
before deployment. Planned follow up studies will determine the effect 
of the combat experience on mental health, emotions, reactions, and 
cognition--shortly after return from Iraq as well as over ensuing 
years. Research is also changing how care is provided to individuals 
with less access to treatment facilities or providers. VA investigators 
successfully adapted a collaborative/team care approach to treat 
depression in older Veterans using telemedicine to address rural health 
disparities. Subsequently, this study provided the support for 
implementing telemedicine-based collaborative care in hundreds of small 
rural CBOCs that do not have on-site mental health specialists.
    Moreover, VA is working to better understand risk factors 
associated with suicide and the optimal means to prevent suicide. VA 
investigators focused on suicide prevention recently reported a 
correlation between chronic pain and suicide suggesting an important 
risk factor and highlighting a potentially at-risk group. Additional 
research is ongoing to evaluate the effectiveness of suicide hotline 
interventions, firearm safety, and how to care for Veterans receiving 
treatment for substance use disorder and depression who express 
suicidal thoughts.
                               conclusion
    VA as a system is committed to improving the quality and 
availability of mental health care to Veterans. VA's mental health 
enhancements have included major initiatives--far too many to itemize 
completely, but including effective efforts to increase access to 
mental health care, increase the use of evidence-based psychotherapy 
for the treatment of PTSD and depression, enhance the safe use of 
psychotherapeutic medications, provide effective suicide prevention 
interventions, fully utilize psychosocial rehabilitation and recovery-
oriented services, and ensure the appropriate level of trained staff 
are available to provide needed services. VA firmly believes that each 
Veteran has earned an individual determination of the best treatment 
and routine follow up for his or her specific condition, and its 
clinical guidelines support this endeavor. Thank you again for the 
opportunity to appear, and my colleagues and I are available to address 
any questions from the Committee.
                                 ______
                                 
                The Chart Referenced During the Hearing



                                 ______
                                 
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
 Dr. Gerald Cross, Acting Principal Deputy Undersecretary for Health, 
                  U.S. Department of Veterans Affairs
    Question 1. How is implementation of the Uniform Mental Health 
Services package progressing? Are mental health clinics with weekend 
and evening hours widely available across the system? What are the 
barriers to full implementation?
    Response. We have surveyed the field twice about the status of 
their efforts to implement the requirements of the Uniform Mental 
Health Services Handbook. The most recently completed survey reflects 
the status of implementation as of the end of December 2009. At that 
time, facilities reported implementing approximately 90 percent of more 
than 200 requirements. A recent draft Office of Inspector General (OIG) 
study indicated the same conclusion.
    The draft OIG report specifically looked at the availability of 
weekend and evening hours. They reported that these hours were 
available in 94 percent of 139 VA medical centers, and in 43 percent of 
the 49 very large Community Based Outpatient Clinics (CBOCs).
    Some barriers to full implementation include: space limitation for 
new staff programs as well as difficulties recruiting and hiring the 
needed staff. Additionally, there are barriers with some of the complex 
programs, such as Residential Rehabilitation and Recovery Centers, 
which require a cultural shift as well as establishing new staff and 
programming. The ultimate requirement also includes receiving 
Commission on Accreditation of Rehabilitation Facilities (CARF) 
accreditation. The Office of Mental Health Services (OMHS) works 
closely with the field to accomplish this innovative implementation and 
sites are making excellent progress; however, full implementation will 
take additional time.

    Question 2. What type of coordination is occurring between DOD and 
VA to transition a demobilizing or separating servicemember to VA care, 
or to refer a currently serving servicemember to VA care? How 
effectively is data, such as PDHRA information, being communicated 
between the Departments?
    Response. Of the 1,094,502 servicemembers eligible for VA care who 
have served in Afghanistan or Iraq since FY 2002 through the fourth 
quarter of FY 2009, 46 percent have come to VA for health care which is 
a significantly large number compared to other service eras. This is 
due in part to the efforts of both the Department of Defense (DOD) and 
VA to inform separating servicemembers of their health care and other 
benefits to which they are entitled by virtue of their service to our 
Nation in time of war. VA's outreach efforts to separating 
servicemembers are multiple. Every eligible Veteran receives a letter 
from the Secretary of Veterans Affairs informing them of their health 
care benefits and follow-up letters are sent to those who have not come 
to VA for care. Staff from Vet Centers, VA Regional Offices, and 
medical centers attend Post-Deployment Health Reassessment (PDHRA) 
administrations, National Guard and Reserve Yellow Ribbon events and 
welcome home events at VA medical centers (VAMCs). These events provide 
opportunities to share information about VA health care and other 
benefits such as those involving education and home loans. 
Specifically, DOD provides PDHRA records to VA on those Veterans who 
are referred to VA for care. VA tracks the clinical services provided 
to Veterans referred from DOD for care. DOD has systems in place to 
follow-up on referred Veterans.
    The Federal Partners Work Group on Reintegration of Returning 
Servicemembers and their Families is an interagency group co-chaired by 
Dr. Antonette Zeiss, Deputy Chief Consultant for Mental Health of VA 
and Brigadier General Loree Sutton, Director of the Defense Center of 
Excellence on Psychological Health and Traumatic Brain Injury. The work 
group promotes collaborative actions across agencies and with community 
providers. It has subgroups that focus on strategic collaborations 
between VA, DOD and other Federal and state entities, services for 
families, tracking of Veterans, destigmatization approaches and Veteran 
employment issues.
    For servicemembers who are ill or injured, VA and DOD have 
complementary and integrated team activities including:

     DOD and VA Federal Recovery Coordinators (FRCs) are 
assigned to severely injured servicemembers/Veterans and families. The 
FRCs work to coordinate VA and community benefits and services and 
provide an integrated approach to coordinate medical, social and 
community resources;
     VA Liaisons at military treatment facilities (MTFs) who 
transition injured Veterans to VA;
     Coordination of lodging in Fisher Houses for family 
members of Veterans in extended rehabilitation for war injuries;
     Transition Patient Advocates (TPAs) as navigators or 
advocates for Veterans and family member at VAMCs;
     Operation Enduring Freedom/Operation Iraqi Freedom (OEF/
OIF) Care Management teams that serve as an initial point of contact 
for Veterans and family members and Military Liaisons at VA medical 
centers (e.g. Army Wounded Warrior (AW2) staff);
     VA mental health clinicians support the mental health 
needs of wounded Veterans being treated in Polytrauma rehabilitation 
settings.

    Also, based on the October 2009 VA/DOD Mental Health Summit, VA and 
DOD are collaborating on projects designed to support separating 
servicemembers. This includes the DOD-sponsored ``In Transition'' 
project that provides trained mental health coaches to support 
continuity of care for servicemembers and Veterans who are 
transitioning from mental health care in DOD to VA.
                                 ______
                                 
     Response to Post-Hearing Questions Submitted by Hon. John D. 
      Rockefeller IV to Dr. Gerald Cross, Acting Principal Deputy 
     Undersecretary for Health, U.S. Department of Veterans Affairs
    Question 1. Dr. Cross, while it is good news that VA's new efforts 
are reducing suicide among veterans in active treatment. If the 
statistics of 18 veterans committing suicide and only 5 are known to 
VA, there are 13 veterans not in care. What are the VA's ideas for how 
to find and reach more veterans that need this assistance?
    Response. We will continue to reach out to these Veterans through 
the Hotline, media campaigns and outreach events as well as continue to 
develop relationships with community organizations and individuals who 
may be in a position to make referrals and provide assistance to 
Veterans needing help. We have partnered with organizations such as the 
Student Veterans of America and the American Legion to assist us to 
reach out to Veterans in crisis. We have developed collaborative 
agreements with the IHS and the Department of Health and Human 
Services' Substance Abuse and Health Services Administration (SAMHSA) 
to assist us to reach Veterans in the community who are in crisis.

    Question 2. Dr. Cross, given all the new GI bill students on 
campuses, what is VA doing to help their readjustment from Iraq and 
Afghanistan with combat and IEDs to the new life of a college campus?
    Response. VA has created an Internet page that targets college and 
university counseling center staff to provide them with information 
about common adjustment and mental health issues faced by Veteran 
students. A resource page for Veteran students is also included. The 
page can be accessed at: http://www.mentalhealth.va .gov/College/
index.asp.
    Information about this resource has been broadly disseminated 
throughout VA, in partnership with Veteran Service Organizations, and 
through the National Academic Advisors Association Military Interest 
Subgroup.
    Additionally, VA has established a working relationship with the 
Student Veterans of America, to facilitate development of resources for 
student Veterans. One shared project involves suicide prevention 
efforts. Locally, Suicide Prevention Coordinators, based at each VA 
medical center, include college campuses in their outreach efforts and 
are providing Operation SAVE training to college students.
                                 ______
                                 
Response to Post-Hearing Questions Submitted by Hon. Mark Begich to Dr. 
 Gerald Cross, Acting Principal Deputy Undersecretary for Health, U.S. 
                     Department of Veterans Affairs
    Question 1. How are the Veterans' Affairs Regional offices 
preparing for the surge of Veterans returning in 2010 and 2011 with 
mental health, TBI and PTSD problems?
    Response. By hiring and training additional employees, VA will have 
a stronger and more productive workforce to offset the impact of the 
expected workload increases over the next two fiscal years. We are 
actively exploring process and policy simplification, short-term 
technology enablers, as well as the traditional approach of hiring 
additional employees to address the continued growth of all categories 
of claims.

    Question 2. Alaska's Veterans need additional mental health 
services. The Alaska VA system's participation in the Alaska Psychiatry 
Residency would improve access to mental health care for Alaska's 
Veterans. What financial and political support is necessary for the 
Alaska VA system to be able to participate in the Alaska Psychiatry 
Residency?
    Response. VA is eager to enhance mental health services for all 
Veterans, including those in Alaska. Clinical education programs have 
been shown to be an important source for producing a pipeline of health 
care professionals in a particular geographic area, and should be 
encouraged in under-served areas.
    The Alaska VA Healthcare System (HCS) is actively exploring the 
possibility of participating in a psychiatry residency program. In 
general, the requirements for such participation are as follows:

     An Accreditation Council for Graduate Medical Education 
(ACGME) accredited psychiatry residency program is willing to associate 
with the Alaska VA HCS.
     The Alaska VA HCS is found to be a good learning site with 
experienced psychiatrists who are willing to teach.
     Educational resources for trainees are available; these 
include space, technology, and information resources to support the 
training program.

    The Office of Academic Affiliations could support trainees in a 
psychiatry training providing the above minimum standards are met. The 
financial considerations should not be considered a major barrier in 
this endeavor.
    Recently, VA opened a Psychology Internship Program at the Alaska 
VA HCS. This is currently the only psychology internship program in 
Alaska, and is also a potential program for expansion to meet the 
mental health needs of the Alaskan Veterans.

    Question 3. Rural Veterans are a major concern in my state and 
across the country. What are your plans to coordinate with the Indian 
Health Service (IHS) and Community Health Centers in rural areas to 
provide ``seamless'' services for rural vets? For example, the vet 
should be able to go to the clinic in their village and not have to 
worry about paperwork or denials or to travel over 500 miles for an 
appointment.
    Response. Since the signing of a Memorandum of Understanding (MOU) 
between VA and IHS in 2003, there have been and continue to be a number 
of cooperative arrangements and agreements. For example, tele-
psychiatry clinical demonstration pilots are currently serving Native 
Americans on rural reservations in eight sites covering 13 tribes in 
four western states. In Alaska, a similar initiative is located at the 
Yukon-Kuskokwim Regional Hospital in Bethel. The same initiative is 
under negotiation at the Kotzebue Regional Medical Center. The Care 
Coordination Store and Forward (CCSF) project, in Kenai, Alaska 
includes tele-retinal imaging to screen for diabetic retinopathy, tele-
dermatology and tele-pathology. VHA has also initiated a project to 
expand fee-based authority for primary and mental health care serving 
Native Alaskans in the highly rural areas, a project with potential 
national implications.
    VA and IHS are partnering to allow IHS staff to view (read-only) 
VA's electronic medical record on the Rosebud Reservation in South 
Dakota. A project at the VA Outreach Clinic in Saipan, Commonwealth of 
the Northern Mariana Islands includes the use of contracted part-time 
providers, with on-island tele-health capability, negating the need for 
Veterans to travel to more distant locations for routine examinations. 
In collaboration with VA, IHS has developed a patch for Bar Code 
Medication Administration, which has been tested at Fort Defiance, AZ 
and connectivity has been established with the Tucson VA Centralized 
Mail Out Pharmacy (CMOP).
    In addition to supporting one another in the shared delivery of 
care to rural Veterans who are located on Native lands, VA and IHS have 
embarked on an ambitious cooperative educational program. In FY 2009, 
VA provided 133 training episodes to tribal health care and IHS 
providers. In the first quarter of FY 2010, VA has already provided 80 
training programs. These educational sessions are conducted through 
satellite, video teleconferencing and web-based technologies 
strengthening our shared use of technology, and are highly valued by 
both tribal and IHS providers.
    In closing, the Under Secretary for Health and the Chief Medical 
Officer for IHS agreed in January 2010 to update the 2003 MOU between 
VA and IHS.

