[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
SUICIDE PREVENTION AND TREATMENT: HELPING LOVED ONES IN MENTAL HEALTH
CRISIS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 18, 2014
__________
Serial No. 113-177
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
RALPH M. HALL, Texas HENRY A. WAXMAN, California
JOE BARTON, Texas Ranking Member
Chairman Emeritus JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky FRANK PALLONE, Jr., New Jersey
JOHN SHIMKUS, Illinois BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania ANNA G. ESHOO, California
GREG WALDEN, Oregon ELIOT L. ENGEL, New York
LEE TERRY, Nebraska GENE GREEN, Texas
MIKE ROGERS, Michigan DIANA DeGETTE, Colorado
TIM MURPHY, Pennsylvania LOIS CAPPS, California
MICHAEL C. BURGESS, Texas MICHAEL F. DOYLE, Pennsylvania
MARSHA BLACKBURN, Tennessee JANICE D. SCHAKOWSKY, Illinois
Vice Chairman JIM MATHESON, Utah
PHIL GINGREY, Georgia G.K. BUTTERFIELD, North Carolina
STEVE SCALISE, Louisiana JOHN BARROW, Georgia
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington DONNA M. CHRISTENSEN, Virgin
GREGG HARPER, Mississippi Islands
LEONARD LANCE, New Jersey KATHY CASTOR, Florida
BILL CASSIDY, Louisiana JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky JERRY McNERNEY, California
PETE OLSON, Texas BRUCE L. BRALEY, Iowa
DAVID B. McKINLEY, West Virginia PETER WELCH, Vermont
CORY GARDNER, Colorado BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas PAUL TONKO, New York
ADAM KINZINGER, Illinois JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Ohio
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina
Subcommittee on Oversight and Investigations
TIM MURPHY, Pennsylvania
Chairman
MICHAEL C. BURGESS, Texas DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
MARSHA BLACKBURN, Tennessee BRUCE L. BRALEY, Iowa
PHIL GINGREY, Georgia BEN RAY LUJAN, New Mexico
STEVE SCALISE, Louisiana JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
PETE OLSON, Texas KATHY CASTOR, Florida
CORY GARDNER, Colorado PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
BILL JOHNSON, Ohio JOHN A. YARMUTH, Kentucky
BILLY LONG, Missouri GENE GREEN, Texas
RENEE L. ELLMERS, North Carolina JOHN D. DINGELL, Michigan (ex
JOE BARTON, Texas officio)
FRED UPTON, Michigan (ex officio) HENRY A. WAXMAN, California (ex
officio)
(ii)
C O N T E N T S
----------
Page
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 3
Hon. Diana DeGette, a Representative in Congress from the State
of Colorado, opening statement................................. 4
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, opening statement.................................... 6
Prepared statement........................................... 7
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 7
Hon. Marsha Blackburn, a Representative in Congress from the
State of Tennessee, opening statement.......................... 8
Hon. Janice D. Schakowsky, a Representative in Congress from the
State of Illinois, opening statement........................... 12
Hon. Kathy Castor, a Representative in Congress from the State of
Florida, opening statement..................................... 13
Hon. Bruce L. Braley, a Representative in Congress from the State
of Iowa, prepared statement.................................... 104
Witnesses
Hon. Lincoln Diaz-Balart, Former Representative in Congress...... 14
Prepared statement \1\
Boris D. Lushniak, Acting Surgeon General of the United States,
Department of Health and Human Services........................ 16
Prepared statement........................................... 19
Answers to submitted questions............................... 109
David A. Brent, Endowed Chair, Suicide Studies, and Professor of
Psychiatry, Pediatrics, Epidemiology, and Clinical
Translational Science, University of Pittsburgh................ 30
Prepared statement........................................... 32
Answers to submitted questions............................... 119
Christine Moutier, Chief Medical Officer, American Foundation for
Suicide Prevention............................................. 41
Prepared statement........................................... 43
Answers to submitted questions............................... 127
Joel A. Dvoskin, Assistant Professor of Psychiatry, University of
Arizona, on Behalf of the American Psychological Association... 60
Prepared statement........................................... 62
Answers to submitted questions............................... 135
Submitted Material
Letter of September 17, 2014, from Robert N. Vero, Chief
Executive Officer, Centerstone of Tennessee, to Energy and
Commerce Committee, submitted by Mrs. Blackburn................ 9
Article of July 14, 2014, ``When doctors commit suicide, it's
often hushed up,'' by Pamela Wible, Washington Post, submitted
by Mr. Burgess................................................. 86
Article of September 4, 2014, ``Why Do Doctors Commit Suicide?,''
by Pranay Sinha, New York Times, submitted by Mr. Burgess...... 90
----------
\1\ Mr. Diaz-Balart did not submit a written statement for the record.
(III)
Article of August 2014, ``Modifying Resilience Mechanisms in At-
Risk Individuals: A Controlled Study of Mindfulness Training in
Marines Preparing for Deployment,'' by Douglas C. Johnson, et
al., American Journal of Psychiatry, submitted by Mr. Murphy... 93
Hearing memorandum, submitted by Mr. Murphy...................... 105
SUICIDE PREVENTION AND TREATMENT: HELPING LOVED ONES IN MENTAL HEALTH
CRISIS
----------
THURSDAY, SEPTEMBER 18, 2014
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 11:33 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Tim Murphy
(chairman of the subcommittee) presiding.
Members present: Representatives Murphy, Burgess,
Blackburn, Gingrey, Griffith, Johnson, Long, Ellmers, Upton (ex
officio), DeGette, Braley, Schakowsky, Castor, Tonko, Yarmuth,
and Green.
Staff present: Gary Andres, Staff Director; Leighton Brown,
Press Assistant; Karen Christian, Chief Counsel, Oversight and
Investigations; Noelle Clemente, Press Secretary; Brad Grantz,
Policy Coordinator, Oversight and Investigations; Brittany
Havens, Legislative Clerk; Sean Hayes, Deputy Chief Counsel,
Oversight and Investigations; Robert Horne, Professional Staff
Member, Health; Emily Newman, Counsel, Oversight and
Investigations; Mark Ratner, Policy Advisor to the Chairman;
Macey Sevcik, Press Assistant; Alan Slobodin, Deputy Chief
Counsel, Oversight and Investigations; Sam Spector, Counsel,
Oversight and Investigations; Jean Woodrow, Director of
Information Technology; Peter Bodner, Democratic Counsel; Brian
Cohen, Democratic Staff Director, Oversight and Investigations,
and Senior Policy Advisor; Lisa Goldman, Democratic Counsel;
Hannah Green, Democratic Policy Analyst; Elizabeth Letter,
Democratic Professional Staff Member; and Nick Richter,
Democratic Staff Assistant.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy. Good morning. I now convene today's hearing,
``Suicide Prevention and Treatment: Helping Loved Ones in
Mental Health Crisis,'' a fitting topic during this National
Suicide Prevention Month.
In recent weeks we have read what I think were thoughtless,
uninformed, and at times callous commentary on the tragic death
of Robin Williams. Words describing his death as ``selfish,''
``heathen,'' and ``coward.'' The Academy of Motion Picture Arts
and Sciences tweeted out a picture from the movie ``Aladdin''
with the caption, ``Genie, you are free.''
Now, denigrating the man who died or glorifying suicide as
an escape sends the entirely wrong message and trivializes the
loss and the pain felt by both the deceased and his or her
family.
Today, we take the conversation of suicide out of the dark
shadow of stigma and into the bright light of truth and hope.
Suicide is the deadly outcome of mental illness. Suicide is
what happens when depression kills. Suicide is an epidemic and
its impact is staggering.
Now, I know some have come to me and asked if we could have
a hearing on Ebola, and someday we will. It is a deadly
infectious disease. But to date, no American has died from the
Ebola virus.
But in 2013, 9.3 million Americans had serious thoughts of
suicide; 2.7 million Americans made plans of suicide; 1.3
million Americans attempted suicide; and nearly 40,000 died by
suicide.
Suicide is an American public health crisis. It is a world
health crisis, and that results in more lost lives than motor
vehicle crashes, homicide, or drug use. As we will hear today,
it is the third leading cause of death for young people between
ages 15 to 24, and the second leading cause of death for adults
ages 25 to 34, and each day, we lose 22 veterans to suicide.
In 90 percent of suicide, an underlying diagnosis of mental
illness was a contributing factor. Suicide is the very
definition of a ``mental health crisis.'' The problem is clear
and the need for action is urgent. But our national response to
this crisis has been tepid and ineffectual at best. The age-
adjusted death rates for heart disease, cancer, stroke, and
diabetes are all trending downward as the result of a focused
public and political will to address them. Yet in that same
period, the suicide rate has climbed a stunning 16 percent,
despite substantial Federal spending over the past 60 years and
the development of Federal programs and strategies meant to
reduce suicide.
We have randomized clinical data supporting the
effectiveness of certain treatments to prevent suicide.
However, it is unclear what we are doing to ensure that
evidence-based treatments are reaching out to our loved ones in
need.
Suicides, and suicidal behavior, remain underreported,
undertreated, and cloaked in a stigma that infects our
discussion of all aspects of serious mental illness. The
existing data collection instruments we use are weak, our
research is lagging, and evidence-based treatments often fail
to reach those who can be helped. People do not report suicides
because of stigma, worry about insurance claim issues, or
misattribution of causes.
Following the December 14, 2012, elementary school
shootings in Newtown, Connecticut, this subcommittee has been
reviewing mental health programs and resources across the
Federal Government with the aim of ensuring that tax dollars
reach those individuals with serious mental illness and help
them obtain the most effective care. I thank all members of
this committee for their dedication to this difficult but
important subject.
Helping families in mental health crisis remains my highest
legislative priority, and if we have the courage to confront
mental illness head-on I am certain we can save precious lives.
Now, as I have been traveling the country meeting with
people to talk about mental illness, I have found that some
still grossly misunderstand mental illness. They don't argue
for the right to be well but I hear judges say that it is not
illegal to be crazy. I hear public officials say that they have
the right to be mentally ill even when we know that there are
genetics and neurological components that cause this illness.
It is a brain disease. It is not an uncomfortable way of life.
It is not a non-contentious reality. Mental illness is not a
state of mind. And people who believe those concepts, that we
can just will it away with awareness, I say that such thoughts
are unscientific, that it is uninformed, it is immoral, it is
unethical, and it is wrong.
This subcommittee is dedicated to fight for the right of
people to get treatment and the fight for them to be well, and
I think all members on both sides of the aisle have been so
dedicated in this cause.
So today, to provide some perspective on serious mental
illness and suicidal behavior, and to begin to dispel the most
persistent and pervasive myths and as well as effective
strategies for suicide prevention, we will hear from a number
of witnesses. First will be the Hon. Lincoln Diaz-Balart, our
colleague and our friend who formerly represented Florida's
21st District in Congress; Rear Admiral Boris Lushniak, the
Acting Surgeon General; Dr. David Brent, the Endowed Chair in
Suicide Studies at the University of Pittsburgh, and Director
of the STAR Center, a suicide prevention program for teens and
young children; Dr. Christine Moutier, Chief Medical Officer of
the American Foundation for Suicide Prevention; and Joel
Dvoskin of the University of Arizona. I thank them all for
joining us this morning, but I especially appreciate the
courage shown by our former colleague, Lincoln Diaz-Balart.
Lincoln, by being here today and sharing your story, I know
you are helping to save lives. We talk about statistics and
numbers. For you it is from the heart, and you give help and
hope to those families at risk. So on behalf of all those,
quite frankly, of us who have lost a friend or family member to
suicide, we thank you for being the voice of all of us.
