[Senate Hearing 113-692]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 113-692
 
                MENTAL HEALTH AND SUICIDE AMONG VETERANS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           NOVEMBER 19, 2014

                               __________

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                     COMMITTEE ON VETERANS' AFFAIRS

                 Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Dean Heller, Nevada
Mazie Hirono, Hawaii
                    Steve Robertson, Staff Director
                 Lupe Wissel, Republican Staff Director
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              

                           November 19, 2014
                                SENATORS

                                                                   Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     2
Tester, Hon. Jon, U.S. Senator from Montana......................     4
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     5
Hirono, Hon. Mazie, U.S. Senator from Hawaii.....................     5
Moran, Hon. Jerry, U.S. Senator from Kansas......................     6
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     6
Johanns, Hon. Mike, U.S. Senator from Nebraska...................     7
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........     8
Heller, Hon. Dean, U.S. Senator from Nevada......................     9
Begich, Hon. Mark, U.S. Senator from Alaska......................    11
Boozman, Hon. John, U.S. Senator from Arkansas...................    12

                               WITNESSES

Walsh, Hon. John, U.S. Senator from Montana......................     3
Kudler, Harold, M.D., Chief Consultant for Mental Health 
  Services, Veterans Health Administration, U.S. Department of 
  Veterans Affairs; accompanied by Caitlin Thompson, Ph.D., 
  Deputy Director, Suicide Prevention; and Dean D. Krahn, M.D., 
  Deputy Director, Office of Mental Health Operations............    14
    Prepared statement...........................................    16
    Response to posthearing questions submitted by:
      Hon. Sherrod Brown.........................................    40
      Hon. Richard Blumenthal....................................    40
      Hon. Mazie Hirono..........................................    41
Selke, Susan, mother of Clay Hunt, a deceased Marine Corps 
  veteran........................................................    48
    Prepared statement...........................................    50
    Response to posthearing questions submitted by Hon. Sherrod 
      Brown......................................................    87
Pallotta, Valerie, mother of Joshua Pallotta, a deceased Vermont 
  National Guard combat veteran..................................    51
    Prepared statement...........................................    54
    Response to posthearing questions submitted by Hon. Sherrod 
      Brown......................................................    87
Vanata, Vincent, MSgt, USMC (Ret.), Combat Stress Recovery 
  Program participant, Wounded Warrior Project...................    59
    Prepared statement...........................................    61
    Response to posthearing questions submitted by Hon. Sherrod 
      Brown......................................................    87
Ritchie, Elspeth Cameron, M.D., COL, USA (Ret.), Chief Clinical 
  Officer, District of Columbia's Department of Mental Health....    65
    Prepared statement...........................................    67
    Response to posthearing questions submitted by Hon. Sherrod 
      Brown......................................................    87
Smith, Blayne, Executive Director, Team Red, White and Blue......    73
    Prepared statement...........................................    76

                                APPENDIX

Citizens Commission on Human Rights International; report........    89




                MENTAL HEALTH AND SUICIDE AMONG VETERANS

                              ----------                              


                      WEDNESDAY, NOVEMBER 19, 2014

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:30 a.m., in 
room SR-418, Russell Senate Office Building, Hon. Bernard 
Sanders, Chairman of the Committee, presiding.
    Present: Senators Sanders, Murray, Tester, Begich, 
Blumenthal, Hirono, Burr, Isakson, Johanns, Moran, Boozman, and 
Heller.

              STATEMENT OF HON. BERNARD SANDERS, 
              CHAIRMAN, U.S. SENATOR FROM VERMONT

    Chairman Sanders. OK, let us get to work. I want to thank 
the Members for being here, and all of our guests for being 
here, for what is not only a very important hearing, but is a 
hearing that discusses an issue of huge consequence in our 
country. This will no doubt be a very difficult hearing because 
of what we are going to be touching on today: what happens to 
the men and women who come home from war, who have served us 
with great courage, and what happens to them when they return 
to civilian life, what happens to them and to their families 
who experience unspeakable tragedies.
    Today we have some wonderful panelists who are going to 
talk about what the VA is doing, what the VA should be doing, 
what other private, non-profits are doing. I especially want to 
thank two very, very brave women who are with us this morning. 
I cannot express to you my respect for their courage, because 
both of these women, Susan Selke and Valerie Pallotta, have 
experienced tragedies that are nightmarish.
    But what they have chosen to do is to come forward and give 
us their best ideas in terms of how we can prevent the 
tragedies that they have experienced from happening to other 
families, and we so much appreciate their courage and their 
willingness to share their thoughts with us.
    This is a difficult issue. We know that hundreds of 
thousands of men and women came home with PTSD and/or TBI. We 
will hear what the VA is trying to do to treat those men and 
women, what works, what does not work, and how we move forward.
    We are also going to hear from Senator Walsh who has been 
very active in the whole issue of veterans' mental health and 
suicide in a moment. We thank him for being here. With that, I 
yield the mic to Senator Burr, the Ranking Member.

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

    Senator Burr. Mr. Chairman, good morning and thank you for 
holding this hearing; and thank you to our witnesses today. 
Your insight into VA's mental health programs will be 
tremendously helpful to this Committee.
    I would particularly like to welcome Susan Selke and 
Valerie Pallotta. Thank you for your willingness to be here, to 
share your sons' tragic experiences with this Committee. I know 
this is painful to recount, but it is absolutely crucial to our 
understanding of what our men and women go through.
    I would also like to welcome Vincent and Joan Vanata. Thank 
you for sharing your story with the Committee, which I am sure 
is also difficult to tell. It is important to the Members of 
this Committee to hear firsthand from not only veterans, but 
from families and friends about their experiences accessing 
mental health treatment at the VA.
    Before I turn to today's hearing, I would like to talk just 
a minute about a bill Senator McCain, Blumenthal, and I 
introduced this week, the Clay-Hunt Suicide Prevention for 
American Veterans of 2014, named for Sue Selke's son, which 
will direct VA to review its suicide prevention programs to 
determine which ones actually work, improve the transition from 
the battlefield to civilian life for the National Guard, 
provide incentives for psychiatrists to work at the VA, and 
direct VA to collaborate with non-profit organizations on 
suicide prevention efforts. While this bill will not fix 
everything, it is a big step in the right direction, I believe.
    Now, turning to today's topic, this is my fifth hearing 
over the last 4 years providing oversight of VA's mental health 
programs. At those hearings, we have heard from veterans, their 
families, and their friends about the difficulties at accessing 
appropriate mental health care. While I find it disturbing--
what I find so disturbing is what we will hear today is very 
similar to what we heard in 2011.
    One problem I raised at previous hearings, which still 
applies today, is a misplaced focus on the process of providing 
treatment, for instance, whether VA is actually providing 
evidence-based treatments. As VA's written testimony states, VA 
has made deployment of evidence-based therapies a critical 
element of its approach to mental health care.
    Yet, two studies say the VA does not consistently provide 
evidence-based treatments. More importantly, whether or not VA 
provides evidence-based treatments should not be the focus. The 
focus should be on improving mental health. According to a 
survey of 3,100 veterans by The American Legion, veterans do 
not believe their symptoms are improving. The Legion found that 
more than half of those surveyed felt that there was either no 
improvement or worsening of symptoms following psychotherapy or 
medication prescribed by the VA.
    If more than half of our Nation's veterans do not think 
they are getting better, I believe the focus on whether 
evidence-based treatments is provided might be misguided. Where 
is the veteran in this? I am interested in hearing from VA how 
it tracks the improvement of veterans' mental health after 
receiving care, what flexibility VA gives providers to make 
sure it is individualized, and how VA is working with outside 
providers and organizations to guarantee that if a veteran 
cannot get an appointment at a VA facility, they get the 
treatment they need and deserve somewhere in that community.
    As I have said many times, Government cannot be the only 
solution. VA needs to bring other organizations and providers 
into the fold to help. It also does not take technology to help 
these veterans. It takes compassion and a passion to help. In 
the past, we have heard that veterans felt that VA providers 
did not care. I believe this needs repeating. It takes 
compassion and, as I have said in previous hearings, someone on 
the other end of the phone who sounds like they want to help.
    Before I yield, Mr. Chairman, I would like to address very 
briefly the Veterans Access, Choice, and Accountability Act, 
which was signed into law in August. The Choice Act provided 
$17 billion in funding to help veterans receive care from the 
provider of their choosing, and provides the largest reform in 
VA history.
    While I appreciate the Department providing weekly updates 
to all of our staffs on the implementation of the Act, I 
believe that a $17 billion bill deserves additional oversight 
from this Committee. So, I realize that time is running out in 
this calendar year and in this Congress, but I urge all those 
on the Committee next year to make sure that oversight of this 
reform package is number 1 on our list of priorities for the VA 
Committee.
    I thank my colleagues, I thank the Chair, and I thank our 
witnesses.
    Chairman Sanders. Thank you, Senator Burr.
    Now we are going to hear from Senator Walsh.

                 STATEMENT OF HON. JOHN WALSH, 
                   U.S. SENATOR FROM MONTANA

    Senator Walsh. Chairman Sanders, Ranking Member Burr, thank 
you for allowing me to speak today about an issue that is very 
important to me, our veterans' mental health. This is a 
sensitive topic that I am sure has touched every single person 
in this room. An oft-cited statistic is that 22 veterans die by 
suicide each and every day in this country. If that many men 
and women were dying on the battlefield, this country would be 
up in arms. It simply is unacceptable.
    As the wars in Afghanistan and Iraq have wound down, many 
American families are welcoming back sons, daughters, husbands 
and wives who are changed people. These men and women were 
willing to sign their names on the dotted line. They were 
willing to give their full last measure of devotion, and we owe 
them the opportunity to heal, whether their wounds are seen or 
unseen.
    So, I speak from my own humble experience. Combat changes 
you. When my own battalion returned from combat in Iraq, for 
some of my men the war did not end. I have known too many 
soldiers and airmen who have died by suicide. I think of them 
and their families every single day, and the impact that this 
war has had on our men and women across the country.
    I am pleased to see the renewed attention this year to the 
crisis of veteran suicide from Congress and from the President. 
But I want to focus your attention today on one immediate 
solution. Currently, veterans who serve in combat are eligible 
for prioritized care for 5 years after the end of their 
service. This 5-year period is inadequate. It has become 
increasingly clear that delayed onset PTSD is a serious 
phenomenon and the law today is out of date.
    According to the National Comorbidity Survey, only 7 
percent of people with PTSD seek treatment within 1 year of 
their initial trauma event. The average time it takes to seek 
treatment is well beyond the current 5-year combat eligibility 
period. Several major studies have also shown that between 16 
and 20 percent of combat troops with mental illness suffered 
from delayed onset PTSD, the symptoms of which may not appear 
for several years.
    Given this new research it is unacceptable that soldiers 
who have put themselves in harm's way for our country would 
have their eligibility for prioritized care revoked after only 
5 years. These are soldiers who have walked roads booby-trapped 
with IEDs, experienced intense fire fights with an enemy that 
blended into the civilian population, and in too many cases, 
witnessed friends and comrades injured or killed by the enemy.
    Extending the combat eligibility period for prioritized 
care at the VA is an immediate and affordable option that we 
should pass this Congress, and I emphasize this Congress. So, 
today I close by urging my colleagues to support this year 
extending combat eligibility to 10 years. We should not wait 
another day.
    Mr. Chairman, thank you very much for the opportunity to 
speak.
    Chairman Sanders. Senator Walsh, thank you very much for 
your service, both in the Senate and in the military.
    Let us hear now from Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman. Of course, this is 
always timely, these hearings. I would just say this is 
something that comes with a fair share of challenges. Not only 
do we need all hands on deck, but the challenges of stigma that 
surround mental health is huge in our society. The challenges 
of not having enough mental health professionals--I do not care 
if it is in a rural area or an urban area--it is an incredibly 
important challenge.
    I just talked to Secretary McDonald yesterday. He said even 
in some medical schools, 1 in 17 medical school students are 
taking up mental health or studying mental health issues. We 
have got to figure out a way to transcend those stats and get 
more people not only in the military, but quite frankly, in the 
private sector, too, where it is a huge problem also.
    Then, the ability of the VA to use alternative treatment 
methods is critically important. I mean, different things work 
for different people and we need to give them flexibility. They 
need to have the flexibility to be able to treat these veterans 
who need help.
    I would just say one other thing. We passed an important 
bill in July and it is a very good bill which needs to have 
oversight. Oftentimes, when the VA does not have a mental 
health professional, they cannot get it in the community 
either, meaning, we do not have enough folks. In the eastern 
two-thirds of Montana, east of Billings, which is just about 
half the State, there is one mental health care professional. 
That is both VA and private sector.
    So, we need to help not only our veterans, but the entire 
country deal with this issue as we move forward. I appreciate 
Senator Walsh's comments because I think he is spot-on. People 
do not want to admit they have a problem, and oftentimes it 
takes more than 5 years to get that admission. We need to 
reduce that stigma so they will admit to it earlier.
    Thank you very much.
    Chairman Sanders. Thank you, Senator Tester.
    Senator Isakson.

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

    Senator Isakson. Well, thank you, Mr. Chairman, and I will 
not make a long statement at all out of respect for our 
witnesses, except to say that, Mrs. Pallotta, Mrs. Selke, you 
are in my thoughts and prayers not just today, but every day. 
The sacrifice of your sons for America is what keeps America 
strong, but the testimony about their tragedy is something I 
know is difficult. The VA and others will benefit from your 
willingness to share it and we are grateful to you for doing 
that.
    To the VA members who will testify, I am anxious to hear 
what is happening. I know the testimony says there are 21,158 
mental health professionals now in the VA full-time--
equivalents or employees. I want to know, though, how much of 
that is contract community-based care and how much of it is in-
house controlled care, and what has been done to make sure we 
do a better job of tracking veterans from the time they are 
diagnosed to the time they are treated. That is the most 
dangerous time of all.
    Mr. Chairman, I will yield back after that.
    Chairman Sanders. Thank you, Senator Isakson.
    Senator Hirono.

                STATEMENT OF HON. MAZIE HIRONO, 
                    U.S. SENATOR FROM HAWAII

    Senator Hirono. Thank you, Mr. Chairman. I thank the 
witnesses on this very important subject. Today, more than 1.4 
million veterans receive mental health services from the VA, 
and I just want to mention briefly a person who came to testify 
at a Committee hearing that I held in Hawaii. Her name is 
Captain Elisa Smithers. She is one of these veterans. She is 
one of 120,000 veterans who live in Hawaii and she has 
testified at a field hearing in Hawaii about how she has 
suffered symptoms of traumatic brain injury and post-traumatic 
stress disorder after tours in Iraq and Kuwait.
    She suffered from symptoms so severe that she nearly harmed 
one of her own children. While seeking treatment she 
experienced many obstacles in receiving VA care at her VA 
hospital. She eventually visited a civilian psychologist at a 
Vet Center who she credits with saving her life. Clearly, the 
mental health services that are provided through the VA should 
be accessible, and often the accessibility means that this care 
should be provided in a community health center setting, as Ms. 
Smithers experienced.
    So, we know what the problems--many of the problems with 
the VA--and I agree with all my colleagues who stress the 
importance of collaboration and that we are all in this 
together and this is what we owe our veterans and their 
families.
    Thank you very much.
    Chairman Sanders. Thank you, Senator Hirono.
    Senator Moran.

                STATEMENT OF HON. JERRY MORAN, 
                    U.S. SENATOR FROM KANSAS

    Senator Moran. Mr. Chairman, thank you very much. Just this 
weekend I held a town hall meeting in Riley, KS, in which the 
first question was from a lady whose nephew had committed 
suicide. The question was, what are you doing about it, 
Senator? And while I indicated this hearing was taking place, 
the message to me was, having a hearing is not much comfort to 
anyone who just lost a family member.
    In some ways, I found myself saying things that did not 
mean a lot to this person. So, the point I would make to my 
colleagues and to those who are here today is that this has got 
to be something much different than another hearing about this 
topic, although I am very grateful to you, Mr. Chairman, for 
having this hearing. We need to make sure that the follow-
through occurs and that the families who have suffered so much 
and who continue to increase in number have something to take 
comfort, that their work will result in prevention.
    So, I, too, join my colleagues in thanking these mothers, 
these family members for being here. I appreciate Senator Burr 
and the legislation, the Clay-Hunt Suicide Prevention Act. I 
have become a sponsor of that since learning about it this 
week. And I appreciate what Senator Tester had to say, the 
gentleman from Montana, our states are similar in many ways. 
Just the lack of health care professionals is so profound.
    We have worked with the VA a decade trying to get them to 
utilize community mental health centers across our State, and I 
cannot see that there has been much success. So, I am anxious 
to hear that while the resources are short, are we utilizing 
the public sector resources within the VA that the VA is 
incapable of providing correctly.
    Mr. Chairman, this is a serious topic, one of importance to 
us; and I look forward to finding solutions in the follow-
through to make sure that suicide is prevented among our 
military men and women and their families.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Moran.
    Senator Murray.

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

    Senator Murray. Well, thank you very much, Mr. Chairman, 
for holding this really important hearing today. There really 
is no issue as pressing as providing quality, timely mental 
health care and suicide prevention programs to our Nation's 
heroes. The problem is familiar to everyone here, but as 
Senator Moran said, the solutions seem sort of elusive and we 
need to focus on that.
    Senator Walsh just testified, as we all know, 22 veterans 
die per day because of suicide. I think it is important to note 
that rates have continued to increase among female veterans who 
use VA care, and among male veterans who are 18 to 24 who use 
the VA the rate has skyrocketed to 79 per 100,000. According to 
VA's access data, wait times for new mental health patients has 
been virtually unchanged. It is still 36 days over the 5 months 
that the VA has provided us the data.
    So, I am very concerned about whether the VA and local 
communities are prepared with the resources and policy and 
training to help our veterans in serious crisis. We all know 
when our men and women in uniform have the courage to come 
forward and ask for help, the VA has to be there not only with 
high quality and timely care, but the right type of care to 
best meet the veterans' needs.
    So, we have got to demand progress on all those areas. And 
as has been mentioned, we passed a new VA reform bill to help 
veterans get care just a few months ago. It included a 
temporary authority to improve access to community providers 
for veterans who are having trouble accessing VA care.
    But a recent report by the RAND Corporation raises some 
serious concerns about whether private sector providers are 
ready to give high-quality care to our veterans and suggests we 
have to do a lot more to expand the use of evidence-based 
treatments and a lot more to help providers understand the 
unique needs and the culture of our servicemembers and our 
veterans.
    The reform bill included some critically needed funds to 
build and strengthen the VA for the long term, but there are a 
lot more needs going forward. The VA has got to start planning 
and requesting the necessary resources now so it will be 
prepared to meet the growing demand for mental health care far 
into the future. So, there is a lot more work to be done. Just 
one suicide, just one veteran in crisis, or just one family 
struggling to make it through is just one too much.
    I, too, want to thank you for this hearing and I want to 
thank Mrs. Selke, Mrs. Pallotta, and Mr. and Mrs. Vanata for 
being here today. It is incredibly difficult to talk about 
these issues, which we all really admire your courage and your 
strength for being willing to be here to share your stories 
with us today, because it is those stories and our 
understanding of them that will keep us focused on this, which 
I really appreciate.
    Chairman Sanders. Senator Murray, thank you very much.
    Senator Johanns.