    Question 4. In states, such as Alaska, where Psychological Health, 
TBI, and Suicide resources are low and the workforce is underdeveloped, 
is there a mechanism to encourage VA to work with state/community 
leaders that are working hard to develop the same care in the civilian 
sector and having similar workforce, access, or outreach/identification 
challenges. How will (or can) telemedicine be used to increase access 
to Psychological Health, TBI and suicide services and supports?
    Response. VA actively engages the public and private sector to 
identify, coordinate, and utilize providers and facilities within the 
catchment areas of VA facilities to provide services that meet the 
needs of Veterans. Such collaborations have been successful in 
complementing VA care. For example, in FY 2009, over 3,800 Veterans 
with TBI received inpatient and outpatient hospital care and medical 
services from public and private entities, with a total disbursement of 
$21,375,168.
    VA uses Telehealth to provide medical care services and support to 
more than 260,000 Veteran patients, including Veterans in Alaska and in 
rural locations in other states. VHA Telehealth has increased access to 
VA medical center service and support to 500 CBOCs and to 41,000 
Veteran patients at home. VHA plans to increase Telehealth activity by 
30 percent in FY 2010.
    Increasingly, tele-mental health provides a mechanism for 
specialist care within VA to diagnose, treat and prevent depression 
with expanded accessibility to patients locally using health 
information and telecommunication technologies. There is good evidence 
to show that these telehealth interventions are effective and 
comparable to face-to-face delivery of services. Over 30 peer-reviewed 
scientific articles have substantiated the role for tele-mental health 
in expanding access to care.
    Telehealth services are an important element of VA's Uniform Mental 
Health Services. The most common clinical videoconferencing Telehealth 
application in VHA is tele-mental health used to link Veteran patients 
at the CBOC with their mental health provider at the VAMC. In FY 2009, 
VHA provided tele-mental health services to almost 40,000 Veteran 
patients during more than 128,000 encounters.
    The Alaska VA HCS has established a Tribal Veterans Representative 
Program that uses local community volunteers to help VA in reaching out 
to Alaska native Veterans. Alaska VA HCS has made special efforts to 
reach out to Alaska Native Tribal Health Consortium organizations. A 
group of VA staff has traveled to rural areas to provide education on 
PTSD, TBI, and suicide awareness and prevention. Further, Alaska VA HCS 
has signed an MOU with Alaska's Department of Military and Veterans 
Affairs that outlines a partnership to work together to meet the needs 
of returning soldiers.
    Alaska is served by four Vet Centers located in Anchorage, 
Fairbanks, Kenai and Wasilla. An American Indian counselor on staff at 
Anchorage provides outreach services to Veterans in remote American 
Indian and Native Alaskan villages, many not accessible by roads. On a 
biannual basis, remote villages are visited by the counselor traveling 
via bush plane and/or the Alaska National Guard. Remote villages are 
contacted by radio transmission beforehand to announce the date of 
arrival. The visiting Vet Center counselor provides informational VA 
brochures, briefings, and some counseling to Veterans and family 
members.
    Staff from VISN 20 in Alaska participate in the Alaska Brain Injury 
Network, a non-profit organization created by the Alaska mental health 
trust to provide resources to Alaska residents with TBI and integrate 
and share services from different sectors (Federal, state, Native, 
private) for individuals with TBI. Telehealth is used to provide 
follow-up comprehensive TBI evaluations from a VA medical center 
provider to Veteran patients at rural clinics. Such a Telehealth link 
has been established with the CBOC in Fairbanks, with plans for the 
Kenai and Juneau CBOCs. This practice, also used in the VHA Eastern 
Colorado Health Care System, continues to expand.
    VHA is also in the final acceptance testing phase of a Home 
Telehealth Disease Management Protocol (DMP) for mild TBI that will be 
deployed throughout VA to eligible Veteran patients on home Telehealth 
devices.
    Regarding suicide prevention efforts relevant to rural Veterans, 
OMHS has established mechanisms for access to care for those Veterans 
in crisis through the use of the Hotline and Chat Service. VA Suicide 
Prevention Coordinators have been conducting outreach programs in all 
communities included in their respective catchment areas to involve 
community organizations in the referral process. There is a pilot 
project in Oregon that educates community health care personnel to do 
suicide prevention outreach to Veterans, and provide initial services 
and facilitate on-going care with VA using tele-mental health.
    Finally, the VHA Polytrauma Telehealth Network established in 2006, 
links the four VA Polytrauma Rehabilitation Centers and 17 VA 
Polytrauma Network Sites from across the Nation (including the San Juan 
VAMC). All of these sites are part of VHA's larger Clinical 
Videoconferencing Network that currently reaches 500 CBOCs. VHA is 
defining patient criteria and clinical pathways to enable CBOCs to link 
appropriate patients into care via the polytrauma Telehealth network.

    Question 5. Are there telemedicine options for specialty therapies 
for TBI, such as physical therapy, speech therapy, occupational therapy 
or counseling?
    Response. Yes, currently, there are 60 VA sites providing 
rehabilitation using Telehealth with planned expansions in FY 2010 in 
the areas of speech pathology, mild TBI home Telehealth, Spinal Cord 
Injury (SCI), and post-amputation medical services and support.
    In 2009, 17 of 21 VISNs provided some form of tele-rehabilitation 
with an overall increase in workload of 31 percent from the previous 
year. Speech therapy accounted for 72 percent of this workload, and 
Telehealth was also used to provide physical therapy and occupational 
therapy services. New initiatives are underway to utilize telehealth 
for audiology services

    Question 6. Will case management be utilized? Why?
    Response. Polytrauma/TBI specialty case managers are part of the 
interdisciplinary rehabilitation teams that care for Veterans and 
servicemembers with polytrauma and TBI. They participate in the 
development of the individualized rehabilitation and re-integration 
care plans, and oversee the implementation of the plan, including 
securing the necessary resources to assist Veterans, servicemembers and 
families through recovery, rehabilitation, and re-integration into the 
community.
    The Polytrauma Telehealth Network is utilized by these specialty 
case managers to assess the psychosocial needs of the patient and the 
family, help coordinate the necessary services to address those needs, 
and to coordinate rehabilitation care including outreach to community 
resources.
    Case management is a core component in the provision of care and 
services to help OEF/OIF servicemembers and Veterans restore or 
maintain their functioning within the context of their family 
relationships and community re-integration post-deployment. Case 
managers for patients with complex, multiple injuries, including TBI, 
amputation and psychological trauma require specialized knowledge and 
skills. Patients and families need long-term case management services 
to ensure coordination of services, evaluation of ongoing 
rehabilitation needs, and supportive services to assist with successful 
community reintegration. In rural or underserved areas of the country, 
case managers assist Veterans and their families to identify and access 
community, state and local resources close to the Veteran's home. 
Services are provided across a continuum of care that may include 
inpatient and outpatient rehabilitation, long-term care, transitional 
living, community re-integration programs, and vocational 
rehabilitation and employment services.
    Each VA medical center has a Case Management team consisting of 
both a clinical component (registered nurses and social workers) that 
includes the OEF/OIF Program Manager and OEF/OIF case managers and a 
non-clinical component led by Transition Patient Advocates (many of 
whom are OEF/OIF Veterans). The Program Manager coordinates clinical 
care and oversees the transition and care for this population. OEF/OIF 
case managers coordinate patient care activities and ensure that all 
clinicians providing care to the patient are doing so in a cohesive and 
integrated manner. Transition Patient Advocates help Veterans navigate 
the VA system and Veterans Benefits Administration (VBA) team members 
assist Veterans with the benefit application process and provide 
education about VA benefits.
    All severely ill and injured OEF/OIF servicemembers and Veterans 
receiving care at VA are provided a case manager. All others are 
screened for case management needs and, based upon the assessment a 
case manager is assigned as indicated. The patient and family serve as 
integral partners in the assessment and treatment care plan. Our case 
managers maintain regular contact with Veterans and their families to 
provide support and assistance to address any health care and 
psychosocial needs that may arise.

    Question 7. What are you doing to ensure that Veterans are being 
provided the best possible psychiatric care? Statistics show that 40% 
of those servicemembers who die by suicide had previously been seen at 
Behavioral health. Are the treatments effective? Do we have 
appropriate, timely, cultural and effective treatments available?
    Response. We know that a little less than 50 percent of VHA 
Veterans who died by suicide had a mental health diagnosis. We believe 
this is due to VA's ongoing efforts to provide quality mental health 
services to all Veterans. There is an ``enhanced care package'' for 
Veterans who have been identified as high risk for suicide. It includes 
suicide-specific interventions such as safety planning and engagement 
into evidence-based psychotherapies. We will continue to enhance our 
mental health services as more information on the effectiveness of our 
programs becomes available.

    Question 8. What are you doing to reach out to families, especially 
parents, to provide education on emergency mental health issues, how to 
identify them and what to do about it?
    Response. VHA Handbook 1160.01 identifies family involvement and 
family services, when appropriate and in connection with the treatment 
of the Veteran, as an essential component of the mental health program. 
To facilitate this patient--centered, family focused transformation in 
services, the Handbook requires that the clinical provider discuss with 
the Veteran the need and the benefits of family involvement in their 
care annually and at the time of discharge if there has been an 
inpatient stay. As part of this process, the provider must seek the 
consent of Veterans to contact family as necessary in connection with 
Veterans' treatment. Additionally, every medical center will provide a 
continuum of family services within existing statutory and regulatory 
authority either on site, by tele-mental health, with community 
providers through sharing arrangements, contracting, or non-VA fee 
basis care to the extent the Veteran is eligible. Providing education 
on emergency mental health issues, including how to identify them and 
what to do about them, are addressed in our graduated continuum of 
services that meet the varying needs of Veterans and their families.
    The continuum of family services includes:

     Family Consultation. Family consultation involves the 
family meeting with a trained mental health professional as needed to 
resolve specific issues related to the Veteran's treatment or recovery, 
which may include emergency mental health issues. The intervention is 
brief, typically one to five sessions are scheduled for each 
consultation. Consultations may be provided on an as needed or 
intermittent basis; if more intensive ongoing effort is required, the 
family can be referred for Family Psychoeducation.
     Family Education. Family education is a set of techniques 
to provide families with the factual information necessary to partner 
with the treatment team to support a Veteran's recovery. Typical topics 
include symptoms, likely treatments, recognizing relapse, identifying 
and managing sources of stress, minimizing crises, and increasing 
problem-solving skills. Family education may be offered through written 
and video materials, one day workshops and/or regularly scheduled 
meetings conducted over time by professionals (e.g. the Support and 
Family Education (SAFE) program) or by trained family members (e.g. the 
National Alliance on Mental Illness Family to Family Education Program 
(NAMI FFEP)). The Veteran may or may not be present at family education 
meetings.
    In June 2008, VHA signed an MOU with NAMI to offer the NAMI FFEP in 
at least one VHA facility in each state during a two year period 
starting in June 2008. The selected VHA facility and local NAMI 
affiliate serve as models to continue this partnership throughout all 
VISNs.
     Family Psychoeducation (FPE). Family psychoeducation is a 
type of evidence-based family therapy that focuses on developing coping 
skills for handling problems posed by mental illness in one member of 
the family. The models of family psychoeducation share a number of 
components, including careful assessment, provision of education, 
problem-solving training, and an emphasis on improving current 
functioning. Interventions can be offered in a single family format 
(e.g. behavioral family therapy) or multi-family group format (e.g. 
multiple family group therapy). Veterans are typically present during 
the FPE sessions.

    With regard specifically to emergency mental health issues, massive 
outreach programs have been established by the Suicide Prevention 
Coordinators at each facility. These include face-to-face presentations 
about how to recognize when someone is in trouble and how to get help. 
In addition, posters, mailings and mass media public service 
announcements have been made available across the country. VA has 
developed its own Veteran-specific ``gatekeeper'' training program for 
communities and families called Operation S.A.V.E. (Signs Ask Validate 
Encourage) which is provided in all communities. VA has developed 
family and age-specific suicide and suicide attempt education materials 
for distribution. VA will continue to seek out ways on local levels to 
communicate with families and communities.
    In addition, in FY 2009 VA produced Public Service Announcements 
(PSAs) starring actor Gary Sinise and news personality Deborah 
Norville. The PSAs aired from October 2008 to September 2009. The 
company contracted for PSA distribution reported that the PSA aired 
over 17,000 times across the country in 118 markets on 222 stations, 
one national cable outlet, and one local cable outlet. Although no 
longer airing, the PSAs are available on a number of Web sites: VA's 
Mental Health Service; House Committee on Veterans' Affairs; the 
official Web site for the US Air Force; and, the Web sites for the 
Military Officers Association of America, Military Lawyer Blog, 
American Legion, National Association of State Directors of Veterans 
Affairs, YouTube, CBS News, etc. A Google search of ``Suicide 
Prevention PSA Gary Sinise,'' displays 20 pages of citations. Mr. 
Sinise has agreed to do another PSA for which funding is available in 
FY 2010. Production of this new PSA is planned for the summer of 2010 
with release over the 2010 holiday season.

    Question 9. Is the VA utilizing peer-based support to help them 
with their behavioral health issues? What are you doing to try to build 
peer-based support for Veterans?
    Response. Currently, peer services are provided at 33 percent of VA 
facilities and the number of such services is growing; these are a 
vital component of optimal Veteran-centered mental health care. VHA 
Handbook 1160.01, Uniform Mental Health Services in VA medical centers 
and Clinics, requires medical centers and very large CBOCs to provide 
individual and group counseling for Veterans with serious mental 
illness through the use of Peer Support Technicians. In addition, 
Residential Rehabilitation Treatment Programs and Psychosocial 
Rehabilitation and Recovery Centers require the inclusion of Peer 
Support Technicians as part of their staffing.
    OMHS has developed job-specific competencies for Peer Support 
Technicians to ensure the high quality of the services provided by 
peers. These competencies are based on the certification examinations 
for peers as administered by some states and outside-VA mental health 
organizations. Finally, OMHS is providing funding for currently-
employed Peer Support Technicians to become certified by an outside 
agency.

    Question 10. How does one diagnose, treat, and prevent depression 
and mental health disturbances in remote areas, for Veterans or 
civilians, this is a difficult task. The use of telepsychiatry and 
methods of selecting high risk populations after discharge are 
important, what methods are being used? Any evidence they are 
successful?
    Response. The diagnosis, treatment and prevention of depression in 
both Veteran and non-Veteran populations in remote areas is based upon 
the same clinical, legal, evidence and health care organizational 
principles as for patients in non-remote areas. The challenges in 
remote areas are the logistic ones of access for both patients and 
practitioners. There are circumstances where there is an obvious need 
for face-to-face service delivery in which case physical health care 
access and associated travel provide the solution. Increasingly tele-
mental health provides a mechanism for specialist care within VA to 
diagnose, treat and prevent depression with expanded accessibility to 
patients locally using health information and telecommunication 
technologies. There is good evidence to show that these Telehealth 
interventions are effective and comparable to face-to-face delivery of 
services. Over 30 peer-reviewed scientific articles have substantiated 
the role for tele-mental health in expanding access to care.

    Question 11. If a family member of a suicide victim requests an 
Inspector General investigation, and their benefits have already been 
approved, can they be denied due to a request for a further 
investigation or the filing of an IG complaint?
    Response. Following the death of a Veteran due to suicide, a 
determination may be made that service connection for cause of death is 
established, and Dependency and Indemnity Compensation benefits may be 
awarded to surviving family members. The request by family members for 
an Inspector General (IG) investigation or the filing of an IG 
compliant would not affect the continued eligibility for those 
benefits.
    All decisions rendered by the Veterans Benefits Administration 
regarding entitlement to or eligibility for benefits, are made based on 
all the evidence of record. The results of an IG investigation would 
only affect previously approved decisions if they provided new evidence 
altering a prior VBA entitlement or eligibility decision.

    Question 12. There are cases in which family members have been 
encouraged to seek help for their spouse or child when they fear they 
may be suicidal as a result of combat related PTSD. Is there a plan to 
provide families with a safe place to call where they can access care 
for their loved one?
    Response. Family members are encouraged to call the VA Suicide 
Hotline (and many do) to get help for their loved ones. The Hotline 
works with all third party callers (families, friends, co-workers, 
etc.) to get Veterans the help they need.