[The prepared statement of Mr. Murphy follows:]
Prepared statement of Hon. Tim Murphy
In recent weeks we have read the thoughtless, uninformed,
and at times callous commentary on the tragic death of Robin
Williams. Words describing his death as ``selfish,''
``heathen,'' and ``coward.''
The Academy of Motion Picture Arts and Sciences tweeted out
a picture from the movie ``Aladdin'' with the caption, ``Genie,
you're free.''
Denigrating the man who died or glorifying suicide as an
escape sends the entirely wrong message and trivializes the
loss and pain felt by both the deceased and his or her family.
Today, take the conversation about suicide out of the dark
shadow of stigma and into the bright light of truth and hope.
Suicide is the deadly outcome of mental illness. Suicide is
when depression kills. Suicide is an epidemic and its impact is
staggering.
Infectious diseases like the Ebola virus is gaining
attention and concern, as it should. Some have asked for a
hearing on the Ebola virus, but to date, not one American has
died from Ebola.
By comparison, in 2013, 9.3 million Americans had serious
thoughts of suicide; 2.7 million made suicide plans; 1.3
million attempted suicide and nearly 40,000 died by suicide.
Suicide is an American public health crisis, that results
in more lost lives than motor vehicle crashes, homicide, or
drug use. As we will hear today, it is the third leading cause
of death for young people ages 15-24, and the second leading
cause of death for adults ages 25 to 34. Each day, we lose 22
veterans to suicide.
In 90 percent of suicide, an underlying diagnosis of mental
illness was a contributing factor. Suicide is the very
definition of a mental health crisis.
The problem is clear and the need for action is urgent.
But, our national response to this crisis has been tepid and
ineffectual at best. The age-adjusted death rates for heart
disease, cancer, stroke, and diabetes are all trending downward
as the result of a public and political will to address them.
Yet, in that same time period, the suicide rate has climbed
a stunning 16 percent, despite substantial Federal spending
over the past 60 years and the development of Federal programs
and strategies meant to reduce suicide.
We have randomized clinical data supporting the
effectiveness of certain treatments to prevent suicide.
However, it is unclear what we are doing to ensure that
evidence-based treatments are reaching our loved ones in need.
Suicides, and suicidal behavior, remain underreported,
undertreated, and cloaked in a stigma that infect our
discussion of all aspects of serious mental illness. The
existing data collection instruments we use are weak, our
research is lagging and evidence-based treatments often fall to
reach those who can help.
Following the December 14, 2012, elementary school
shootings in Newtown, Connecticut, this subcommittee has been
reviewing mental health programs and resources across the
Federal Government, with the aim of ensuring that tax dollars
reach those individuals with serious mental illness and help
them obtain the most effective care.
Helping families in mental health crisis remains my highest
legislative priority. And, if have the courage to confront
mental illness head on I am certain we can save precious lives.
Some in the country still grossly misunderstand mental
illness. They don't argue for the right to be well--but
gleefully declare that it's not illegal to be crazy. Some even
say they have the right to be seriously mentally ill even
though we know it is a genetic and neurological brain disease.
To those people I say this: Mental illness is not a state
of mind or an attitude. Such a belief is unscientific. It is
uninformed. It is immoral. It is unethical, and it is wrong.
This subcommittee is dedicated to fighting for the right to
get treatment and the right to be well.
To provide some perspective on serious mental illness and
suicidal behavior, and to begin to dispel the most persistent
and pervasive myths and as well as effective strategies for
suicide prevention, we will hear from the following:
The Honorable Lincoln Diaz-Balart, our colleague who
formerly represented Florida's 21st District in Congress; Rear
Admiral Boris Lushniak, the Acting Surgeon General; Dr. David
Brent, Endowed Chair in Suicide Studies at the University of
Pittsburgh, and Director of the STAR Center, a suicide
prevention program for teens and young children; Dr. Christine
Moutier, Chief Medical Officer of the American Foundation for
Suicide Prevention; and Joel Dvoskin of the University of
Arizona.
I thank them all for joining us this morning, but I
especially appreciate the courage shown by our former
colleague, Lincoln Diaz-Balart.
Lincoln--by being here today and sharing your story, I know
you are helping to save lives and give hope to those at risk.
On behalf of all who have lost a friend or family member to
suicide, thank you.
Mr. Murphy. And now I would like to give Ranking Member
Diana DeGette an opportunity to deliver remarks of her own.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you very much, Mr. Chairman. Your
dedication to this issue shows, and I want to commend you for
trying to work in a bipartisan way to actually do something
about it.
Suicide takes the lives of about 40,000 Americans every
year, and of course, that leaves behind millions of devastated
parents, children, spouses, and friends. So if there is
anything that we can do in this committee to help suicide
prevention efforts, we should do so, and I want to thank all
the witnesses for coming over today and talking to us.
I particularly want to thank our former colleague, Lincoln
Diaz-Balart, who is going to talk today about his son, Lincoln
Gabriel Diaz-Balart, who suffered from mental illness and
committed suicide last year. I can't imagine as the parent of
two young women how you could come do this, and I want to thank
you for coming, and I want to let you know that our hearts and
sympathy go to you and your family.
We also have Dr. Boris Lushniak, the Acting Surgeon
General; Dr. Christine Moutier, who is the Chief Medical
Officer from the American Foundation of Suicide Prevention;
David Brent, a Professor in Psychiatry from the University of
Pittsburgh; and Dr. Joel Dvoskin, a Clinical and Forensic
Psychologist, and member of the University of Arizona faculty
who is here today. All of you should give us a really diverse
view on what we can do to begin to deal with this.
We have talked a lot of time in this subcommittee this past
year about mental health issues. We have learned a lot of
important things. We have learned about the need to
appropriately target mental health funding and the need to
adequately fund mental health research. We have learned about
the importance of health insurance that provides coverage for
people with mental illnesses and why the mental health parity
of the Affordable Care Act has made such a big difference for
those patients and their families. I think that the testimony
that we will take today will only help us expand our
understanding.
Some of these issues I know are politically sensitive, and
Mr. Chairman, I know how badly you want to pass comprehensive
mental health legislation. I support that goal. We have been
working assiduously to try to come up with a bipartisan bill
that can be accepted by the leadership on both sides of the
aisle, and we have Democrats who stand willing and able, as you
know, Mr. Chairman, who have sat down with you, who have sat
down with other members on both sides of the aisle to put this
bill together, and so I really think it is precisely because we
have spent so much time on these issues that if we didn't put
the lessons that we had learned in these oversight hearings to
practice in legislation, then it may all be for naught.
This subcommittee has limited time and resources, and
frankly, these mental health issues are one of the very
important issues that we have tackled in this Congress, but we
have also done a lot of other productive work this Congress on
drug compounding that led to bipartisan legislation. We have
had some high-profile hearings on the GM debacle. I am hoping
that that will result in legislation to improve motor vehicle
safety.
And I am also disappointed because I do think there are a
couple of other issues that we could look at even before the
election but certainly before the end of this Congress. The
first one I have requested a hearing on is the Ebola outbreak,
and I am sure, Mr. Chairman, you did not mean to imply that
simply because no American lives have been lost that we
shouldn't look at this because there have been hundreds of
lives lost in Africa and with the potential of a pandemic if we
don't address this issue. And so I think it would be very
useful to have a hearing before the end of the year on Ebola in
this subcommittee, and I think we could really help see what
our public health system is doing to help address these issues.
The second letter that you have, Mr. Chairman, and I have
talked to Chairman Upton about this, is a letter asking this
subcommittee to look at the way that the NFL and the other
sports leagues are addressing domestic violence. This committee
has oversight over major league sports, and frankly, the way
that domestic violence has been minimized in the NFL and other
sports leagues deserves investigation by this committee. There
is still time to do this, and I would hope that we could work
in a bipartisan way to make this happen.
I also hope that we can make progress on the goals of
today's hearing, which is reducing suicides and improving
suicide prevention efforts.
So Mr. Chairman, thank you for calling this hearing. I look
forward to working with you on this issue and all of the many
issues that we face, and most importantly, retaining our
committee's jurisdiction over all of these issues. I am trying
to channel Mr. Dingell today. Thank you very much.
Mr. Murphy. Thank you. I appreciate it. The gentlelady
yields back. I now recognize the chairman of the full
committee, Mr. Upton, for 5 minutes.
OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Upton. Well, thank you, Mr. Chairman, and I appreciate
your statement at the beginning and Ms. DeGette's as well.
So today we are here to examine the domestic, and indeed
global, public health crisis that is suicide. It has been noted
that 40,000 Americans every year commit suicide. This hearing
is a natural outgrowth of this subcommittee's groundbreaking
investigation of Federal programs addressing serious mental
illness following the December 2012 tragedy in Newtown,
Connecticut, and I know for a fact that probably every member
here on this committee but our colleagues and our friends and
neighbors at home in fact have been impacted with someone who
has committed suicide.
No discussion of the full burden on our society of serious
mental illness is complete without a discussion of suicide. For
over 90 percent of them, the victim had been diagnosed with,
yes, a mental illness. And tragically, our Nation's vets are
one of the populations hardest hit by the crisis. While one in
ten Americans has served our country, sadly over the last
couple of years, one in every five suicides has involved a vet.
Like other areas covered by our committee's work on 21st
Century Cures, success will depend on our ability to close the
gaps between advances in scientific knowledge about treating
serious mental illnesses, which have been extensive, and how
the Federal Government prioritizes and delivers these
treatments to the most vulnerable populations. Our delivery of
mental health services must keep up with the impressive pace of
research and innovation in the field.
There is significant public misunderstanding and
misperceptions for sure regarding suicide. We hope that our
ongoing work will educate the public about the many treatments
available to address serious mental illnesses and help correct
misconceptions that stand in the way of access to life-saving
mental health care for many of the most vulnerable of our
friends, family, and neighbors. The Federal Government has
spent billions of dollars on the worthy effort of minimizing
the impacts of mental illness over the last couple of years; we
need to ensure that these investments can make a difference.
I appreciate the witnesses that are here, particularly our
good friend, Mr. Lincoln Diaz-Balart.
[The prepared statement of Mr. Upton follows:]
Prepared statement of Hon. Fred Upton
Today, we are here to examine the domestic, and indeed
global, public health crisis that is suicide. Suicide claims
nearly 40,000 Americans and over 800,000 lives worldwide in any
given year. This hearing is a natural outgrowth of this
subcommittee's groundbreaking investigation of Federal programs
addressing serious mental illness following the December 2012
tragedy in Newtown, Connecticut.
No discussion of the full burden on our society of serious
mental illness is complete without a discussion of suicide. For
over 90% of suicides, the victim had been diagnosed with a
mental illness. And tragically, our Nation's veterans are one
of the populations hardest hit by this crisis. While one in ten
Americans has served our country, sadly over the last 2 years,
one in every five suicides has involved a vet.
Like other areas covered by our committee's work on 21st
Century Cures, success will depend on our ability to close the
gaps between advances in scientific knowledge about treating
serious mental illness--which have been extensive--and how the
Federal Government prioritizes and delivers these treatments to
the most vulnerable populations. Our delivery of mental health
services must keep up with the impressive pace of research and
innovation in the field.
There is significant public misunderstanding and
misperception regarding suicide. We hope that our ongoing work
will educate the public about the many treatments available to
address serious mental illness and help correct misconceptions
that stand in the way of access to life-saving mental health
care for many of the most vulnerable of our friends, family,
and neighbors. The Federal Government has spent billions of
dollars on the worthy effort of minimizing the impacts of
mental illness over the years; we need to ensure these
investments can make a difference.