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

    Senator Johanns. Mr. Chairman and Ranking Member Burr, 
thank you again for holding this hearing. A very, very 
important topic. I also want to express to all the family 
members who are here how much we appreciate the difficult, 
difficult issue and what a difficult time of year. My hope is 
that the testimony will shed light on directions forward.
    It was about 32 years ago that I was drawn to public 
service because I wanted to help people who had mental health 
issues and disabilities. It seemed the perfect way to do that 
was to run for Lancaster County Commissioner, and that was my 
first job in public service. It seems fitting that one of my 
last hearings, if not my last hearing, will be on the topic of 
mental health issues all these years later.
    I have learned a lot over those years. When I was Governor 
of Nebraska, we did sweeping mental health reform because we 
could see that our services were concentrated in a given area, 
but not spread across the State. We wanted to do more with 
community-based services.
    I only mention this because one of the lessons I learned 
over and over again through the years is that with appropriate 
services, mental health issues are treatable. People do get 
better. They return to lives that bring them happiness and joy. 
But without those services, very much the opposite happens.
    Our job is to try to figure out how we deal with that 
puzzle, that very difficult issue of how to provide services to 
people who need it. But to anyone who might be listening in who 
is wondering if is it time to give up, it is not. I want to 
just implore those people to reach out to us. Our job is to try 
to figure out a way that we can help to provide the services 
they need to provide the stability which they can build a 
platform in their life to start putting things back together.
    For any family who has been through this, it is--the pain 
of watching a family member deteriorate from a mental health 
standpoint is indescribable, and the difficulty of accessing a 
system that is confusing and complex and challenging, that also 
is indescribable. Somehow we have got to figure out a better 
way, because at the most important time in this person's life, 
when they are crying out for help, it should be a simple, 
straight-forward pathway to access that help instead of the 
complexity that family members and loved ones oftentimes face.
    So, I will return where I started and just thank the family 
members. I understand the pain and agony, but I think you can 
educate us on ways forward to try to deal with the issues that 
we face.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Johanns.
    Senator Blumenthal.

             STATEMENT OF HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thanks, Mr. Chairman, and thank you and 
Ranking Member Burr for having this hearing, which I think is 
one of the most important that we have held on this Committee. 
I think we share that opinion. And I want to thank the family 
members who are here as well.
    The experience each of us has had with these problems has 
been heart-breaking and riveting. Mine was most prominently 
with a young Marine, Justin Eldridge, from southeastern 
Connecticut who braved and survived combat in Afghanistan, 
mortar fire, sniper fire, and returned to his family, his 
children and his wife with post-traumatic stress and traumatic 
brain injury.
    He was seeking mental health care at the Connecticut VA 
facility. He had already gone through a long battle for 
benefits, which I was helping him with, but there was a 
significant gap in the continuity of his care. Basically, he 
slipped between the cracks of care and slipped into suicide.
    The gap that he leaves for his family and children is 
irreplaceable and the suicide that he suffered was unnecessary 
and avoidable. We will all live with our own feelings of 
obligation, not just regret, but feelings about what we could 
have done, each of us, to prevent it. I was a member of the 
Marine Corps League that he started in southeastern 
Connecticut. All of us knew that he was having that kind of 
difficulty, but none of us knew the black hole of despair and 
depression that he was suffering from.
    So, this problem has real life implications, real 
consequences for all of us. VA recently released data that 
indicates a wide disparity of wait times for mental health 
appointments in Connecticut and the country. In Connecticut 
they range from 12 or 13 days in Willimantic and Waterbury to 
as long as 55 days at Home Instead.
    For every veteran suffering from this despondency, despair, 
depression, every day is like a lifetime, and there is simply 
no excuse for even 12 or 19 days. But 55 days is exactly the 
root of the problem and the consequences are not only 
emotional, but practical. We need to do more to try to prevent 
those wait times, increase the quality of care, make sure that 
we keep faith with veterans who are suffering, as Senator Walsh 
said, from the unseen, invisible wounds of war that can be as 
devastating and life changing as even the most horrific 
physical and visible wounds of war.
    So, again, I thank the families. I thank all of you, my 
colleagues, for feeling so deeply as you do about this issue.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Blumenthal.
    Senator Heller.

                STATEMENT OF HON. DEAN HELLER, 
                    U.S. SENATOR FROM NEVADA

    Senator Heller. Thank you, Mr. Chairman. First I would like 
to take a moment to acknowledge our witnesses that are here 
today and some of the families, but in particular Ms. Selke and 
Ms. Pallotta. As a Committee, we truly do admire your bravery 
and your strength for coming here today to talk about your 
sons. We cannot begin to imagine your loss, but your sons 
served our country with valor.
    In honoring that, we must take care of every veteran from 
here on out that comes home. They need to be taken care of. 
Chairman Sanders and Ranking Member Burr, I want to thank you 
for bringing this issue in front of our Committee, especially 
because of the impact it has on veterans throughout the State 
of Nevada and across this country.
    It is easy to put this in perspective for me. Between 2008 
and 2012, 593 veterans from Nevada were lost to suicide. Six 
months ago I may have looked at these numbers and asked why it 
was so high. What is missing within the VA are the mental 
health benefits that so many veterans across this country need 
to avoid resorting to suicide.
    I think we know now that a big part of the problem is 
veterans' access to care at VA facilities. This is such a 
critical issue to get right at the VA because of the rippling 
effect that it has on veterans' well-being, whether it is 
medical care, mental health treatment, or support during 
transition to civilian life. Veterans being forced to wait for 
care from the VA can be very detrimental.
    That is why I have asked the Las Vegas VA director to send 
me reports about wait times for primary care, specialty care, 
and the mental health treatment for southern Nevada veterans. 
Every 2 weeks, for both Las Vegas and Reno, I track these 
numbers for improvements. In the most recent data, patients 
already receiving mental health care from the VA facilities in 
Nevada wait a week or less for appointments.
    Unfortunately, the average wait time for new patients 
seeking mental health treatment is 23 days in Reno and double 
that in Las Vegas. Even worse, a clinic in northwest Las Vegas 
has an average wait time of over 64 days for new patients. 
Veterans in need of mental health treatment absolutely cannot 
be waiting more than 2 months to be seen.
    I have been pushing every one of these facilities to 
improve their wait times in the coming months and want to hear 
from the VA today about their resources, what resources it will 
be devoting to mental health treatment. We must also remember 
that scheduling an appointment is not the only barrier to 
receiving care. Veterans must also qualify for this care.
    One of the best ways to ensure veterans qualify for mental 
health services is by reducing the VA's disability claims 
backlog. Veterans with Post Traumatic Stress who have PTSD-
related claims approved will be able to access VA's mental 
health services and treatment. This claims backlog is an issue 
that I have brought up during every Committee hearing because I 
believe it should be a top priority of the VA and of this 
Committee itself.
    It is why I sent a letter to the Chairman requesting that 
he reschedule a legislative hearing to consider my bipartisan 
bill to address the VA claims process. Nevada veterans have one 
of the longest wait times in the Nation at 248 days, on 
average, to complete a claim, and 240,000 veterans nationwide 
are still waiting longer than the VA's 125-day deadline.
    Until this backlog is eliminated, veterans in Nevada and 
throughout this country will continue to face delays to access 
to the mental health treatment that they need and deserve. With 
22 veteran suicides a day, nearly 600 veteran suicides in 
Nevada over the last 5 years, it is clear something must be 
done to improve the current state of mental health services at 
the VA. The VA facilities in my State know that I will use my 
oversight role in this Committee to continue holding them 
accountable for performances, timeliness, and the quality of 
care they provide to Nevada veterans.
    I look forward to hearing from the witnesses today about 
the VA, about what the VA is doing to address this crisis, and 
how Congress can help in this effort.
    Mr. Chairman, thank you.
    Chairman Sanders. Thank you, Senator Heller.
    Senator Begich.

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

    Senator Begich. Mr. Chairman and Ranking Member, thank you 
very much for holding this hearing. Thank you for the work you 
have done. This may be one of my last hearings, but I think a 
very important hearing in many ways. You know, Alaska has 
77,000 veterans. To the families that are here, I have talked 
to many families who have lost their loved ones through suicide 
in Alaska not only during my time here as Senator, but also my 
time when I was Mayor of Anchorage. I recognize the pain, the 
loss that you all feel. I am honored to have you here to help 
us better understand.
    The work that has to be done is significant. And when I 
think about the hearings that I have participated in the last 6 
years, you know--we have lots of hearings on these issues. The 
question is, what are we going to do? Having oversight hearings 
are important, but you have got to put resources with it.
    Just assuming the private sector is going to absorb all 
this is not realistic. The private sector does not have enough 
mental health providers to provide for the current load of 
individuals who are not in the military or in the veteran 
system. That is just a fact. We have to do more to improve the 
system. That means also the VA has to recognize that you have 
to authorize not only psychiatrists that you have, but also 
many different types of mental health providers.
    There are different levels of services that an individual 
may need that may not be to a full psychiatrist level opening 
those doors, but it does mean that we have to have some 
priorities. I may not be here to fight for those. I may be on 
the outside, you can rest assured, to all the members here, 
screaming about this issue as I have done for the last 6 years.
    When we send $500 million to fund rebels in ISIS with no 
funding source to pay for it, but when we debate veterans' 
bills, we can never find the money is outrageous. I am hopeful 
this hearing will shed some light on what we really need, which 
is more professionals in the arena to service these 
individuals, not only veterans but all across this country.
    Mental health services has been secondary to health care. 
The Affordable Care Act finally made it parity. The Health 
Services Act finally made it a parity. But now we have to put 
resources to it. That does not mean just more speeches. It 
means actually in a budget that will be provided by the 
majority in May or April, that they actually put resources to 
this effort.
    It means passing legislation that I have sponsored on 
ensuring that there is loan forgiveness for people who get into 
the field of mental health services. It means also changes in 
the way we do telemedicine. We did it with our active military. 
I was very happy to support an amendment that makes 
telemedicine available for active military anywhere in this 
country, to tap into telemedicine no matter where they live.
    That doctor does not have to be certified in the State they 
live in. They just have to be certified in this country 
somewhere. That to me is what we need to do with the veterans' 
care. On top of that, the issue that veterans' care for mental 
health services no longer require a co-payment; I was very 
honored to be able to work on that with the VA.
    But it is, again, going to be about resources.
    Training the next generation of mental health providers, 
not just psychiatrists, but counselors and group facilities and 
other activities. It means actually putting real money to it, 
because as hard as it is for these families, there are many 
other families that cannot get access even if they are a VA 
veteran. We have to do everything we can.
    I am hopeful that this hearing will not only describe the 
issues that we face as a society when it comes to our veterans 
and the care that they deserve after serving our country, after 
we told them to go do certain things for us, but also bring the 
resources that are required.
    I will say it again. You know, it will be billions we will 
be spending on what is going on in ISIS without any funding 
source for it. We will just spend the money. But I can 
guarantee you, it will be like deja vu. I will see it from a 
different viewpoint. Instead of in the chambers, I will be 
watching painfully C-SPAN. And in a positive way to C-SPAN 
people, but I will be watching.
    What I am hoping for is that we do not debate the resources 
needed for our vets. You are for veterans or you are not. We 
put the money on the table they deserve for the service they 
have given us. And mental health services--suicide prevention 
is a critical need. I would just hope, as the next session 
occurs, that after these kind of hearings, that there actually 
is fundamental funding that makes a difference for these 
families, families that are still out there struggling that I 
hear from every day.
    So, Mr. Chairman, I thank you and the Ranking Member for 
holding this hearing. It is crucial. I hope the ideas I have 
presented will be ideas that others will take up to ensure that 
we have better access for our veterans. But keep in mind, 
mental health services in this country, there is just not 
enough, veteran or non-veteran. We have to be realistic about 
that and be honest with the American people that we are going 
to do something to change this for the country.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Begich.
    Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Chairman Sanders and Ranking 
Member Burr for holding this hearing. Hopefully this is just 
one of many more in the future as we continue to delve into 
such an important subject, in fact, perhaps one of the most 
important subjects that we do face as a Committee.
    I would also like to extend a warm welcome to the families 
that are here. There is simply no substitute for your presence, 
so we do appreciate you very, very much.
    As has been stated, 22 veterans commit suicide every day in 
the United States. To say this is unacceptable would be a gross 
understatement. It is nothing short of a tragedy.
    The Departments of Defense and Veterans Affairs must 
continue to aggressively address the problem. Much is being 
done to improve, expand, and increase access to mental health 
care, but we must do better. Significant resources have been 
directed toward medical care within the VA. Between fiscal year 
2008 and fiscal year 2016, advanced appropriations requests, 
the funding has increased by $24.5 billion, or 72 percent.
    During the same period, mental health care programs have 
seen increased funding at $1.8 billion, or 42 percent. 
Certainly we need to do much more. However, increasing the 
funding to these programs, while helpful and necessary will not 
solve the problem. The culture of the VA must change to become 
permissive and flexible.
    The complaint that I hear from so many veterans is they 
feel the VA is a restrictive bureaucracy whose first instinct 
is to say no. I have heard many veterans characterize their 
experience within the VA as being hostile. For veterans who 
need health care, especially mental health care, this is 
totally unacceptable.
    The response that these veterans should hear is, yes; let 
me figure out how to help you with that. A veteran who is 
having suicidal thoughts should never be turned away because of 
bureaucratic red tape.
    I continue to be concerned about the VA's over-reliance on 
medication as a means of treatment within the VA. The use of 
opioids and psychotropic medicines certainly have a place in 
health care, but I believe that VA over-prescribes these 
medications and does not effectively monitor their use amongst 
veterans.
    Unchecked, these medications can do more harm than good and 
are oftentimes a contributing factor to veteran suicide. A pill 
alone is not the answer. VA must embrace a holistic approach to 
providing mental health care and promoting wellness. The VA has 
made significant efforts to increase evidence-based treatment, 
but there is still room for improvement.
    I look forward to hearing how the VA plans to improve this 
process and overcome existing barriers to providing evidence-
based treatment. I also look forward to hearing about VA's 
efforts to increase its mental health workforce.
    Thank you very much, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Boozman.
    At this time, we welcome our first panel to this morning's 
hearing on Mental Health and Suicide Among Veterans. 
Representing the VA is Dr. Harold Kudler. Dr. Kudler, thanks 
for being with us. Dr. Kudler is VA's Chief Consultant for 
Mental Health Services. Dr. Kudler is accompanied by Caitlin 
Thompson, the Deputy Director of VA's Suicide Prevention 
Program, and Dr. Dean Krahn, the Deputy Director of VA's Office 
of Mental Health Operations.
    We thank you all very much for being with us this morning. 
Dr. Kudler, you can begin.

 STATEMENT OF HAROLD KUDLER, M.D., CHIEF CONSULTANT FOR MENTAL 
     HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. 
    DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY CAITLIN 
THOMPSON, Ph.D., DEPUTY DIRECTOR, SUICIDE PREVENTION; AND DEAN 
   D. KRAHN, M.D., DEPUTY DIRECTOR, OFFICE OF MENTAL HEALTH 
                           OPERATIONS