    Question 13. What are the staffing levels in VA facilities and how 
do you see that growing and sustaining?
    Response. VA currently has over 20,000 ``Core Mental Health Staff'' 
(psychiatrists, psychologists, social workers, and nurses) who provide 
care to Veterans with mental health conditions. This represents a 44 
percent increase over the staffing levels in VA at the end of FY 2005, 
when there were 13, 950 mental health providers. We anticipate 
sustaining this staffing level, with some slight additional growth over 
time, as facilities hire additional approved staff in hard-to-recruit 
parts of the country.

    Question 14. Do you have outside groups/evaluators to determine if 
the VA programs are successful?
    Response. VA has numerous outside groups that provide evaluation of 
VA programs. Some key examples include:

     The Joint Commission includes review of mental health 
programs in all medical facility reviews.
     VA's Suicide Hotline was recently reviewed by the American 
Association of Suicidology Crisis Center Accreditation Team and 
received the highest scores possible and a full accreditation. The 
Hotline also has a full CARF accreditation.
     VA requires that many rehabilitation programs receive CARF 
accreditation, including Residential Rehabilitation Treatment Programs 
(RRTPs) and Psychosocial Rehabilitation and Recovery Centers.
     In addition, VHA contracts with Mathematica to conduct 
evaluations of all RRTPs, including on-site visits.
     VHA is currently in the process of a Government 
Performance and Results Act (GPRA) evaluation project to evaluate 
mental health programs; the study is contracted to the RAND 
Corporation.

    Question 15. Should the Mental Health professionals who are working 
with DOD carryover to VA? For example, the professionals (case manager, 
etc.) follow the person, rather than go from DOD to VA, continuity of 
service provider?
    Response. We do not believe that mental health professionals should 
``carry over'' from DOD to VA, as this would involve significant 
logistical concerns and would work geographically for a minority of 
servicemembers. However, we do agree that efforts should be made to 
provide continuity of transition from DOD to VA for mental health 
patients transferred from one Department to the other, for either 
inpatient or outpatient care. For this reason, the in-Transition 
Program was developed in response to a DOD Mental Health Task Force 
recommendation to ``maintain continuity of care across transitions'' 
(5.2.2). This new program went active within DOD on February 1, 2010. 
The in Transition voluntary coaching and assistance program can provide 
a bridge of support for servicemembers while they transition between 
health care systems or providers. VA is enthusiastically partnering 
with DOD to implement this program for those transitioning to VA mental 
health care.

    Question 16. What type of classes is the VA offering for education 
and prevention of suicide and MH issues?
    Response. All VA staff are required to take suicide prevention 
training. There is a web-based clinical program that includes risk 
assessment and treatment strategies for all providers and a general 
awareness program for non-clinicians. In addition, a variety of 
training regarding specific Veteran populations and providers has been 
developed and is offered on a regular basis via national and regional 
suicide prevention conferences and web-based training efforts. Monthly 
calls are held with the Suicide Prevention Coordinators and programs 
have been developed for them to share with their facility staff on 
specific suicide prevention strategies such as safety planning.

    Question 17. What are the non-traditional programs the VA is 
providing?
    Response:

     Veterans Chat is an innovative way for Veterans to seek 
help through VA. VA is exploring ways to provide patient information 
and education through MyHealtheVet. Pilot sites now allow Veterans to 
interact directly with their providers.
     VA also offers care online through MyHealtheVet, as 
covered in other questions.
     VA's use of tele-mental health for direct care provision 
is also innovative and unmatched in any other part of the health care 
system in the United States.
     VA's intensive training to ensure that Veterans can 
receive evidence-based psychotherapy for a variety of mental health 
problems is innovative.
     VA has a work group to review Complementary and 
Alternative Medicine (CAM) approaches to mental health care, as well as 
for other medical problems. Currently no approaches reach a sufficient 
level of evidence for VHA to endorse their use, but we remain open to 
expansion as evidence supports such action.

    Question 18. What are the faith-based programs the VA have or work 
with?
    Response. VA Center for Faith-based and Neighborhood Partnerships 
(CFBNP) is a staff office in the Office of the Secretary of Veterans 
Affairs.
    The CFBNP develops partnerships, works collaboratively, and 
provides relevant information to faith-based, non-profit, community and 
non governmental organizations. Our goal is to assist these 
organizations in working effectively with our Veterans and their 
families.
    Our purpose is to expand the participations of our external 
partners in VA programs equipping them to better serve the needs of our 
Veterans and their families. CFBNP is the only faith-based program at 
the Department of Veterans Affairs.
    In FY 2009 and 2010, VA CFBNP has worked with the organizations 
listed below in the following ways: attendance at VA CFBNP roundtables, 
forums, trainings and or conferences. We have also presented at various 
events hosted by some of these organizations.

     South Avenue United Methodist, Pittsburgh, PA
     YWCA of Greater Pittsburgh, PA
     Salvation Army of Pittsburgh, PA
     Church under the Bridge, Waco, TX
     Greater Vision Church, Houston, TX
     Mission WACO, Waco, TX
     Salvation Army of WACO, Waco, TX
     Korean Churches For Community Development, Los Angeles, CA
     Cassa Madad Community Development Corp., Woodworth, LA
     Goodwill Industries International, Inc., Rockville, MD
     Quad Area CAA, Inc., Hammond, LA
     Catholic Charities, New Orleans, LA
     First Baptist Church of New Orleans, New Orleans, LA
     Mount Olive Baptist Church, Pensacola, FL
     American Red Cross, Washington, DC
     First Non-Denominational Church of Jesus Christ, Arcola, 
TX
     Abundant Life Church, Edgewater Park, New Jersey
     Emmanuel House Recovery Community, Detroit, MI
     Coming Home Project, San Francisco, CA
     Volunteers of America Greater New Orleans, New Orleans, LA
     Dare Mighty Things, Arlington, VA
     Ministry on the Go!--Baton Rouge, LA
     Eighth Episcopal District African Methodist Episcopal 
Church, Jackson, MS
     Non-profit for Utah, Provo, UT

    Question 19. What is the outreach to Veterans from the VA to get 
information to Vets?
    Response. Numerous mechanisms exist to get information to Veterans. 
There are formal mailings, calls and VA participation in DOD events as 
well as informal mass public health messaging on buses and public 
transportation vehicles. We have developed public service announcements 
on suicide prevention and safe driving. We have developed a large 
internet presence through web pages and social media sites.
                                 ______
                                 
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
           Caitlin Thompson, Ph.D., Clinical Care Coordinator
    Question 1. Are any resources needed to make the Suicide Hotline 
program more successful?
    Response. No additional monetary resources are needed at this time. 
We need everyone to continue to urge Veterans and their families to 
call the Hotline or use the Chat Service. Additionally, we need public 
support to destigmatize the concept of getting help for emotional 
issues.
                                 ______
                                 
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
  Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant and Chief 
             Psychologist, Office of Mental Health Services
    Question 1. Do you believe VHA is conducting adequate ongoing 
analysis of its suicide reduction programs to determine the most 
effective strategies to reduce suicide?
    Response. We believe that VHA is conducting extremely thorough 
analyses of its suicide reduction programs. All of the following are 
done:

     We continually analyze available data to look at rates and 
effectiveness.
     We require a monthly report from each facility which is 
reviewed to identify trends, not only in numbers but also risk factors 
and care elements.
     We do annual aggregate reviews on both suicides and 
suicide attempts.
     Our Evaluation Center in Ann Arbor, MI is continually 
looking at VA information in regards to national data.
     We have weekly meetings with the Suicide Prevention Staff 
and the Evaluation Center to continue to look at the information we 
have to provide the most current information to the field. Recently, we 
have released two memorandums to field staff to ensure they are aware 
of recent suicide risk findings. A direct result of these weekly 
reviews has been a memo concerning the relationship between pain and 
suicide and another memo concerning suicide risk in patients with 
Traumatic Brain Injury (TBI).

    Question 2. How effectively do you believe VHA monitors patient 
adherence to treatment?
    Response. Monitoring adherence to treatment is an essential 
clinical function done by staff directly delivering care to Veterans. 
VHA does not have a national program to monitor adherence to mental 
health care, nor is this best handled at the national level. VHA does 
have a policy that any patient receiving mental health care who misses 
an appointment unexpectedly (i.e. not calling in or otherwise notifying 
the provider of a need to change an appointment) must be contacted to 
determine the reason for the missed appointment and to establish a new 
return appointment (unless the Veteran refuses to do so). A minimum of 
three follow-up attempts to contact the Veteran are required to ensure 
the patient is linked back into care. If the patient is known to be at 
high risk for suicide, follow-up attempts should include a visit to the 
patient's home with the assistance of community based local crisis 
response teams or law enforcement if the patient cannot otherwise be 
contacted. This requirement for active follow-up also triggers an 
opportunity for providers to discuss adherence and any concerns the 
Veteran may have about their treatment regimen.

    Question 3. How fully has VHA integrated the TIDES Project into 
each of its outpatient facilities system-wide?
    Response. Translating Initiatives for Depression into Effective 
Solutions (TIDES) is an evidence-based care management model that VHA 
has implemented in routine practice as part of the primary care-mental 
health integration (PC-MHI) program. Consistent with the PC-MHI 
program, it has expanded to include activities addressing anxiety 
disorders, problem use of alcohol, other substance use disorders, and 
Post Traumatic Stress Disorder (PTSD). TIDES is one of several care 
management models that may serve as a component to a facility's PC-MHI 
program. Presently, 24 VHA facilities across 12 VISNs have care 
management programs based on the TIDES model. The Steering Committee 
for Mental Health/Primary Care integration continues to conduct 
training to assist additional sites in developing a TIDES component for 
their care. Training on another model, the Behavioral Health Lab, also 
is provided, and sites can select which of these care management 
programs to institute.

    Question 4. We know that the stigma associated with mental health 
problems is a serious barrier to Veterans seeking treatment. What else, 
in addition to VA's current efforts to overcome stigma, would be 
beneficial?
    Response. VA has been diligent in dealing with the stigma issues 
associated with mental health problems and will continue to work on 
them. In the area of suicide prevention specifically, VA has developed 
a mass media campaign including posters, bus and train displays, public 
service announcements and community education programs. VA has recently 
increased the required number of outreach activities from three to five 
per month for all of our local Suicide Prevention Coordinators and they 
have been asked to focus on both local Veterans Service Organizations 
(such as the American Legion, which has partnered with VA to promote 
suicide prevention awareness) and college campuses. VA has increased 
access to care mechanisms by developing the Suicide Hotline and VA Chat 
Service which allows Veterans to access care anonymously initially. VA 
has asked the suicide prevention coordinators, OEF/OIF coordinators, 
and homeless coordinators to initially meet with Veterans outside of VA 
to establish relationships. The Vet Centers offer services that are not 
associated with the ``stigma'' of mental health in the form of 
readjustment counseling.
    It will take all of these approaches, and more, to break down these 
barriers. VA needs community support and assistance to do this. VA 
knows that leadership at all levels can be influential in breaking down 
barriers and setting examples. Senior DOD leaders are providing this 
support, which is very beneficial. Dr. Rudd spoke to this in his 
testimony. VA is working with national and community leaders to provide 
support and examples of effective actions. VA continues to work with 
families to make them aware of the signs and symptoms of people in 
trouble and provide them with ways to seek help. VA plans to work with 
employers to recognize signs of difficulty and encourage them to assist 
Veterans to get assistance. This is a national undertaking and VA will 
continue to do its part.

    Question 5. Do patient outcomes indicate that inpatient or 
outpatient mental health programs are more cost effective when 
considering the cost of the patient recidivism?
    Response. A global statement cannot be made because some conditions 
are better treated in an inpatient setting, and many others can be 
treated very effectively in an outpatient setting. VA provides care in 
a number of inpatient, residential rehabilitation, and outpatient 
settings, and strives to provide care in the least restrictive setting 
possible. The general trend in recent decades has been a substantial 
transition to care predominantly in outpatient settings, with increased 
utilization of residential rehabilitation care and decreased 
utilization of inpatient care and length of stay in inpatient. Fewer 
patients with mental health conditions are being treated in inpatient 
settings, and their average length of stay on an inpatient unit has 
also declined substantially, compared to 10 and 20 years ago. These 
changes are driven primarily by the mandate to provide care in the 
least restrictive setting, to sustain a Veteran's contact with and 
identity with the community (i.e. avoid institutionalization), and to 
promote a model of care that emphasizes psychosocial rehabilitation 
with a recovery orientation. This model of care is well supported by 
evidence and provides the greatest hope for quality of life to Veterans 
being treated for mental health problems.

    Question 6. How can VA better address the unique challenges of 
providing mental health services in the rural setting in light of the 
unique challenges that face rural communities?
    Response. Availability of VA's CBOCs and use of tele-mental health 
services have improved access to mental health care for rural Veterans. 
Contracting with community providers is another vehicle for improving 
access to mental health care. Each of these continues to be expanded to 
make the full array of mental health services available and accessible 
to Veterans living in rural areas. In addition, several innovative 
strategies are underway:

     Section 107, Pub. L. 110-387 authorized VA to conduct a 
three year pilot program to assess the feasibility and advisability of 
providing mental health services to OEF/OIF Veterans who reside in 
rural areas and do not have ready access to VA mental health services. 
VISNs 1, 19 and 20 (VA New England Healthcare System, Rocky Mountain 
Network and Northwest Network) are participating in the pilot program 
and are in the process of negotiating contracts with community 
providers. It is anticipated that all the pilot programs will be 
operating by October 2010 and be completed by the end of September 
2012.
     An expansion of the Mental Health Care Intensive Care 
Management--Rural Access Network for Growth Enhancement (MHICM-RANGE) 
initiative has been supported by VA's Office of Rural Health. This 
initiative adds mental health staff to CBOCs, enhances tele-mental 
health services and uses referrals to community mental health services 
and other providers to increase access to mental health care in rural 
areas. The expansion of MHICM-RANGE has also led to four research 
studies initiated in VISN 16 (South Central VA Health Care Network) to 
investigate clinical policies or programs that improve access, quality 
and outcomes of mental health and substance abuse treatment services 
for rural and underserved Veterans.
     The Vet Centers provide a continuum of social and 
psychological services including community outreach to special 
populations, professional readjustment counseling to Veterans and 
families, and brokering of services with community agencies that 
provide a key access link between the Veteran and other needed VA and 
non-VA services. A core value of the Vet Centers is to promote access 
to care by helping Veterans and families overcome barriers that impede 
the receipt of needed services. To extend the geographical reach of Vet 
Center services, the Readjustment Counseling Service (RCS) has 
implemented initiatives to ensure that new OEF/OIF combat Veterans 
living at a distance from existing services have access to care. 
Following the on-set of hostilities in Afghanistan and Iraq, the Vet 
Center program hired 100 OEF/OIF Veteran Outreach Specialists to 
proactively contact their fellow returning Veterans at military 
demobilization sites, including National Guard and Reserve locations. 
The RCS' Mobile Vet Center (MVC) program is another major initiative 
for extending the geographical outreach and counseling services to OEF/
OIF combat Veterans and their families. To facilitate access to 
services for Veterans in hard-to-reach outlying areas, RCS has deployed 
50 Mobile Vet Centers to strategically selected Vet Centers across the 
country. The placement of the vehicles is designed to cover a national 
network of designated Veterans Service Areas (VSAs) that collectively 
cover every county in the continental United States. The 50 MVCs are 
used to provide early access to returning combat Veterans via outreach 
to active military demobilization sites, including National Guard and 
Reserve sites, and extending services to Veterans at PDHRAs. The 
vehicles are also extending Vet Center outreach to more rural 
communities distant from existing VA services.
     OMHS has partnered with the My HealtheVet Program office 
and Office of Information and Technology (OI&T) to develop online 
resources designed to complement traditional mental health services, 
and to expand access to these services to Veterans in rural areas. OMHS 
is working closely with the Office of Health Information and OI&T to 
develop My Recovery Plan--an online, interactive application designed 
to support Veteran-centered, evidence-based mental health practices. 
Sections of My Recovery Plan will be available for self-paced 
independent work, while other areas will be made available to Veterans 
in conjunction with work with a provider. Both approaches can 
facilitate treatment for Veterans in rural areas.