I'd like to welcome Acting Surgeon General Boris Lushniak,
as well as the mental health professionals appearing before us
today, Drs. Brent, Moutier, and Dvoskin. I also want to
especially thank our former colleague, Mr. Lincoln Diaz-Balart,
for sharing his deeply personal story. This is an issue that
hits very close to home for many of us, and we are hopeful
today's hearing aids the national dialogue.
Mr. Upton. I yield to Dr. Burgess, who will yield to Mrs.
Blackburn.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. Thank you, Mr. Chairman, and thank you for
bringing us here during Suicide Prevention Month. My thanks to
the witnesses for presenting today. Thank you, Mr. Chairman,
for correctly outlining that suicide amongst veterans that have
recently attracted national headlines, and appropriately so.
Perhaps this morning we will learn something about what has
been learned and what is being done.
I also want to highlight a particular population that is
often overlooked when we discuss suicide and suicide
prevention, and that is the Nation's physicians. America's
doctors, the people on the front lines of suicide prevention,
are some of the most at risk of suicide and having suicidal
thoughts. This is troubling, and I hope we can hear how it is
being addressed. Physicians and dentists are the most likely
occupations to take their own lives. Physicians are more than
twice as likely, and as it turns out, female physicians are
more than three times likely to commit suicide, and it also
affects a disproportionate share of young doctors. Dr. Brent's
testimony states that insomnia is the single most significant
predictive symptom for suicide, and what I would be interested
in hearing, is that because a symptom of worsening depression
or is in fact a causative factor that exacerbates some of the
things that lead one to contemplate taking their own life. The
medical profession deals with many challenges. Perhaps the most
prominent challenge is that not every patient can be fixed.
Watching patients suffer can be very isolating, and it can take
a toll.
We are here today to begin a discussion about why this is
the case and how Congress can help, and I look forward to
hearing our witnesses, and yield to the gentlelady from
Tennessee, the vice chair of the full committee.
OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TENNESSEE
Mrs. Blackburn. I thank you, Dr. Burgess, and I do welcome
our witnesses.
I want us to think about this: 105. That is the number of
individuals that will take their life today: 105. Many more
will attempt it, and as we have prepared for the hearing, one
of the things that I have found interesting and of note is that
through the decades with all the research, with millions of
taxpayer dollars spent, what we have not seen is a reduction in
the suicide rates, the number of suicides that are attempted
and committed, and I know we are all seeking to find answers to
this. We each have been touched by those that have attempted or
have committed suicide, and it is a very tender issue.
I have the Centerstone Research Institute in Nashville that
has done tremendous work on the issue of youth suicide and is
working with the juvenile justice system, and Mr. Chairman, I
would like to submit a letter for the record from Centerstone.
Mr. Murphy. Without objection, yes.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mrs. Blackburn. And with that, I thank the witnesses and
yield back.
Mr. Murphy. Thank you. I now recognize Ms. Schakowsky for 5
minutes.
OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS
Ms. Schakowsky. Thank you, Mr. Chairman. I want to thank
you for holding this hearing. Suicide affects many, many
people. It has been close to me as well, and it is entirely
appropriate that we address this topic.
I want to tell you, our dear former colleague, Lincoln
Diaz-Balart, how much I appreciate, I think we all appreciate,
you coming here today. It takes a special kind of guts to come
here and talk about your son Lincoln, who suffered from mental
illness, committed suicide last year, and I can only imagine
the pain of losing a child to suicide. My heart goes out to
you.
Mr. Chairman, I applaud your legislative and oversight
efforts this Congress on mental health issues, and I know that
you are really trying to make a difference, but I am disturbed
by what appears to be a growing disconnect between the facts we
hear at oversight hearings and our failure to heed those facts
when it comes to writing legislation. We have heard a few
ongoing themes at this Congress' mental health hearings and
forums. We have heard about the importance of high-quality
health insurance coverage for those with serious mental
illness. Individuals suffering from mental illness need broad
coverage. They need continuity of care. They need to be able to
afford their treatments. Witness after witness has told us the
same thing, and we will hear the same thing today. Earlier this
year, the president of the American Psychological Association
said that the availability of this coverage under the
Affordable Care Act represented ``a watershed moment in the
effort to prevent suicide.''
But Mr. Chairman, some of the Republican legislative
approaches have ignored this evidence. Your colleagues have
voted over 50 times to dismantle Obamacare and take health
insurance away from millions of Americans. And Mr. Chairman, we
have also heard about the importance of adequately funding
mental health research. We hear the same about funding for
suicide prevention efforts today. But Mr. Chairman, the
Republican legislative approach has ignored this evidence.
Again and again, your colleagues have voted on funding on an
appropriations bill including sequestration and the Ryan budget
that have resulted in stagnant budgets for mental health
research. And today, Mr. Chairman, we will hear about the
availability of guns as a risk factor for suicide. Dr. Brent's
testimony says that among healthy youths, and I quote, ``The
only factor that differentiated suicides and controls was the
presence of a loaded gun in the house.'' But Mr. Chairman, when
we talk about legislation to improve mental health outcomes,
prevent mass violence, prevent suicide, your Republican
colleagues refuse to even consider guns as part of the problem.
The purpose of our oversight hearings ought to be to inform
the legislative process, but in this committee, that is not
happening. Over and over again, our witnesses tell us one thing
but the Republican majority does something else. That is a
shame, Mr. Chairman. I hope we can listen carefully to our
witnesses today and finally act on what they tell us.
And I would like to yield the remainder of my time to
Congresswoman Castor.
OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF FLORIDA
Ms. Castor. I thank my friend, Congresswoman Schakowsky,
for yielding the time, and I want to thank you, Mr. Chairman
and Congresswoman DeGette, for continuing to focus on the
challenges families have all across this country with mental
health issues, and I would like to welcome our former
colleague, Lincoln Diaz-Balart from Florida. Lincoln, you are
representing families all across this country in speaking out
on their behalf, and I want to thank you for your courage in
talking about your son and his depression and suicide last
year, and thank you for encouraging improvements in public
policy when it comes to suicide prevention, and here is why
this is so important. In America, the rates of suicide are
going up, particularly among young people and veterans. There
is some distressing news that yes, as Congresswoman Schakowsky
summarized, there have been budget cuts to the National
Institutes of Health, the Centers for Disease Control,
substance abuse and mental health treatment, and it is going to
be much more difficult to tackle these problems if we remain in
this atmosphere of devolution.
But the good news is that the Affordable Care Act is now
providing coverage to millions of previously uninsured
Americans requires that all new individual and small group
insurance plans cover mental health and substance abuse
disorder services as one of the ten essential health benefits.
Plans are required to cover these services at parity with
medical and surgical benefits, significantly expanding
lifesaving services. A February 2014 report by the American
Mental Health Counselors Association found 6.6 million
uninsured adults with serious mental health and substance use
conditions will be eligible now for health insurance coverage
including coverage for mental health and substance abuse
through the new Affordable Care Act marketplaces and exchanges.
The president of the Psychological Association of America
said that notwithstanding the politics of the Affordable Care
Act, the prospect that millions of Americans will have health
insurance covering mental health benefits at a level comparable
with their physical health care is a watershed moment that
could truly destigmatize mental health care and suicide
prevention services.
Thank you. I yield back.
Mr. Murphy. Thank you.
I would now like to introduce our first witness. He is the
Honorable Lincoln Diaz-Balart, an attorney and consultant based
in Miami, Florida. He is a former Member of Congress, where he
served with great distinction between 1993 and 2011. He is here
today to share for the first time a moving and personal story
about Lincoln Gabriel. I greatly appreciate you being here,
Lincoln. Normally at this time we would swear in a witness, but
after consulting with the chairman and the ranking member, we
all agree that an oath to be sworn is not necessary today
because you speak from the heart, and the heart binds a voice
to the truth far greater than a mere oath would.
So with that, I will now give you time for your opening
statement.
STATEMENT OF HON. LINCOLN DIAZ-BALART, FORMER MEMBER OF
CONGRESS
Mr. Diaz-Balart. Mr. Chairman and Ranking Member DeGette
and members of the committee, when you called, Mr. Chairman,
last week and graciously asked if I would consider speaking
here today, I consulted with my son Daniel. He and his older
brother, our dearly beloved Lincoln Gabriel--L.G.--were very
close, and I have ultimate trust in Daniel's judgment. I
explained to Daniel what you had told me, Mr. Chairman, with
the subcommittee, the experts, the Surgeon General, who will
testify here today, will consider helping loved ones in mental
health crisis. Daniel's words were, ``Of course L.G. would want
you to be there. If one person who might not otherwise get help
is able to get treatment because of that hearing and its
aftermath, L.G. would be happy.''
My son Lincoln Gabriel was a blessing to all who got to
know him. He was all love. His was not a theoretical love. It
was a constant, practical love demonstrated by his daily
actions, and above all by his deep respect for all human
beings. L.G. was ultimately generous. He was intelligent,
courageous and of profound religious faith. He never allowed
his illness, his deep depression, for which he took medication,
to stop him from demonstrating his respect and his love for all
human beings he came across.
Christina, Daniel and I miss him dearly, and we will
continue to miss him for the rest of our days in the hope of
our ultimate reunion with him.
Congress honored Ukraine today by receiving its President
in a joint meeting. After their Orange Revolution, I went to
Ukraine in December 2005, and the First Lady at the time, Mrs.
Yushchenko, asked if my community would be able to help some of
Ukraine's most severely handicapped, physically handicapped,
children. I said yes, so in October 2007, 10 children arrived
in south Florida from Ukraine needing prosthetics for arms or
legs, or both. Our community and some south Florida firms
responded admirably. Nine of the ten children were fitted with
prosthetics. But I remember my then-Chief of Staff, Ana
Carbonell, calling me from the airport when the children
arrived explaining we have so much work to do with one
particular young woman, 18-year-old Natalia. Natalia, a
beautiful young woman, was born with extremely small arms and
legs, and her back structure did not allow her to sit up. Hers
was not a case for prosthetics. It was much more serious. She
lived each day on a small wooden platform with wheels face
down. The First Lady of Ukraine had been very impressed by the
fact that, despite her physical disability, Natalia is an
artist. She paints with a brush she holds with her teeth.
But Natalia's dream was to be able to sit in a wheelchair
and face life sitting up. She had had multiple surgeries in
Ukraine, but they had failed. A south Florida surgeon, Dr. Hari
Parvataneni, volunteered to operate. The community donated the
funds to pay for her hospital stay. Natalia's surgery was
successful. After her surgery and rehabilitation, she was able
to sit upright and live independently in her new wheelchair.
She stayed in south Florida for months for her
rehabilitation. Ana Carbonell and her husband, Gus Monge,
opened their home to her. During those months, L.G. became
Natalia's friend. He was so proud of what our community had
done for those children. L.G.'s first and his last Instagram
posts were photographs of Natalia's paintings. I carry his last
Instagram post with me. Some friends of L.G.'s wrote, ``This is
pretty cool. Who painted it?'' ``A family friend from Ukraine
named Natalia,'' L.G. answered.
I have never met anyone more respectful of all human beings
than my son Lincoln Gabriel. As I said, he was all love. I must
admit I believed that all you need is love. I never thought our
tragedy of May 19, 2013, was possible, but it was possible.
Sometimes love is not enough.
Assertive, proactive intervention is sometimes required to
get needed treatment to those in mental health crisis, and
thorough discussion of their illness with those who are sick.