    Dr. Kudler. Thank you, and good morning, Chairman Sanders, 
Ranking Member Burr, and Members of the Committee. Thank you 
for this opportunity to discuss the provision of mental health 
care to veterans, and particularly those who are at risk for 
suicide. I am accompanied today by Dr. Dean Krahn, Acting 
Director of Mental Health Operations, and Dr. Caitlin Thompson, 
Deputy Director for VHA Suicide Prevention.
    I want to say before I begin my formal remarks that I want 
to thank the families. I want to thank all the veterans, the 
veterans who are outside with flags when we came in today. We 
are here to support you and stand with you. We are here to 
learn from you. And, I hope that this meeting will help us do 
exactly that.
    Long deployments and intense combat conditions require 
comprehensive support for the emotional and mental health needs 
of veterans and their families. Accordingly, VA continues to 
develop and expand its mental health system. The number of 
veterans receiving specialized mental health treatment from VA 
has risen each year from over 900,000 in fiscal year 2006 to 
more than 1.4 million in fiscal year 2013. During that same 
period, our mental health outpatient staff grew from 7,000 to 
over 13,000.
    We believe this increase is partly attributable to our 
proactive screening which identifies veterans with symptoms of 
depression, Post Traumatic Stress Disorder, or substance abuse, 
as well as those who have experienced military sexual trauma. 
VA has partnered with the Department of Defense to develop the 
VA/DOD Integrated Mental Health Strategy to advance a 
coordinated public health model that improves access, quality 
effectiveness and efficiency of mental health services.
    VA has many entry points for VHA mental health care, 
including 150 medical centers, 820 community-based outpatient 
clinics, 300 Vet Centers providing readjustment counseling, 70 
mobile Vet Centers, a national veterans crisis line, VA staff 
on college and university campuses, and a variety of other 
outreach efforts.
    Our OEF, OIF, OMD transition care management teams are 
located at every VA medical center and welcome returning 
veterans providing specialized care management services as 
those veterans transition from DOD to VA.
    VA's mental health system is designed to address the 
changing needs of veterans as they age. While the term veteran 
often sums of images of young men and women, the Vietnam 
generation is now the largest veteran cohort. VA's highly-
innovative community-based Vet Center system was created 
specifically for veterans of the Vietnam era and continues to 
track their evolving needs.
    The Vet Center mission, though, has expanded over time to 
serve veterans of all combat eras at sites of care across the 
entire United States and its possessions. VA mental health is a 
leader in developing on-site coordinated mental health within 
primary care settings and within home-based care programs.
    At VA, we insist that suicide prevention is everyone's 
business. Although we understand why some veterans may be at 
increased risk, we continue to investigate and act assertively 
with the ultimate goal of eliminating suicide among veterans. 
This quest has proven long and hard for veterans and for all 
Americans.
    Between 1999 and 2010, the rate of suicide increased by 27 
percent among all middle-aged Americans--American males. But it 
actually decreased by 16 percent among middle-aged males who 
used VA health care. In considering the veteran population 
alone, suicide rates during that same period increased by 
nearly two-thirds among middle-aged veterans who did not use VA 
services. But it actually decreased by one-third among middle-
aged veterans who used VA care.
    America's veterans represent many different subgroups and 
each have their own risk factors and each require unique 
interventions. We still have a good deal to learn about how to 
provide that. As part of that process, DOD and VA have built a 
joint Suicide Data Repository to improve our understanding of 
patterns of suicide among veterans and servicemembers.
    With assistance from State partners, VA is now better able 
to assess the effectiveness of its suicide prevention programs 
and we can identify at risk veterans earlier and apply specific 
interventions tailored to their needs. These data will help VA 
replicate our most effective suicide prevention programs in 
different care settings, including rural settings, and test 
their applicability across generations, male, female, young, 
old, and across sites of care.
    VA has over 700 full-time employees dedicated solely to 
suicide prevention. These include over 300 suicide prevention 
coordinators with boots on the ground at every VA medical 
center and at our largest CBOCs. They ensure that all 
appropriate measures are being taken to prevent suicide among 
veterans.
    The Veterans Military Crisis Line connects veterans and 
servicemembers and their family and friends with qualified, 
caring VA responders through a confidential toll-free hotline 
offering 24/7 emergency assistance. Since we established it in 
2007, there have been roughly 39,000 life-saving rescues alone. 
That is an average of 27 rescues every day.
    As of June 2014, the crisis line received over 1.2 million 
calls, over 175,000 chat connections, over 24,000 text 
messages. The crisis line has also made over 220,000 referrals 
to VA suicide prevention coordinators.
    Mr. Chairman, we know our work to deliver the mental health 
care which veterans deserve will never be entirely finished. We 
know that losing one veteran to suicide shatters an entire 
world. Veterans who reach out for help must receive that help 
when and where they need it in the terms that they value. 
Therefore, VA will act continuously to improve mental health 
and suicide prevention services.
    We appreciate the opportunity to appear before you today 
and to discuss these vitally important issues and we thank you 
for your support. My colleagues and I are now prepared to 
respond to any questions you may have.
    [The prepared statement of the Dr. Kudler follows:]
     Prepared Statement of Dr. Harold Kudler, Chief Mental Health 
 Consultant, Veterans Health Administration (VHA), U.S. Department of 
                            Veterans Affairs
    Good morning, Chairman Sanders, Ranking Member Burr, and Members of 
the Committee. Thank you for the opportunity to discuss the provision 
of mental health care to Veterans, particularly those who are at risk 
for suicide. I am accompanied today by Dr. Dean Krahn, Deputy Director 
of Mental Health Operations and Dr. Caitlin Thompson, Deputy Director 
of VHA Suicide Prevention. My written statement will provide a brief 
overview of VA's mental health care system and programs for suicide 
prevention.
                      mental health care overview
    Since September 11, 2001, more than two million Servicemembers have 
deployed to Iraq or Afghanistan. Long deployments and intense combat 
conditions require comprehensive support for the emotional and mental 
health of Veterans and their families. Accordingly, VA continues to 
develop and expand its mental health system. The number of Veterans 
receiving specialized mental health treatment from VA has risen each 
year, from 927,052 in Fiscal Year (FY) 2006 to more than 1.4 million in 
FY 2013. We anticipate that VA's requirements for providing mental 
health care will continue to grow for a decade or more after current 
operational missions have come to an end. VA believes this increase is 
partly attributable to proactive screening to identify Veterans who may 
have symptoms of depression, Post Traumatic Stress Disorder (PTSD), 
substance use disorder, or those who have experienced military sexual 
trauma. In addition, VA has partnered with the Department of Defense 
(DOD) to develop the VA/DOD Integrated Mental Health Strategy to 
advance a coordinated public health model to improve access, quality, 
effectiveness, and efficiency of mental health services for 
Servicemembers, National Guard and Reserve, Veterans, and their 
families. Among the President's 19 new executive actions to improve the 
mental health of Servicemembers, Veterans, and their families, 
announced on August 26 is a further enhancement of transition from DOD 
to VA and civilian health care by ensuring that all Servicemembers 
leaving the military who are receiving care for mental health 
conditions are automatically enrolled in the inTransition program. In 
this program, trained mental health professionals assist these 
Servicemembers through ``warm handoffs'' to new care teams in VA or in 
the community. Further, mental health medications prescribed by DOD 
clinicians will be carried over into VA care unless a specific safety 
or clinical reason to make a change is identified. Those Servicemembers 
with multiple, complex, severe conditions such as Traumatic Brain 
Injury, psychological trauma, or other cognitive, psychological, or 
emotional disorders will benefit by development of a single, joint 
comprehensive care plan between DOD and VA providers.
    VA has many entry points for VHA mental health care. These entry 
points include 150 medical centers, 820 Community Based Outpatient 
Clinics (CBOCs), 300 Vet Centers providing readjustment counseling, a 
Veterans Crisis Line, VA staff on college and university campuses, and 
other outreach efforts. To serve the growing number of Veterans seeking 
mental health care, VA has deployed significant resources and increases 
in staff toward mental health services. Since March 2012, and with 
support from the President's Executive Order's focus on increasing 
mental health staffing, VA has added 2,444 mental health full-time 
equivalent employees and hired over 900 peer specialists and 
apprentices. Under the President's executive actions, VA will pilot the 
expansion of peer support beyond traditional mental health settings 
into primary care clinics in order to better connect with Veterans 
wherever they seek care.
    As of April 2014, VHA has 21,158 Mental Health full-time equivalent 
employees providing direct inpatient and outpatient mental health care. 
VA has expanded access to mental health services with longer clinic 
hours, telemental heath capability to deliver services, and standards 
that mandate immediate access to mental health services to Veterans in 
crisis. Starting in FY 2012, the Office of Mental Health Operations 
initiated site visits to every VHA healthcare system to review and 
facilitate compliance with VHA mental health policy. All healthcare 
systems were visited in FY 2012 and subsequently one third are being 
visited each year. Recommendations are made to address opportunities 
for improvement identified as part of the site visit process and 
progress is monitored by the Office of Mental Health Operations. In an 
effort to increase access to mental health care and reduce any stigma 
associated with seeking such care, VA has integrated mental health into 
primary care settings. From the beginning of FY 2008 through July 2014, 
VA has provided more than 4 million Primary Care-Mental Health 
Integration (PC-MHI) clinic visits to more than 1,016,000 unique 
patients. This improves access by bringing care closer to where the 
Veteran can most easily receive these services, and improves quality of 
care by increasing the coordination of all aspects of care, both 
physical and mental. In addition, a second round of VA Community Mental 
Health Summits has recently been completed at virtually all major VA 
facilities across the Nation and analysis of feedback from VA and 
Community participants is underway. Based on 2013 Summit 
recommendations, Community Mental Health Points of Contact have been 
identified at every VA Medical Center and each 2014 Summit included 
featured presentations on best practices in support of military and 
Veteran families and in populating the National Resource Directory in 
order to enhance referral to VA and community resources across America 
for use by any Servicemember, Veteran, family member, referring 
clinician or other stakeholder.
    VA has made deployment of evidence-based therapies a critical 
element of its approach to mental health care and offers a continuum of 
recovery-oriented, patient-centered services across outpatient, 
residential, and inpatient settings. State-of-the-art treatment, 
including both psychotherapies and biomedical treatments, are available 
for the full range of mental health problems, such as PTSD, substance 
use disorders, and suicidality. While VA is primarily focused on 
evidence-based treatments, we are also assessing complementary and 
alternative treatment methodologies that need further research, such as 
meditation and acupuncture in the care of PTSD. VA has trained over 
6,100 VA mental health professionals to provide two of the most 
effective evidence-based psychotherapies for PTSD, Cognitive Processing 
Therapy and Prolonged Exposure Therapy, as indicated in the VA/DOD 
Clinical Practice Guideline for PTSD\1\. VA operates the National 
Center for PTSD, which guides a national PTSD mentoring program, 
working with every specialty PTSD program across the VA health care 
system. The Center has begun a PTSD consultation program for any VA 
practitioners (including primary care practitioners and Homeless 
Program coordinators) who request consultation regarding a Veteran in 
treatment with PTSD. So far, the consultation program has provided 
1,818 consultations and triaged an additional 143 requests from the 
Suicide Risk Management Consultation Program.
---------------------------------------------------------------------------
    \1\ http://www.healthquality.va.gov/guidelines/MH/ptsd/cpg_PTSD-
FULL-201011612.pdf
---------------------------------------------------------------------------
    We know that there have been issues with Veteran access. We take 
those concerns seriously and continue to work to address them. 
Receiving direct feedback from Veterans concerning their care is 
vitally important. During the fourth quarter of FY 2013, as part of 
VHA's effort to seek direct input from Veterans in understanding their 
perceptions regarding access to care, we conducted a survey of over 
40,000 Veterans who were receiving mental health care These results, 
and other outreach to Veterans, aid us as we strive to improve the 
timeliness of appointments; reminders for appointments; accessibility, 
engagement, and responsiveness of clinicians; availability and 
agreement with clinician on desired treatment frequency; helpfulness of 
mental health treatment; and treatment with respect and dignity.
             programs and resources for suicide prevention
    Overall, Veterans are at higher risk for suicide than the general 
U.S. population, notably Veterans with PTSD, pain, sleep disorders, 
depression, and substance use disorders. VA recognizes that even one 
Veteran suicide is too many. We are committed to ensuring the safety of 
our Veterans, especially when they are in crisis. Our suicide 
prevention program is based on enhancing Veterans' access to high-
quality mental health care and programs specifically designed to help 
prevent Veteran suicide.
    In partnership with the Substance Abuse and Mental Health Services 
Administration's National Suicide Prevention Lifeline, the Veterans 
Crisis Line/Military Crisis Line (VCL/MCL) connects Veterans and 
Servicemembers in crisis and their families and friends with qualified, 
caring VA responders through a confidential toll-free hotline (1-800-
273-TALK (8255), then press 1) that offers 24/7 emergency assistance. 
This August marked seven years since the establishment of the initial 
program, which was later rebranded to show its direct support for 
Servicemembers. It has expanded to include a chat service and texting 
option. As of June 2014, the VCL/MCL has rescued 39,000 actively 
suicidal Veterans. As of June 2014, VCL/MCL has received over 1,250,000 
calls, over 175,000 chat connections, and over 24,000 texts; it has 
also made over 220,000 referrals to Suicide Prevention Coordinators 
(SPC). In accordance with the President's August 31, 2012, Executive 
Order titled, ``Improving Access to Mental Health Services for 
Veterans, Servicemembers and Military Families,'' VA completed hiring 
and training of additional staff to increase the capacity of the VCL/
MCL by 50 percent.
    VA has a network of over 300 SPCs located at every VA medical 
center and the largest CBOCs throughout the country. Overall, SPCs 
facilitate implementation of suicide prevention strategies within their 
respective medical centers and clinics to help ensure that all 
appropriate measures are being taken to prevent suicide in the Veteran 
patient population, particularly Veterans identified as being at high 
risk for suicidal behavior, and the SPCs engage in outreach to other 
Veterans, family members, and community partners. SPCs receive follow-
up consults from the VCL/MCL call responders after immediate needs are 
addressed and any needed rescue actions are made. SPCs are required to 
follow up on consults received from the VCL/MCL within one business day 
to ensure timely access to care for Veterans callers who need 
additional support, treatment, or other services, including enrollment 
into VA's health care system. SPCs also plan, develop, implement, and 
evaluate their facility's Suicide Prevention Program to ensure 
continual quality improvement and excellence in customer service. SPCs 
are responsible for implementing VA's Operation S.A.V.E (Signs of 
suicidal thinking, Ask the questions, Verify the experience with the 
Veteran, and Expedite or Escort to Help). This is a one-to-two hour in-
person training program provided by VA SPCs to Veterans and those who 
serve Veterans to help prevent suicide. Suicide prevention training is 
provided for every new VHA employee during Employee Orientation. It has 
now been provided to staff within the Veterans Benefits Administration 
and, through the Presidents' new executive actions, training will be 
provided for volunteer tax preparers at over 200 tax assistance 
facilities through partnership between VA and the Treasury Department. 
Further, the President's new executive actions mandate that refresher 
courses and training updates be developed and delivered at regular 
intervals. Our goal is to increase mental health awareness wherever 
Veterans and their family members are present and to continuously 
enhance and expand our response to their needs.
    SPCs participate in outreach activities, which remain critically 
important to VA's goals of reducing stigma for mental health issues and 
improving access to services for all Veterans. Examples include 
community suicide prevention training and other educational programs, 
exhibits, and material distribution; meetings with state and local 
suicide prevention groups; and suicide prevention work with Active 
Duty/National Guard and Reserve units as well as college campuses. To 
date, each SPC is required to complete five or more outreach activities 
in his or her local community each month.
    Veterans may be at high risk for suicide for various reasons. 
Determination of suicide risk is always a clinical judgment made after 
an evaluation of risk factors (e.g., history of past suicide attempts, 
recent discharge from an inpatient mental health unit), protective 
factors, and the presence or absence of warning signs. VHA Handbook 
1160.01, ``Uniform Mental Health Services in VA medical centers and 
Clinics,'' requires inpatient care be available to all Veterans with 
acute mental health needs (including imminent danger of self harm), 
either in a VA medical center or at a nearby facility through a 
contract or sharing agreement.
    To ensure that high-risk Veterans are being monitored 
appropriately, SPCs manage a Category I Patient Record Flag (PRF) with 
a corresponding High-Risk List. The primary purpose of the High Risk 
for Suicide PRF is to communicate, consistent with appropriate privacy 
protections, to VA staff that a Veteran is at high risk for suicide, 
and the presence of a flag should be considered when making treatment 
decisions. Once a Veteran is identified as high risk, the SPC ensures 
that weekly contact is made with the Veteran for at least the first 
month, and that continued follow-up is made, as clinically appropriate. 
The SPC works with the treatment team to ensure that patients 
identified as being at high risk for suicide receive follow-up for any 
missed mental health and substance abuse appointments at VA. Clinicians 
are required to initiate at least three attempts to contact Veterans on 
the High-Risk List who fail to appear for mental health appointments 
and ensure appropriate documentation. If attempts to contact the 
Veteran are unsuccessful, the SPC collaborates with the Veteran's 
treatment team to decide what further action is appropriate involving a 
range of options from continued outreach efforts to the Veteran and/or 
family members up to requesting local law enforcement perform a welfare 
check in person.
    SPCs ensure that all Veterans identified as high risk for suicide 
have completed a safety plan that is documented in their medical 
record, and that the Veteran is provided a copy of his or her safety 
plan.
    National suicide prevention outreach efforts continue to expand and 
include targeted efforts for Veterans, Servicemembers, families, and 
friends. VA has sponsored public service announcements, rebranded and 
optimized the VCL/MCL Web site for mobile access and viewing, and 
developed social and traditional media advertisements designed to 
inform Veterans and their families of VA's VCL/MCL resources including 
phone, online chat, and text services. September was National Suicide 
Prevention Month, and VA launched its new outreach campaign theme for 
this year, ``The Power of 1,'' which emphasizes that just one person, 
one conversation, or one small act can make a big difference to a 
Veteran or Servicemember in crisis by offering hope and connections to 
confidential support and resources.
    In addition, VA established an online Community Provider Toolkit 
\2\ for individuals outside of VA who provide care to Veterans. This 
provides an important resource in the wake of the Veterans Access, 
Choice, and Accountability Act of 2014. This Web site features key 
tools to support the mental health services provided to Veterans 
including information on connecting with VA, understanding military 
culture and experience, and working with patients with a variety of 
mental health conditions. There is also a comprehensive Suicide 
Prevention Mini-Clinic that provides clinicians with easy access to 
useful Veteran-focused treatment tools, including assessment, training, 
and educational handouts.\3\
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    \2\ http://www.mentalhealth.va.gov/communityproviders
    \3\ http://www.mentalhealth.va.gov/communityproviders/
clinic_suicideprevention.asp
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    In 2010, DOD and VA approved plans for a Joint Suicide Data 
Repository (SDR) as a shared resource for improving our understanding 
of patterns and characteristics of suicide among Veterans and 
Servicemembers. The combined DOD and VA search of data available in the 
National Death Index represents the single largest mortality search of 
a population with a history of military service on record. The DOD/VA 
Joint SDR is overseen by the Defense Suicide Prevention Office and VA's 
Suicide Prevention Program.
    On February 1, 2013, VA released a report on Veteran suicides 
including data from the SDR, a result of the most comprehensive review 
of Veteran suicide rates ever undertaken by VA. With assistance from 
state partners providing real-time data for SDR, VA is now better able 
to assess the effectiveness of its suicide prevention programs and 
identify specific populations that need targeted interventions. This 
new information will assist VA in identifying where at-risk Veterans 
may be located and improving the Department's ability to target 
specific suicide interventions and outreach activities in order to 
reach Veterans early and proactively. These data will also help VA 
continue to examine the effectiveness of suicide prevention programs 
being implemented in specific geographic locations (e.g., rural areas), 
as well as care settings, such as primary care, in order to replicate 
effective programs in other areas. VA continues to receive state data 
that are being included in the SDR. VA plans to update the suicide data 
report later this year.
    In 2011, the most recent year for which national data are 
available, the age-adjusted rate of suicide in the U.S. general 
population was 12.32 per 100,000 persons per year. At just over 12 for 
every 100,000 U.S. residents, the 2011 rate of suicide has increased by 
approximately 15 percent since 2001. Rates of suicide in the United 
States are higher among males, middle-aged adults, residents in rural 
areas, and those with mental health conditions.
    The most recent available data show that suicide rates are 
generally lower among Veterans who use VHA services than among Veterans 
who do not use VHA services. In 2011, the rate of suicide among those 
who use VHA services was 35.5 per 100,000 persons per year; a decrease 
of approximately 6 percent since 2001. Rates of suicide among those who 
use VHA services have remained relatively stable; ranging from 35.5 to 
37.5 per 100,000 persons per year over the past 4 years. Despite 
evidence of increased risk among middle-aged adults (35-64 years) in 
the U.S. general population, rates of suicide among middle-aged adults 
who use VHA services have decreased by more than 16 percent between the 
years 1999-2010. For males without a history of using VHA services, the 
rate increased by more than 60 percent, whereas for males with a 
history of using VHA services, the rate decreased by more than 30 
percent. Decreases in suicide rates and improvements in outcomes were 
also observed for some other high-risk groups. Between 2001 and 2010, 
rates of suicide decreased by more than 28 percent among VHA users with 
a mental health or substance abuse diagnosis, and the proportion of VHA 
users who die from suicide within 12 months of a survived suicide 
attempt has decreased by approximately 45 percent during the same time 
period.\4\
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    \4\ http://www.blogs.va.gov/VAntage/11973/january-2014-va-suicide-
data-update/
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    In response to these findings, VA has been focusing on public 
health and community programming. This includes increased and targeted 
outreach efforts throughout the country to Veterans and their family 
members with significant emphasis on safety. We encourage Veterans and 
their families to learn more about mental illness and to take 
precautions particularly during times of stress (e.g., properly storing 
weapons and medications). Being alert to items in the environment that 
offer potential means of suicidal behavior can make a life-saving 
difference during a crisis. Messaging and interventions are geared 
toward those who are most at risk for suicide, including our younger 
male Veterans, women Veterans, Veterans with mental health conditions, 
and established patients who are known to be at high risk for suicide. 
Strategies include specialized training for VHA staff to enhance their 
recognition and treatment of those at risk, and offering Veterans 
skills-building and other preventive strategies to address major 
stressors in their lives. Furthermore, VA is engaged in ongoing 
research to determine the most effective mental health treatments and 
suicide prevention strategies. Finally, VA has established the Mental 
Health Innovations Integrated Project Team that is working to implement 
early intervention strategies for specific high-risk groups including 
Veterans with PTSD, pain, sleep disorders, depression, and substance 
use disorders. Through early intervention, VA hopes to reduce the risk 
of suicide for Veterans in these high-risk groups.
                 readjustment counseling service (rcs)
    VA's RCS provides a wide range of readjustment counseling services 
to eligible Veterans and active duty Servicemembers who have served in 
combat zones and their families. RCS also provides comprehensive 
readjustment counseling for eligible Veterans and Servicemembers who 
experienced military sexual trauma, as well as offering bereavement 
counseling to immediate family members of Servicemembers who died while 
on active duty. These services are provided in a safe and confidential 
environment through a national network of 300 community-based Vet 
Centers located in all 50 states (as well as the District of Columbia, 
American Samoa, Guam, and Puerto Rico), 70 Mobile Vet Centers, and the 
Vet Center Combat Call Center (877-WAR-VETS or 877-927-8387). In FY 
2013, Vet Centers provided over 1.5 million visits to Veterans, active 
duty Servicemembers, and their families. The Vet Center program has 
provided services to over 30 percent of Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New Dawn Veterans who have left 
active duty. A new executive action will promote awareness of Vet 
Centers for combat Veterans, Servicemembers, and their families through 
a new outreach campaign that partners VA with First Lady Michelle Obama 
and Dr. Jill Biden's Joining Forces initiative.
                           closing statement
    Mr. Chairman, VA is committed to providing timely, high quality 
care that our Veterans have earned and deserve, and we continue to take 
every available action and create new opportunities to improve suicide 
prevention services. We appreciate the opportunity to appear before you 
today, and my colleagues and I are prepared to respond to any questions 
you may have.

