[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]
                          



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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:]
    
    
 
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    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:]
   
   
 
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    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:]
    
 
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    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:]
    
 
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    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:]
    
  
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    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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