I have come before you today to thank you for focusing on
this painful issue and to thank the mental health experts, the
physicians, those in the NGOs, in the Executive Branch, the
Surgeon General, all those working to prevent tragedies such as
the one my family experienced. Please, find common ground.
Overcome differences in order to make progress.
As my son Daniel said, if one person who might not
otherwise get help is able to get treatment because of this
hearing and its aftermath, L.G. would be happy.
Thank you.
Mr. Murphy. We thank our friend and our colleague for his
words of motivation and challenge, and we will heed that
challenge.
Now, as our next set of witnesses are coming to the table,
I will read your introductions. Please have a seat as your
nameplate is put down.
We are going to be joined today by Rear Admiral Boris
Lushniak, who is the Acting United States Surgeon General. He
oversees the operation of the U.S. Public Health Service
Commissioned Corps comprised of approximately 6,800 uniformed
health officers. Also, Dr. David Brent is the Endowed Chair in
Suicide Studies and Professor of Psychiatry, Pediatrics,
Epidemiology and Clinical and Translational Science at the
University of Pittsburgh. Dr. Christine Moutier is the Chief
Medical Officer of the American Foundation for Suicide
Prevention, and Dr. Joel Dvoskin is an Assistant Professor of
Psychiatry at the University of Arizona and is here today
testifying on behalf of the American Psychological Association.
I will now swear in the witnesses. You are aware that the
committee is holding an investigative hearing, and when so
doing has the practice of taking testimony under oath. Do any
of you have an objection to taking testimony under oath? Seeing
none, the Chair then advises you that under the rules of the
House and the rules of the committee, you are entitled to be
advised by counsel. Do any of you desire to be advised by
counsel during your testimony today? You all say no. In that
case, if you would please rise and raise your right hand, I
will swear you in.
[Witnesses sworn.]
Mr. Murphy. And all have answered affirmatively, so you are
now under oath and subject to the penalties set forth in Title
XVIII, Section 1001 of the United States Code. I am going to
ask you each to give a 5-minute opening statement. We will
begin with Dr. Lushniak.
STATEMENTS OF BORIS D. LUSHNIAK, ACTING SURGEON GENERAL OF THE
UNITED STATES, DEPARTMENT OF HEALTH AND HUMAN SERVICES; DAVID
A. BRENT, ENDOWED CHAIR, SUICIDE STUDIES, AND PROFESSOR OF
PSYCHIATRY, PEDIATRICS, EPIDEMIOLOGY, AND CLINICAL
TRANSLATIONAL SCIENCE, UNIVERSITY OF PITTSBURGH; CHRISTINE
MOUTIER, CHIEF MEDICAL OFFICER, AMERICAN FOUNDATION FOR SUICIDE
PREVENTION; AND JOEL A. DVOSKIN, ASSISTANT PROFESSOR OF
PSYCHIATRY, UNIVERSITY OF ARIZONA, ON BEHALF OF THE AMERICAN
PSYCHOLOGICAL ASSOCIATION
STATEMENT OF BORIS D. LUSHNIAK
Mr. Lushniak. Thank you so much, Chairman Murphy, Ranking
Member DeGette and members of the subcommittee.
What a way to start in terms of hearing the words of the
Honorable Lincoln Diaz-Balart. Oftentimes in public health we
get caught up, certainly in subcommittees we get caught up. We
get caught up in numbers, we get caught up in programs, we get
caught up in initiatives and successes and failures. I submit
to you, sir, starting off with a personal and poignant story
such as presented to us really sets the tone for what all this
is about, that this ends up being that one life at a time, and
yet we know that although he came here very heroically to
discuss the story of his son and their family's tragedy, the
repercussions of that spread out, and each and every year, as
we already heard, almost 40,000 people have stories like that.
Let us remember those 40,000. Let us focus on the public health
impact of this terrible scourge in our land.
I want to share with you the opening dedication of this,
the 2012 National Strategy for Suicide Prevention, and it goes
like this. To those who have lost their lives by suicide to
those who struggle with thoughts of suicide, to those who have
made an attempt on their lives, to those caring for someone who
struggles, to those left behind after a death by suicide, to
those in recovery, and to all those who worked tirelessly to
prevent suicide and suicide attempts in our Nation.
This is one of those quintessential components of any
program, of any initiative, certainly initiatives out of the
Office of the Surgeon General that it is not one person, it is
not one group. It is incredible clinicians as I have to the
left of me. It is incredible political structures and leaders
that I see in front of me. It takes that proverbial village to
have success in public health.
For over a decade, the Office of the Surgeon General has
led in this topic matter. This has been a priority. Surgeon
General David Satcher back in 1999 put out the first call to
action, and in 2001, the National Strategy for Suicide
Prevention. Most recently, my predecessor, the former Surgeon
General Regina Benjamin, in partnership with the National
Action Alliance for Suicide Prevention updated this U.S.
National Strategy for Suicide Prevention.
I am here as an Acting Surgeon General. I am a career
officer in the U.S. Public Health Service, but here committed
to demonstrate the commitment of the Office of the Surgeon
General to continue to be visible and a long-term supporter of
our Nation's work in suicide prevention. I don't come to you as
a psychologist, psychiatrist, behavioral science expert. These
are people to the left of me here. We have that expertise
behind me. My chief of staff, Captain Robert DeMartino, also a
member of the U.S. Public Health Service, is a psychiatrist by
training. He is there embedded within the immediate Office of
the Surgeon General. I come to you as a person trained in
family medicine, preventive medicine, and dermatology. I bring
my commitment to a public health approach and public health
expertise to these issues.
Let me define this public health approach. What is the
problem? We define the problem through surveillance and data.
Why did it happen? We identify the causes and understand the
risks and protective factors. What works? We develop and
evaluate innovations, programs, and policies. How do you do it
and accomplish the goal? We implement and ultimately
disseminate interventions that work, evidence-based
interventions.
While the Office of the Surgeon General doesn't direct or
have oversight over specific programs or agencies within the
Department of Health and Human Services, the ability of that
title of Acting Surgeon General or the Surgeon General to bring
the Nation's attention and focus onto important public health
issues remains an important and necessary part of our efforts
to prevent suicide in our Nation. We play a leadership role to
bring together Federal and non-Federal partners, inspire them
to identify the solutions, take collective action to address
these key issues. That collaborative leadership was fundamental
to creation of this, the national strategy.
Incidence of suicide, as we have heard, in spite of an
encouraging trend between 1995 and 2005, has sadly remained
largely undisturbed. Many people will ask why. The unsatisfying
answer is, suicide is a complex problem that defies a simple
solution. Still, there are many clues out there in the
international realm. The United Kingdom's steady, significant
reductions in suicide rates included access to 24-hour crisis
care, assertive outreach for people with severe mental illness.
In Taiwan, follow-up aftercare after suicide attempts led to a
63 percent reduction. Means reduction has been successful in
international settings. Regardless of the means, those who die
by suicide are far from being the only ones affected by that
tragedy.
We have this as a catalyst, the National Strategy for
Suicide Prevention, work together by HHS agencies and outside
partnerships, 13 goals, 60 objectives, reducing suicides over
the next 10 years. We work together with the National Action
Alliance for Suicide Prevention, a public-private endeavor. We
have many examples of successes, and yes, sir, many examples of
failures in this.
With the emphasis on effective treatment to prevent suicide
and reattempts, one of our goals, we have various therapies
that are out there that are available and need to be utilized
in this evidence-based world. We are engaged in a long-term
effort to change how our society thinks about serious mental
illness and suicides. We have to work on those changes.
Mr. Murphy. If you could wrap up?
Mr. Lushniak. While much has been done, we know more needs
to be done. I applaud you for bringing attention to this issue.
I urge your continued support for suicide prevention.
Thank you, Mr. Chairman, Ranking Member DeGette and members
of the subcommittee, and I look forward to further discussion.
[The prepared statement of Mr. Lushniak follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Doctor.
Dr. Brent, you are recognized for 5 minutes.
STATEMENT OF DAVID BRENT
Mr. Brent. First, I would like to thank you and your staff
for inviting me. It is an honor to be here.
I would like to make a few points about what I think are
things that we can do now that can decrease the suicide rate,
and it starts with the premise that the single most important
risk factor for suicide remains mental disorder, and there is
evidence that if you improve the quality of treatment of mental
disorder that you can decrease the suicide rate. This has been
demonstrated regionally in studies based in primary care. There
are pharmacoepidemiologic data that show that there is an
inverse relationship between prescriptions for antidepressants
and the suicide rate, and one of the ways that we think about
how mental illness contributes to the risk for suicide is that
it affects a balance between distress and restraint and that
when you have low restraint against suicide and high levels of
distress, that is when suicide ensues, and this is why
insomnia, I think, is one of the most important risk factors
for suicide. It is underrecognized. Many people are not well
trained in its treatment. The way that it contributes is that
it tends to increase disinhibition and dysphoria, which is a
really bad combination and something that can either
precipitate or exacerbate suicidal thoughts.
There also are efficacious treatments for suicidal
behavioral, and the issue is really one of dissemination at
this point, and I will just mention one of them, dialectic
behavior therapy, but there are several others, and what they
have in common is that they have a clear model for suicidal
behavior. They collaborate with the patient, and they have a
safety plan that the patient can implement when they have
suicidal urges.
Another barrier to prevention of suicide, I believe, has to
do with the inadvertent effects of the black-box warning of the
FDA, which warns against suicidal events that may occur with
antidepressant treatment, and what we have seen as an untoward
consequence of that is a decline in the rate of diagnosis of
depression and even a decline in referrals for psychological
treatments for depression in adolescence, and although it is
controversial, there are some studies showing that that is
correlated with an uptick in suicide.
Another thing that I think should be in our portfolio has
to do with evidence-based prevention. The Washington State
Institute for Public Policy has done cost-benefit analyses on
different prevention programs and showed that there are certain
ones that are evidence-based and yield a very high return for
investment, and I think that some of these could decrease risk
factors that we know are related to suicide such as aggression
and substance abuse.
The issue of lethal agents in suicide--guns in the United
States--having a gun in the house greatly increases the risk of
suicide, and it is not only in people who have mental illness,
although that is the most concerning issue, but in our studies,
we found that individuals where there wasn't a clear mental
disorder, the only factor that differentiated between suicide
victims and people in the community was having a loaded gun in
the home, and so we know that there are interventions that can
be done in primary care that can at least encourage people to
store guns in a secure manner so that a disinhibited or
impulsive act won't lead to a fatality, and we would urge that
this be considered as an important public health measure.
There are service system changes that can lead to
improvement in the suicide rate, and Dr. Lushniak alluded to
this, but in England, they showed that implementation of care
coordination, 24-hour beds, crisis beds, assertive outreach if
people don't show up for their appointments, and dual diagnosis
treatment, that is, substance abuse and mental disorder
combined. When they implemented these recommendations, it was
associated with a decline in the suicide rate.
And so to conclude, I just wanted to share what I think are
some recommendations that may help us to reduce the suicide
rate, which has to do with improved recognition and treatment,
and I think the most promising area, and this is in
collaborative care where mental health treatment is collocated
in primary care, dissemination of evidence-based treatments
that have been shown to reduce suicide, coordination of care
and the mental health service systems, innovations that have
been shown in England to reduce suicide, and I think that there
are some research areas that could have relatively high payoff
quickly. One is whether better recognition and treatment of
insomnia could have an effect on the suicide rate, safety
counseling in primary care, whether restriction of availability
of lethal means could reduce the suicide rate, and I think
research on trying to find agents that have a more rapid onset
of antidepressant effect than the ones that we are currently
using, and finally, evidence-based prevention judiciously used,
and I think these recommendations, many of them are partly in
place now, I think could make a favorable impact on the suicide
rate.