    Chairman Sanders. Dr. Kudler, thanks very much for being 
here and for your testimony. Dr. Kudler, this country, above 
and beyond the VA, faces a major crisis. We do not have enough 
doctors, we do not have enough nurses, we do not have enough 
psychiatrists, we do not have enough psychologists. Yet, we end 
up spending almost twice as much per person on health care than 
any other country. Why? That is always another discussion.
    This Committee, which I am proud to have played an active 
role with all of the Members here, passed one of the most 
comprehensive pieces of veterans legislation in recent history, 
$16.5 billion in additional funding for VA health care, and 
further, $5 billion to give VA the ability to hire more doctors 
and mental health counselors.
    Senator Tester started off by making the right point. There 
are parts of this country--Senator Moran in Kansas has the same 
issue--where we have virtually no mental health capabilities. 
In my office, and I think I speak for every Member up here, I 
get calls all of the time that I will never forget: the call 
from a woman who stated her brother is suicidal, homicidal. 
What can you do? We cannot find a place for him in the 
Burlington, VT, area. This goes on all over this country.
    Question: we gave you $5 billion to get more doctors and 
mental health providers. How are you doing on that? Are you 
going to significantly increase the number of mental health 
practitioners in VA?
    Dr. Kudler. First of all, Senator, thank you and thank your 
colleagues for the assistance. It makes a world of difference. 
$5 billion, though, while it is an awful lot of money, is not 
earmarked for mental health. It is not under the control of us 
in mental health. We are hoping that money will be put where it 
is needed.
    Chairman Sanders. But it is there for mental health 
professionals, certainly.
    Dr. Kudler. It is there for mental health professionals, 
among others, and to build programs, among others. I believe 
this money is a great stop gap. We will be able to squeeze a 
little more juice from the lemon that exists, but as everyone 
here has pointed out, there is not enough juice in the lemon to 
cover all the capacity that is needed to meet the needs of 
veterans, and the Nation as a whole is in a mental health 
shortage crisis and is only awakening to that now.
    I believe this will be a great help and we will use it to--
--
    Chairman Sanders. Is the VA aggressively going out trying 
to bring mental health professionals into the VA?
    Dr. Kudler. Yes, we are. We are----
    Chairman Sanders. Can you give us a progress report?
    Dr. Kudler. We have identified vacancies across the Nation 
and opportunities for expansion and we are filling those 
systematically. The Secretary himself is going from medical 
school to medical school reaching out to new graduates and the 
people to convince them to go into mental health and join us. 
We are helping to support those efforts.
    We are partnering with SAMHSA and other organizations to 
identify folks interested in working with VA and with veterans, 
and to improve the coordination of care between different 
sites. We are working with the Association of American Medical 
Colleges.
    Chairman Sanders. Good. I was with the Secretary in Vermont 
at the University of Vermont and at Dartmouth. Several Members 
here raised a very important point. Ideally, no matter what the 
ailment, people should be able to get in to see a practitioner 
in a reasonable period of time. In mental health, it is even 
more important. When people are hurting, they do not want to 
hear that they have to wait 2 months to see a provider.
    They do not want, as Senator Johanns correctly said, have 
to overcome a bureaucratic maze. When people are hurting, they 
should be able to get the help they need. I know that is hard 
and I know that VA is not the only bureaucratized institution 
in America.
    But my two questions are, it is unsatisfactory to hear from 
my colleagues here about the long wait periods that folks 
struggling with mental health conditions have to overcome 
before they get in. What are we doing about that?
    Dr. Kudler. Dr. Krahn, could you speak to that, please?
    Dr. Krahn. Yes, thanks. Obviously, waiting even an extra 
day is too much when you are in crisis, and the VA is actually 
mandated to have both emergency and same-day care for veterans 
who need that, and the Veterans Crisis Line, Military Crisis 
Line has 24/7----
    Chairman Sanders. Let me--I have a limited amount of time.
    Dr. Krahn. I am sorry.
    Chairman Sanders. I apologize. But you have heard from 
colleagues here----
    Dr. Krahn. Right.
    Chairman Sanders [continuing]. That some veterans have had 
to wait, in some cases, months. Say I am a veteran struggling 
with suicidal thoughts. I do not want to be waiting for months. 
What are we doing about that?
    Dr. Krahn. The best way we are able to reach out to people 
is by making more and more points of access that are available 
24/7/365, whether that be by phone, by walking into an 
emergency room, or by walking into same-day walk-in clinics.
    Chairman Sanders. And are we making progress doing that?
    Dr. Krahn. Well, we are making progress in doing that. And 
the other thing we do is the integrated care.
    Chairman Sanders. Dr. Krahn, let me ask this. Is the goal 
that when somebody calls who is in trouble, that they will be 
able to get to see somebody that day?
    Dr. Krahn. That is the goal.
    Chairman Sanders. Last question. As one of my colleagues 
also mentioned, not every treatment works for everybody in the 
same way. We need a variety of treatments. Some if us are 
supportive of complementary and alternative medicine, which 
works well for some people. First, does VA have the flexibility 
that it needs.
    I also want to go back to a point that Senator Johanns 
raised. Are we making any progress in breaking down this old 
bureaucracy where somebody walks in and they have got to fill 
out 18 forms and they go over here and they are on the phone 
and wait, get me three initials and fill out this additional 
form? And I know this is hard and I do not mean to be--it is 
true of bureaucracies all over the country, but especially with 
folks in mental health. Are we saying, come on in, sit down, we 
are with you? Are we trying to make progress on that?
    Dr. Kudler. We have created a number of paths into the VA 
that are human and involve warm hand-offs. I think of the Vet 
Centers and the 100, still called GWOT, Global War on 
Terrorism, outreach people who have themselves lived through 
Iraq and Afghanistan and now work there, 60 percent of the 
workforce of the Vet Centers are combat veterans. There are 
OEF, OIF, OMD case managers at every VA medical center. We have 
transition teams between DOD and VA.
    Where these inlets exist, it is warm and personal. But they 
do not exist in enough places and not everybody knows the way 
into them. So, we have to build still bigger funnels. I want to 
add, in terms of listening and flexibility, I recently moved 
into my new office. My wife and I moved my analytic couch into 
that office, not because we are going to start practicing 
analysis in the VA full- time, but my point is, anyone who sees 
that office knows that I try to listen and that I want a model 
for all of us.
    We need to listen to veterans and respond in their terms.
    Chairman Sanders. We need to know that they are hurting and 
they need to know that we are there for them.
    Dr. Kudler. And we feel that pain, yes.
    Chairman Sanders. OK. Thank you.
    Senator Isakson.
    Senator Isakson. Thank you, Chairman Sanders. I held a 
hearing in Atlanta a year-and-a-half ago over the tragic 
suicides that took place at the VA hospital on Clairmont Road. 
We had three in a short period of time, one in the hospital and 
two that took place between the time of diagnosis for being at 
risk for their life and the time they got to a community-based 
clinic appointment. They fell through the crack over a 6- to 8-
day period of time.
    Atlanta has done a good job of improving that system and we 
have had only one tragedy in the last 18 months since that 
time, and one is too many, but we have certainly made 
improvement. What is the VA doing systemwide to see to it that 
the hand-off from initial diagnosis to first treatment is 
seamless and that the veteran has a way to communicate back and 
forth with the professionals so they do not take their own 
life?
    Dr. Kudler. Every patient who is in mental health in VA is 
assigned a care manager, someone whose job is to integrate and 
oversee the plan. So, you do not have a bunch of different 
people doing a bunch of different things and no one integrating 
that care. And at the time, that person is identified and is 
part of the treatment plan, that they track what goes on to 
prevent exactly what you described.
    Senator Isakson. In your testimony on page 3, the written 
testimony, you have a statement that says, VA has trained over 
6,100 VA mental health professionals to provide two of the most 
effective evidence-based psychotherapies for PTSD. One is 
cognitive processing therapy and the other is prolonged 
exposure therapy. Can you describe those two for me?
    Dr. Kudler. Very briefly. These are two therapies that both 
work on the same basic principle, which is that what creates 
and maintains PTSD is the fact that every time you try to think 
about these things and solve the problems, untie the knots, you 
will begin to avoid. So, they both represent ways to overcome 
that avoidance. Cognitive processing: by working with the 
veteran to help realize how they have tied themselves in a knot 
then untie those knots. Every time you think of that, you think 
of yourself as a failure. Are you a failure? No, we are not 
totally a failure. Perhaps you begin to look at these things.
    Prolonged exposure says, look, we are going to take you 
back there in a controlled way. I will go there with you and we 
will think about these things, and you will see that this is 
not more than you can stand. It is horrible, but not more than 
you can stand. Over time and in a very structured way, you 
begin to think, you know, I can be in my own life and I can 
begin to live my own life again.
    I hope that is helpful, Senator.
    Senator Isakson. Well, I may show my ignorance here. 
Hopefully I am going to show that I have got some intelligence. 
But I went to the VA hospital in Atlanta recently and saw two 
computer-based carrels, if you will, that were simulating what 
exactly--is that what you are talking about?
    Dr. Kudler. Exactly. You are talking about Dr. Barbara 
Rothbaum's work with virtual reality, with the Atlanta VA being 
a world leader in developing that program. That is a particular 
way of using virtual reality to take that exposure therapy and 
make it even more real and vivid.
    Senator Isakson. Mr. Chairman, the reason I bring this up 
is, we have a tremendous manpower shortage in terms of medicine 
and paraprofessionals and clinical people. But there are 
technologically-based therapies that can serve a lot more 
people than just one doctor could ever serve. And so, as we 
look to hire enough numbers to put in the box in terms of 
employees, we ought to be thinking outside the box on proven 
technologies where one doctor or one clinician can actually 
operate and supervise for a number of patients.
    The day I was in the clinic watching, 24 different veteran 
patients came in. They had three operating carrels and two 
supervisors. That is a great ratio and the program has been 
very successful.
    Last point. Again, this is on manpower. I think the VA 
basically is a 21st century problem operating in an 20th 
century environment. When I go to my doctor today in Atlanta, I 
get in a little small office where the nurse comes in, takes my 
temperature, takes my blood pressure, asks me what my 
prescriptions are, and I sit down and wait for the doctor to 
come in.
    There are six separate offices just like that and six other 
patients waiting just like I am. The doctor comes in and goes, 
one, two, three, four, just goes through very quickly, which is 
the reason why VA doctors serve two-thirds of the number of 
people that private-sector doctors serve.
    I do not think our facilities are modern enough in the way 
they are organized to support more capacity on the part of 
physicians. Do you agree with that?
    Dr. Kudler. Dr. Krahn, I do not know if you want to take 
that?
    Dr. Krahn. Well, I think the problem you are describing is 
a bigger problem in primary care, specialty medical, and 
surgical care.
    Senator Isakson. Not in mental health.
    Dr. Krahn. Right. Actually, that is a big problem--space 
and to be efficient and support staff to be efficient is a very 
big problem in VA and, actually, much of the Veterans Access 
Choice and Accountability Act money is going in that direction 
as well as in direct hires of providers. In mental health, you 
should know that we can compare psychiatrists and psychologists 
fairly directly in work productivity with both academic and 
private practice providers.
    Our psychiatrists are more productive than academic 
comparison groups, less productive than private. Our 
psychologists are just about at the academic to slightly above 
the academic level. So, we compare much more favorably with 
average work productivity than other parts of VA does.
    Senator Isakson. Thank you very much for your testimony.
    Chairman Sanders. Thank you, Senator Isakson.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. Do you have 
veterans staffing your hotline?
    Ms. Thompson. We do, yes.
    Senator Tester. At what rate?
    Ms. Thompson. At this point I would say it is about 20 to 
30 percent are veterans and some are still in service. And then 
the majority of those are family members.
    Senator Tester. I think it is critically important. Do you 
guys monitor wait time on the hotline?
    Ms. Thompson. We do.
    Senator Tester. Are people put on hold?
    Ms. Thompson. People--do you want to take this, Dean?
    Dr. Krahn. People are actually rolled over to back-up 
hotlines when we are over----
    Senator Tester. The question is, if I am a veteran in 
crisis and I call that hotline, how long is it before I am 
talking to a real person?
    Dr. Krahn. I would have to get that exact number for you.
    Senator Tester. The fact is that you guys need to--you need 
to monitor that. That is pretty damn important moving forward.
    Dr. Krahn. It is. I just do not have that number with me.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Tester. OK. If you could get that, that would be 
great. The Chairman brought up a question about the bill that 
we passed in July. What is the biggest health care challenge 
that you have in the VA right now, Dr. Kudler?
    Dr. Kudler. I think capacity, the number of mental health--
--
    Senator Tester. Overall capacity or capacity in mental 
health?
    Dr. Kudler. Actually I think capacity in mental health 
right now. Of course, that is my focus. That is what I am most 
concerned about.
    Senator Tester. I would hope you would say that. The 
signature injury coming out of Iraq and Afghanistan is PTSD.
    Dr. Kudler. PTSD and really in combination. I have spent my 
entire career trying to raise people's awareness and my own 
about PTSD. But PTSD rarely travels alone.
    Senator Tester. Right.
    Dr. Kudler. PTSD, substance abuse, depression, traumatic 
brain injury.
    Senator Tester. No argument at all. The question is, we 
have allocated $16.5 billion, $5 billion for recruitment--and I 
heard hesitancy in your voice that you did not have the 
resources because it was not earmarked for mental health--if 
that is true, we need to have the Secretary in here for a visit 
to discuss it, because the fact is the injuries coming out of 
these wars have a lot to do with unseen problems. Hopefully 
somebody is listening besides you in the VA and will deal with 
that.
    You have got to have the resources. If you do not have the 
resources, mental health is not going to go away and everybody 
around this panel in their opening statement talked about the 
lack of professionals in that business.
    Dr. Kudler. I want to say I think this panel is extremely 
well informed and would love to have you around our conference 
tables more often, actually. The fact is that our Secretary is 
entirely on our side. I feel totally supported and he gets it. 
He is out there looking for psychiatrists. I never thought that 
would happen.
    Senator Tester. I hear you. But, the fact is that there 
should be no hesitancy. $5 billion is a lot of dough and you 
guys should be able to utilize that to take care of this mental 
health problem in the VA. By the way, I think that helps the 
whole country move forward.
    I want to talk about mental health and the mobile Vet 
Centers. They are critically important. They are critically 
important in rural areas. Are they staffed with mental health 
professionals? So, if a veteran comes in, can you actually deal 
with it?
    Dr. Kudler. I think the Vet Center is one of the best 
things VA ever did and it is 21st century, and their staff 
includes a combination of people who are sort of peer support, 
people with life experience and mental health professionals, 
social workers, and psychologists.
    Senator Tester. That is good. So, they have that and it 
does not matter if you are in Montana, Alaska, or a more 
populated place?
    Dr. Kudler. They will come to you if, in fact, the need is 
in Montana or Alaska.
    Senator Tester. OK. Very good. Can I ask what the DOD is 
doing to help you? I get contacted not a lot, but by some 
veterans that say, ``you know what? I have got some issues, but 
I am never going to admit to it because I will never be able to 
get a job.'' Is the DOD helping you to be able to determine who 
is at risk that need help so that you can do some outreach?
    Dr. Kudler. Colonel Ritchie, who is on the next panel, and 
I have worked together since at least 2002 when she was the 
Senior Behavioral Health Consultant to the Army Surgeon 
General, and we have built into each of the branches and into 
DOD all sorts of partnerships. We have in our office people who 
have joined VA and DOD activities. I think we are doing a 
tremendous job. This was not true before these wars, but it has 
been true over the years and it keeps building.
    Senator Tester. OK. As one of these guys talked about, 
over-medication--I think it was Senator Boozman, actually, who 
talked about over-medication--is this a problem? Is this is a 
systemwide problem or does it happen rarely?
    Dr. Kudler. You know, there are several levels of the 
question so I will try to answer briefly. Reliance alone on 
medicine, which I heard stated, I think is a mistake. One has 
to listen, one has to talk, one has to be engaged. The 
therapeutic relationship is more powerful, I believe, than any 
medicine.
    However, are we generally over-using medicine? No, I do not 
believe so. I think we fail to communicate.
    Senator Tester. That is all I needed to know.
    Dr. Kudler. Thank you, sir.
    Senator Tester. I am going to ask a question the Chairman 
asked you. I am going to ask it a little different way. Are you 
aggressively looking for alternative treatments for mental 
health?
    Dr. Kudler. Absolutely.
    Senator Tester. Can you give me some examples?
    Dr. Kudler. We are working, looking at alternative medicine 
and applying them wherever we can. We are looking at--the VA is 
actually one of the leaders in using ketamine, a drug that 
normally we would think of as a drug to abuse, but it may have 
a role both in depression and in PTSD. We have led the way in 
researching this.
    Senator Tester. What about things like--I will just lay it 
on the line--fishing, horses, mother nature?
    Dr. Kudler. Vet centers have been doing it forever and we 
have a lot of great community partners, we will hear from some 
today, who are for that. We are for it, too.
    Senator Tester. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Tester.
    Senator Moran.
    Senator Moran. Mr. Chairman, thank you very much. Doctor, 
thank you for your presence here today. It seems like everybody 
is on a rush today to make sure we get our questions in and 
answers and I will be the same way. Two things that have 
occurred trying to bring services closer to home to veterans 
who live in rural America.
    One was a pilot program called ARCH. A second one was the 
passage of the Choice Act in which if you live more than 40 
miles from a facility, you are entitled to those services being 
attained at a place of your choice, presumably your home. In 
the case of ARCH, there is a pilot program in Kansas. The 
community mental health centers have attempted to be a 
participant in that program. I do not think it has been 
successful.
    On that, they have not been successful in being allowed 
that opportunity. I worry about the same circumstance under the 
Choice Act. I am still waiting for an answer from the 
Department of Veterans Affairs in regards to how do you define 
a facility? Forty miles from a facility is different than 40 
miles from a facility that provides the services that the 
veteran needs.
    So, we may have a CBOC, an outpatient clinic someplace, but 
they do not provide mental health services. Is that going to be 
an impediment toward a veteran who lives within that 40 miles 
but cannot get the services he or she needs at that outpatient 
clinic?
    I am interested in knowing whether that is a discussion 
that has been ongoing with you and others at the VA because how 
we define what a facility is is going to determine whether very 
many veterans are actually going to be able to access health 
care at home under the Choice Act.
    In somewhat of a follow-up to the Senator from Montana, we 
have been pushing the VA for years to better include marriage 
and family therapists and licensed professional mental health 
counselors. We have not seen a lot of evidence and, in fact, I 
questioned the Secretary on this topic, the previous Secretary, 
back in September without much of an answer as to whether or 
not we are now going out beyond what we perhaps traditionally 
have thought of as mental health providers and bringing in the 
numbers that actually do exist, particularly in a State like 
mine.
    There are marriage and family counselors. There are 
professional counselors, but they are not being integrated 
within the Department of Veterans Affairs. Is any of that 
changing? Then I would capsulate those two questions.
    Tell me specifically, is the VA a different place today 
with a new Secretary? Can we expect a different outcome than 
what we have heard most members around this table describe 
about bureaucracy, culture? Is there a real change within the 
VA? Is life different for those who work there, but more 
importantly, does that translate into life being different for 
the veterans that the VA is intended to serve?
    Dr. Kudler. All right. Thank you. I will start with the 
last question. I believe the VA is significantly different with 
the new Secretary. There is an energy and there is a different 
way of approaching problems. There is the support and there is 
a willingness to be outgoing and engaging that is powerful. I 
believe it is spreading across our----
    Senator Moran. If you are an employee at the VA and you 
have a complaint about the way VA operates, is it different 
today in your ability to communicate that and find a result and 
feel comfortable that your job is secure, that you are doing 
something noble instead of something oppressive?
    Dr. Kudler. I can call that man's cell phone number and I 
can use a new electronic suggestion box, which I know gets 
results because I get pinged back when people make other 
suggestions.
    Senator Moran. Thank you.
    Dr. Kudler. Yes, sir. You brought up rural health. I have 
spent the last 5 years trying to develop rural health programs 
in North Carolina, Virginia, and West Virginia. You are 
absolutely right. Given that 40 percent of all veterans are 
from rural America and they tend to have a higher incidence of 
PTSD and they have less access to mental health, it is an 
essential question.
    You also bring up marriage and family counselors, the whole 
idea of licensed professional counselors. In doing a lot of 
outreach in the community, I met a lot of these folks and I did 
not realize that in the past they were not allowed to be 
TRICARE providers independently. They had to be supervised and 
the VA also was not hiring these people.
    These people are exactly who is out there in rural areas 
and they are accessible and they are part of the community. 
Yes, VA is engaging them. It is not as fast as any of us hope. 
We are working on increasing that across the country, but we 
are absolutely focused on doing that and we will achieve that.
    Senator Moran. The question I asked about those licensed 
professionals 6 months ago that got no answer from the VA, I 
will submit those questions again in writing. But you would 
tell me that today the answer would be things are changing and 
we are recruiting, encouraging, and hiring those licensed 
professionals?
    Dr. Kudler. We are doing that, and I will say to be 
absolutely clear that I am dedicated to doing that. Where we 
still have slow starts, I want to see that proceed.
    Senator Moran. Do you know, if you are a veteran that lives 
within 40 miles of a VA facility that does not provide mental 
health services, whether or not those services will be provided 
at home?
    Dr. Kudler. Thank you for bringing me back to that. My 
understanding--and if I am wrong about this I want to know from 
you and from my colleagues--every community-based outpatient 
clinic of any size has got to have a mental health component. 
It is scaled to the size of that community and the size of that 
clinic. It is integrated between primary care and mental 
health. No longer VAs down the hall or several blocks away.
    And if we do not have enough capacity at the moment to 
manage, we will have telehealth capacity to bring mental health 
directly into that area. Dr. Krahn, am I right?
    Dr. Krahn. That is certainly the goal at every site.
    Senator Moran. Which is a different answer: that is the 
goal.
    Dr. Krahn. That is--I cannot say that it happens at every 
place and I cannot say that they can deliver every type of care 
at every CBOC. So, I am trying to be very, very correct to you.
    Senator Moran. Thank you very much for the honesty. Mr. 
Chairman, I will conclude, but here is an important point for 
the VA. If there is a facility within 40 miles, it may not 
provide the services that the veteran needs and you cannot 
define, under the Choice Act, that that person is not 
entitled--is not capable of getting these services at home 
because there happens to be a facility despite not providing 
the needed services.
    Finally, please give me the name of somebody that we can 
talk to about getting the Community Mental Health Centers of 
Kansas, which spread across our 105 counties--they are 
everywhere--somebody at the VA who will listen to them about 
how they can provide services to veterans at home. Thanks.
    Dr. Kudler. We will do that. Thank you, sir.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Moran. Mr. Chairman, thank you.
    Chairman Sanders. Thank you, Senator Moran.
    Senator Murray.
    Senator Murray. Mr. Chairman, we are focused on the VA 
today, as we should be, on the issue of suicides, but I think 
Senator Tester's point about the DOD is extremely important, 
and if we are to start way back when someone is in service and 
embed mental health experts with our troops, I think that it 
will go a long way in making sure that they know what they need 
to do when they get home.
    He also mentioned the fact that many of our veterans are 
not putting veteran on their resume when they seek a job, and 
that is because of this issue. We need the public to better 
understand this as well. So, this is a very broad topic.
    I do want to ask about the VA today. This is a critical 
piece of this puzzle and I am really concerned that the VA is 
not making enough progress to bring down the wait times for 
mental health care. According to your own statistics, wait 
times for new mental health patients have remained unchanged 
since June 9, almost 36 days. Why have we not seen this come 
down?
    Dr. Krahn. I think that there is a difficulty in 
increasing--there are two issues to access. Right? How do we 
deliver care and how many people are there to deliver care? 
Getting more people on board does take time and that is a slow 
process.
    The other aspect is sort of how we bring people into care. 
Many of those initial appointments, same day appointments, or 
actually same day interactions, may or may not show up as first 
appointment, on the data. So, I am somewhat worried about 
whether or not those same-day emergency stops are counted or 
even if they should be counted. We could have a long debate 
about that.
    But I believe people are getting in, in emergent 
situations, or can touch VA or be touched by VA in emergent 
situations.
    Senator Murray. I think that is a point that we need to 
understand.
    Dr. Krahn. But, we need to do better, obviously.
    Senator Murray. We cannot have someone call to get an 
appointment and be told that they can get one in 5 weeks when 
they have a problem.
    Dr. Krahn. Right.
    Senator Murray. We have got to make sure, and I want to 
know that that's happening across the country. But it is also 
the quality of care once they get in, and I am very concerned 
about the new report by the RAND Corporation which looked at 
mental health providers' proficiency with the military culture 
and whether they are experienced with this.
    Their findings raise a lot of concerns. According to the 
RAND analysis, only about 6 percent of civilian providers are 
ready to deliver mental health care that is evidence-based and 
culturally competent. I know you have put your provider toolkit 
online, but what are we going to do to make sure these 
community providers have the knowledge to do what they need to 