    Question 7. Access to care is a critical concern. Dr. Rudd's 
testimony suggested putting providers on college campuses to reach OEF/
OIF Veterans. What else should VA be doing to make mental health care 
more available?
    Response. VHA is implementing the Uniform Mental Health Services 
Handbook, designed to ensure consistent access to services for Veterans 
in VAMCs and CBOCs. A recent survey of the field indicated that as of 
December 31, 2009, the VAMC Handbook implementation rate for VAMCs and 
CBOCs was 98 percent.
    Among the initiatives that are in place to assist community and 
rural health care providers is an Internet Web site with basic 
information on assessment and treatment of PTSD designed for college 
mental health counselors who, like many community providers, may not 
have knowledge about military service or experience treating combat 
related PTSD and other disorders associated with war. It can be 
accessed on the Internet at www.mentalhealth.va.gov/College/index.asp. 
Access to services is supported increasingly by Internet-based 
resources such as the VA OEF/OIF web site at www.oefoif.va.gov and the 
National Center for PTSD's web site at www.ptsd.va.gov, as well as a VA 
presence on social media sites such as Facebook and Twitter.
    Other initiatives from OMHS include implementation of Public Law 
110-387 (Veterans' Mental Health and Other Care Improvements Act of 
2008) Title I, Section 107. Three pilots will be implemented in VISNs 
1, 19, 20 to assess the feasibility and advisability of providing 
mental health services to OEF/OIF Veterans who reside in rural areas 
and do not have ready access to mental health services through VA 
facilities. The effort will focus on Veterans who served as members of 
the National Guard or Reserves as well as those separated from active 
duty. Services will be provided through collaboration with community-
based entities including community mental health centers, the Indian 
Health Service (IHS), and other providers. The three VISNs are 
negotiating contracts with community providers. It is anticipated that 
all the pilot programs will be operating by October 2010 and be 
completed by the end of September 2012.
    Telehealth capability is being expanded in rural CBOCs and also for 
home Telehealth approaches. tele-mental health brings expert clinical 
care and consultation services as close as possible to the Veteran.
    In addition, VA's RCS has deployed 50 Mobile Vet Centers across the 
Nation specifically to meet the needs of rural Veterans and families. 
The placement of the 50 Mobile Vet Centers was designed to cover a 
national network of designated Veterans Service Areas, inclusive of 
every county in the continental US and not to augment the services at 
any particular Vet Center.
                                 ______
                                 
Response to Additional Post-Hearing Questions Submitted by Hon. Daniel 
 K. Akaka to Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant 
        and Chief Psychologist, Office of Mental Health Services
    Question 1. Please elaborate on the differences between inpatient 
care for women veterans and residential care for women veterans.
    Response. Inpatient care and residential care are significantly 
different models of care The inpatient care model is a very short 
length-of-stay (a few days to at most a couple of weeks) for those who 
are most acutely ill, are a danger to themselves or others, and cannot 
safely receive treatment in a less restrictive environment. The goal is 
symptom stabilization. Inpatient care is typically in locked units, 
with patients not able to come and go at will.
    Residential care is rehabilitation-focused care, with lengths of 
stay of many weeks or even months, with time for prolonged treatment. 
Residential programs provide a strong emphasis on rehabilitation and 
recovery services and offer this longer-term treatment to Veterans who 
may have a wide range of problems, illnesses, or rehabilitative care 
needs requiring more intensive treatment than can be provided in an 
outpatient setting. Residential care programs are typically open units 
that instill personal responsibility and support and strengthen the 
patient's links to family and community.
    Thus, the goals, structure, and personal experience of someone in 
the inpatient level of care vs. the residential level of care would be 
extremely different.

    Question 2. How many ``women only'' residential care units are 
there in the VA system? Where are they located? How many Veterans does 
each of them accommodate? What condition are they treated for in these 
facilities?
    Response. Mental Health Residential Rehabilitation Treatment 
Programs (MH RRTP) provide residential treatment in a 24-hour, 7 days 
per week, supervised and therapeutic milieu for Veterans in need of 
more intensive treatment of mental health conditions and addictive 
disorders than can be provided in an out-patient setting. Women 
Veterans comprised 5.2 percent (1,789) of the total episodes of care in 
MH RRTP in FY 2009 (North East Program Evaluation Center--NEPEC). Most 
MH RRTPs have the capacity to serve women Veterans. In FY 2009, there 
were a total of 237 operational MH RRTP providing more than 8,440 
treatment beds, which includes 252 beds dedicated to women Veterans in 
35 of the programs (NEPEC). Of those, there are six MH RRTP that are 
dedicated to serving women Veterans in a setting where no male patients 
would be receiving care on the same unit at the same time:

     Boston, MA: 8 beds
     Brockton, MA: 8 beds
     Batavia, IL: 6 beds
     Lyons, NJ: 10 beds
     Temple, TX: 8 beds
     Palo Alto, CA: 10 beds

    The most prevalent diagnoses of women Veterans receiving services 
in MH RRTP are substance use disorder (SUD), PTSD, and depression.

    Question 3. Of the women requiring inpatient care services at VA 
facilities, how many of them are receiving care for Military Sexual 
Trauma (MST)? What other conditions require inpatient care for women 
Veterans? Do you receive many complaints from women veterans with 
regard to the location of the inpatient care services for them within 
the VA facilities?
    Response. OMHS produces reports annually on the amount of 
outpatient Military Sexual Trauma (MST) related care at each facility 
and the proportion of all patients with a history of a positive MST 
screen who have received MST-related care. MST-related care is 
monitored using the MST encounter form checkbox in the Computerized 
Patient Record System (CPRS) electronic medical record system. The 
encounter form checkbox allows clinicians to specially designate VHA 
encounters when they have provided MST-related care as part of the 
check-out procedure for an outpatient visit. This designation is 
available for any outpatient VHA encounter of a patient with a positive 
MST screen. However, inpatient care does not have a parallel checkout 
process that would allow providers to designate that an inpatient stay 
was related to MST. Therefore at this time, OMHS is not able to track 
the number of women receiving inpatient MST-related care.
    Inpatient care is appropriate for women Veterans who are acutely 
ill and are a danger to themselves or others and cannot safely receive 
treatment in a less restrictive environment than the locked, controlled 
inpatient unit.
    OMHS does not receive many complaints from women Veterans regarding 
the location of the inpatient care services for them within VA 
facilities. However, OMHS understands that continued efforts to enhance 
safety and security on inpatient units, and especially the 
psychological experience of safety and security on inpatient units, is 
a priority effort for mental health care settings as well as other 
health care settings in VHA. Clear standards for such enhanced safety 
and experience of psychological safety are laid out in the Uniform 
Mental Health Services Handbook and OMHS continues to monitor toward 
full implementation of those standards.
    It is important to understand, however, that the majority of care 
in a setting with bed capacity for women (and men) Veterans is provided 
in the RRTPs. VHA also offers mental health care to women Veterans on 
Residential Rehabilitation Treatment Program (RRTP) units.

    Question 4. What is the percentage of women mental health providers 
within VA?
    Response. Among VHA employees at the start of FY 2010, 55.1 percent 
of psychologists are female; 72.2 percent of social workers are female; 
and 41.2 percent of psychiatrists are female.

    Question 5. What is the percentage of women veterans receiving 
health care services for MST? What other mental health conditions 
require women veterans to receive care?
    Response. Among women outpatients in FY 2009, 21.9 percent (53,295) 
had a positive screen for MST. Among women with a positive MST screen 
69.7 percent (37,132) had at least one MST-related outpatient encounter 
during FY 2009.
    MST is an experience, not a diagnosis. Women Veterans receive 
mental health care, including MST-related mental health care, for a 
variety of mental health conditions diagnosed by VA providers. In FY 
2008, the top five primary diagnoses for women associated with MST-
related mental health encounters were PTSD (46.6 percent), major 
depression (20.1 percent), mania or bipolar disorder (7.7 percent), 
schizophrenia and psychoses (5.6 percent), and SUDs (4.0 percent).
    Women Veterans receive care for all mental health conditions, 
including depression, PTSD, SUDs, and various psychotic disorders.
                                 ______
                                 
Response to Post-Hearing Questions Submitted by Hon. Daniel K. Akaka to 
Theresa Gleason, Ph.D., Deputy Chief Mental Health Services, Office of 
                        Research and Development
    Question 1. Can you describe how the Quality Enhancement Research 
Initiatives (QUERI) have translated evidence-based practice into real-
world clinical care and how VA might use such findings to improve the 
delivery and patient outcomes of its mental health and substance abuse 
services?
    Response. The QUERI program uses a systematic approach to translate 
evidence-based practices in high-priority areas such as mental health. 
QUERI identifies proven practices, examines where there are gaps in 
delivering those practices and why, creates and tests interventions to 
close those gaps, and finally demonstrates how these strategies can be 
implemented on a larger scale within VHA. One of the most important 
lessons from QUERI is the need to align multiple parts of the health 
care system to make sure important practices are measured, prioritized, 
rewarded and facilitated at multiple levels of the organization. The 
QUERI program has participated in developing VA guidelines, performance 
measures, training programs, education for Veterans and tools to help 
facilities implement new practices.
    The Mental Health QUERI, under a series of projects beginning ten 
years ago with ``TIDES'' (Translating Initiatives for Depression into 
Effective Solutions), developed interventions to address problems in 
care for the large number of Veterans with depression. They used a 
proven model of collaborative care where mental health nurse care 
managers assist primary care providers in managing depressed patients 
and facilitate collaboration between primary care and mental health 
specialists. To facilitate the uptake of this, they developed 
educational and training materials for providers and managers, 
specialized software for care managers to monitor their patients, and 
programs to help new sites implement this new model of care. QUERI 
studies demonstrated that the intervention led to more patients 
receiving effective treatments and to improvements in quality of life 
and demonstrated that the program was cost-effective. This model has 
been implemented in over 50 practices in VA as part of efforts to meet 
Uniform Mental Health Services handbook requirements and improve care 
of depressed patients in primary care. The model has also been extended 
to patients being treated in Human Immunodeficiency Virus (HIV) care 
settings and substance abuse clinics.
    Investigators are also testing methods to disseminate telemedicine-
based collaborative care for depression to rural, community-based 
outpatient clinics (CBOCs). Participating CBOCs have improved 
performance on the national measure for antidepressant medication 
continuity and 32 percent of Veterans completing the intervention 
responded to treatment. This web-based clinical information system for 
depression care management also is being used at some primary care 
mental health integration (PCMHI) sites to support clinical activities.
    As a result of QUERI Substance Use Disorder (SUD) projects, VA has 
implemented national clinical reminders for alcohol screening and for 
brief intervention which can prevent more serious alcohol-related 
problems. As a result, over 95 percent of all Veterans are routinely 
screened for problem drinking, and rates of documented brief alcohol 
intervention have been increasing steadily since January 2008, when the 
clinical reminder developed by the QUERI was disseminated. In the first 
year, rates of brief intervention increased from 42 to 58 percent.
    QUERI investigators have also developed a care model for patients 
who do not respond to brief interventions, decline referral to 
addictions specialty care, and are at high risk of having alcohol use 
disorders. This care model provides brief interventions that reduce 
problem drinking in over 50 percent of Veterans getting the 
intervention and provides outpatient medical withdrawal and 
pharmacotherapy for preventing relapse in those Veterans with alcohol 
dependence. Prescribing these medications like naltrexone has 
substantially increased over the past three years, although it remains 
well below optimal utilization.
    QUERI investigators have also developed a reminder for assessing 
depressive symptomatology among persons in treatment for substance use 
disorders. The reminder incorporates the PHQ-9 (the nine item 
depression scale of the Patient Health Questionnaire) depression screen 
with additional questions needed to discern if current symptoms are 
likely non-substance-induced. The reminder provides the assessment 
tool, scores it, and provides evidence-based treatment recommendations 
based on the score.
    QUERI SUD investigators have improved continuity of care and 
treatment retention through Veteran engagement in self-help groups and 
specific improvements and expansions in opiate maintenance treatment. 
They have developed a Web site that provides clinicians with an 
empirically-based ``3-Step Referral Method'' for engaging SUD patients 
in 12-step and other self-help groups. Opiate maintenance treatment has 
been substantially improved through three evidence-based QUERI 
interventions: 1) extensive training and Drug Enforcement Agency (DEA) 
certification of providers to prescribe buprenorphine for cost-
effective maintenance treatment in the over 120 VA facilities where 
methadone maintenance is not available, 2) Doubled medication doses in 
methadone and buprenorphine maintenance from sub-therapeutic levels to 
national guideline levels, and 3) Implemented contingency management 
therapies throughout SUD programs.

    Question 2. What are the determinants of best practices that 
optimize the cost-effectiveness of mental health and substance abuse 
care?
    Response. Standards for mental health care are driven primarily by 
evidence regarding the evidence-base for interventions, with the 
philosophy that the most effective care is also the most cost-effective 
given VHA's life time commitment to the Veterans we serve. Short term 
cost-benefit is not as important as knowing that care is provided that 
will decrease current symptoms, increase psychosocial rehabilitation 
and recovery, and that have been shown to have the greatest likelihood 
of decreasing future relapses. VA and DOD develop Clinical Practice 
Guidelines for major mental health conditions. These are developed and 
regularly updated to incorporate all of the current evidence on 
effective care and also contain information relevant to cost 
effectiveness. VHA endorses utilization of these Clinical Practice 
Guidelines and they have been incorporated into the Uniform Mental 
Health Services Handbook to provide consistent guidance to mental 
health providers in the field.