Thank you.
[The prepared statement of Dr. Brent follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Doctor.
Now, Dr. Moutier, if you would pull the mic close to you
and turn it on. We appreciate your testimony.
STATEMENT OF CHRISTINE MOUTIER
Ms. Moutier. Mr. Chairman and members of the committee,
thank you for inviting the American Foundation for Suicide
Prevention, AFSP, to testify today. I am Christine Moutier, and
I am AFSP's Chief Medical Officer. I would like to submit my
full written statement for the record, and Mr. Chairman, thank
you for your longstanding leadership in mental health and
suicide prevention.
The magnitude of suicide's toll on our society is immense,
but my message today is hopeful and actionable. While suicide's
roots are complex with biological, psychological, and social
determinants at play, clearly oftentimes suicide is the result
of an unrecognized or untreated mental illness, and when one in
four Americans have a diagnosable mental health condition but
only one in five of those are seeking professional help, we
have a lot of work to do. We must elevate the layperson's
understanding of how mental health problems are experienced or
what they look like in loved ones, and we must highlight help-
seeking as the smart, responsible thing to do when you sense a
change in mental health just like you would be proactive with
any other aspect of your health.
Suicide risk tends to be the highest when multiple risk
factors come together or precipitating life events in a person
with a mental illness. We can start by better recognizing and
effectively treating those health problems. On a population
level, we can implement more upstream approaches such as
shoring up community and peer support, teaching students social
and emotional skills, making mental health care accessible and
available to all, and addressing the health care system's
failures, training frontline citizens like teachers, first
responders and clinicians, and limiting access to lethal means.
The good news is that suicide is preventable, and thanks to
a grassroots movement catalyzed by both suicide loss survivors
and the emerging voice of those with their own history of
suicide attempts, the fight against suicide is reaching a
tipping point. I believe we need to focus on three key policy
areas to bend the curve of our Nation's suicide rate, and these
areas include suicide prevention research, suicide prevention
programs, and support programs for those who are touched by
suicide.
Research is vitally important to understanding what
actually works to prevent suicide. Suicide research must focus
on the gaps in the science, which, if understood, would have
the greatest potential impact on reducing suicide burden.
AFSP uses a strategic approach to fund the best science
with an eye toward impact. One AFSP-funded study, for example,
trained primary care physicians in a region of Hungary that
happened to have one of the world's highest suicide rates and
found that their training led to a reduction in suicide rates
in that region at least until the effect of the training had
passed a couple years later. Studies of bridge barriers dispel
the myth that people bent on suicide will find a way since
suicide rates for the whole region diminished following their
construction, and, as you have heard, clinical intervention
studies have found promising results for those at highest risk
for suicide such as people who have had a suicide attempt.
AFSP believes that the Federal Government must
substantially increase funding of suicide research in the hopes
of obtaining similar reductions in mortality that have come
from strategic investments in other major public health
problems like heart disease, HIV/AIDS, and cancer. Federal
funding of research is far from commensurate with suicide's
morbidity and mortality toll.
Suicide prevention needs to encompass a broad range of the
issues that put people at risk for suicide and conversely,
prevention needs to emphasize the conditions that provide a
protective effect against suicide. The best strategies are
multidimensional and sustained. They use education, media
campaigns, targeted screening, resilience building, system
changes that treat mental health problems as health issues and
not disciplinary ones, and they address access to lethal means.
Prevailing cultural perceptions about suicide and mental
health keep 80 percent of people with a mental health problem
from getting help. To address this appalling level of mental
health illiteracy, we must provide education universally to
eradicate stigma and shatter the real and perceived barriers
that keep people suffering in silence. Suicide touches many,
many lives, but only recently as more and more people are
speaking out about their experiences has the need for action
become so apparent. Ten years ago, our organization had only a
handful of people banding together. Today we have over 100,000
people walking and raising awareness for suicide prevention
every year. It is time to wage war on suicide and put a stop to
this tragic loss of life. I believe we can accomplish a goal of
reducing the suicide rate in our country 20 percent by 2025.
This is our organization's goal. Science can provide a clear
roadmap, and I believe the American people are ready for a
greater understanding of the issue. If we push hard with an
effective strategy, we can save lives.
Thank you.
[The prepared statement of Ms. Moutier follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Doctor.
Now Dr. Dvoskin, you are recognized for 5 minutes. Make
sure the microphone is on and pull it close to you.
STATEMENT OF JOEL A. DVOSKIN
Mr. Dvoskin. Chairman Murphy, Ranking Member DeGette and
members of the committee, my name is Dr. Joel Dvoskin. I am a
clinical and forensic psychologist. I am a faculty member at
the University of Arizona College of Medicine. I also serve as
Chairman of the Governor's Advisory Council on Behavioral
Health for the State of Nevada. I thank you for holding this
hearing, and I am appearing today on behalf of the American
Psychological Association, which is the largest scientific and
professional organization representing psychology in the United
States. APA supports the committee's focus on ensuring that our
Nation does all it can to prevent suicide.
As you have heard, suicide is a complex and multifaceted
problem. It is also a form of violence, but with access to
appropriate treatment, it can be prevented, and that is
probably one of the more important things I want to say to you
today, and you have heard from other people is that we know how
to prevent suicide; we just don't do it.
Any act of interpersonal violence including mass homicides,
which have gotten a lot of attention, are suicidal acts. The
majority of people who commit mass homicide die. They either
kill themselves, they are shot by police, or their life as they
know it is over because they go to prison or hospital for the
rest of their life. So if we prevent suicide, we will prevent
mass homicide; we will just never know it because you never
know which person would have decided to end their life at the
expense of many others.
APA views suicide prevention as an essential part of
violence prevention. As you have heard from Dr. Brent, suicide
is an impulsive act, especially angry impulsivity, where an
individual is desperate to relieve their suffering and can't
figure out another way to do so.
Suicide risk can be reduced through identifying and
providing support to address the factors that drive a person to
consider suicide as well as the factors that disinhibit people
and allow them act on those drives.
Much of my current work is--I am a board member of the
National Association to Protect Children, and one of the
important points I want to make is that child abuse and trauma
is an important risk factor for suicide among a whole bunch of
other bad life outcomes. Programs such as the National Child
Traumatic Stress Network are essential to our efforts to
prevent suicide.
Much of my own work is focused on jails and prisons. I was
glad to hear you mention DBT. Just yesterday, I spent all day
in the women's prison in Huron Valley in Michigan, where they
have done, to my knowledge, the first DBT program in a prison
in America as a large part of their effort to prevent suicidal
acts among their inmate population.
By using a public health and prevention approach,
experience shows that we have reduced jail suicides by about
two-thirds in every jail that has implemented a public health
approach to suicide prevention. It is very simple. You ask
people at the front door if they are thinking of killing
themselves, and if they say yes, which they often do, you keep
them alive until the crisis passes.
You have heard about interagency collaboration and
programs. One example is the crisis intervention teams, which I
know that Chairman Murphy has been supportive of, a program
that has been developed with law enforcement, but CIT is
worthless if the police don't have anybody to refer the person
to. So in the absence of good mental health care, CIT, which is
a tremendously valuable program, loses a lot of its
effectiveness.
One of the most important things I want to share with you
today is the fact that we have completely neglected to use the
most important behavioral change agent in America to fight
suicide, and that is television advertising. Television got
everybody in America to put deodorant on every morning, but we
have never tried to use it to change behavior on a much more
important thing, and I think the committee could use its power
to get some cooperation from television advertisers to fight
stigma and to get people to tell us when somebody they care
about, their life is in danger due to suicide. We know what
works, but not all Americans have access to the effective
treatment and crisis intervention that is necessary.
We need to have more trained professionals including people
who have been through problems with mental illness and are very
effective peer service providers. I very much agree with the
chairman's push to at least revisit the Medicaid IMD expansion,
which will hopefully make more acute crisis beds available for
people who are now choking emergency rooms where people can't
get lifesaving treatment, and it is bad treatment for a serious
mental illness or a psychiatric crisis as well.
My time is almost done. I just want to add a couple of
other things. One of them is that the National Violent Crime
Reporting System currently only exists in 16 States, and I urge
you to consider expanding that nationwide so that we can do
some of the research that you have heard about before.
I want to express my deep appreciation of the committee's
work and its ongoing attention to the prevention of suicide and
the treatment of serious mental illness in America. Over my
many years in this field, I have seen tremendous progress in
figuring out how to fight suicide. We just don't implement
these tools broadly enough. Suicide, like so many tragedies, is
the direct result of despair, and there is only one cure for
despair, and that is hope. It is my hope that our political
parties can join together in a bipartisan effort to give people
in the most acute despair some measure of hope for a better
life by improving the services that are provided to people
experiencing emotional crisis and psychological pain. This can
happen to any of us, and we must ensure that help is there in
time of crisis.
Can we afford to do this? I would propose to you that given
the costs of each suicide, we can't afford not to.
Thank you very much.
[The prepared statement of Mr. Dvoskin follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you. I thank all the panelists for your
important testimony. Let me open up questions here for 5
minutes, and we will alternate with other questions.
Surgeon General, in 2010, a progress review on the National
Strategy on Suicide Prevention prepared by the Suicide
Prevention Resource Center identified the ultimate policy goal
behind the national strategy as reducing the morbidity and
mortality of suicide behaviors. Is this the aim of the national
strategy as you understand it as well?
Mr. Lushniak. It is to a large extent, and morbidity, I
have to clarify here. Morbidity is the world of attempts,
right?
Mr. Murphy. We all know that within the realm of suicide,
there is a whole spectrum and it starts with the concept of,
you know, suicide ideation, suicide planning, suicide attempts,
and then suicide, and so ultimately within the national
strategy is really a concerted effort across multiple
Government agencies and with the private sector components to
be able to say, as already stated here, to reduce that
incredible burden on our society, the number of ultimate
suicides that do occur.
Mr. Murphy. Thank you. Also, in September of this year, in
a blog post, NIMH Director Tom Insel noted that despite
increased availability of mental health care and medications
for depression, the U.S. suicide rate has remained largely
unchanged and of, course, we also know in some areas, it has
gone up. Would you agree that this data suggests that our
national strategy dating back to 2001 has not been effective in
reducing the number of deaths by suicide and we need to make
some changes?
Mr. Lushniak. Well, I think the changes are in progress of
being made. I think going back to 2001, we realized in 2001 was
the first strategy. This most recent strategy came out under
Surgeon General Benjamin back in 2012. So actually this is
second anniversary of the release of this strategy. So it is
too early, in my view, to say that things are not successful,
yet I realize we are all frustrated with the fact that success,
if it is going to be there, is coming rather slowly, and so
there is a frustration.
Now, built into this are multiple other changes that are
going on including the idea of, you know, one of the objectives
of this, objective 5.4, which focuses on efforts to increase
access to and delivery of effective behavioral health services.
Now, that certainly has changed with the Affordable Care Act.
The Mental Health Parity and Addiction Equity Act will give 60
million people extended access to mental health and substance
use disorder services, and depression screening, alcohol misuse
screening, and counseling are now covered as pre-preventive
services under ACA. So my sense is that to be able to go back
to 2001 saying things aren't working, my sense is, I am going
back to 2012 and re-analyzing it.
Mr. Murphy. It is clear we have to do something, and as I
have talked with former Congressman Lincoln Diaz-Balart, he
told me that access was not a problem, and I am sure we would
agree that for Robin Williams, insurance and money was not a
problem.
But Dr. Brent, you have seen considerable success in some
of your research, in particular, the STAR Center. How has the
STAR Center performed? And I think it is the only one of its
kind in Pennsylvania, and is it serving as a model for other
States in terms of ability to have positive results?
Mr. Brent. Well, I don't know how unique it is, but our
program is funded by the Commonwealth of Pennsylvania and it
allows us to do things that often clinicians don't do because
it is not billable, but I would say that the things that we do
that I think lead to our effectiveness, we spend a lot of time
on supervision and training using evidence-based treatment. We
work as a team, and so decision-making is shared and you are
less likely to make a mistake than if you have multiple
opinions. We spend time coordinating with other institutions so
our clinicians will go to schools, inpatient units and so on.
This is not reimbursed currently but we feel that it is
important. And I would say that we have a sense of mission and
discovery, and I think we are critical about our own work, and
we are always looking to improve.
Mr. Murphy. And we hope you will continue to share much of
that research with this committee because it is an exemplary
program.
Dr. Moutier, the Washington Post ran an article in its
August 12, 2014, issue quoting you extensively in the media
treatment of Robin Williams' suicide. In particular, you took
issue with a tweet by the Academy of Motion Pictures Arts and
Sciences which you argued ran contrary to a healthy dialog. I
don't know if we have that tweet available. Right there. And it
says, ``Genie, you are free.'' How can the American Foundation
of Suicide Prevention and similar groups bring the myths and
facts about suicide and suicide prevention to the attention of
organizations and commentators acting on social media? Could
you please comment on how we need to change that?
Ms. Moutier. Yes. I think that speaks exactly to the
disconnect and the level of ignorance that is out there.
Obviously they meant well with that statement, and little did
they realize that to a vulnerable individual, especially a
young, vulnerable person, that really presents an idea that
suicide is being idealized and it is a solution and makes it
more acceptable, and I am sure they did not mean to do that but
that kind of messaging is being done still to this day quite
frequently.
My organization partners with other organizations. We have
already produced media guidelines for safe messaging, and
actually maybe even effective prevention messaging about
suicide after an event has occurred that has the public's
attention. We are doing things like working with the media. We
just attended a conference this week to try to raise this level
of education. We have friends in the Associated Press who are
working to, for example, get the term, the phrase ``committed
suicide'' banned from the AP Style Guide, which would be a
measure of progress as well so that it is not associated with a
criminal act.
Mr. Murphy. Thank you very much. I now recognize Ms.
DeGette for 5 minutes.
Ms. DeGette. Thank you very much.
Dr. Lushniak, access to treatment is going to be a key part
of any efforts we make in suicide prevention and reduction. Is
that correct?
Mr. Lushniak. Yes. I think it is a key feature.
Ms. DeGette. Thank you.
Mr. Lushniak. Let me back up just----
Ms. DeGette. OK. I need to keep moving.
And Dr. Brent, in your testimony, your written testimony,
you say, ``Access to good quality mental health treatment can
reduce risk.'' Is that correct?
Mr. Brent. Yes.
Ms. DeGette. And I would assume, Dr. Moutier, you agree
with that as well, that people have to have access to quality
treatment, right?
Ms. Moutier. Yes.
Ms. DeGette. And Dr. Dvoskin?
Mr. Dvoskin. Yes.
Ms. DeGette. OK. So going back to you, Dr. Lushniak, what
were you going to clarify?
Mr. Lushniak. Well, it is interesting because I think
access to be able to diagnose appropriately severe mental
illness----
Ms. DeGette. Right.
Mr. Lushniak [continuing]. And being able to treat it
appropriately is the key feature.
Ms. DeGette. Yes.
Mr. Lushniak. One of the disturbing factors that we have
seen in terms of the data that come in is that the majority of
suicides that do occur have had access to medical care.
Ms. DeGette. Right.
Mr. Lushniak. They----
Ms. DeGette. But they don't necessarily have access to
psychological care.
Mr. Lushniak. But also the issue here is----
Ms. DeGette. Is that right?
Mr. Lushniak [continuing]. Whether that issue--whether as
you are having your blood pressure taken, whether----
Ms. DeGette. Whether they are asking about that?
Mr. Lushniak. Exactly.
Ms. DeGette. That is correct. And Dr. Dvoskin, part of the
thing is that we haven't had high-quality psychological care,
particularly for adolescents. Isn't that correct? I mean, what
we have heard in all these hearings this year that we have been
having is that we don't have nearly enough trained mental
health professionals for adolescents, and that pediatricians
and others who are treating these young people don't have the
psychological training. Would you agree with that?
Mr. Dvoskin. Some do and many don't.
Ms. DeGette. OK. And Dr. Brent, in your written testimony,
one of--and actually, Dr. Dvoskin, you talked about this too in
your testimony. You were talking about DBT, which is dialectic
behavior therapy. Is that right?
Mr. Brent. Yes.
Ms. DeGette. And dialectic behavior therapy is a very
intensive and expensive therapy. Is that correct?
Mr. Brent. Yes.
Ms. DeGette. But it seems to have shown through the studies
that it works. Is that right?
Mr. Brent. Yes. Can I----
Ms. DeGette. Yes. Turn the mic on, please.
Mr. Brent. There are briefer versions and there are other
treatments like cognitive behavior therapy.
Ms. DeGette. Right.
Mr. Brent. There is one study----
Ms. DeGette. Right.
Mr. Brent [continuing]. In nine sessions, they were able to
cut the suicide rate in half.
Ms. DeGette. Right, but still, the cognitive behavior
study, that costs money too and it needs trained professionals
to administer. Is that right?
Mr. Brent. Yes.
Ms. DeGette. Yes? OK. Thanks. So the reason I am asking
these questions is because, of course, one thing we tried to do
when we passed the Affordable Care Act is, we tried to give
people mental health coverage as a result, and in fact, there
was a report earlier this year by the American Mental Health
Counselors Association that nearly 7 million uninsured adults
with serious mental health and substance abuse conditions are
now eligible for health insurance coverages under the ACA
marketplaces and for 27 States through Medicaid, and so Dr.
Dvoskin, I wanted to ask you, do you think that it is important
that we expand mental health coverage to people as we are
expanding our health care in general?
Mr. Dvoskin. Mental health coverage crisis response is
terribly important, so even if someone is in treatment, if
there is--many suicidal crises occur late at night when crisis
response teams, fire and rescue, police agencies are the
responders, and a competent crisis response has suffered very
badly from the decreases in mental health funding in the public
mental health system over the last 15 years.
Ms. DeGette. Right. So even though we are giving people
more access to mental health in the ACA, we still need to fund
that crisis treatment, and we have heard that loud and clear.
Mr. Dvoskin. Yes, ma'am.
Ms. DeGette. Dr. Lushniak, I want to ask you if you can
talk about what has happened that you have seen since the
Affordable Care Act has given increased coverage of mental
health services and what that will mean in your efforts for
suicide prevention.
Mr. Lushniak. Well, certainly, I think it is too early to
see whether we have a success or a failure here. The success
is, we do have coverage. As I mentioned already, both the
Affordable Care Act as well as the Mental Health Parity and
Addiction Equity Act will give 60 million, 6-0 million people
expanded access to mental health and substance use disorder
services. So the idea here is that access, will access bring us
success? Certainly, I think access is going to be a positive
influence.
Ms. DeGette. But it is not the only thing.
Mr. Lushniak. But right now it is not the only thing. It is
helpful. It is heading in the right direction but it really
dovetails into what I think all of our messages was. We are
dealing with a very complex public health issue here, a very
complex mental health issue here, and it is multifactorial with
multifactorial resolutions. There is not going to be one simple
answer saying access will solve the whole problem.
Ms. DeGette. Thank you. Thank you very much, Mr. Chairman.
Mr. Murphy. Thank you. I now recognize Mr. Griffith of
Virginia for 5 minutes.
Mr. Griffith. Thank you very much. I appreciate that.
I will let any of you jump in on this. One of the things
that we haven't discussed in detail but is a part of that
multi--and I am not going to pronounce the word right, but
multi reasons why someone might commit suicide. I noticed an
article that I read indicated that there are families who
suffer from depression who have multiple members who have
committed suicide and other families who suffer with a history
of depression who do not have suicide, not a single one, and I
am wondering what the thoughts are. Do you all believe--and
everybody can answer this. Do you believe that there is a gene
that we might be able to identify that would say these folks
with depression are more likely to commit suicide than other
folks, and do we target or do we put special attention on those
who have a family history both of the mental illness of
depression and a resulting suicidal act in the family?
Mr. Lushniak. And I will start, and then we can open it up
to the panel. Certainly, there are genetic influences on a
variety of conditions--substance use, abuse of substances.
Alcoholism obviously has a genetic predisposition. There are
also mental health disorders, severe mental health disorders
that do have a genetic connection there as well. We know a
definite risk factor is having a family member who has
committed suicide. We know that is a risk factor, and the whole
idea of genetics and its tie-in with suicide I think is still
to be determined in our research world, and I will pass the
microphone on to the clinicians here to further give their
opinion on this.
Mr. Brent. Well, there is definitely a genetic influence to
suicide, and the families that you were describing, the two
types of families, is strong evidence for that, but that
doesn't mean that it is caused by a single gene, and I think
that when we deal with families where there has been a
completed suicide, we have to tell people actually that you are
at increased genetic risk but genetics isn't destiny. If you
have a risk that is 40 per 100,000 instead of 10 per 100,000,
the odds are still with you, and so I think it is important not
to oversell that. At the same time, we are chasing what might
be some genetic factors that could be contributing to suicide
risk but it is not going to be one gene.
Mr. Dvoskin. I would just add that looking at this through
a public health lens, it is very easy to identify the people
who are deserving of extra attention, who is at higher risk,
people who have tried before, people who have close families
who have killed themselves. So we don't lack for an ability to
identify the at-risk population.
Mr. Griffith. Did you want to add anything?
Ms. Moutier. Well, I think I will just say, as you heard,
we have things that we can implement now. Research is fine and
good, but if it doesn't translate into something that is
actionable to actually help people, I think in many cases what
you are hearing is that we have evidence-based strategies and
now we have growing access to care. Now we have to link the
two. So I think there are things that we need to do now, and
continuing to more robustly fund research is very important. We
are probably some years away from that genetic answer for
predicting suicide risk but it could be there, absolutely.
Mr. Griffith. Well, I appreciate that and hope that while I
know that is just one piece of the puzzle, I would hope that
the researchers and both private and governmental areas would
continue to look into that.
Switching gears, I would ask the Surgeon General if he
could comment on the possibility of using the U.S. Air Force's
suicide prevention program as a possible model for the other
branches because obviously we are all concerned with the high
increase and the large numbers of our armed forces who returned
from combat.
Mr. Lushniak. Certainly. I think it is a discussion that I
can certainly have and will have with the other Surgeons
General of the Army and Navy as well as the Air Force, my
fellow surgeons, if you will. That being said, I think the Air
Force is a great model. The Air Force has two components to
their program. One component is the wingmen component, which is
servicemen watching out for other servicemen. The other
component is actually built into a youth prevention program.
I think the bottom line to all of this, and it really goes
back to this public health model that I described earlier,
ultimately, we are looking for what works. Part of what works
is to be able to look at innovations, look at changes and
properly evaluate them because ultimately as we go further to
implement this, whether it is across the armed services or
whether it is across the Nation, I have to have proven systems
that work before nationwide implementation goes. But I think we
are on that pathway to find out what is working and to see how
it is implementable, even in terms of further pilot studies.
Mr. Griffith. And Mr. Chairman, if you all will indulge me,
I am going to go back to the first question because something
came to my mind.