    Question 3. With regard to the integration of mental health 
services into primary care settings, have any studies measured the 
success of these initiatives at various phases of the treatment and 
recovery process? For instance, while the integration of mental health 
services into the primary care setting may increase access to mental 
health services by reducing the stigma for seeking help, has the 
primary care setting been effective at retaining patients in need of 
more extensive, ongoing mental health care?
    Response. Implementation of PC-MHI into routine practice within VHA 
is an evidence-based practice supported by prior VA and non-VA 
research. PC-MHI implementation began during FY 2007 and expanded with 
the requirements of the Uniform Mental Health Services Handbook in FY 
2009. Studies presenting data on these implementation efforts have not 
presently been published; however, there are several sources of 
pertinent data to report:

    a. First, significant improvements in screening for depression, 
alcohol misuse and PTSD have occurred during the period of PC-MHI 
implementation. Specifically, depression screening performance was 83 
percent in FY 2008, 93 percent in FY 2009, and 96 percent in FY 2010 
(first quarter); alcohol misuse screening was 87 percent in FY 2008, 95 
percent in FY 2009, and 97 percent in FY 2010 (first quarter); and PTSD 
screening was 79 percent in FY 2008, 94 percent in FY 2009, and 98 
percent in FY 2010 (first quarter).
    b. Second, a study presently undergoing peer review found that the 
prevalence of diagnoses for depression, anxiety, PTSD, and alcohol 
abuse increased more from FY 2007 to FY 2008 in facilities with PC-MHI 
program encounters than those without such program activity. This 
demonstrates PC-MHI program activity is building on screening to 
achieve greater case identification.
    c. Third, the average number of PC-MHI encounters per unique 
Veteran was 2.38 in FY 2008 and 2.42 in FY 2009. This demonstrates 
engagement beyond initial case identification within the primary care 
setting.
    d. Finally, another study presently under peer review found no 
decrease in rates of mental health clinic encounters for new patients 
by facility PC-MHI status during 2008-2009.

    Together, the data above show improvements in screening, case 
identification, overall uptake, and retention of Veterans in mental 
health care across all care settings within the VHA system.

    Question 4. Access to care is a critical concern. Dr. Rudd's 
testimony suggested putting providers on college campuses to reach OEF/
OIF veterans. What else should VA be doing to make mental health care 
more available?
    Response. VHA is implementing the Uniform Mental Health Services 
Handbook, designed to ensure consistent access to services for Veterans 
in VAMCs and CBOCs. A recent survey of the field indicated that as of 
December 31, 2009, the VAMC Handbook implementation rate for VAMCs and 
CBOCs was 98 percent.
    Among the initiatives that are in place to assist community and 
rural health care providers is an Internet Web site with basic 
information on assessment and treatment of PTSD designed for college 
mental health counselors who, like many community providers, may not 
have knowledge about military service or experience treating combat 
related PTSD and other disorders associated with war. It can be 
accessed on the Internet at www.mentalhealth.va.gov/College/index.asp. 
Access to services is supported increasingly by Internet-based 
resources such as the VA OEF/OIF web site at www.oefoif.va.gov and the 
National Center for PTSD's web site at www.ptsd.va.gov, as well as a VA 
presence on social media sites such as Facebook and Twitter.
    Other initiatives from OMHS include implementation of Public Law 
110-387 (Veterans' Mental Health and Other Care Improvements Act of 
2008) Title I, Section 107. Three pilots will be implemented in VISNs 
1, 19, 20 to assess the feasibility and advisability of providing 
mental health services to OEF/OIF Veterans who reside in rural areas 
and do not have ready access to mental health services through VA 
facilities. The effort will focus on Veterans who served as members of 
the National Guard or Reserves as well as those separated from active 
duty. Services will be provided through collaboration with community-
based entities including community mental health centers, the Indian 
Health Service (IHS), and other providers. The three VISNs are 
negotiating contracts with community providers. It is anticipated that 
all the pilot programs will be operating by October 2010 and be 
completed by the end of September 2012.
    Telehealth capability is being expanded in rural CBOCs and also for 
home Telehealth approaches. tele-mental health brings expert clinical 
care and consultation services as close as possible to the Veteran.
    In addition, VA's RCS has deployed 50 Mobile Vet Centers across the 
Nation specifically to meet the needs of rural Veterans and families. 
The placement of the 50 Mobile Vet Centers was designed to cover a 
national network of designated Veterans Service Areas, inclusive of 
every county in the continental US and not to augment the services at 
any particular Vet Center.

    Question 5. How effectively is VHA utilizing an evidence-based 
screening methodology for determining which treatment setting might be 
more effective for certain patients with specific risk factors?
    Response. VHA is effectively using evidence-based screening for 
identifying cases of depression, alcohol misuse and PTSD; performance 
for these respective screenings was 96 percent, 97 percent, and 98 
percent in the first quarter of FY 2010. Furthermore, primary care-
mental health integration is an evidence-based program that enhances 
subsequent evaluation and treatment planning, including identification 
of the treatment setting most appropriate to a Veteran's clinical needs 
and preferences.

    Question 6. In addition to Veterans severely injured and those 
returning from combat zones, do any of you have any recommendations for 
identifying less obvious groups of veterans who might be at an 
increased risk for suicide?
    Response. We know the common risk factors for suicide and do screen 
for depression and PTSD on a regular, recurring basis. If Veterans 
screen positive for these they are then assessed for suicide risk.

    Question 7. We know that the stigma associated with mental health 
problems is a serious barrier to veterans seeking treatment. What else, 
in addition to VA's current efforts to overcome stigma, would be 
beneficial?
    Response. VHA is implementing the Uniform Mental Health Services 
Handbook, designed to ensure consistent access to services for Veterans 
in VAMCs and CBOCs. A recent survey of the field indicated that as of 
December 31, 2009, the VAMC Handbook implementation rate for VAMCs and 
CBOCs was 98 percent.
    Among the initiatives that are in place to assist community and 
rural health care providers is an Internet Web site with basic 
information on assessment and treatment of PTSD designed for college 
mental health counselors who, like many community providers, may not 
have knowledge about military service or experience treating combat 
related PTSD and other disorders associated with war. It can be 
accessed on the Internet at www.mentalhealth.va.gov/College/index.asp. 
Access to services is supported increasingly by Internet-based 
resources such as the VA OEF/OIF web site at www.oefoif.va.gov and the 
National Center for PTSD's web site at www.ptsd.va.gov, as well as a VA 
presence on social media sites such as Facebook and Twitter.
    Other initiatives from OMHS include implementation of Public Law 
110-387 (Veterans' Mental Health and Other Care Improvements Act of 
2008) Title I, Section 107. Three pilots will be implemented in VISNs 
1, 19, 20 to assess the feasibility and advisability of providing 
mental health services to OEF/OIF Veterans who reside in rural areas 
and do not have ready access to mental health services through VA 
facilities. The effort will focus on Veterans who served as members of 
the National Guard or Reserves as well as those separated from active 
duty. Services will be provided through collaboration with community-
based entities including community mental health centers, the Indian 
Health Service (IHS), and other providers. The three VISNs are 
negotiating contracts with community providers. It is anticipated that 
all the pilot programs will be operating by October 2010 and be 
completed by the end of September 2012.
    Telehealth capability is being expanded in rural CBOCs and also for 
home Telehealth approaches. tele-mental health brings expert clinical 
care and consultation services as close as possible to the Veteran.
    In addition, VA's RCS has deployed 50 Mobile Vet Centers across the 
Nation specifically to meet the needs of rural Veterans and families. 
The placement of the 50 Mobile Vet Centers was designed to cover a 
national network of designated Veterans Service Areas, inclusive of 
every county in the continental US and not to augment the services at 
any particular Vet Center.

    Question 8. Have male and female veterans differed much in their 
treatment outcomes for various models of mental health services? If so, 
how well do you believe VA has factored such differences into its 
treatment programs?
    Response. VA utilizes evidence-based treatments that have been 
shown to be effective for both men and women in numerous research 
trials, and VA uses adaptations for women as needed and supported by 
evidence. Analyzing the impact of gender on outcomes specifically among 
Veterans is complicated, and somewhat time-consuming. Women make up 
about 10% of our treated patient population, so there is a constant 
imbalance in sample sizes that needs to be addressed. This is further 
complicated by the fact that female Veterans are disproportionately 
younger--a greater percentage of them are from the current OEF/OIF era, 
while a greater percentage of male Veterans are from the older, Vietnam 
era. The table below documents these trends, showing the numbers of 
unique Veterans treated in recent years in Mental Health settings, and 
in any VA treatment setting.




    These factors skew direct comparisons between all males and 
females, or the average male versus the average female. Nonetheless, we 
do gather and analyze data on relative utilization, lengths of stay, 
and similar variables for male versus female Veterans being served in 
specific settings such as Residential Rehabilitation Treatment Programs 
(RRTPs).
    Within RRTPs, we have observed that:

     Women have shorter lengths of stay (approx 2 days);
     They are less likely to have an irregular discharge;
     They are more likely to be discharged to a VA hospital;
     They are less likely to be readmitted; and
     They have more outpatient care after discharge than men.

    See attached table on outcomes for RRTP programs.

    
    

    Among patients with Alcohol Use Disorders or Substance Use 
Disorders (AUD/SUD), we have observed that women tend to:

     engage in specialty treatment at higher rates than men;
     stay in treatment longer; and
     have better long-term outcomes.

    In short, women tend to be more comfortable seeking help for AUD/
SUD treatment as it is generally provided.
    However, other studies, including some in VA, have found that women 
with SUD may have more psychiatric comorbidities and additional 
psychosocial challenges which may complicate treatment engagement and 
recovery.
    VA has been putting efforts into making specialty SUD treatment 
more appealing and accessible for Veterans of both genders. Recognizing 
that women Veterans may be more likely to reach specialty care, but 
have special needs once engaged, VA has been developing a special mix 
of services for female Veterans at its specialty SUD treatment 
programs. In FY 2008, approximately one-third of VA specialty SUD 
treatment clinics offered specific treatment services for women, and we 
(who is WE?) VHA expects these services will continue to expand.
    Among Veterans with Serious Mental Illness (SMI), a group of VA 
researchers reported in 2008 a number of gender differences they 
observed. They found that the females in their sample, as compared to 
males, were:

     younger;
     more likely to be diagnosed as having bipolar disorder;
     more likely to have completed a high school education;
     more likely to be employed;
     less likely to be married; and
     more likely to live alone.

    In addition, female respondents in the study reported greater use 
of health services outside of the VA. In this study, the female 
Veterans were found to have more severe symptoms on average, but rated 
their own self-perceived health and mental health more positively.
    Among Veterans with Post Traumatic Stress Disorder (PTSD), we have 
observed that women treated in intensive PTSD programs had:

     Significantly lower PTSD symptoms;
     Significantly lower alcohol use scores (ASI);
     No difference in drug use scores;
     No difference in reports of violence;
     No difference in days worked; and
     No difference in satisfaction with care.

    In short, there is a complex pattern of gender differences observed 
among the Veterans treated in the VA. VA continues to recognize and 
respond to gender-based differences and needs. Clinicians or officials 
continue to monitor the impacts our programs have on men and women, and 
continue to make adjustments in the delivery of services in response to 
any patterns observed.

    Question 9. Do you believe VHA is conducting adequate ongoing 
analysis of its suicide reduction programs to determine the most 
effective strategies to reduce suicide?
    Response. We believe that VHA is conducting extremely thorough 
analyses of its suicide reduction programs. All of the following are 
done:

     We continually analyze available data to look at rates and 
effectiveness.
     We require a monthly report from each facility which is 
reviewed to identify trends, not only in numbers but also risk factors 
and care elements.
     We do annual aggregate reviews on both suicides and 
suicide attempts.
     Our Evaluation Center in Ann Arbor, MI is continually 
looking at VA information in regards to national data.
     We have weekly meetings with the Suicide Prevention Staff 
and the Evaluation Center to continue to look at the information we 
have to provide the most current information to the field. Recently, we 
have released two memorandums to field staff to ensure they are aware 
of recent suicide risk findings. A direct result of these weekly 
reviews has been a memo concerning the relationship between pain and 
suicide and another memo concerning suicide risk in patients with 
Traumatic Brain Injury (TBI).