One of the factors is also substance abuse, and I am
wondering if there are any programs out there--we talked
earlier about educating people on what you might do and why
television--we have learned, you know, everybody should use
deodorant but we haven't learned how to deal with suicide. For
those families that have a history of both substance abuse and
suicide, I wonder how much work is being done on encouraging
those families to be abstinent when it comes to both alcohol
and other substances.
Mr. Lushniak. I think certainly when we look at all the
risk factors--and I think we sort of described it earlier--we
know a lot of the risk factors that exist out there. Now, how
all these are bundled together, which is the family's history
component in addition to the substance use or abuse component,
we certainly look and try to strengthen our specific prevention
activities within those populations, but in essence, we
sometimes break them apart. In other words, the substance use
is treated differently than the family history one. But again,
I will turn to the clinicians here who do this on a daily
basis.
Mr. Brent. So substance abuse prevention is an interesting
issue because it is so prevalent, especially in adolescents and
young adults, that there is argument that a universal
prevention actually makes more sense than targeting people that
are at high risk, and in that policy institute I mentioned, the
Washington State Policy Institute, they have identified several
intervention programs that are low-cost that are, you know,
relatively brief that have shown to reduce substance abuse by
about a third in communities where it had been implemented.
Mr. Murphy. The gentleman's time is expired but if you
could get us copies of--any time any of you reference any
study, I hope you will get us copies. That is valuable.
Mr. Griffith. Thank you, Mr. Chairman. I appreciate the
committee's indulgence.
Mr. Murphy. Thank you. Now Ms. Castor is recognized for 5
minutes.
Ms. Castor. Thank you, Mr. Chairman, and thank you to the
panel.
I don't think it is an understatement to say that there is
a suicide crisis among America's veterans. The Department of
Veterans Affairs estimates that 22 veterans commit suicide
every day. I am not going to use that, I have learned. What is
the proper way to say it then?
Ms. Moutier. Died by suicide.
Ms. Castor. Twenty-two veterans die by suicide every day,
about 7,000 per year. Veterans are three times as likely to die
by suicide as non-veterans. The number of suicides among
veterans is outpacing the number of combat deaths. So this is a
real national tragedy.
Dr. Lushniak, why are we seeing these trends. I think
people kind of understand the stresses, but what can you tell
us?
Mr. Lushniak. Well, again, you know, the big question is
why, why we see such trends. I mean, we certainly know one of
the risk factors is serving in military. Certainly in military
during wartimes, the stressors increase. The issues as, you
know, Chairman Murphy well knows by going on--he was sharing
with me his experiences going to Walter Reed twice a month to
be able to treat and to diagnose and to assist in individuals
who are coming back with traumatic brain injuries, who come
back with PTSD. We are in a time where there are more such
service members who are coming back. That is part of the issue.
The other issue also is the issue of serving in any of our
uniformed services brings with it its stress, its separation
from family, its separation from one's normal environs. So
there are multiple reasons for that.
Let me tell you to some extent sort of the cooperation that
is going on right now, to a great extent the cooperation that
is going on right now, and this specifically goes back to a
question we had earlier in terms of the surveillance. Part of
the way we get risk factors is being able to monitor what is
going on out there, and we heard a little bit about the
National Violent Death Reporting System, that it is only in 18
States right now. I can tell you today that the CDC has awarded
new grants to expand this from 18 to 32 States. But on top of
that, there also now is an expansion to actually both CDC and
NIH working with the Department of Defense and working with the
Veterans Administration system to link their data sets or the
data across their data sets. Now, why is this important?
Ultimately, I am still looking, you know, for further
information about risk factors, and if I can get more precise
information from VA databases, if I can get more information
from the Department of Defense databases, for those individuals
who have died from suicide, this is very helpful for us to plan
the next series of strategies.
Ms. Castor. I represent the Tampa Bay area, and in Tampa we
have the Haley VA Hospital. It is known as the busiest VA in
the country and it is home to one of the five polytrauma
centers, so we see the most severe cases of TBI and spinal cord
injury, but I was there a couple of weeks ago talking to a
veteran that had been deployed about three or four times and
was from Fort Bragg and was a tough guy and was known as a
leader, and he said to me, let me tell you my story, you know,
I am a tough guy and I came back and I had my wonderful family
and they are supportive and things were going all right, and
then a couple of months later something just snapped, and he
said I recommend that the VA system and all of you do a better
job up front when folks come home, even if we say, oh, we are
fine and we are OK, and they are physically healthy, to not
just accept it, and I think the Congress has put a lot of
resources into this but Dr. Lushniak, what can you tell us now
about what the Federal Government is doing? We have heard a
good summary, but how it is really working? Oh, I am sorry. I
mean Dr. Dvoskin.
Mr. Dvoskin. I agree that the Federal Government could
profit from better coordination of its efforts, and I also
think the efforts needed to be targeted along the lines that
you have heard today from my colleagues, but just to give you
one example, access to care doesn't mean very much if you can't
get to a psychiatrist or a psychologist, and there aren't
nearly enough mental health professionals in the United States,
not nearly enough. There are wonderful clinicians in the VA but
there aren't enough of them. It takes 5 years to expand a
residency program in psychiatry, and medical schools are loathe
to go into the process, so we are automatically something we
have done to ourselves 5 years behind the curve to increase the
number of psychiatrists that are being trained at some of these
wonderful medical schools, and you can't bill for a resident.
You can't bill Medicaid for the services provided by a
resident. Well, this is something we are doing to ourselves.
There is no reason in the world for that rule, but it is
something that we do.
So there are a lot of ways that the Federal Government
could streamline existing programs, coordinate existing
programs, and add the kind of evidence-based practices that my
colleagues have talked about today.
Mr. Murphy. Thank you. The gentlelady's time is expired.
And now Dr. Gingrey is recognized for 5 minutes.
Mr. Gingrey. I thank Chairman Murphy, Dr. Murphy, for the
hearing. This legislative hearing of course is extremely
important and I commend him for his bill, H.R. 3717. I gave him
the thumbs-up just a second ago that I absolutely want to be
signed on as cosponsor of this legislation. It is a hugely
important issue, and I thank him for that.
Let me, Dr. Moutier? Is that----
Ms. Moutier. Moutier.
Mr. Gingrey. Moutier. Yes. Let me ask you a few questions
and then maybe the time remaining, the other panelists, the
Surgeon General.
Dr. Moutier, in addition to the factor of age, ethnicity
also plays a role in the incidence of suicides, why has there
been a consistently high suicide rate for elderly white men
relative to all other groups? Any information on that?
Ms. Moutier. Sure. I can speak to that while we also speak
to the largest rise that we have seen in suicide rates perhaps
ever, which is in middle-aged men actually, 35 to 64 years old.
Over the last decade, their rates of suicide rose almost 50
percent. I would speak to a number of things including all the
basic things that you have already heard about the prevalence
rates of mental health problems and distress and what happens
when we don't take proactive care of ourselves. I would cite
the role of culture that we have had in particular segments of
society and we think about military veteran, physician, and
first responder populations, what they all have in common is
higher rates of suicide than the general population and a very
tough macho sort of can't acknowledge being a human being type
of culture.
Mr. Gingrey. Well, let me just interrupt you. Thank you for
that, and I just intuitively think, you know, the pressures of
life as you get a little older and the financial pressures are
greater and maybe the children and the grandchildren didn't
turn out quite the way you wanted them to and you get a little
depressed, and so that leads--well, not a little depressed.
That leads to my next question, and if you would comment on the
statistic that 90 percent of the people who commit suicide were
previously diagnosed with mental illness. Is it known what
percentage of these diagnoses are comprised of--well, would
quality as a serious mental illness?
Ms. Moutier. That is a really good question, and it is
actually that in greater than 90 percent of the cases of
suicide that have been studied through this method of
psychological autopsy method had a diagnosable mental health
condition. In most cases, they actually had not necessarily
been diagnosed or treated. So that method is a little bit
tricky.
Among those who had a diagnosable mental health condition,
the majority of them, it was a substance abuse combined with a
mood disorder. So depression is actually the most common mental
illness represented in those studies but next comes substance
abuse, substance abuse combining with depression and bipolar
disorder, and then other conditions like personality disorders
and psychotic disorders. All of those are represented by the
vast majority of that 90 percent is depression, substance
abuse, and other mood disorders.
Mr. Gingrey. Well, your response is why really I am so
excited about Dr. Murphy's bill because it addresses a lot of
those issues and gets right to the core of the problem.
Mr. Lushniak.
Mr. Lushniak. Lushniak, yes.
Mr. Gingrey. Oh, what the heck. Dr. L, our Surgeon General,
let me ask you this. Suicide among those who serve in our armed
forces and among our veterans is a matter certainly of national
concern. The 2012 National Strategy for Suicide Prevention
identified the United States Air Force suicide prevention
program as a possible model for use in other settings including
civilian. Are there particular evidence-based programs in use
at either the Department of Veterans Affairs or the Department
of Defense like the Air Force that you would recommend
expanding to our civilian health care system as well?
Mr. Lushniak. Well, certainly there are multiple programs
within the VA system, within the DOD, within Health and Human
Services. I will provide one example. Although, you know,
evaluation is always the difficult thing with any programs, but
I will describe the Lifeline, the crisis call-in line that
exists out there. I mean, here is an example where last year in
1 year alone, a million calls come in to a Lifeline system.
This is a call-in system that already--and there is evidence
saying that once people have called in, there are positive
repercussions from that call-in.
So the reality is, we have systems built in all through,
and the real question that ends up--and I will sort of go back
to the Robin Williams tragedy recently, is the fact that there
was another peak right after that tragedy of call-ins to that
Lifeline, and it really does dovetail into, there are so many
aspects to this, so many programs that exist right now, and I
think right now, 2 years after the release of this strategy, we
still are in the evaluation stage, along with the experts that
are here at the table to come up with that final, you know,
final set of recommendations, if you will, which is, what are
we going to go with nationwide, what are we really going to
push, because right now we have multiple pilots going on, and I
think that we will be soon ripe for a time period where we can
evaluate those programs and decide what really works, and it is
going to be multiple answers. It is not going to be one----
Mr. Gingrey. General, or I should say Admiral, thank you so
much. I realize my time--and thank you for your patience, Mr.
Chairman, and I yield back.
Mr. Murphy. Thank you. I now recognize Mr. Tonko for 5
minutes.
Mr. Tonko. Thank you, Mr. Chair, and thank you to our
witnesses. Many of you mentioned the impact that suicide has
not only on the victim but the toll it takes on surrounding
family, friends, and community. I would venture to say that
everyone in this room today has been personally affected by
suicide at some point in his or her life. The numbers
surrounding this epidemic are astounding. While we are in this
hearing today, it is estimated that nine people across this
country will complete suicide.
Dr. Moutier, just to ensure that everyone in this room and
watching this hearing has access to accurate information, what
actions should one take if they or someone they know is
expressing risk signs for suicide?
Ms. Moutier. Sure. I think the first thing to say, which
sounds very basic, but if it is somebody that you know and not
yourself is to don't write it off, don't write off that thing
that you just observed to the stress of the day because we do a
lot of that in our society. So I think just approaching the
person in a caring, concerned way and engaging in a caring
conversation just like you would normally. Mental health, we
need to get all the, you know, mysterious sort of stigma out of
it and just start having normal conversations that express
caring, that say if you are in that kind of distress, I want to
help you get the help that is going to get you back to your
normal baseline way of being, that this is something that can
happen to anyone of us. It is part of the human condition, so
normalizing that.