    Chairman Akaka. Thank you very much, Dr. Cross.
    Dr. Thompson, do you have any further comments for me?
    Ms. Thompson. It is just such an honor to be here today and 
especially to be representing the staff of 160 hotline 
responders and their staff who are up in Little Canandaigua, 
New York.
    I do have a story that I would like to tell about one of 
the rescues that we had. I am just going to tell it. This 
happened in October. At about 1 p.m., one of my colleagues took 
a call from a Vietnam veteran in his 60s who said that he was 
on his way into a Wal-Mart to purchase razor blades for the 
sole purpose of killing himself. As Bruce, my colleague, tried 
to gather more information from the veteran, he hung up. He 
tried to call back, but there was no answer, and the veteran 
appeared to use a cell phone, which is sometimes really hard to 
trace.
    About a half-hour later, another colleague--her name is 
Gloria--answered the call of a veteran who told her that he had 
purchased razor blades and was going to kill himself. Again, 
Gloria tried to keep him on the phone, trying to engage him, 
asking about his location, but the veteran again hung up. Our 
staff tried to pinpoint his location through his phone number, 
but we couldn't. There wasn't enough information.
    Finally, 20 minutes passed again and this time it was my 
hotline phone that rang. An older man started to yell that he 
was bleeding. He had slit open his wrists with broken razor 
blades, he had told me. I tried to calm him down, asking him to 
tell me where he was, but he initially refused. He didn't want 
me to send help. He wanted to die, he told me. He was homeless, 
lost contact with his family. He said that he really had 
nothing to live for.
    I tried to work through why he was actually calling. Just 
that very act of picking up a telephone and dialing a number 
for a suicide hotline usually signifies an ambivalence that 
people really--whether or not they do or they don't want to 
die. I was able to keep him on the line, and as we talked, he 
would vacillate between saying that he wanted to die and he 
wanted to live. And then the conversation was just punctuated 
by these moments when he would panic and scream about his 
bleeding and begging me to help him.
    Of course, my first priority was to keep him engaged and 
awake and also to gather as much information about his location 
as possible so that rescue could be sent immediately. After a 
while, he started to give clues. He said he was near a dumpster 
in an Applebee's parking lot. He was wearing a green T-shirt 
and jeans. He was in a small town in North Carolina. And 
finally, he told me the intersection near the parking lot. With 
that, he hung up the phone.
    And with the help of other hotline staff and local North 
Carolina authorities, we found him within 15 minutes. He was 
still alive. He was taken to a local hospital and then had 
continued care with his suicide prevention coordinator at his 
local VA.
    And I tell this story because it is so indicative of the 
stories that happen every day. It illustrates so powerfully how 
this immediate access to mental health professionals over the 
phone can save lives. Even though this veteran wasn't able to 
engage immediately and accept the help that he needed within 
the first couple calls, he just continued to call back until he 
was ready to engage and we were always ready for him. So I just 
happened to be the responder who answered the phone when he was 
ready.
    Thank you for letting me tell this story.
    Chairman Akaka. Thank you very much, Dr. Thompson.
    Dr. Cross, thank you for sharing the chart on the reduction 
in suicides for VA patients. It is good to see rates going down 
for VA patients. Dr. Cross, does this chart represent suicides 
for all patients or does this chart just represent suicides 
that have occurred related to an inpatient stay?
    Dr. Cross. Sir, these were folks who have engaged with any 
part of our VA Health Care programs, inpatient, outpatient, and 
we worked with the CDC to get the national death index data and 
we bump up our enrollees, or the folks who are using our 
services, against that data set. It is probably the best data 
we have. That is the most current data, by the way, from the 
CDC that is available. It takes--there is a little bit of lag 
time.
    Chairman Akaka. Dr. Thompson, at the outset, thank you for 
what you do on behalf of veterans. I believe the suicide 
prevention lifeline is one of the great successes in the fight 
against suicide. Can you illustrate for us what one of the 
calls you take might sound like?
    Ms. Thompson. What it would sound like? Well, the person--
you mean what the veteran would sound like when he calls?
    Chairman Akaka. Yes.
    Ms. Thompson. It really--it varies so greatly. We have 
calls from veterans who are just coming home, so from ages 18 
to over 80. We have had World War II veterans who also call. 
Many times, their calls are, I am not quite sure why I am 
calling. I am not sure if this is the right place for me. Or if 
there is an immediate crisis, then there is a serious panic. We 
are also getting so many calls from family and friends who are 
calling for their veterans who don't know what to do and this 
is their first way to reach out. So it certainly varies quite a 
bit.
    Chairman Akaka. Thank you.
    We will have a second round. Let me pass it on to Senator 
Burr for his questions.
    Senator Burr. Dr. Cross, welcome, and to your talented 
team, I thank all of you for your commitment to our country's 
veterans.
    Dr. Thompson, let me ask you, I found it shocking, because 
we have been focused on OEF and OIF--that seems to be the 
immediacy that we are dealing with, and all of a sudden you 
tell us a story about a Vietnam veteran. How do the counseling 
techniques differ from a Vietnam veteran to a veteran that you 
might get a call from today that is out of Iraq or Afghanistan; 
or do they?
    Ms. Thompson. They differ in the way that we have to manage 
how raw the emotions are, particularly for the OEF/OIF veteran. 
The memories are so fresh, so at times, we will have to talk 
veterans down from flashbacks, for instance, in the middle of 
the night if they are calling, and those tend to occur more 
frequently with our newer veterans coming home.
    I wouldn't say that the counseling techniques vary 
dramatically. Our immediate assessment is of safety and of 
their risk of suicide and whether or not they have means at 
home. And then what goes on from there is just support and 
attempting to get them as quickly as possible connected with 
their local services and their local VA. So I wouldn't say that 
it varies too dramatically.
    Senator Burr. OK. And again, I want to reiterate what the 
Chairman said. A great deal of congratulations on the direction 
of the trend right now, that we are doing much better, and I 
think we are learning. But let me go to Mr. Hanson's story 
specifically. I would like to get an idea from you as to once 
you take that phone call, and this was Daniel Hanson calling in 
this case, and you have walked him back from the ledge, you 
have referred him to a VA service, what follow-up happens, if 
any, on the handoff of him to that local VA entity. Is there 
any boot in the butt, to use the terminology he and I used, 
that happens? Is there an offensive effort on the part of the 
local VA with that individual, not waiting for Mr. Hanson to 
call, that they call him?
    And then I will go back to Dr. Cross just to address, is 
there more we can do when you have got a clinician that is 
working with somebody that has finally opened up to them and 
said, you know, I do think about this. I do think about this. 
Well, we have got this service, this service, and this service. 
Do we need to do more to actively get them involved, enrolled, 
treated?
    Ms. Thompson. So the hotline has this wonderful 
collaboration with each of the local VAs across the country and 
the suicide prevention coordinators at each of those VAs. If 
anybody calls and they are--if any of our veterans calls--if 
Mr. Hanson had called and said, yes, I would like to be 
connected with the suicide prevention coordinator, that suicide 
prevention coordinator would have called him within 24 hours, 
hands down. So that always happens. There is always a reaching 
out. And then the hotline follows up to ensure that that 
handoff happened.
    From there, the Suicide Prevention Coordinators, and Dr. 
Kemp may be able to speak more about this in terms of how much 
they attempt to find the person. But there is always a real 
effort to follow up with the veteran.
    Senator Burr. So let me go to you, Dr. Cross. Is the red 
flag that she gets different than the red flag that a clinician 
might get when they have got the veteran in seeing them on a 
regular treatment basis and the veteran says, you know, yes, 
last night, I thought about suicide. Does the same red flag go 
off?
    Dr. Cross. You know, Senator Burr, your opening question 
was, is there more that should be done, and my response is, I 
think, in my view, there is always more to be done with any 
situation, however complex it may be, and that situation 
sounded pretty darn complex to me. We can always find more 
somewhere within the system, some other route that we can 
pursue, and we should do that.
    One of those routes, by the way, is our Vet Centers. A 
great program that we have, and I think we are going to have 
about 299 of them by the end of the year. Dr. Al Batres is in 
the audience and runs that program. Sometimes that provides an 
alternative venue, a different kind of feel, maybe a little bit 
less--a lot less bureaucratic, very focused on combat veterans 
being treated by combat veterans themselves. Sometimes those 
different venues work for the different situations and we have 
those available. So that would have been a good resource in 
that situation.
    Senator Burr. Just one statement, and with the Chair's 
indulgence, I will ask one last question. I know I have got 
colleagues that are here. I can't stay for a second round, and 
so I will be very quick.
    I sense that if the call went to Dr. Thompson's area, that 
it would initiate a very proactive effort on the part of the VA 
entity to connect with this person and to pull them in. I am 
not sure from Mr. Hanson's experience being inpatient when he 
talked about suicide it initiated the same proactive effort. It 
was more of a buffet presentation of services that he might 
look at taking advantage of, and that may be an area we want to 
look at. You may tell me the data shows everybody that walks in 
at some point mentions this, so everybody would be in a 
proactive state. I personally believe the earlier we can get 
them into treatment, the longer we can keep them there, the 
less likely we are to get a phone call to Dr. Thompson's area, 
and I think the goal should be to make sure that we don't need 
the functions that her area actually does. That is the best 
data.
    I want to go very quickly, though, to the treatment that 
Mr. Hanson did find that worked for him. It is community-based, 
and I think it is faith-based. How open are we at VA to look at 
contract partnerships for efforts, not just exclusively rural 
because we don't have a facility close enough or a treatment 
plan, but say we have identified a program that has a proven 
track record of working--and as we weed through and find we 
need to look at other maybe non-traditional ways to do it, that 
we are willing to insert people into those programs?
    Dr. Cross. Senator, I am going to ask Dr. Zeiss to comment 
just a bit more, but I was pleased to see the representative 
from NAMI here today discuss the relationship that we have with 
them out in the civilian community. You know, from a budgetary 
point of view, we are spending about $4 billion a year on 
various types of fee-based services out in the community. A 
portion of that is related to mental health. But I would like 
to ask Dr. Zeiss to comment.
    Ms. Zeiss. Well, I am happy to do that. I think that Mr. 
Hanson's case is very complex and it is important for us to 
think through together what could VA do, what more should we be 
thinking about doing, and what kind of partnerships would make 
sense.
    I think that there have been some changes since his time 
with VA. We are constantly trying to improve. Some things we 
have already done that might have made it different for him: we 
now require that everyone receiving mental health care have a 
principal mental health provider. A person who is receiving 
multiple services, as he was, would be assigned someone who is 
that core central person who he could feel cares about him, 
would know him best, would be the person to turn to to get a 
more clear sense of how to integrate different treatment 
components. We think that can make a difference.
    We also have instituted throughout the system far more 
intensive outpatient programs. So instead of 1 hour a week, 
which we agree for the complexity he is describing would not be 
sufficient, these are at least 3 hours a day, at least 3 days a 
week, with an interdisciplinary team working to deliver very 
complex and intensive services.
    There are other things. I could go on. We have been trying 
to bolster many of the kinds of gaps that he describes and that 
we also saw and have been very committed to filling.
    In addition, we completely agree with statements that we 
need to have partnerships, that we can't do it alone, which we 
need to continue to explore. If there is a level of care that 
VA is not able to provide in rural or in urban or suburban 
settings, we should look for what are well-tested programs. We 
do have the mechanisms for doing either fee-basis or contract 
care, and the Uniformed Mental Health Services Handbook does 
mandate that people should look at those if there is something 
beyond what VA is able to provide.
    Again, we need to keep looking at how well our advancements 
might help cases like Mr. Hanson's that we weren't ready for a 
few years ago. But we also need to continue to look at 
partnerships.
    Senator Burr. Thank you for that answer. More importantly, 
thank you for the ever-changing treatment process that we go 
through. It does prove that the VA is listening and learning 
and making every effort to try to pass that on to the veterans.
    Thank you, Mr. Chairman. Thank you.
    Chairman Akaka. Thank you, Senator Burr.
    Senator Murray, your questions.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you very much, Mr. Chairman. I really 
appreciate your having this hearing. It is an extremely 
important issue that affects so many people and their families 
and their communities and everyone around them. How we deal 
with this issue, I think, is really visible to our men and 
women who serve, that we are going to be there for them when 
they come home. So I really appreciate the focus on this.
    I want to thank all the witnesses who are here today, 
especially those who are sharing their personal stories. I know 
how difficult it is and challenging to you, yet it helps us 
understand what you go through so that we can make sure we have 
got the right resources and are doing the right thing at the 
VA. So, I really appreciate that, in particular.
    Mr. Chairman, everything is exacerbated for a man or woman 
coming home from service, particularly in this tough economic 
time when they are struggling to get a job, when they are 
dealing with PTSD issues, mental health issues, and coming home 
in this current economic climate. Not being able to find a job 
exacerbates it for a lot of our men and women who have served 
us.
    I have been looking at this issue of employment and 
veterans and have been working on legislation that I hope to 
introduce shortly to help our veterans when they come home to 
get a job and to feel more secure as part of this piece of the 
puzzle, to help them feel more stable and secure versus going 
to the downward cycle that we have seen so many of our veterans 
go. So I will be looking forward to sharing that with all of 
you and getting your input on it.
    One of the things that concerns me on this issue in 
particular is that veterans who come home and have PTSD, 
suicidal behavior, or mental health issues, require intensive 
care for a very long time. It isn't just a matter of a few days 
or a few weeks or a few months or even a few years. We know 
that triggers for relapse--whether it is marital issues or 
inability to find and hold a job, as I just talked about--exist 
in everyday life for everyone, and we know that a lot of our 
veterans self-medicate to deal with those issues which 
contributes to this, as well.
    I understand that the VA is working really hard now to deal 
with PTSD and provide care for those who are affected, but how 
are you working to transition them from their intensive care 
regime that you are providing back into civilian life for the 
long-term?
    Dr. Cross. Senator, let me ask Dr. Zeiss and Dr. Kemp both 
if they could comment on that.
    Ms. Zeiss. Well, we agree with you very much about veterans 
returning to work and to full roles in the community, at school 
for many returning veterans, which we expect will ultimately 
lead to work, but also being part of their families, their 
places of worship, all those community roles that are 
important. We are working with the Department of Labor. They 
have a wonderful program called Heroes at Work that you are 
probably aware of.
    We also have within mental health a strong compensated work 
therapy and supported employment program. So, if it is mental 
health problems that are preventing people from being able to 
find or keep a job, part of their mental health plan can be 
utilizing these vocational rehabilitation programs. Those are 
designed to get them back to work in the community.
    The success of those programs is pretty great, and we are 
happy to gather some information for you about that, given your 
interest in employment.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to 
  Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant and Chief 
  Psychologist, Office of Mental Health Services, U.S. Department of 
                            Veterans Affairs
    Question. Senator Murray requested information on VA Office of 
Mental Health Services (OMHS) efforts to assist Veterans with 
employment issues.
    Response. OMHS provides work restoration and employment services 
for Veterans with mental health problems through its Compensated Work 
Therapy (CWT) and vocational rehabilitation programs. These programs 
are incorporated into the Veteran's treatment as part of VHA's 
comprehensive efforts to improve community integration for Veterans. 
CWT is authorized by 38 U.S.C. Section 1718 to provide work skills 
training and career enhancement, job development and placement, and 
post-employment support services. As a part of Patient Care Services, 
Therapeutic and Supported Employment Services within OMHS, administers 
the CWT programs. VA service connection is not required to receive 
treatment in CWT, nor can VA benefits be reduced, denied, or 
discontinued based on participation. Only individuals with Veteran 
status who are eligible for VHA services can participate, and a VHA 
clinical referral is required.
    Per VHA Handbook 1160.01, Uniform Mental Health Services in VA 
medical centers and Clinics, each medical center must offer Therapeutic 
and Supported Employment Services to Veterans who are receiving care 
through VA and who have a mental health diagnosis with associated 
functional impairment and whose treatment plan includes a goal for the 
Veteran to receive employment assistance. Therapeutic and Supported 
Employment Services guide the CWT programs, which consist of both the 
Transitional Work program and the Supported Employment program. CWT 
partnerships for both Transitional Work and Supported Employment are 
developed through Memoranda of Agreement with Federal Government 
agencies, county and state entities, and local businesses.
    Transitional Work for involved Veterans occurs in a variety of work 
settings at all VA medical centers as well as in partnership with 
community employers. Veterans work a specified number of hours per week 
under the direct supervision of VHA staff or private company employees 
in their Transitional Work assignment. Transitional Work placements are 
generally time limited, and participants receive compensation at or 
above the Federal or state minimum wage (whichever is greater). 
Participants are paid at wages commensurate with comparable wages for 
workers employed in the community. There is no employer-employee 
relationship between VA, participating companies or organizations, and 
Veterans for those in Transitional Work experiences.
    Supported Employment is an evidence-based practice integrating 
vocational services into treatment at the earliest possible time for 
individuals with severe mental illness. The primary focus of Supported 
Employment is to provide the on-going support services--including 
workplace accommodations and on-the-job support--these Veterans need to 
obtain and maintain employment. Supported Employment positions are 
developed in both public and private sector businesses, and individuals 
are not prevented from receiving Supported Employment services because 
of the lack of prior work history or vocational goal.
    In FY 2009, Transitional Work and Supported Employment served over 
30,000 Veterans at 169 VHA locations, and Veterans earned in excess of 
$50 million. The personnel expenditure for the CWT programs in 
combination for FY 2009 was $26,000,000. Approximately 40% of Veterans 
participating in any component of CWT secure competitive employment at 
the time of discharge from the program (including approximately 70% of 
Transitional Work Veterans and approximately 25% of Supported 
Employment Veterans).

    Ms. Zeiss. In addition, there is this kind of interesting 
relationship between Mr. Hanson's situation and his need for 
more long-term possibly inpatient care and evidence that, in 
many ways, having care provided in an outpatient environment 
that is intensive enough to meet the complexity and severity of 
the problems and which keeps people connected with their 
families and their communities and where the family can be a 
part of the treatment is one of the things we also really want 
to emphasize and make sure that we are thinking about--not just 
treating the individual mental health problem of the veteran, 
but treating that in the context of his home situation, his 
family, and making sure that we are supporting re-entry and the 
ability to recover and thrive in the community.
    Senator Murray. I think that is really important, because 
we can't just treat this like coming to the VA with a cold and 
we are sending you home.
    Ms. Zeiss. Absolutely.
    Senator Murray. And the transition and long-term support of 
this is extremely important and I will be exploring that more 
as I put my legislation together, so I appreciate that.
    Dr. Cross, I wanted to ask you, because I was deeply 
disturbed, as I think everyone was, by the news in January that 
the VA's preliminary data shows a dramatic increase in veteran 
suicide between 2005 and 2007. The fact that our veterans are 
serving and sacrificing only to return to spiral into this 
depression and suicide is appalling, I think, to all of us.
    The preliminary data did suggest that access to VA service 
does make a difference in suicide prevention. That is good 
news. But if we are truly going to make a difference, the VA 
needs a more comprehensive effort. These numbers show that the 
duty of providing mental health services and outreach to 
returning veterans is still a challenge at the VA. The 2008 
RAND study revealed that nearly 20 percent of military 
servicemembers who have returned from Iraq and Afghanistan 
reported symptoms of post traumatic stress or major depression, 
but only half sought treatment.
    So I wanted to ask--it has been 9 years for the post-9/11 
war effort. What the VA is doing, is it a matter of resources? 
Is it a matter of hiring people? Is it a matter of greater 
attention? What is it we could be doing to dramatically turn 
this around?
    Dr. Cross. Senator Murray, I would like to ask Dr. Kemp, 
sitting right next to me, who is the Director of the Suicide 
Hotline, to talk in just a moment about the specific part on 
the rates and so forth.
    You know, I think the biggest challenge that we have is 
getting folks to come in and getting them engaged in treatment. 
We were concerned when looking at the numbers coming back from 
OIF and OEF, the numbers of soldiers who had not yet come in 
for any health care-related service. So we have a program 
called Seven Touches, where through a variety of mechanisms 
that we reach out to them.
    One of those, by the way, was we called them all. We hired 
a contractor to make 700,000 phone calls and called every one 
of them. We made 500,000 contacts of them. We found that we got 
wrong phone numbers, and sometimes they had left off--they had 
changed their phone number when they went over for deployment, 
shut down their phone line, shut down their address, and so the 
information we had was incorrect. We then hired a detective 
agency to go find the new phone numbers and feed them to the 
contractor to make those calls. As a result of that, or 
partially as a result of that, at least a couple hundred 
thousand people are now in our health care system that might 
not have been otherwise.
    A key point for me is there is no one mechanism of outreach 
that is going to work for everybody. Sending a letter out is 
very nice. It probably doesn't work that well.
    You know, the thing that really matters, ultimately, is 
looking somebody in the eye, being there personally, being 
onsite, and talking to them by saying, hey, I am from the VA. I 
am available. So, we are doing that at the post-deployment 
sessions. Our Vet Center staff and others, our medical services 
staff, go out there and do that face-to-face.
    Senator Murray. With the veteran.
    Dr. Cross. With the veteran----
    Senator Murray. Are you working with the families----
    Dr. Cross [continuing]. With the servicemembers returning.
    Senator Murray [continuing]. And the employers and the 
schools and everywhere else the VA might touch so they know 
that----
    Dr. Cross. Part of the Yellow Ribbon effort is related to 
families. But I am going to ask Dr. Kemp to talk about that. 
And if I have a chance, I would really like to have Dr. Batres 
talk about some of his work in outreach, as well.
    Senator Murray. OK.
    Ms. Kemp. Thank you, Senator, for your question. I think it 
is incredibly important. In my written testimony, I do explain 
a little bit more about how we got some of the rate information 
that we are presenting.
    One of the issues within the VA is when we look at what we 
call the case mix of people that we care for. It is higher than 
in the general population, which means that when we look at 
veterans who come back and have taken the Post-Deployment 
Health Screening, out of those who screen positive for PTSD and 
depression, they are more likely to come to the VA for care, 
which is, in essence, a good thing. They are the people who 
really do need us immediately.
    But it does give us a population that is somewhat different 
than the rest of the country when we are working with people 
with mental illness and who do show some evidence of suicide 
risk. So we are dealing with a little different population to 
begin with, and the fact that we have been able to decrease the 
rates of suicide among veterans who get care at the VA, then it 
is a really very positive----
    Senator Murray. Yes, I know the chart, but that doesn't 
show--that is only inpatient data, right? That is not clinics?
    Ms. Kemp. It is all patients who receive care in any--who 
touch the VA in any way.
    Senator Murray. OK, but it doesn't include veterans who 
have not----
    Ms. Kemp. It does--right. Right. So I think we have--and 
people have brought it up a couple of times today--there is 
that group of people that we don't see and that we don't touch, 
and while their rates are remaining constant or in general 
probably they are at higher risk for suicide, we are obligated 
morally and ethically to try to find them.
    So we have done several new outreach programs with the 
Suicide Prevention Coordinators. They are required at their 
sites to do five programs a month now out in their communities, 
and not just the communities where the medical centers are, but 
the communities within their network of care; so communities 
where all the community-based clinics are and surrounding 
areas.
    We have developed a program called Operation Save, which is 
the VA version of a gatekeeper program which is veteran-
specific, and we have provided this thousands of times in 
various communities over the past year across the country and 
will continue to do so.
    The Suicide Prevention Coordinators themselves go to the 
Yellow Ribbon events and the post-deployment events to make 
sure that people have the number, the information, know how to 
get in touch with us. We have worked with the Department of 
Defense to develop materials and programs that are similar to 
theirs so that especially families are comfortable with the 
materials that they get and they know what it means. It 
provides our access information, like the ACE program for 
suicide prevention which is now a program that goes through the 
DOD and VA.
    We have done a great deal of public media campaigning. We 
have had posters on buses and mass transport situations across 
the country. We have had Public Service Announcements--I don't 
know if you have seen them--by Gary Sinise and Deborah 
Norville, which have been immensely successful.
    We just completed work with SAMHSA to do a series of focus 
groups for younger veterans in rural areas to see if the 
message that we are trying to get across is resonating with 
them. And to be honest, we found out that it is not always, 
that they are sometimes not relating to some of these posters 
and the Public Service Announcements that we have done. So we 
are reworking those quickly to provide a different message. 
They like the flags. They like the patriotic message. We didn't 
always get the symbols right. We didn't get the right uniforms 
on the right people asking the right questions. So we are 
quickly trying to work that out.
    I think it is, as we talked about earlier, not just a VA 
problem. This is a national issue and we all have to work 
together to get that number out. We chose to use the National 
Suicide Prevention number for a reason, so that people would 
not have a different number than their spouses or their 
families or their coworkers. And if people see other people 
asking for help, it makes it a little easier for them to ask. 
So the things that Dr. Rudd said about messaging are extremely 
important, and we know we have to work hard to do that.
    Senator Murray. And do you have the resources? Have we 
given you enough----
    Ms. Kemp. We do have the resources to do that, but we need 
your continued help to do it outside the VA, too. You know, one 
of the stigma issues is that this is not just a veteran 
problem, either. This is a national problem and we are all in 
this together. It is OK for everybody to get help, and veterans 
deserve the help in very special ways. And we are here for 
them.
    Senator Murray. Mr. Chairman, I have gone way over my time.
    Dr. Cross, did you have someone else you wanted to speak? 
With the Chairman's permission, if we could----
    Mr. Rudd. Dr. Batres runs the Vet Centers, one of our 
highly successful programs, and I want him to talk about 
outreach for a moment, as well.
    Senator Murray. Mr. Chairman, if you wouldn't mind, if he 
could respond to that.
    Mr. Batres. Good morning, Senator Murray. A couple of 
things. One is the increase in Vet Centers that I want to flag 
out. We have gone from 232 to almost 300 by the end of this 
fiscal year. So there has been an increase in our services in 
that fashion.
    Inherent in that is who we hire, and over 33 percent, more 
than a third of all my employees have served in Iraq and 
Afghanistan, and they are the ones who are staffing and they 
tend to reflect the community. And that, to me, is an important 
transformational change, that we need to hire the young folks 
to balance the old folks, like myself, in terms of connecting 
and doing the outreach, because that is a very important 
component.
    I believe I am free to talk about this, but we are going to 
be hiring a trained family therapist at every Vet Center. And 
so at every Vet Center, we will have the capacity to see 
families, because that is an increasing need for the veterans 
who are coming out, and be more integrated----
    Senator Murray. What is your timeline for having that?
    Mr. Batres. We are hoping to hire 70 by the end of this 
fiscal year, but 180 by the end of next year, and we do have 
the funding, because I am sure that will be the second 
question. The Secretary has approved that and we are moving 
forward in doing that.
    We are also exploring and have committed part of our 
outreach to OEF/OIF women veterans because of the increasing 
number of them. So when we talk family therapy, sometimes the 
recipient is not a male but a female who is married to a combat 
veteran who is female, and we are embracing all of those 
challenges and trying to do the best we can to address that.
    The other element that Dr. Cross referred to was our 50 
Mobile Vet Centers that are now canvassing areas, in particular 
VMOBE sites, outreach, PDHRAs, which gives us a lot of capacity 
to address those issues more directly; and our partnerships 
with some other organizations like the Wounded Warrior Project 
and other groups where we are recruiting returning troops early 
on with their family members and providing activities for them 
together so that we can engage the family more in educating 
them about the returning needs of veterans.
    I hope my response is helpful.
    Senator Murray. OK, that is, and Mr. Chairman, if you 
wouldn't mind, he brought up women veterans. I just wanted to 
ask about inpatient facility care for women veterans. They have 
very few options, and of the $218 million in the President's 
budget geared toward women veterans, are there funds to expand 
that capability?
    Dr. Cross. Yes, Senator, and I would like Dr. Zeiss to give 
you some more details on what we are going to do.
    Ms. Zeiss. Well, first of all, we make a distinction within 
VA that I think is an important one between inpatient and 
residential rehabilitation and we need to make efforts in both 
those arenas. They offer different levels and types of care.
    Currently, in terms of classic acute inpatient--that would 
be a very short length of stay for someone at risk of harm to 
themselves or others--we have not tried to establish separate 
women's inpatient units but to create in our current units 
areas that are separated, where the woman has the opportunity 
to lock her door, although staff can access it certainly since 
there might be suicide risk; to create greater safety and 
security, emotionally, and psychologically for women veterans; 
and to increase our staff with providers who are sensitive to 
women's issues and who can then provide care in those settings.
    We do track the percent of women mental health staff that 
we have since one of the requirements is that women can request 
a mental health provider of the same gender, or opposite gender 
if they prefer, and we do have sufficient staff to do that.
    Senator Murray. Can I interrupt you? So you are saying that 
you are establishing a room for women in the facilities----
    Ms. Zeiss. A section.
    Senator Murray. Anecdotally, most women tell me that 
military sexual trauma is a part of their experience. So 
putting them into a facility with men is really intimidating.
    Ms. Zeiss. Right. Well, and that is why I wanted to make 
the distinction to the residential rehabilitation facilities, 
which are a longer stay, deal with not that immediate urgent 
need but with the needs of women who may have mental health 
disorders after military sexual trauma or for other reasons, 
you know, after a combat experience.
    We do have an increasing number of women-only units for the 
residential rehabilitation for treatment of PTSD and other 
mental health problems. They have staff that are very sensitive 
to the needs of women veterans. We have been gradually growing 
those and follow closely how fully they are utilized and how we 
need to keep expanding such units as the number of women 
veterans continues to grow and they continue to enter VA at a 
very high rate. So we will be expanding those programs.
    Senator Murray. All right. Well, my time is way over, so if 
I could explore with you outside the Committee hearing where 
those are and where the numbers are----
    Ms. Zeiss. Sure.
    Senator Murray [continuing]. Because I am hearing a lot 
there is not enough mental health----
    Ms. Zeiss. We would be happy to.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to 
  Antonette Zeiss, Ph.D., Associate Deputy Chief Consultant and Chief 
  Psychologist, Office of Mental Health Services, U.S. Department of 
                            Veterans Affairs
    Question. Are there Mental Health Residential Rehabilitation and 
Treatment Programs (MH RRTP) that provide separate physical areas for 
women Veterans?
    Response. MH RRTPs provide residential treatment in a 24-hour, 
seven days per week, supervised and therapeutic milieu for Veterans in 
need of more intensive treatment of mental health conditions and/or 
addictive disorders. All MH RRTPs have the capacity to serve women 
Veterans. In Fiscal Year (FY) 2009, there were a total of 237 
operational MH RRTPs providing more than 8440 treatment beds which 
includes 252 beds dedicated to women Veterans in 35 of the programs 
(North East Program Evaluation Center, NEPEC). Women Veterans comprised 
5.2% (1,789) of the total episodes of care in MH RRTP in FY 2009 
(NEPEC).
    VA has initiated numerous enhancements to ensure the privacy, 
safety and security of women Veterans. In January 2008, all MH RRTP 
were mandated and funded to provide 24/7 on-site supervision, keyless 
entry and locks for all female bedrooms and bathrooms as well as closed 
circuit monitoring of all public areas. By January 2009, all programs 
reported 100% compliance to VA Central Office. Further, the MH RRTP 
Handbook released in May 2009, addresses the unique needs of women 
Veterans by requiring that all MH RRTP must maintain environments that 
support women Veterans' dignity, respect and safety; separate and 
secure sleeping and bathroom arrangements must be provided for women 
Veterans; that gender-specific treatment and rehabilitation services be 
available and that services provided to women Veterans must be on par 
with services for male Veterans.