If it is a matter of safety, then of course you have to act
a little more urgently, and in that case, certainly local
emergency departments are available. Also, the National Suicide
Prevention Lifeline, 1-800-273-TALK is a number to call 24/7
for yourself or for somebody you are concerned about.
Mr. Tonko. Thank you. And Dr. Moutier, the Affordable Care
Act in conjunction with the Mental Health Parity and Addiction
Equity Act, all of those have strengthened insurance coverage
for mental health benefits for an estimated 60 million people,
yet according to a recent New York Times story detailing
experiences in Kentucky, many people are still having trouble
accessing coverage due to an overwhelmed delivery system.
Failure to access services in a timely fashion could be
devastating for those contemplating suicide as you just
indicated. What more do we need to do to ensure that there will
be an adequate supply of providers to handle the mental health
needs of our community?
Ms. Moutier. I think it starts with both improved training
of the existing health care workforce as well as down the
pipeline, the medical students and other disciplines who are
coming up. People may be shocked to know that in only two
States in our country is suicide education a small module on
suicide even mandated for mental health clinicians who are in
training. So we have so much work to do, and in some ways I
would say that should give us hope because we can do that kind
of thing. You have already heard that to expand the workforce
of mental health clinicians is right now we sort of just tied
our own hands behind our back. We are not able to do that when
we can't even expand our residency training programs and other
disciplines as well. So I think there are a number of things
that can be done from a policy standpoint that we should really
take a hard look at that are creating the obstruction.
Mr. Tonko. Thank you very much.
Admiral Lushniak, in your testimony you refer to the recent
World Health report on suicide. Does this report tell us where
the United States stands in comparison to other nations in
preventing suicides, and if so, are there lessons to be learned
from other countries, other cultures that are doing a better
job of preventing suicide?
Mr. Lushniak. Well, in terms of the lessons, where we
stand, I will have to get back with you on that data set in
terms of how we stand relative to other nations, but certainly
when we look at what is going on in the world, right, we know
that national-based programs tend to work, and it really goes
back to what I have said earlier. We start off small but things
that do work ultimately can be put at the national level. We
mentioned examples of the United Kingdom, right, where there
are access, for example, a 24-hour crisis line, assertive
outreach for people with severe mental illness, written
policies on follow-up for those patients. Taiwan, I talked
about a 63 percent reduction. We also have evidence that means
reduction, right, the means of that suicide being reduced, and
I will describe something that sounds very strange but in
Australia, as a result of motor vehicle exhaust suicides, there
was a link to changes in their carbon monoxide emission
standards. So an engineering improvement, an air pollution
improvement in fact led to a change, to a decrease in carbon
monoxide poisonings. I think we have to look at the world and
learn from those aspects, that in fact we haven't talked much
about the means of suicide and we talked a little bit about
safety, we talked about the idea, but across the board, if we
are able to have some control of the means of that death by
suicide, we can actually have impacts, and we see that from the
international realm.
Mr. Tonko. Thank you. Some very interesting concepts, and
with that, Mr. Chair, I yield back.
Mr. Murphy. The gentleman yields back. I now recognize Ms.
Schakowsky for 5 minutes.
Ms. Schakowsky. You know, Dr. Moutier, I was concerned
after Robin Williams' suicide that some people were saying in
their tributes to him, he is now finally at peace, that he is
in a better place. I am glad to hear that there were more calls
to suicide hotlines but were there more suicides?
Ms. Moutier. That won't be known for some time because of
this problem with surveillance that you have been hearing
about, so even when we ask the question, is the program working
for preventing suicide, we are operating on the most recent
data from the CDC, which is 2011. We are 3 years----
Ms. Schakowsky. I just think that--and you were talking
about language before. I think when someone does take his or
her own life that people should be encouraged to say if you are
feeling suicidal, get help, you know, rather than oh, finally,
you know, like sometimes we will say someone who has been
suffering with cancer where they are finally out of their
misery and in a better place. That is not applicable, I don't
think, here.
The other thing, Dr. Brent, I know you focus on, or you
have dealt with adolescents and young adults. I hope all of you
actually will check out--I have a bill called the Mental Health
on Campus Improvement Act. A friend of mine, her son at Harvard
committed suicide, just horribly tragic, and it has a public
health component, a campus health component but also authorizes
a grant program to give campuses more resources to address
mental health, and I know the Association for University and
College Counseling Centers directors have been very supportive
of this legislation.
So, Dr. Brent, are we doing enough in our educational
institutions and on campuses?
Mr. Brent. Well, obviously, I don't think we can ever say
we are doing enough, but I think that the Jed Foundation, which
is a foundation focused on college suicide that is based in New
York, has done a tremendous job with setting certain standards
for what campuses ought to have in terms of availability of
mental health and actually certifying campuses as having
exemplary programs, and I believe there have even been some
evaluations of these interventions that have shown some
beneficial effects.
Ms. Schakowsky. The Jet Foundation?
Mr. Brent. Jed, J-e-d. It is named for--Phil and Donna
Satow, it is named for their son, who committed suicide when he
was at Arizona State University.
Ms. Schakowsky. Dr. Lushniak or Dr. Dvoskin, I wondered if
you want to just comment on that.
Mr. Lushniak. Let me go back to sort of the first part of
your question and the issue--and it is a flabbergasting issue
and the issue of sort of how the media can portray can really
affect the public perception of this, and we saw this come on
as Robin Williams' suicide. We have goals within our national
strategy, and two of them are very particular to this. Goal
number two is implement research and foreign communication
efforts, and goal number four is promote responsible media
reporting, and this framework for successful messaging, it is
an initiative designed to advance this national strategy of
changing the public conversation about suicide and suicide
prevention. The Alliance that I had mentioned, this National
Action Alliance for Suicide Prevention, the private-public
partnership, in fact has an institute that is now set up to
provide journalists with crucial training to effectively
communicate to the public about suicide and mental health.
I think there are two aspects to this from a public health
perspective, public health communication perspective, one of
which is, we can't stigmatize the concepts of severe mental
illness, mental health issues nor stigmatize a conversation
about suicide. Long gone are the days that these are whispered
in hallways--oh, did you hear what happened, this is terrible.
We need to bring it front and center as a public health issue
with scientific evidence that can solve that public health
issue.
At the same time, we have to be able to work with the
media, we have to work with public communications aspects of
our society that don't portray suicide as an answer to a
problem.
Ms. Schakowsky. Right.
Mr. Lushniak. That somehow it is successful, that somehow
it is glorified. We really have to be able to still have that
public perception that this is something that has innate and
multiple factors associated with it, but it is preventable.
Ms. Schakowsky. Thank you.
Mr. Lushniak. I will follow up with one last imagery, and
that is my daughter last night at dinner, and she asked me,
``Dad, what are you doing tomorrow?'' I said I was honored to
be brought in front of this subcommittee. ``What are you
talking about, Dad?''--a 17-year-old senior in high school--and
I said I am talking about suicide prevention. Her answer was,
``It is not preventable, it just happens,'' and we have to
change that. That is the daughter of the Acting Surgeon
General. We had a long conversation afterwards.
Ms. Schakowsky. Doctor, I know Dr. Dvoskin wants to say
something.
Mr. Dvoskin. I just wanted to add, in Vienna, Austria, they
had a spate of suicides by people jumping in front of subway
trains, and they were all on the front page above the fold of
the two newspapers in Vienna. They were owned by families, and
the two publishers got together and had a meeting that was
occasioned by a social science researcher who said to them, you
are making this worse because every time you publicize these
suicides in this manner, the rate goes way up. They made a
gentlepersons' agreement to stop doing it. They stopped putting
the suicide reports on the front page, and the phenomenon
stopped immediately. There is a study that is published--I will
get it to the chairman----
Ms. Schakowsky. I would be interested, because in Chicago
area, we have had that problem with people jumping in front of
trains. It has been in the----
Mr. Dvoskin. We had the same thing with mass homicide. They
put the picture of the perpetrator three times the size of the
anchor and it makes the perpetrators of mass homicide the most
interesting, fascinating people in America, which is exactly
what they wanted, and it makes it seem like a way to be cool
and to matter and to no longer be depressed and sad and
disconnected and feeling insignificant. All you got to do is
kill a bunch of people, and the electronic media is making it
worse.
Ms. Schakowsky. Get us the Hamburg study. I would like to
see it. Thank you.
Mr. Murphy. I thank the members. I thank the panelists.
Just clarifying questions, Dr. Moutier and Dr. Brent. You
said substance abuse, that increases risk. Any particular
substances?
Ms. Moutier. It is across the board but certainly alcohol
would be the most common, and just to clarify, there are people
with addictions who are at risk for suicide, and then there is
the use of substances in the act of dying by suicide, and they
are overlapping but sort of separate subsets, and in about half
the cases of suicide, a substance was at play.
Mr. Murphy. Thank you. I just want to clarify too, in the
study referred to as the Good Behavior Game that was
referenced, my understanding is that the authors of that study
said it did reduce suicide ideation but had no impact on
suicide acts, but the idea that you are all bringing up is
evidence-based is important.
Now, I want to end this with an important note and ask you
each a simple question. Can we prevent suicide with proper
intervention? Dr. Lushniak?
Mr. Lushniak. Without a doubt, sir.
Mr. Murphy. Dr. Brent?
Mr. Brent. Yes.
Mr. Murphy. Dr. Moutier?
Ms. Moutier. Absolutely, yes.
Mr. Murphy. Dr. Dvoskin?
Mr. Dvoskin. Yes.
Mr. Murphy. Does treatment work for people with mental
illness? Dr. Lushniak?
Mr. Lushniak. Yes.
Mr. Murphy. Dr. Brent?
Mr. Brent. Some of the time, but it is better than no
treatment.
Mr. Murphy. Dr. Moutier?
Ms. Moutier. Yes, and it needs to be the right treatment.
Mr. Murphy. Thank you. And Dr. Dvoskin?
Mr. Dvoskin. Yes.
Mr. Murphy. And that is important what you said. The proper
treatment will work, and that is why we have to get people to
access with the right trained professionals.
Now, one more time, Dr. Moutier, what is that phone number
people can call?
Mr. Brent. 1-800-273-TALK, and that is the National Suicide
Prevention Lifeline.
Mr. Murphy. And there are lifelines in people's communities
as well they can look up.
I want to thank this committee. I know that we will be
breaking here for the next few weeks and Congress will not be
here. This committee is exemplary. I continue to get comments
around the Nation as I visit communities to talk about mental
health. This is an issue that Congress has not been willing to
take up at all, let alone in the depth, so this is exemplary,
and my colleagues on both sides of the aisle share the passion
for helping people in mental health crisis. I want to thank you
all.
I also want to ask unanimous consent. Dr. Burgess asked if
we can include articles, one from Health and Science, ``When
doctors commit suicide, it's often hushed up,'' and an article
from the New York Times, ``Why Do Doctors Commit Suicide?'' I
would also like to submit for the record an article from the
American Journal of Psychiatry, ``Modifying Resilience
Mechanisms in At-Risk Individuals: A Controlled Study of
Mindfulness Training in Marines Preparing for Deployment,'' by
Drs. Johnson, Potterat, and others. Without objection, I will
include those in the record.
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Mr. Murphy. Let me also say, I ask unanimous consent that
the members' opening statements be introduced in the record.
Without objection, those will be there.
I would like to thank all the witnesses and members that
participated in today's hearing. I remind members they have 10
business days to submit questions to the record, and I ask that
all the witnesses agree to respond promptly to the questions.
Thank you so much for your dedication and passion, and with
that, I adjourn this hearing.
[Whereupon, at 1:16 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
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