    Senator Murray. Thank you. Thank you, Mr. Chairman. I 
apologize.
    Chairman Akaka. Thank you very much, Senator Murray.
    Dr. Thompson, at the outset, again, I want to thank you on 
behalf of our veterans. I believe that your work has made a 
difference and we want to continue to move in the areas where 
we can kind of get the help.
    Dr. Zeiss, the veterans outreach is one of my primary 
concerns. VA certainly has a number of excellent VA initiatives 
in this regard. A compelling op-ed in today's Washington Post 
on suicides makes the point that when someone at risk of 
suicide makes a decision to take their own life, it becomes 
difficult to change their mind. Everything they see and do 
reinforces their decision.
    Dr. Zeiss, with that in mind, what else can VA do to reach 
out to more veterans and bring them into the VA health care 
system?
    Ms. Zeiss. Well, I am happy to answer that, but I think 
there are others here on the panel who also can address that.
    In the Office of Mental Health Services, our suicide 
prevention plan begins with the notion that the best suicide 
prevention is good mental health care that will address needs 
before people get to the point of being in suicidal crisis. So 
we have developed very effective mechanisms to help people who 
are in suicidal crisis that Dr. Kemp and Dr. Thompson can talk 
about, and they do guide many outreach efforts.
    In addition, we have bolstered our basic mental health 
services and we have tried very much to get the word out about 
that so that veterans who may have thought that if they came to 
VA, we really did not have the staffing or the programs or the 
commitment to serve their needs, can hear that, in fact, we 
have hired over 5,000 new mental health staff in the last few 
years, we have new programs, we have the capacity and, very 
strongly, the commitment to help them.
    Our office does outreach primarily through the Suicide 
Prevention Coordinator program, so I would want Dr. Kemp to 
speak to that. We also try to collaborate and support the 
excellent efforts of the Vet Centers, who are very committed to 
outreach efforts.
    I think what our office has tried to do and will continue 
to try to do in terms of outreach is to support the Post-
Deployment Health Reassessments by joining the Vet Center staff 
who are always there. They have staff who can meet with the 
veteran face-to-face, help him get enrolled in VA right at the 
Post-Deployment Health Reassessment if they are Reserve, Guard, 
or other separated veterans, and make sure that they get linked 
to primary care and to any mental health appointments that they 
should need.
    We also work with SAMHSA to try to get out destigmatizing 
messages and to try to let the country know what is available 
for veterans and the importance of coming in to receive mental 
health care.
    We certainly agree there is always more we can do, so we 
are open to other ideas.
    Chairman Akaka. Are there any further comments on this from 
the panel? Dr. Kemp?
    Ms. Kemp. You know, again, thank you for the question. 
Monday, I had the opportunity to speak here in Washington to a 
convention of American Legion commanders who were here wanting 
to know--what they wanted to know from me is what they could do 
to make a difference. One of the things that we talked about 
was setting an example for both our newer veterans and their 
friends, a lot of older veterans across America, and just 
letting them know that it is OK to get help. We discussed ways 
that we could provide all of the Legionnaires across the 
country with Operation Safe Training so that they would know 
the signs and symptoms of someone having difficulty and how to 
get them services.
    At this point, one of our biggest outreach needs, I 
believe, is for the community to be aware of what we do and 
what we offer, and help each other get our services. That is 
our goal.
    The American Legion, by the way, has really pledged their 
support to this effort, so it is an exciting opportunity for 
us.
    I think, also, leadership at all levels needs to set 
examples and people need to know, again, that it is OK to ask 
for services and to tell us that they are in trouble. When 
community leaders, political leaders, their military leaders 
set those examples, it is our obligation to be there to provide 
those services that people are seeking. We can help them with 
those messages, but we need everybody's help in this effort.
    Chairman Akaka. Are there any further comments on that 
question?
    Otherwise, Dr. Cross and Dr. Kemp, we have two different 
answers with regard to what this important chart shows. For the 
record, is this all points of care, clinics included, or only 
inpatient settings?
    Ms. Kemp. My understanding is that this chart represents 
all points of care, and the numbers that I have worked with and 
that are in my written testimony deal with veterans who utilize 
any point of care within the VA system.
    Chairman Akaka. Dr. Cross, do you have any further comments 
on that?
    Dr. Cross. No, sir. That is my understanding, as well.
    Chairman Akaka. Yes. Well, in closing, again, I want to 
thank all of you for appearing today. Your contribution is 
important as this Committee moves forward on improving VA's 
mental health care and suicide prevention efforts. With rising 
suicide rates, these issues are all too pressing for all of us. 
For me and for this Committee, our focus is ensuring that VA 
fully implements all the mental health programs that have been 
authorized in recent years. VA now has resources and the tools 
with which to help veterans in need. We still are searching for 
at what point we can determine who needs the help and to try to 
get them into the services that are available, and we need to 
also work with the active service side before they become 
veterans.
    So, this is something we will continue to work on. We look 
forward to partnering with you in doing this and also with the 
community and, of course, the families. So all of us working 
together, we think we can help the cause of preventing 
suicides.
    So with this, thank you very much again. This hearing is 
now adjourned.
    [Whereupon, at 11:25 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


             Prepared Statement of Hon. Roland W. Burris, 
                       U.S. Senator from Illinois
    Thank you Mr. Chairman, and thank you to our witnesses for being 
here today. Every time a veteran commits suicide in our country, the VA 
has failed in its responsibilities. It is the charge of VA, and this 
Committee, to continue working until no veteran falls through the 
cracks and every veteran gets the mental health services that he or she 
needs.
    The 2004 VA Mental Health Strategic Plan was a good start, and 
Senator Akaka's 2008 mental health improvement bill took further 
strides in addressing substance abuse and co-morbid disorders. These 
efforts have led to some great successes, and likely saved thousands of 
lives. However, clearly, we are not doing enough, in either the VA OR 
Department of Defense. Suicide rates continue to climb, and suicide now 
claims more lives from our Armed Forces than war efforts in the Middle 
East.
    I am anxious to hear the expertise and experience of our esteemed 
panel. Their testimony will no doubt bring needed attention to this 
issue and help us as we move forward in our efforts to fully meet the 
mental health needs of our veterans.
                                 ______
                                 
            Prepared Statement of Hon. Frank R. Lautenberg, 
                      U.S. Senator from New Jersey
    As a young man, I answered the call to service and wore our 
Nation's uniform with pride. I was not a hero, but I did my duty for 
the country I love. And one principle I have always insisted on is 
this: we can't just stand by our military on the battlefield--we have 
to stand by them when they return home, too.
    Right now, military personnel are committing suicide at disturbing 
rates, and the trend is getting worse. Last year, more U.S. military 
personnel took their own lives than were killed in combat in Iraq. And 
for our veterans, the picture is just as bleak: the Veterans 
Administration estimates that 18 veterans take their own lives every 
day.
    The need to improve mental health care for our servicemembers and 
veterans is clear and demands a new sense of urgency.
    We must do better, and we can do better.
    In my home state of New Jersey, there's a model of success for 
confronting this problem.
    Along with our state's Department of Military and Veterans Affairs, 
the University of Medicine and Dentistry of New Jersey has created an 
innovative program called Vet2Vet. This program, which works with 
members of the New Jersey National Guard, has kept thousands of 
military personnel, veterans and their loved ones from suffering in 
silence.
    While suicide rates are rising at a startling pace nationally, 
there has not been a single suicide among the New Jersey National Guard 
during Vet2Vet's first four years of operation.
    Instead of waiting until they return from combat, Vet2Vet starts 
its work with servicemembers pre-deployment and then helps them 
readjust when they return from service.
    Central to the program is the veteran-operated helpline that 
provides servicemembers, veterans and their families access to all 
types of support services, not just mental health support. Vet2Vet 
closes gaps in the system by working in coordination with state and 
community-based programs to take advantage of existing resources.
    One of the reasons Vet2Vet has worked is that it relies on the 
skills and know-how of veterans. These trained vets counsel fellow 
veterans and their families--getting them the resources they need and 
doing regular, comprehensive follow-ups.
    Putting veterans on the frontlines of the phone lines helps 
eliminate the stigma that discourages servicemembers and veterans from 
reaching out for help. It also gives veterans good-paying jobs doing 
what they do best: serving and protecting.
    We are fortunate that our state has taken the lead on this critical 
issue, but there's no reason the rest of the country's military 
shouldn't have access to the same quality care that's being offered in 
New Jersey.
    New Jersey's success should not be an anomaly--it should be the 
norm.
    That is why I have urged Secretary Erick Shinseki to take UMDNJ's 
model and make it available to every military member and every veteran 
in every state.
    We have a responsibility to serve our military and their families 
as well as they've served us. Until military suicides are a thing of 
the past, we cannot rest.

    Thank you.
                                 ______
                                 
   Prepared Statement of Three Wire Systems, LLC and Health Net, Inc.
    Mr. Chairman and distinguished Members of the Committee, we 
appreciate the offer from Ranking Minority Member Burr to submit 
testimony for the record. Our statement will provide an overview and 
results to date of the VetAdvisor Support Program (VetAdvisor), an 
innovative evidence-based program designed to provide mental health 
outreach and health coaching services to Operation Enduring Freedom and 
Operation Iraqi Freedom (OEF/OIF) Veterans and their families, 
regardless of their geographical location. VetAdvisor uses non-
traditional telehealth/virtual health delivery platforms to improve 
Veteran awareness of, and access to, the mental health support to which 
they are entitled.
    VetAdvisor is an ongoing Veterans Integrated Service Network (VISN) 
12 program, augmenting and supporting existing VA behavioral health 
care services, and assisting Veterans with challenges they face during 
reintegration into civilian life. Working in partnership with VA, 
VetAdvisor assists Veterans and their families on a continuous basis, 
providing complementary, non-clinical support to Veterans identified 
and referred to the program by VA. VetAdvisor provides telephonic 
screening and referral to a VA medical facility, when necessary, and 
also offers an internet-based or telephonic health coaching component 
to assist these Veterans with the challenges they face as they work to 
reintegrate into their communities and families. The program focuses on 
identifying and working with Veterans who have, or are at risk for, 
PTSD, substance abuse, suicide and homelessness. This telephonic and 
virtual approach to screening and coaching helps eliminate the stigma 
Veterans often associate with seeking mental health services.
    We thank the Committee for its leadership and appreciate its 
interest in this important issue. We believe VetAdvisor has the 
potential to assist veterans not only in VISN 12, but in VISNs across 
the country, especially in rural areas. It provides a cost-effective, 
appropriate and popular expansion of VA's reach to allow for convenient 
follow-up with Veterans VA identifies as at risk. Without this program, 
many of these Veterans might not return to VA to get the help they need 
to successfully return to their jobs, school and families.
    VetAdvisor was initiated in 2007 by VISN 12, in partnership with 
Three Wire Systems, LLC (Three Wire), a Service Disabled Veteran Owned 
Small Business, and MHN, a Health Net company. VetAdvisor targets 
veterans who are already enrolled at VA medical facilities using 
primary health care services, but are not participating in mental 
health care.
    Veterans who sign up with VA after returning home do not always 
seek help until their mental health needs are critical. This may be due 
to a lack of understanding of symptoms, denial that a problem exists, 
lack of awareness of available mental health support, or stigma. 
VetAdvisor addresses these barriers through its telephonic/virtual 
approach to behavioral health care. VetAdvisor contacts those Veterans 
who may not take the initiative to get involved in mental health care 
before a tragedy or problems occur. VetAdvisor does this by using a 
proactive outreach approach:

     Using Computerized Patient Records provided by VA, Client 
Service Representatives call Veterans to thank them for their service. 
When appropriate, the representative offers immediate access to a 
licensed, trained and experienced behavioral health clinician (e.g., 
Licensed Clinical Social Worker) called a Health Coach.
     The Health Coach telephonically assesses the Veteran 
through a series of VA-approved screenings. The screenings cover both 
medical and behavioral health conditions associated with serving in 
combat to include: Post Traumatic Stress Disorder (PTSD), Traumatic 
Brain Injury (TBI), suicidal ideation, substance abuse, depression and 
common medical screenings.
     The VA medical facility is provided with the results of 
these screenings. The results are used for follow-up and further 
evaluation. Once Veterans with behavioral issues are identified, they 
are encouraged to enroll in the Health Coaching Program.
     The Health Coaching Program facilitates and supports 
Veteran involvement in existing VA services. A Health Coach is assigned 
to the Veteran for regular contact, advocacy and support.
     Coordination continues with the Veteran, Health Coach, and 
Primary Care Physician for as long as necessary.

    In addition to telephonic communication, VetAdvisor provides Health 
Coaching through virtual collaboration technology--the VetAdvisor 
Virtual Room (VVR). In the VVR, the Veteran and the Coach interact as 
avatars. This highly immersive virtual environment provides strong 
feedback that enhances collaboration and communication. Virtual 
technology assists Veterans in their reintegration efforts in a number 
of ways. One of the major advantages is that it allows for the Veteran 
to discuss personal issues from the privacy of his or her own home. 
Second, it saves the Veteran time and travel costs associated with 
office visits. For today's Internet savvy generation of Veterans and 
their families, this form of communication feels more natural than 
traditional communication methods.
    The initial VetAdvisor pilot in VISN 12 covered an 18-month period 
and a population of over 10,000 Veterans. Through this pilot, over 
1,100 Veterans were directed to VA medical facilities for follow-up on 
positive screening results. The statistics support the program's 
success: when a Veteran was successfully contacted, there was a 95 
percent acceptance for Health Coach screening appointments.
    The types of issues discussed in Health Coaching sessions cover a 
wide range. The top issues are anxiety, occupational, PTSD and 
depression. The figure below illustrates the range of issues addressed 
in the sessions.




    VetAdvisor's proactive outreach and screening for behavioral issues 
has proven to be an effective tool in helping Veterans access services 
to treat or prevent potential issues such PTSD, depression, substance 
abuse, suicide and homelessness. It is designed to provide support when 
and where the Veteran chooses, and to help motivate those who realize 
they may benefit from help to seek help. It augments existing VA 
services by being pro-active rather than just waiting for the Veteran 
to seek care. The VetAdvisor program would be a way to immediately 
improve the VA's involvement and assistance to OEF/OIF Veterans in all 
VISNs, and would ensure that these Veterans do not fall through the 
cracks following their initial visit to and enrollment in VA.

    On behalf of Three Wire Systems and Health Net, we would like to 
thank you again for your interest in the VetAdvisor program and for 
your commitment to ensuring that our veterans and their families 
receive the care and services they may need.

      

                                  