do?
    Dr. Kudler. Yes, that is a problem. Actually, that RAND 
study replicates something we did in the VA originally and 
found the same findings. I worked with Dr. Tanielian on the 
report a little bit, at least its release. There is a 
significant problem that most civilian providers do not even 
take military history, tell us they do not know much about 
military culture, tell us they do not know how to connect with 
VA.
    There was a report published just this morning. I got the 
report for Military Medicine, this month's issue, showing 
something like 60 percent of community doctors felt that they 
really did not know how to work with VA when they had a veteran 
in their practice. How do we----
    Senator Murray. But we just passed this bill saying anybody 
outside the 40 miles can go to a provider. If they are not 
competent and capable of dealing with this, we are creating 
another problem in the future. How do we address that?
    Dr. Kudler. Well, first of all, I still think the Choice 
Act was a move forward, but now, as you say, we have to make 
sure that there is community competence. The question is 
always, access to what? And what we are doing is using 
educational tools that already exist and finding ways to 
disseminate them.
    We have a mental health community provider Web site in the 
VA with all kinds of tools and training to provide that 
crosswalk. We have created, through the IMHS process, the 
Mental Health Interagency Strategic Plan, an online training 
which has just been released on military cultural competence 
which is free, offers free education credit for doctors and 
psychologists, all the health professionals on military 
culture. We are building these crosswalks and we are reaching 
out through our VAs at all facilities. We have done 150 
community mental health summits this year; we did them last 
year and we will do them next year.
    Senator Murray. OK. My time is running out and I want to 
ask another critical question, yet I think this is something we 
need to have oversight on in the future; to really follow that 
this law has been implemented. So, we are seeing the suicide 
among middle-aged male veterans who use the VA decrease. You 
mentioned that. But female veterans who use the VA has 
increased by 31 percent. What is happening?
    Ms. Thompson. Thank you so much for asking that, Senator. 
We are as concerned as you are and we are trying to better 
understand why that is, why those rates of suicides among women 
are increasing as is that youngest male population. One thing 
that I also want to say is that we also know that veterans use 
firearms more than non-veterans during--when they are feeling 
suicidal. And we know that women veterans are using firearms at 
an increased rate compared to non-veteran women.
    We know that firearms--if you use a firearm when you are 
suicidal, there is a 90 percent chance that you will die. If 
you use medications, prescription medications, which is what 
most women non-veterans tend to use, there is a 3 to 4 percent 
chance that you will die because there is an opportunity to be 
reached before they die.
    Senator Murray. I appreciate that response, but I think we 
also have to look at whether or not the VAs are meeting women's 
specific needs----
    Ms. Thompson. Absolutely.
    Senator Murray [continuing]. And why are they increasing 
dramatically? Are the programs not effective? Are they not 
feeling that they should ask about it? Is it something else? 
This is really concerning to me; it is something that I will be 
following very closely as well.
    Ms. Thompson. Understandably. Thank you.
    Chairman Sanders. Thank you, Senator Murray.
    Senator Johanns.
    Senator Johanns. Thank you, Mr. Chairman. Sometimes it is a 
little difficult to even know where to begin. But let me offer 
a thought or two and this will lead to where I am trying to go. 
I disagree vehemently with the testimony I have heard about 
over-medication. I think over- medication and inconsistent 
medicating is a problem throughout the mental health system. It 
is with the VA, it is with private psychiatrists, and to 
downplay that, I think, ignores reality.
    The second thing I would say is that even a medication that 
works, as you know, oftentimes has very severe side effects. 
So, you have this individual who has maybe spent years--part of 
the time in combat, part of the time in training--in very 
responsible positions, and all of a sudden things are falling 
apart for him back home.
    They are put on this medication. They become lethargic, 
they start losing confidence in themselves, and family 
relationships start being strained and falling apart, and the 
world is just cascading downhill for them. That is the reality 
of medicating.
    I am not saying there is not a place for it. Of course, 
there is a place for it, and I would argue, if it is medication 
that is part of the solution, it should be utilized. But I 
think to ignore the impact of over-medicating and inconsistent 
medicating, again, is to ignore reality.
    Another thing I want to mention, and this leads me to my 
question. I had an insight a year or so ago. The Chairman had a 
hearing much like this. We were questioning veterans and this 
one veteran explained something to me that I must admit I had 
missed. This veteran described their time in the military as 
very difficult.
    He said, he was always surrounded by peer support, by 
people who were going through the same thing, going through the 
same difficult atmosphere in the absence of family and the 
absence of friends in a part of the world where it was very, 
very tough, but still surrounded by people. He said, things 
started falling apart when that disappeared. ``I left the 
military, I went home, and they were not there anymore.''
    Here is my point. I love the fact that research is 
developing more medications that may help more people. I love 
the fact that there are smart people who can prescribe those 
medications. But I think we are missing a point here and that 
is, if we are not developing the peer support--you see, I have 
this concept that a veteran could walk into a VA center or 
hospital and ask, when does the next peer group meet? I need 
some help.
    They say, they meet tonight. We hope you are there. And we 
do not need to have you fill out any forms. Just the fact that 
you are a veteran will get you to this support. Maybe there is 
somebody in that room who says, you know, I have been down this 
road and I found this doctor who prescribed something for me 
and it is working. But I also started doing some other things.
    Why are we not doing more of that? Why are we not trying to 
support these men and women who come home with others who have 
had the same experience? Does that not just make sense? And you 
do not need multi-billions of dollars to get veterans to help 
veterans. It comes naturally. What am I missing here?
    Dr. Kudler. You are right on target and I wish you were 
teaching some of our medical students. The fact is that VA has 
really embraced peer support. I have mentioned the Vet Centers. 
They have been doing this since the 1970s, and in fact, you do 
not have to sign up even for VA care to use a Vet Center. That 
principle was there from the beginning. We have been following 
the President's Executive Order of 2012 and exceeded his demand 
that we hire 800 peer support specialists across America. We 
have well over 900 and we are growing rapidly.
    Peer support is now being integrated, thanks to the most 
recent Presidential actions, into primary care settings as well 
for that kind of engagement. And I absolutely agree with you 
that that is one of the warm paths in. I also agree with you 
that if we are using medicine to push people away while trying 
to push their symptoms away, instead of engaging them as people 
and engaging their problems as part of our work.
    As the core part of our work, we are all making a terrible 
mistake. What over-medication is for an individual I found over 
the years harder to decide because sometimes people need a lot 
of medicine. Once in a while you will find that a medicine is 
what makes psychotherapy possible when a patient cannot even be 
in the room with you or their memories unless that medicine 
helps them have a longer fuse to then face the issues and work 
on them with you.
    So, I absolutely agree with you also and I apologize if my 
remarks in any way trivialized this idea that there are many 
people on more medicine than they need and those medicines are 
used in ways that actually get in the way of the process you 
and I are both trying to describe here.
    Senator Johanns. My statement used up all my time, but, Mr. 
Chairman, I just hope we are not over-engineering something 
here. I worry about that because I agree with what you are 
saying about medications, et cetera. But, quite honestly, I 
think if you could bring people to bear who have been down this 
road, that could make a big difference. Thank you, Mr. 
Chairman.
    Chairman Sanders. Let me just say, I think Senator Johanns, 
what he is talking about, is community. People who served in 
the military have an extraordinarily strong community of people 
depending upon each other every day, then they come home and 
they lose that. I think, Senator, what you are talking about is 
rebuilding that community for people to support each other.
    Senator Blumenthal.
    Senator Blumenthal. Thanks, Mr. Chairman. I want to pursue 
the line of questioning that Senator Johanns began because I 
think it is absolutely critical. I have held meetings around my 
State with veterans. Some of them have occurred at what are 
called Oasis, which are basically college- and school-based 
centers. They are not medical. They are just meeting rooms. 
They are literally a room where veterans can come together and 
call that place their own. They put up their posters. They have 
got a coffee machine, they have donuts, and they just come 
together ``without medication.''
    I met with a group just a week or so ago and they talked to 
me, in very graphic, moving terms, about what it meant just to 
be with each other. I know that peer support specialists are 
part of this program. With all due respect to the peer support 
specialists, I would respectfully suggest that this kind of 
resource may not always require a trained specialist, but maybe 
just a veteran, and I have in mind the kind of veteran who got 
involved, in part, because I reached out to him at the 
suggestion of another veteran, just made a call to him out of 
the blue. And he came to one of these meetings.
    I do not think it involves necessarily a doctor or a nurse 
or a medical person, but just a veteran who is empowered and 
enabled to perform this function. I do not want to use too much 
of my time with a statement about the importance of this topic, 
but I would like to know, and maybe you can provide this answer 
in writing, specifically what the current peer support program 
embodies and how it could be expanded to fund meeting rooms on 
State campuses, State schools--which already should be a part 
of this program--private colleges and universities. But then 
beyond the college or school setting, in communities, how that 
outreach function could be expanded. I know this is a topic 
that you are thinking about, so I would appreciate your 
expanding on the testimony that you have given already.
    I do want to ask you about your testimony, because I think 
there are some very important questions about the age group 
that you do not cover. You talk about middle-aged veterans, 
which as I understand it, are the 35-to-64-year-old group, and 
in that group rates of suicide have come down by 16 percent for 
those adults who use VHA services. In the population as a 
whole, the rates have remained stable. Correct?
    Dr. Kudler. They have actually gone up.
    Senator Blumenthal. Well, they have gone up. Exactly, they 
have gone up from 35.5 to 37.5 percent. Right? So, the rates 
are coming down for middle-aged adults who use VA services. 
They rates have gone up a little bit for the overall group, but 
they seem fairly stable at 35 to 37 percent.
    Dr. Kudler. Well, let us not take up time with the numbers.
    Senator Blumenthal. Well, here is where I am going. What 
that says to me is that among other age groups, suicide rates 
have risen dramatically for veterans who use your services, not 
just women, but men. Can you tell me how much they have risen? 
For example, for--and this is, so far as I can see, nowhere in 
your testimony--for the age group 18 to 25 or 20 to 29, for the 
younger population of veterans. Because after all, most of the 
veterans who are leaving the service right now are in that 
younger age group, right? So, what is the rate there?
    Ms. Thompson. We are extremely concerned about this younger 
population.
    Senator Blumenthal. Well, I know you are concerned.
    Ms. Thompson. No, I know, but I do not have the actual--I 
believe it is up to 70, and this is over time. So, the rates, I 
would have to find the exact number.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Blumenthal. I think that is the elephant in the 
room.
    Ms. Thompson. Is what----
    Senator Blumenthal. The elephant in this room. What is 
happening in that younger group?
    Ms. Thompson. You are absolutely right.
    Senator Blumenthal. You are given middle-aged----
    Ms. Thompson. No----
    Senator Blumenthal [continuing]. Friends who use your 
services.
    Ms. Thompson. We certainly acknowledge that that rate is 
increasing, and so, what are we doing about this? We need to 
provide, and we are providing, very, very specific outreach to 
those youngest veterans that have come home.
    Senator Blumenthal. Well, we are talking about more than 
just outreach, with all due respect. We are talking about--and 
this is the really critical point here--we are talking about a 
group that uses your services.
    Ms. Thompson. Absolutely.
    Senator Blumenthal. You have reached out to them.
    Ms. Thompson. Yes.
    Senator Blumenthal. They are in your doors. They are using 
your services and they are committing suicide at a higher rate.
    Ms. Thompson. Yes. So--yes. We are trying to understand why 
this is. We are at a loss as much as a lot of people are. We 
certainly----
    Senator Blumenthal. I mean, you know, this is, with all the 
publicity surrounding the wait times and people dying, are they 
dying because of the wait? Are they not? People are dying at a 
higher rate----
    Ms. Thompson. Yes.
    Senator Blumenthal [continuing]. Who use your services.
    Ms. Thompson. Yes, and this youngest group, absolutely. We 
are very, very focused on this.
    Senator Blumenthal. I do not know what more to say because 
my time has expired. I apologize, Mr. Chairman.
    Ms. Thompson. We hear you.
    Senator Blumenthal. OK. Thank you.
    Chairman Sanders. Thank you, Senator Blumenthal.
    Senator Boozman.
    Senator Boozman. Thank you, Mr. Chairman. Following up on 
Senator Blumenthal, what is the average age of the veteran that 
decides to take their life? In the VA, what is the average age 
of veterans that are taking their lives?
    Ms. Thompson. Who died by suicide? Well, I do not know the 
average age, but we do know that 70 percent of veterans who 
died by suicide are 50 years old and older. So, even though----
    Senator Boozman. Older group.
    Ms. Thompson. Yeah.
    Dr. Kudler. And that is by far the largest group of 
veterans. That is one reason why we focused on that.
    Senator Boozman. And what percentage have been deployed?
    Ms. Thompson. In terms of that 70 percent, it is 
difficult----
    Senator Boozman. Well, percentage of veterans that are 
taking their lives. What percentage of those have been deployed 
overseas?
    Ms. Thompson. Well, what we know about those military 
members--and we are looking at the veteran numbers--but we know 
that those who have died who are servicemembers, fewer than 
half have ever been deployed. There is a perception that the 
number of deployments, the combat experience that people have 
is a primary reason that people are dying by suicide at these 
high rates. In fact, we are learning the opposite.
    Senator Boozman. I think the point that Senator Blumenthal 
tried to make, which I am trying to make, is that those two 
groups are very different.
    Ms. Thompson. Absolutely, yes.
    Senator Boozman. And they need to be treated very 
differently, which I do not think we are doing right now. You 
know, we have a one-size-fits-all, which is a totally different 
thing. I am a little concerned or a little confused about the 
wait times. You know, you said it is mandated that it is the 
day. If a family practitioner sees a patient and, in the course 
of that examination, he is concerned that perhaps this 
individual is having problems and he writes down on the chart, 
you know, he needs a consult. How long does that take?
    Dr. Krahn. Well, actually, over 90 percent of facilities 
and over 90 percent of large CBOCs, there will be a co-located 
collaborative mental health person in the building and they 
should be able to walk that person over to the office and see 
them.
    Senator Boozman. Well, they should be able to. Where does 
the 33 days come in then? What is that?
    Dr. Krahn. That is a prospective. It is like if you make an 
appointment by, say, call in by phone and say, when is the next 
appointment? It is that far out. But if you come in----
    Senator Boozman. If you walk the person over, they see you, 
and then they say, well, you need to come back. Then it is 33 
days?
    Dr. Kudler. And that is a very important point, Senator, 
because what often happens----
    Senator Boozman. Because that is not really--you know, I am 
just checking a box, but it is really not seeing the point.
    Dr. Kudler. Our standard is that they will be seen that 
day, but that does not get shown. That is not reflected in that 
longer wait time. That is to get the next official appointment. 
Quite frankly, they will often be seen back in other ways or 
other clinics earlier. They will be seen that day by a mental 
health professional if they need that help, and anyone can 
refer them and they can self- refer there.
    Senator Boozman. But if they--in follow-up appointments, it 
is probably 33 days?
    Dr. Kudler. Yes, I think that is right.
    Senator Boozman. So, they are actually not starting 
treatment for an extended period of time.
    Dr. Kudler. They do not get an official mental health 
appointment, though they may be seen in other ways. 
Unfortunately, our system does not capture all the ways we do 
it. For instance, we might have them come back to the emergency 
room and that will not be recorded as a mental health 
appointment. Nonetheless, they may have that mental health 
appointment, or a phone call which may not be registered as a 
mental health appointment. But, yes.
    Senator Boozman. Tell me about the over-medication. It is a 
problem not only in the VA, it is a problem throughout the 
entire country. The idea of saying that we are not over-
medicating, to me, does not make any sense at all. Right now 
the United States uses more opioids than the entire rest of the 
world put together. It is the major problem as far as drug 
dependency now. It is replacing almost everything else.
    So, I think it is a problem and I think it is something 
that we need to talk about and actually do something about. 
Now, I do not know if you have situations where after somebody 
does take their own life, if there is any follow-up to that 
where you look and see, you know, what they are on, what 
happened to them, you know, if they got seen or whatever.
    But, I would suspect that those studies, in dealing with 
people that have had this problem, actually being out in the 
real world, talking to people at VSOs, talking to our veterans, 
talking to families that have gone through this, you know, 
anecdotally, there is a significant problem with many of the 
people that are in that situation.
    Dr. Kudler. And, Senator, I want to apologize if I misspoke 
or misrepresented. I do believe there is such a thing as over-
medication. It is just hard to judge from a distance. Is this 
that or is that that? I also want to point out that we are 
doing education and reviews at every level--computerized 
reviews, personal reviews, and ongoing education for our own 
staff.
    And particularly about opioids, which we do not prescribe 
as a mental health medicine. I do not use opioids to treat any 
mental health illness.
    Senator Boozman. But that is all connected, too; and as a 
mental health provider, you should be able to look at the chart 
and see that this patient----
    Dr. Kudler. And I can.
    Senator Boozman [continuing]. Is on a bunch of opioids----
    Dr. Kudler. I can.
    Senator Boozman [continuing]. And you should be getting 
them off the opioids.
    Dr. Kudler. Yes. We, in fact, do that.
    I wonder if Dr. Thompson would like to respond, also, to 
the question of what we do in follow-up with a suicide.
    Ms. Thompson. Yes. We have established what we call a 
behavioral health autopsy program so that any veteran that we 
hear about who has died by suicide, whether they are in the VA 
or not, the Suicide Prevention Coordinator in that area will go 
through an extensive record review and then will reach out to a 
family member in order to talk with them about what the gaps 
are, what might have happened, were there over-medication 
concerns.
    We have not put out any formal reports yet, but we plan to 
very soon.
    Senator Boozman. Thank you, Mr. Chair.
    Chairman Sanders. Thank you, Senator Boozman.
    Senator Begich.
    Senator Begich. Thank you very much. Let me follow-up on a 
couple of things you had noted, I think in response to one of 
the questions. It was to the Chairman on the amount of 
resources you have and I think your words were, it is a good 
stop gap. So, is your concern that that money will not 
continue? Is that a concern? I want to understand what you mean 
by stop gap, and then I have some very specific questions.
    Dr. Kudler. It is my understanding, I hope not a 
misunderstanding, that the funds in the--many of the funds in 
this bill, in this law, are time limited, and when they are 
out, they are out. We may not be able to sustain some of the 
activities we build. We can build great things, but can we keep 
them going?
    Senator Begich. Right. That is what I thought you were 
pointing to, and I think your point, without you saying it, was 
if we pass laws like this, the Choice Act, and we put funding 
in it, we also have to have sustainable funding. Am I hearing 
that right?
    Dr. Kudler. Yes, sir.
    Senator Begich. OK. I want to make sure that is clear again 
because I will not be here after January, but I want to make 
sure my colleagues hear exactly what you are saying, so a 
couple years from now, we do not hear complaints that, geez, 
why did you not do it? You will have the actual answer on the 
record, that you did not sustain the funding. So, I wanted to 
make sure that is on there.
    Second, what is the ratio of actual--you may not know this 
right offhand, but--actual people who deliver the care, 
psychiatrists, to a veteran? You have told me the numbers were, 
I think, 900,000 up to now 1.4 million. What is your ratio? You 
did talk about 7,000 to 13,000 more people, but what is the 
ratio for a physician or a psychiatrist? Or does it make sense 
what I am asking you?
    Dr. Krahn. I can give you the ratio, first of all, for all 
FTE, provider FTE in outpatient services and it is 8.1 
providers per 1,000 veteran mental health users in outpatient 
care. About one-seventh----
    Senator Begich. Do you know what the private----
    Dr. Krahn. No, I actually do not have a comparison because 
it is very difficult to get that comparison and our populations 
are so----
    Senator Begich. But I am assuming that a psychiatrist is 
not seeing 1,000 patients.
    Dr. Krahn. No. There would be about 1.2 psychiatrists on 
the average for every 6 other providers. So, it is about 1.2 
out of 7, right in that range. With that team, the 
psychiatrists can work together to handle about 1,000.
    Senator Begich. 1,000 people?
    Dr. Krahn. With 1.2----
    Senator Begich. Psychiatrists.
    Dr. Krahn. But you may have another prescriber, like a 
nurse practitioner or pharmacist, a psychologist or two, social 
worker, et cetera.
    Senator Begich. Let me jump to one thought which requires 
no answer. It is just something I hope you would work on. As 
you know, at DOD there are some issues with recognized 
educational requirements of certain colleges and certain 
degrees so DOD has actually waived that so they can tap into 
current mental health counselors and others. DOD has done that. 
I would hope that you would do the same thing. It is critical 
to get those different layers of services available.
    It is not always psychiatrists--no disrespect to the VA 
doctor--but, you know, different counselor services are needed 
depending on the degree of the mental health issue. So, I ask 
this all the time. It seems like it is a struggle to just get 
movement on it, so just put that over here.
    But I do want to say, since this is probably my last 
hearing so I will talk about Nuka.
    Chairman Sanders. Though not for too long.
    Senator Begich. Not too long. Yet, here is why I want to 
talk about it, because when Senator Isakson talked about the 
doctor visit, that is actually an old model. That is a model 
that we are trying to get rid of, because what happens--tell me 
if I am wrong about this. When that patient comes in and they 
just come for the check-up, the physician shows up for 5 
minutes, 10 minutes, the nurses check their pulse and their 
blood pressure and everything, and they leave. They never ask 
about mental health. They are not asking about hearing, eyes, 
and so forth.
    The Nuka model, which my understanding is the VA is now 
contracting to try to implement this in certain regions 
throughout the country because it is a holistic approach, 
because you may have someone who comes in who has no issues in 
their mind about mental health services they need, but if they 
go through this model, the odds are someine might realize this 
person needs some additional services. Is that a fair 
statement?
    Dr. Kudler. Sir, in fact, Nuka is a cultural model of 
delivering health care and it is exactly what the VA needs. 
This is my personal opinion.
    Senator Begich. I want to have you say that again so the 
Chairman hears it. It is what the VA needs and that is why you 
are now contracting to try to implement this in certain 
regions, to test that model, because that old style of walking 
into a doc, get into your little box, and wait for him to show 
up for 10 minutes after the nurse checks your blood pressure, 
your temperature, your weight and your height; then the next 
thing you know, actually you might have a mental health issue 
that they never will detect.
    Dr. Kudler. Well, it speaks to what Senator Sanders said 
earlier in his comments. You know, it is military culture and 
the VA is all about military culture.
    Senator Begich. Right.
    Dr. Kudler. And it is great that we are hiring all these 
people, but if we do not train our own people in military 
culture and then train all the people who might refer people 
about military culture, we are missing the critical element 
that pulls all this together and the actual meaning of the VA.
    So, Nuka is one model for us to build that in, but we have 
to build it around that military model.
    Senator Begich. That is right. Well, let me end on this, 
Mr. Chairman. You have a tough challenge; there is no question 
about it. The families that will be up next will tell us about 
the challenge. We have seen--I think the Chairman said it very 
clear--we hear it every day. You know, people call our offices 
or we run into them or their families.
    How we approach this mental health system for the VA cannot 
be in isolation of the mental health system of this country. If 
we do that, we will fail. I think my worry is that when we 
passed the Choice Act--I think Senator Murray mentioned it--and 
that is where are the results?
    Well, in isolation, you cannot get the results as quick as 
you want--26 months ago. To train someone in this mental health 
service area is months and years. But, if we now draw and 
extract from the private sector--the recruitment that you are 
doing--then we are going to now have this problem over here in 
the private sector which veterans also access without saying 
they are a veteran.
    So, I hope you would, as you do this and this Committee 
looks at this holistically in mental health, because if we do 
not do this as a national model, you will not be as successful 
as we need you to be for the veterans of this country.
    Dr. Kudler. The truth is that only about one-third of all 
veterans use VA health services.
    Senator Begich. Right.
    Dr. Kudler. Two-thirds are out there and----
    Senator Begich. Already, without the Choice Act.
    Dr. Kudler. Without the Choice Act; and they are not 
recognized by their own clinicians as veterans. Something is 
broken.
    Senator Begich. That is right. Thank you, Mr. Chairman.
    Chairman Sanders. With that, let me thank Dr. Kudler, Dr. 
Krahn, and Dr. Thompson very much. Thank you so much for being 
with us.
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
Dr. Harold Kudler, VA Chief Consultant for Mental Health Services, U.S. 
                     Department of Veterans Affairs
    Question 1. Dr. Harold Kudler, in your position and testimony as 
Chief Mental Health Officer for the VA, you mentioned the VA's 
Operation S.A.V.E. program, which denotes the V as ``Verifying the 
experience.'' I am curious if you could go into further detail about 
how you verify the experiences, especially if there was no physical 
wound or decoration for bravery?
    Response. Operation S.A.V.E. is a one to two-hour gatekeeper 
training program provided by VA suicide prevention coordinators to 
Veterans and those who serve Veterans. Optional role-playing exercises 
are included. Operation S.A.V.E. training consists of the following 
four components:

    1. Brief overview of suicide in the Veteran population
    2. Suicide myths and misinformation
    3. Risk factors for suicide
    4. Components of the S.A.V.E. model (Signs of suicide, Asking about 
suicide, Validating feelings, Encouraging help and Expediting 
treatment)

    Operation S.A.V.E. was developed by the Education Core of the VISN 
19 Mental Illness Research, Education and Clinical Center. It consists 
of a PowerPoint presentation, training script, instructors guide and 
toolkit, pre- and post-evaluation instructions, evaluation forms, 
tracking sheets, and Operation S.A.V.E. brochures.
    Regarding the ``V'' for ``Verifying the experience/Validating 
feelings'' in the S.A.V.E. model, the ``experience'' discussed is the 
Veteran's experience of feeling suicidal. This experience is captured 
in the ``A'' component of the S.A.V.E. model during which a Veteran is 
asked if he/she is feeling suicidal. If a Veteran endorses feeling 
suicidal, the next step is to verify the suicidal thoughts and validate 
the feelings associated with the suicidal thoughts. By verifying the 
thoughts and validating the feelings, individuals are able to encourage 
the Veteran to receive help and expedite getting the Veteran the care 
that may be immediately needed.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
 to Dr. Harold Kudler, VA Chief Consultant for Mental Health Services, 
                  U.S. Department of Veterans Affairs
Suicide Prevention
    Question 2. In a study cited by the New York Times of soldier 
suicides researching military suicide risk models, it was found that 
many factors contributed to risk levels of suicide. Some of these 
factors associated with higher risk were expected, such as previous 
suicide attempts, a history of weapon use and symptoms of severe 
traumatic brain injury, such as hearing loss. Others were less obvious, 
like a higher IQ and being older than 26 at enlistment. I would like to 
commend Dr. Kessler, whose team tested these factors--I urge the VA to 
incorporate this new prediction program to allow doctors to better 
track high-risk soldiers after discharge. We should consider how we can 
use these at-risk analytics and the factors identified to focus our 
provision of mental health care and take preventive measures where 
appropriate.
    Dr. Kudler, you mentioned that the VA is pursuing a large number of 
research topics regarding suicide and mental health. Can the VA 
undertake a study of predictive indicators for risk of suicide using 
third party data or lifestyle indicators?http://www.nytimes.com/2014/
11/13/health/new-prediction-model-could-reduce-military-suicides-study-
finds.html
    Response. VA has developed a model for predicting suicide risk 
among those who receive VHA services using data from electronic medical 
records. Results from this effort were recently reported in the 
American Journal of Public Health. http://dx.doi.org/10.1176/
appi.ps.201400031 VA is currently exploring opportunities for enhancing 
and refining models for predicting suicide risk; including the use of 
third party data and mechanisms for safe use of potentially sensitive 
information available from these resources.
Suicide Rates
    Question 3. Dan Thurston, the Chairman of the Connecticut Veterans 
and Military Coalition, expressed that peer support is a positive step 
toward suicide prevention and builds greater camaraderie for those 
transitioning back into civilian life. In prior wars, it was often 
easier for Veterans' to stay in contact with soldiers from their unit. 
Dr. Kudler, could you please provide the suicide rates of Veterans by 
era of service to determine any differentiation between suicide rates 
among Veterans of different wars?
    Response. Information on rates of suicide by cohort is currently 
limited to Veterans from Operation Enduring Freedom, Operation Iraqi 
Freed and Operation New Dawn (OEF/OIF/OND) who use VHA health care 
services. In fiscal year 2011, the rate of suicide among OEF/OIF/OND 
Veterans who used VHA services was 42.1 per 100,000 . Data for other 
cohorts is being acquired through the VA/DOD Suicide Data Repository 
through collaboration between VA, DOD and the Centers for Disease 
Control and Prevention. Rates of suicide among Veterans from the 
Vietnam and Gulf War cohorts will be available as new information is 
obtained later this year.
Unemployment
    Question 4. I have heard from constituents that one of the greatest 
stressors on returning Veterans is both unemployment and 
underemployment. Dr. Kudler, does the VA coordinate mental health 
services with assistances in veterans' employment? What support does 
the VA provide for veterans with post-traumatic stress who are seeking 
employment and do you assist employers with accommodating veterans 
suffering from post-traumatic stress?
    Response. VA has created a Veterans Employment Toolkit (www.va.gov/
vetsinworkplace). This is an important tool to help employers, managers 
and supervisors, human resource professionals, and employee assistance 
program (EAP) providers relate to and support their employees who are 
Veterans and members of the Reserve and National Guard. In this 
toolkit, users can learn about Veterans and the military, such as what 
Veterans bring to the workplace and what the military structure and 
culture is like. They can also learn how to support employees who are 
Veterans or members of the Reserve or National Guard in the workplace, 
through reading about common challenges and how to help, reviewing 
communication tips, reading a report about Veterans in the workplace, 
or by downloading handouts to use with EAP clients. Finally, Veterans 
and their family members can use this toolkit to find employment 
resources for Veterans.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
Dr. Harold Kudler, VA Chief Consultant for Mental Health Services, U.S. 
                     Department of Veterans Affairs
Military Families and Caretakers
    Question 5. Many Veterans and their families in Hawaii have found 
that there is not enough support for military families and caretakers 
when servicemembers transition back to civilian life. Families and 
caretakers often feel overwhelmed and unprepared to help their loved 
ones. Please describe VA's efforts at improving mental health and 
suicide prevention programs available specifically for our military 
families and caretakers in Hawaii.
    Response. Partnering with families is an essential component of VA 
mental health services. Consistent with a recovery philosophy, 
flexibility is a key principle when involving families in care. VA 
offers a continuum of family services to meet varying needs including 
family education/training, consultation, and marriage and family 
counseling. National training programs in several evidence-based 
practices for marital and family counseling are available for 
clinicians. VA also has an active monthly training program for 
clinicians on family issues and interventions of particular relevance 
to Veterans and has developed a family services Web site as a resource 
for VA providers.
    Initiatives specific to VA-Pacific Islands include:

     VA Family Services training staff conducted a 3 day on-
site clinical training in Behavioral Family Therapy for Serious 
Psychiatric Disorders and Veteran-Centered Brief Family Consultation 
family consultation for 20 VA clinicians;
     Five VA Hawaiian mental health clinicians have completed 
the VA four day training in Integrative Behavioral Couples Therapy for 
marital Distress (IBCT) including a mental health clinician from 
American Samoa;
     VA Family Services Trainings include guidance on suicide 
assessment and encourage family clinicians to collaborate with Suicide 
Prevention Coordinators; and
     VA family Services has established collaborative 
relationships with a prominent VA researcher, Dr. Julia Whealin, 
affiliated with the National Center for PTSD-Pacific Islands Division 
on the uses of telehealth to meet family needs in Hawaii

    VA recognizes the crucial role that caregivers play in helping 
Veterans recover from injury and illness and in the daily care of 
Veterans in the community. VA values the sacrifices Caregivers make to 
help Veterans remain at home. Caregivers are partners in the care of 
Veterans and VA is dedicated to providing them with the support and 
services they need. The Caregivers and Veterans Omnibus Health Services 
Act of 2010, signed into law by President Obama on May 5, 2010, allows 
VA to provide unprecedented services and supports to Family Caregivers 
of Veterans. The Caregiver Law (P.L. 111-163, Title 1) establishes a 
comprehensive National Caregiver Support Program with a prevention and 
wellness focus that includes the use of evidence-based training and 
support services for Family Caregivers. Pub. L. 111-163 established 
additional support and services for Family Caregivers of eligible post-
9/11 Veterans seriously injured in the line of duty under the Program 
of Comprehensive Assistance for Family Caregivers including education 
and training, a monthly stipend paid directly to the Family Caregiver, 
enrollment in VA's Civilian Health and Medical Program (CHAMPVA) if the 
Family Caregiver is not already eligible under a health care plan, an 
expanded respite benefit, mental health services, and travel, lodging, 
and per diem to attend required training as well as to attend the 
Veteran's medical appointments. As of [June 2015] VA has served 316 
caregivers in Hawaii since inception of Comprehensive Assistance.
    The Suicide Prevention Program at VA-Pacific Islands Health Care 
System (VAPIHCS) provides support to families of Veteran's through 
Community Outreach activities at the State of Hawaii Suicide Prevention 
Task Force as well as the Department of Defense. Through Outreach 
activities, the family members are informed of the services available 
at VA Mental Health Service including family therapy, the Veteran's 
Crisis Line, support groups and individual mental health treatments for 
Veterans. VAPIHCS recently presented information at a State Suicide 
Prevention Conference in April 2015 in which there was a ``'breakout 
session'' for Veterans and their families. At times, VAPIHCS refers 
Veteran family members to community support services available through 
other providers who are members of the State of Hawaii Task Force. The 
Suicide Prevention Program also collaborates with the VA Caregiver 
Support Program. There have been occasions when a provider in the 
Caregiver Support Program identifies a caregiver in the program who 
needs additional Mental Health support. The Caregiver Support program 
contacts the Suicide Prevention Program to arrange for the caregiver to 
receive services.
    The Suicide Prevention Program at VAPIHCS will be in a position to 
do more for family members in the future their two new hires have 
increased the staffing from one Suicide Prevention Coordinator and one 
Program Support Assistant to two full-time clinicians (one Suicide 
Prevention Coordinator and one Suicide Prevention Case Manager) as well 
as a Suicide Prevention Peer Support Specialist.
Female Veterans
    Question 6. Female Veterans in Hawaii have told me that VA is not 
doing enough to assist female combat Veterans suffering from PTSD or 
TBI. What is VHA's overall approach to helping female Veterans facing 
mental health issues? Please provide details on the type of treatments 
available to female Veterans in Hawaii who have experienced sexual 
assault or trauma? Specifically, what do you identify as VA's 
shortcomings? What is VA's plan to address these shortcomings; and what 
is the timeframe for these changes to be implemented?
    Response. VA is enhancing facilities, training health care staff, 
and improving access to services to meet the current and future health 
care needs of women Veterans. More than 400,000 women Veterans are 
currently utilizing the VA health care system. Of these, over 40% use 
VHA mental health services.
    VHA offers a full continuum of mental health services to women 
Veterans including: outpatient assessment, evaluation, psychiatry, 
individual, group and family therapy; specialty services for conditions 
such as PTSD and substance use disorders; and inpatient and residential 
treatment options.
    VA has enacted universal screening programs for some of the most 
common mental health conditions, including those faced by women, such 
as depression, PTSD, alcohol use, and military sexual trauma (MST). 
These screening programs provide an opportunity to identify those 
individuals in need of mental health care and refer them to appropriate 
mental health services. Screening rates for depression, PTSD, and 
alcohol use are very high (96%-99%), exceed private sector rates, and 
do not significantly differ by gender.
    Evidence suggests that women Veterans may differ from men in the 
prevalence and expression of certain mental health disorders, and 
responses to treatment. VA policy requires that mental health services 
be provided in a manner that recognizes that gender-related issues can 
be important components of care. For example, all VHA facilities must 
ensure that every outpatient and residential program has an environment 
that can accommodate and support women with safety, privacy, dignity, 
and respect. Residential and inpatient programs must provide separate 
and secured sleeping and bathroom arrangements including, but not 
limited to, door locks and proximity to staff for women Veterans. All 
residential programs, including those in Hawaii, report compliance with 
these requirements.
    Finally, VHA has strong clinical training initiatives in place to 
ensure that mental health providers have the knowledge and skills to 
meet the unique treatment needs of the growing population of women 
Veterans accessing VHA services. These include didactic 
teleconferences, expert case consultation and a web-based training 
curriculum on women's mental health needs across the reproductive 
lifespan (e.g., psychiatric disorders during and after pregnancy). In 
addition, the Women's Mental Health Section of VHA Mental Health 
Services is currently developing a women's mental health mini-residency 
curriculum. This 3-day intensive training event is designed to provide 
VA mental health providers (up to 200 attendees) with the clinical 
knowledge and skills to provide gender-sensitive care to women 
Veterans. Participants will help to disseminate best practices for 
women Veterans' mental health care to providers and leadership at their 
local facilities and at the VISN level.
            Treatment available to female combat veterans in Hawaii 
                    suffering from PTSD or TBI
    All Veterans, men and women, newly enrolled into the VA Pacific 
Islands Healthcare System (VAPIHCS); are confidentially screened for 
PTSD, Military Sexual Trauma (MST), and TBI consistent with national 
clinical reminder guidelines. For those presenting first to mental 
health (MH), the screening is performed by a MH provider and Veterans 
are referred for services accordingly. For Veterans presenting first to 
primary care (PC), they are screened by trained PC providers. If 
requesting to speak with a MH provider, warm hand-offs within Primary 
Care to the Integrated Care Team are prioritized; if a warm hand-off is 
not readily available, a consult is placed and the Veteran is contacted 
by an MH provider.
    Female (and male) combat Veterans diagnosed with PTSD are offered 
outpatient evidence-based psychological treatments for PTSD through the 
Traumatic Stress recovery Program (TSRP), the outpatient PTSD team in 
VAPIHCS. Clinical services and groups offered include two primary 
evidence-based treatments: Prolonged Exposure Therapy (PE) and 
Cognitive Processing Therapy (CPT). Veterans are also given options for 
group-based treatments, including Unified Protocol for Transdiagnostic 
Treatment of Emotional Disorders, Dialectical Behavior Therapy, General 
Coping Skills, Anger Management, Cognitive Behavior Therapy for 
Insomnia, Mindfulness Drop-in Groups, and Seeking Safety. Additionally, 
Veterans are given the option of adjunctive pharmacological treatment 
(e.g., medication management), based on need and preference.
    Veterans living on the outer islands have access to MH providers 
including psychiatrists, social workers, addiction therapists and 
psychologists (depending upon the location of the Community Based 
Outpatient Clinic (CBOC)). CBOCs without a provider trained in offering 
an evidence-based psychotherapy may refer the Veteran for Telemental 
Health for Evidence Based Practice (EBP) for PTSD.
            Treatment available to female Veterans in Hawaii who have 
                    experienced sexual assault or trauma
    Military sexual trauma (MST) is the term used by VA to refer to 
sexual assault or repeated, threatening sexual harassment experienced 
during military service. Not all MST survivors have long-term 
difficulties, but some experience chronic physical and mental health 
problems, including PTSD, depression, and substance use disorders. 
Recognizing that many survivors of sexual trauma do not disclose their 
experiences unless asked directly, it is VA policy that all Veterans 
seen for health care are screened for experiences of MST. In fiscal 
year (FY) 2014, 523 or 27.5% of female Veterans seen for health care at 
VAPIHCS had reported a history of MST when screened by a VA health care 
provider.
    All VA treatment for physical and mental health conditions related 
to MST is provided free of charge. Service connection is not required, 
and Veterans may be able to receive free MST-related care even if they 
are not eligible for other VA services. VA offers a wide range of 
treatment services, and every VA health care system provides MST-
related care. Additionally, VA has long recognized that gender-specific 
issues are an important component of providing care to Veterans who 
experienced MST. Creating a treatment environment that respects and 
accommodates MST survivors' gender-related concerns is a top priority. 
For example, national VA policy strongly encourages all VA health care 
facilities to offer Veterans the choice of a same-sex or opposite-sex 
provider for MST-related treatment whenever possible.
    At VAPIHCS specifically, Veterans with PTSD secondary to sexual 
trauma are offered evidence-based psychological treatments for PTSD, 
including Prolonged Exposure Therapy and Cognitive Processing Therapy. 
These are the equivalent of what is offered for PTSD secondary to 
combat trauma, as they have been empirically validated in both 
populations. Veterans are also given options for group-based 
treatments, including Unified Protocol for Transdiagnostic Treatment of 
Emotional Disorders, Dialectical Behavior Therapy, General Coping 
Skills, Anger Management, Cognitive Behavior Therapy for Insomnia, 
Mindfulness Drop-in Groups, and Seeking Safety. Veterans are also given 
the option of pharmacological treatment (e.g., medication management), 
based on need and preference. If a female Veteran and the provider have 
attempted outpatient services and determined that a higher level of 
care is needed, a referral for residential PTSD treatment may be made. 
Veterans who have experienced sexual trauma but whose difficulties are 
other than PTSD (for example, primary difficulties of substance use, 
depression), are offered services within specialty clinics such as the 
Substance Abuse Treatment Program. Through these programs, Veterans are 
offered evidence-based individual and group psychotherapies and 
medication management, as desired. These services are not gender-
specific. Like every VA health care system, PIHCS has a designated MST 
Coordinator who serves as the local point person for MST-related issues 
and can help Veterans access VA services and programs.
    Among women Veterans who screen positive for MST in VA, rates of 
engagement in care and amount of care provided continue to increase 
every year. This is also true for women Veterans receiving care at 
VAPIHCS. In FY 2014, among women Veterans at VAPIHCS, 346 or 66.2% of 
women who screened positive for MST received outpatient care for either 
a mental or physical health condition related to MST. This is an 
increase of 25% from FY 2013, where 277 or 58.4% of women who screened 
positive for MST received MST-related outpatient care. These women 
Veterans had a total of 2,777 MST-related visits in FY 2014, which 
represents an increase of 31% (from 2,114 visits) from FY 2013.
            Challenges related to providing services, and strategies to 
                    address those challenges
    1) The waiting area in mental health may feel uncomfortable to some 
women Veterans because of the large majority of men present in this 
limited area of space.
    What's being done: Providers have been encouraged to develop 
arrangements with women Veterans that they see to meet them in areas 
which made them feel safer. For example, if a woman Veteran has 
endorsed discomfort in waiting in the usual waiting area, they may plan 
with their provider to wait outside on the back lanai, in an unoccupied 
group room adjacent to the waiting room, or on the building's second 
floor landing.
    The Traumatic Stress Recovery Program (TSRP) Orientation group now 
includes specific requests to male Veterans to behave courteously, 
whether in their language or behaviors, toward women in the waiting 
area--this applies to staff, Veterans, or family members. In addition, 
we are actively considering utilization of the Women's Health Clinic 
waiting room for use within mental health appointments.

    2) Women Veterans, while growing in number, still represent a small 
minority of the Veterans who utilize the MH programs. This makes it 
difficult to plan for groups and other women Veterans' activities. 
Previous attempts to expand the number of groups offered specifically 
to women Veterans (with no males present) have either resulted in a 
lack of referrals and/or very low numbers of patients in the groups. 
The insufficient number of group members as well as their lack of 
consistency in attending regularly tends to detract from group 
cohesiveness and effectiveness of intended treatment.
    What's being done: Currently, there is one weekly, ongoing group 
open for women referrals. This group utilizes a Unified Protocol (UP), 
which combines treatment elements from various Evidence-Based Therapy 
protocols. In addition, the Behavioral Health Interdisciplinary Program 
(BHIP) and MST teams jointly offer a Dialectical Behavior Therapy (DBT) 
group which is very useful for women Veterans with PTSD and other 
comorbid disorders. While open both to men and women Veterans, DBT 
provides assistance with emotional regulation and basic skill building 
needed in PTSD treatment. Women Veterans are eligible to participate in 
all other TSRP groups including both psychotherapeutic groups and 
psychoeducational groups, which provide instruction for specific 
problem areas commonly observed with PTSD, such as sleep hygiene, anger 
management, or couples.
    Referrals for PTSD-related services for women tend to comprise 
three different subsets of women: 1) Combat-related PTSD; 2) MST-
related PTSD; and 3) MST without PTSD. While group approaches are 
limited, women Veterans with combat related PTSD have ready access to 
individual therapy within the TSRP. Access to PTSD care within TSRP 
does not differ for men or women Veterans except in one respect: rather 
than routinely referring new consults to the TSRP Orientation group, 
where they are likely to be outnumbered by men, women Veterans may be 
offered the choice of attending an individual TSRP Orientation. This 
additional option for women was implemented in an attempt to avoid 
potential discomfort of the women in their first contact with the 
treatment team. Women Veterans with PTSD secondary to MST are primarily 
seen within the MST program which is housed within the TSRP. A TSRP 
staff member and a psychology resident take primary responsibility for 
such referrals although other TSRP team members may serve as providers. 
EBTs are considered for women Veterans in either of these two 
situations, although other treatment approaches are also available if 
the women Veterans are either not interested or not able to participate 
in an EBT. Other women Veterans with a history of MST, yet who may not 
meet criteria for PTSD, may be seen within the MST program, or 
depending on their presenting concerns and treatment needs may be 
referred to other providers within the larger MH program. All MH 
programs will develop an individualized treatment plan with the Veteran 
which may include medication management and/or other therapeutic 
approaches.

    3) Work, childcare or education limits availability for both group 
participation and individual therapy sessions
    What's being done: Often, women Veterans are unable to attend 
treatment sessions with optimal frequency. Attempts to accommodate 
their availability for scheduling include offering of irregular 
appointment times--until 6:00 pm on Tuesdays, 7:30-11:00 am on 
Saturdays, and beginning at 7:00 am on weekdays.
    Work is currently underway to initiate The Veterans Integration to 
Academic Leadership (VITAL) program, which will offer treatment 
services on college campuses. These additional VA sites of service are 
intended to increase convenience and ease of men and women Veterans in 
accessing care.
National Center for PTSD Pacific Islands Division
    Question 7. Recently, my office was informed that the National 
Center for PTSD has decided to cut a significant number of staff at its 
Pacific Islands Division in Hawaii by January 2015, effectively 
shutting down its operations. Please provide background and an 
explanation of this decision and describe VA's plan going forward for 
the Pacific Islands Division?
    Response. In response to a letter you sent to Secretary McDonald on 
November 26, 2014, asking for information about the status and future 
plans for the Pacific Islands Division of VA's National Center for 
PTSD, VA staff briefed two members of your staff by phone on 
December 19, 2014. Dr. Paula Schnurr, Executive Director of the 
National Center for PTSD (NCPTSD), led the briefing. She began the call 
by stating that the recent changes in staffing are voluntary 
separations and are not due to downsizing. The changes are expected to 
improve outcomes for Veterans with PTSD by allowing the Pacific Islands 
Division to recruit more qualified staff. She also stated that the 
changes would not affect clinical care in Hawaii or the region because 
NCPTSD is not a clinical program and does not deliver clinical 
services; also, the Center's clinical research programs have been 
retained despite the changes.
    Dr. Schnurr then provided a brief overview of the National Center 
for PTSD and a mission description of the Pacific Islands Division. 
NCPTSD is a 7-part consortium that is a Center of Excellence devoted to 
research and education on PTSD. The primary mission of the Pacific 
Islands Division in Honolulu is PTSD research and education in the 
areas of ethnocultural issues and telehealth. The Division was founded 
in 1994 when the Pacific Center for PTSD was disbanded. The Honolulu VA 
Medical Center incorporated the Center's clinical program and NCPTSD 
was asked to incorporate the research and education programs, creating 
a new NCPTSD division. The Pacific Islands Division has struggled since 
its inception to achieve its mission or function comparably to other 
NCPTSD Divisions. There has been extreme difficulty in hiring a 
permanent Director or qualified staff. There have been few projects on 
ethnocultural topics and low productivity. For example, in the 20 years 
that the Division has been in existence, staff have obtained only one 
funded research grant focused on ethnocultural issues.
    In order to help the Division, NCPTSD has enlisted the support of 
two experts on ethnocultural issues in PTSD, one through a telework 
agreement with the Minneapolis VA Medical Center and the other through 
an Interagency Personnel Agreement with the Department of Psychiatry at 
the University of Hawaii Medical School. Research on telehealth has 
been very successful, but the lead for that work has moved to the San 
Diego VA Medical Center. However, she is being retained on a part-time 
telework agreement to continue her telehealth research in the Division.
    Dr. Schnurr then described current staffing and plans for 
rebuilding the Division, beginning with the recruitment of a new 
Director after the current Director retired. That date, originally 
scheduled for May 2015, was pushed back to June 2015. Preparatory work 
to begin the search has been conducted and we anticipate posting the 
position in Summer 2015. A new .5 Administrative Officer and a 1.0 
Administrative Assistant have been hired. Dr. Schnurr and her staff 
meet with the staff of the Pacific Islands Division weekly and as 
needed to provide support and guidance.
Transition program
    Question 8. As mentioned in Dr. Kudler's testimony, providing the 
necessary resources to servicemembers who are transitioning from active 
duty to civilian life is crucial, especially for those who suffer from 
TBI or PTSD. According to the VA an important component to this goal is 
the inTransition program. Please provide a comprehensive update on the 
program as implemented in Hawaii, including numbers on how many 
servicemembers were enrolled and information on how the comprehensive 
care plan is working between DOD/VA providers.
    Response. VA provides comprehensive transition assistance and care 
management for wounded, ill and injured Servicemembers and Veterans who 
served in the military on or after September 11, 2001. Each VA Medical 
Center has a Transition and Care Management (TCM) team whose team 
members are highly experienced and specially trained in the needs of 
transitioning Servicemembers and new Veterans. These teams coordinate 
patient care activities and ensure that Servicemembers and Veterans are 
receiving patient-centered, integrated care and benefits.
    The inTransition program is a DOD program that offers specialized 
coaching and assistance to Servicemembers receiving mental health care 
who are relocating to another assignment, returning from deployment, 
transitioning from active duty to reserve, reserve to active duty, or 
preparing to leave military service. These telephonic coaches initiate 
contact and assist servicemembers regardless of where they are located 
across the world by connecting them to their new mental health 
provider, monitoring their progress and empowering them 24/7 by phone 
or email. The VA TCM team works with the InTransition coaches to ensure 
transitioning Servicemembers and Veterans are connected to VA mental 
health care, if needed, and confirm this connection has been 
established.
    The inTransition program is designed to enhance continuity of care 
for Servicemembers who are relocating within or across Departments and 
who are receiving on-going mental health care. The initiative is 
currently tracked as a key element of the VA/DOD Joint Strategic Plan. 
The inTransition program has opened 8,519 coaching cases since its 
inception in February 2010 through April 2015. The President's 
Veterans' Mental Health Executive Actions, announced in August 2014, 
mandate that DOD automatically enroll in that program all 
Servicemembers leaving the military who are receiving mental health 
care. Automatic enrollment went into effect in May 2015, and as a 
result the inTransition program opened 823 new coaching cases that 
month. DOD does not collect information by state or US territory, so we 
are not able to provide information about the number of servicemembers 
who have been enrolled in Hawaii.
    A Memorandum of Understanding (MOU) between Department of Veterans 
Affairs and Department of Defense for ``Interagency Complex Care 
Coordination Requirements for Servicemembers and Veterans'' was signed 
in July 2014. The MOU is a foundational document that establishes joint 
processes for complex care coordination as directed by the Joint 
Executive Committee and implemented by the VA/DOD Interagency Care 
Coordination Committee. The MOU establishes a requirement to address 
complex care coordination needs of Servicemembers and Veterans when 
both the severity of the wound, illness, or injury is expected to 
result in a prolonged recovery time and/or extensive rehabilitation 
needs call for close interdisciplinary team coordination to achieve 
optimal recovery.
Research on Service Dogs
    Question 9. What is the status of VA's research into the use of 
service dogs to treat Veterans with PTSD? What is the timeframe for its 
completion? In addition, if research shows the effectiveness of service 
dogs for persons with PTSD, will VA implement a service dog program for 
Veterans suffering from PTSD and TBI?
    Response. The study is intended to determine the efficacy of 
providing to service dogs to veterans with PTSD Phase 1 was the initial 
attempt to conduct the study. This consisted of one study site, Tampa 
VAMC, with Veterans in the Tampa, Florida area. Of the original Phase 1 
Veterans, those that have completed the study have chosen to keep their 
dogs, and VA has transferred ownership to them. Although the Phase 1 
study is not enrolling new Veterans, a few who were far into the 
process when the Tampa/Phase 1 study was suspended, were paired with 
service dogs once the Phase 2 multi-site study opened. The Tampa Phase 
I Veterans were at the threshold of pairing and had waited a long time. 
To do right by these Veterans, we made the pairings and those Veterans 
are completing the study protocol. Based upon lessons learned in the 
initial Phase 1 study, new safety features were added for both Veterans 
and dogs. These new safety features apply to all Veteran and dog 
pairings. Phase 2 will be conducted in Atlanta, Georgia, Iowa City, 
Iowa, and Portland, Oregon. Once completed, Veterans may choose to keep 
their assigned dog, free of charge, and VA will transfer ownership as 
indicated. If a Phase 2 Veteran elects not to keep an assigned dog or 
is unable to meet the responsibilities of dog ownership during or at 
the completion of the Phase 2 study, the specially trained dog will be 
placed with another patient or rehomed.
    As of July 2014, three contracts were awarded to provide dogs for 
the study with the following vendors:

     Canine Companions for Independence,
     Armed Forces Foundation (K2 Solutions), and
     Auburn Research and Technical Foundation (iK9).

    The results of the study will not be available until all Phase 1 
and Phase 2 data have been collected and analyzed (see future timeline 
in Section D below). At that time, the results will be shared with the 
National Academy of Sciences for their report preparation, as required 
by paragraph (e)(2) of section 1077.
    Estimated Timeline--This is a complex study and numerous scheduling 
uncertainties remain. Thus far, 49 Veterans have been consented into 
the Phase 2 study, 10 have been paired with a dog, and 35 are currently 
in the observation period prior to being paired.
    At the present time, VA estimates:

    -  By September 2016--If monthly recruiting goals are met, all 
Veterans will be recruited into the study.
    -  By October 2018--If monthly recruiting goals are met, all 
Veterans would complete the study this month, and data collection would 
be complete. Thereafter, the study data would be compiled and prepared 
for peer review and publication in scientific journals.

    Chairman Sanders. Now we are going to hear from our second 
panel. Let me welcome our second panel, and apologize for the 
length of our first panel. The good news is that there is so 
much interest in this issue, virtually every Member of this 
Committee was here today, because they are concerned about the 
issue.
    The bad news is that when every Member is here, it takes a 
long time to discuss and I apologize for keeping you waiting 
this long. So, let me introduce the panelists. First we will 
hear from two mothers who have personally experienced the grief 
of losing a child to combat, and we appreciate more than words 
can describe, your courage in coming here and your desire to 
prevent other families from experiencing the tragedies that you 
have experienced.
    So, we thank Susan Selke, whose son, Clay Hunt, a Marine 
combat veteran, took his life after returning from Afghanistan. 
Then we will hear from Valerie Pallotta of Vermont. Valerie's 
son Joshua, a Vermont National Guard combat veteran, also 
served in Afghanistan and took his own life only a few months 
ago.
    We will then hear from Master Sergeant Vincent Vanata, a 
participant in the Wounded Warrior Project's Combat Stress 
Recovery Program. We thank him very much for being here. We 
will then hear from Dr. Elspeth Ritchie, the Chief Clinical 
Officer of the District of Columbia's Department of Mental 
Health and a member of the Institute of Medicine's committee 
that produced the report, Treatment for Post- Traumatic Stress 
Disorder in Military and Veteran Populations. Dr. Ritchie, 
thank you for being here.
    And then we will hear from the Executive Director of Team 
Red, White and Blue, Blayne Smith. I would ask the clerk to 
turn off the clock for Mrs. Selke and Mrs. Pallotta. Do not 
worry about the time. You take as much time as you need to say 
whatever you want to say. We are extremely appreciative that 
you are here. Mrs. Selke, do you want to begin?

   STATEMENT OF SUSAN SELKE, MOTHER OF CLAY HUNT, A DECEASED 
                  MARINE CORPS COMBAT VETERAN

    Mrs. Selke. Thank you. Chairman Sanders, Ranking Member 
Burr, and distinguished Members of the Committee, thank you for 
the opportunity to speak with you today about this critically 
important topic of mental health care access at the VA, suicide 
among veterans, and especially about the story and experience 
of our son, Clay.
    My name is Susan Selke and I am accompanied here by my 
husband, Richard. I am here today as the mother of Clay Hunt, a 
Marine Corps combat veteran who died by suicide in March 2011 
at the age of 28.
    Clay enlisted in the Marine Corps in May 2005 and served in 
the infantry. In January 2007, Clay deployed to Iraq's Anbar 
Province, close to Fallujah. Shortly after arriving in Iraq, 
Clay was shot through the wrist by a sniper's bullet that 
barely missed his head. After he returned to Twenty Nine Palms 
in California to recuperate, Clay began experiencing many 
symptoms of post-traumatic stress, including panic attacks, and 
was diagnosed with PTS later that year.
    Following the recuperation from his gunshot wound, Clay 
attended and graduated from the Marine Corps Scout Sniper 
School in March 2008. A few weeks after graduation, Clay 
deployed again, this time to southern Afghanistan. Much like 
his experience during his deployment to Iraq, Clay witnessed 
and experienced the loss of several fellow Marines during his 
second deployment.
    Clay received a 30 percent disability rating from the VA 
for his PTSD. After discovering that his condition prevented 
him from maintaining a steady job, Clay appealed the 30 percent 
rating only to be met with significant bureaucratic barriers, 
including the VA losing his files. Eighteen months later, and 5 
weeks after his death, Clay's appeal finally went through and 
the VA rated Clay's PTSD 100 percent.
    Clay exclusively used the VA for his medical care after 
separating from the Marine Corps. Immediately after his 
separation Clay lived in the Los Angeles area and received care 
at the VA medical center there in LA. Clay constantly voiced 
concerns about the care he was receiving, both in terms of the 
challenges he faced with scheduling appointments as well as the 
treatment he was receiving for PTSD, which consisted primarily 
of medication.
    He received counseling only as far as brief discussions 
regarding whether the medication he was prescribed was working 
or not. If it was not, he would be given a new medication. Clay 
used to say, I am a guinea pig for drugs. They will put me on 
one thing, I will have side effects, and then they will put me 
on something else.
    In late 2010, Clay moved briefly to Grand Junction, 
Colorado, where he also used the VA there, and then finally 
home to Houston to be closer to our family. The Houston VA 
would not refill his prescriptions that he received from the 
Grand Junction VA because they said that prescriptions were not 
transferable and a new assessment would have to be done before 
his medications could be re-prescribed.
    Clay had only two appointments in January and February 
2011, and neither was with a psychiatrist. It was not until 
March 15th that Clay was finally able to see a psychiatrist at 
the Houston VA medical center. But after the appointment, Clay 
called me on his way home and said, Mom, I cannot go back 
there. The VA is way too stressful and not a place I can go. I 
will have to find a Vet Center or something.
    Just 2 weeks after his appointment with a psychiatrist at 
the Houston VA medical center, Clay took his own life.
    After Clay's death, I personally went to the Houston VA to 
retrieve his medical records, and I encountered an environment 
that was highly stressful. There were large crowds, no one was 
at the information desk, and I had to flag down a nurse to ask 
directions to the medical records area. I cannot imagine how 
anyone dealing with mental health injuries like PATIENTS could 
successfully access care in such a stressful setting without 
exacerbating their symptoms.
    Clay was consistently open about having Post Traumatic 
Stress and survivor's guilt, and he tried to help others coping 
with similar issues. He worked hard to move forward and found 
healing by helping people, including participating in 
humanitarian work in Haiti and Chile after devastating 
earthquakes.
    He also starred in a public service advertising campaign 
aimed at easing the transition for his fellow veterans, and he 
helped wounded warriors in long distance road biking events. 
Clay fought for veterans in the halls of Congress and 
participated in the Iraq and Afghanistan Veterans of America's 
Storm the Hill to advocate for legislation to improve the lives 
of veterans and their families.
    Clay's story details the urgency needed in addressing this 
issue. Despite his proactive and open approach to seeking care 
to address his injuries, the VA system did not adequately 
address his needs. Even today, we continue to hear about both 
individual and systemic failures by the VA to provide adequate 
care and address the needs of veterans.
    Not one more veteran should have to go through what Clay 
went through with the VA after returning home from war. Not one 
more parent should have to testify before a Congressional 
committee to compel the VA to fulfill its responsibilities to 
those who served and sacrificed.
    I understand that Senator Burr and Senator McCain have just 
introduced an updated and improved version of the Suicide 
Prevention for American Veterans Act, or SAV Act, that is 
similar to the House version of the bill, and have also named 
the bill after our son, Clay, like the House. We thank them for 
stepping up to try to get something meaningful done to address 
this issue.
    The reforms, evaluations, and programs directed by this 
legislation will be critical to helping the VA better serve and 
treat veterans suffering from mental injuries from war. Had the 
VA been doing these things all along, it very well may have 
saved Clay's life.
    We know that time is short in this Congress, but we hope 
that Majority Leader Reid will prioritize getting this done for 
our veterans before you all leave for the holidays.
    Mr. Chairman, Richard and I again appreciate the 
opportunity to share Clay's story and our recommendations for 
how we can help ensure the VA will uphold its responsibility to 
properly care for America's veterans. Thank you.
    [The prepared statement of Mrs. Selke follows:]
    Prepared Statement of Susan Selke, Mother of Veteran, Clay Selke
    Chairman Sanders, Ranking Member Burr, and Distinguished Members of 
the Committee, Thank you for the opportunity to speak with you today 
about this critically important topic of mental health care access at 
the VA, suicide among veterans, and especially about the story and 
experience of our son, Clay.
    My name is Susan Selke and I'm accompanied by my husband, Richard. 
I'm here today as the mother of Clay Hunt, a Marine Corps combat 
veteran who died by suicide in March 2011 at the age of 28.
    Clay enlisted in the Marine Corps in May 2005 and served in the 
infantry. In January 2007, Clay deployed to Iraq's Anbar Province, 
close to Fallujah. Shortly after arriving in Iraq, Clay was shot 
through the wrist by a sniper's bullet that barely missed his head. 
After he returned to Twenty Nine Palms in California to recuperate, 
Clay began experiencing many symptoms of post-traumatic stress, 
including panic attacks, and was diagnosed with PTS later that year.
    Following the recuperation from his gunshot wound, Clay attended 
and graduated from the Marine Corps Scout Sniper School in March 2008. 
A few weeks after graduation, Clay deployed again, this time to 
southern Afghanistan. Much like his experience during his deployment to 
Iraq, Clay witnessed and experienced the loss of several fellow Marines 
during his second deployment.
    Clay received a 30 percent disability rating from the VA for his 
PTS. After discovering that his condition prevented him from 
maintaining a steady job, Clay appealed the 30 percent rating only to 
be met with significant bureaucratic barriers, including the VA losing 
his files. Eighteen months later, and five weeks after his death, 
Clay's appeal finally went through and the VA rated Clay's PTS 100 
percent.
    Clay exclusively used the VA for his medical care after separating 
from the Marine Corps. Immediately after his separation Clay lived in 
the Los Angeles area and received care at the VA medical center there 
in LA. Clay constantly voiced concerns about the care he was receiving, 
both in terms of the challenges he faced with scheduling appointments 
as well as the treatment he received for his PTS, which consisted 
primarily of medication.
    He received counseling only as far as a brief discussion regarding 
whether the medication he was prescribed was working or not. If it was 
not, he would be given a new medication. Clay used to say, ``I'm a 
guinea pig for drugs. They'll put me on one thing, I'll have side 
effects, and then they put me on something else.''
    In late 2010, Clay moved briefly to Grand Junction, Colorado, where 
he also used the VA there, and then finally home to Houston to be 
closer to our family. The Houston VA would not refill prescriptions 
Clay had received from the Grand Junction VA because they said that 
prescriptions were not transferable and a new assessment would have to 
be done before his medications could be re-prescribed.
    Clay only had two appointments in January and February 2011, and 
neither was with a psychiatrist. It wasn't until March 15th that Clay 
was finally able to see a psychiatrist at the Houston VA medical 
center. But after the appointment, Clay called me on his way home and 
said, ``Mom, I can't go back there. The VA is way too stressful and not 
a place I can go. I'll have to find a Vet Center or something.''
    Just two weeks after his appointment with a psychiatrist at the 
Houston VA medical center, Clay took his own life.
    After Clay's death, I personally went to the Houston VA medical 
center to retrieve his medical records, and I encountered an 
environment that was highly stressful. There were large crowds, no one 
was at the information desk and I had to flag down a nurse to ask 
directions to the medical records area. I cannot imagine how anyone 
dealing with mental health injuries like PTS could successfully access 
care in such a stressful setting without exacerbating their symptoms.
    Clay was consistently open about having PTS and survivor's guilt, 
and he tried to help others coping with similar issues. He worked hard 
to move forward and found healing by helping people, including 
participating in humanitarian work in Haiti and Chile after devastating 
earthquakes.
    He also starred in a public service advertising campaign aimed at 
easing the transition for his fellow veterans, and he helped wounded 
warriors in long distance road biking events. Clay fought for veterans 
in the halls of Congress and participated in Iraq & Afghanistan 
Veterans of America's annual Storm the Hill to advocate for legislation 
to improve the lives of veterans and their families.
    Clay's story details the urgency needed in addressing this issue. 
Despite his proactive and open approach to seeking care to address his 
injuries, the VA system did not adequately address his needs. Even 
today, we continue to hear about both individual and systemic failures 
by the VA to provide adequate care and address the needs of veterans.
    Not one more veteran should have to go through what Clay went 
through with the VA after returning home from war. Not one more parent 
should have to testify before a congressional committee to compel the 
VA to fulfill its responsibilities to those who served and sacrificed.
    Senator Burr, I understand that you and Senator McCain just 
introduced an updated and improved version of the Suicide Prevention 
for America's Veterans Act, or SAV Act, that is similar to the House 
version of this bill, and have also named your bill after my son, Clay, 
like the House. Thank you for stepping up to try to get something 
meaningful done to address this issue.
    The reforms, evaluations, and programs directed by this legislation 
will be critical to helping the VA better serve and treat veterans 
suffering from mental injuries from war. Had the VA been doing these 
things all along, it very well may have saved Clay's life.
    We know that time is short in this Congress, but we hope that 
Majority Leader Reid will prioritize getting this done for our veterans 
before you all leave for the holidays.
    Mr. Chairman, Richard and I again appreciate the opportunity to 
share Clay's story and our recommendations for how we can help ensure 
the VA will uphold its responsibility to properly care for America's 
veterans.
    Thank you.

    Chairman Sanders. Thank you very much, Mrs. Selke.
    Mrs. Pallotta.

  STATEMENT OF VALERIE PALLOTTA, MOTHER OF JOSHUA PALLOTTA, A 
         DECEASED VERMONT NATIONAL GUARD COMBAT VETERAN

    Mrs. Pallotta. Good afternoon, Mr. Chairman, Committee 
Members. My name is Valerie Pallotta. If you could just bear 
with me, it has been only 6 weeks since my son ended his life. 
I felt it was very important to be here in front of you, so 
important--this is not in my testimony, but I do not fly and 
this is the third time I have flown in my life. That is how 
important I feel this is.
    People say our son Joshua was a hero. His last words on 
Facebook were, ``I see death in every thought. They taught me 
how to put this uniform on; I just cannot get it off.'' These 
are lyrics from ``A Soldier's Memoir'' by Mitch Rossell. Our 
son's last text to his father was a link to this song. He sent 
this song to all of his friends and his loved ones. He wanted 
everyone to have a better understanding of what he was going 
through. This song describes what PTSD was like for him. I 
encourage you to look it up online.
    At 3:37 on the morning of September 23, 2014, my husband 
and I were awakened by a loud knocking at the door. As I looked 
out the window to see who was knocking at that hour, I saw two 
Burlington police officers. My heart started to race as I knew 
it had to have something to do with my son. He has been 
arrested, was my first thought. My head started pounding and my 
ears started ringing. I felt like I was going to pass out. I 
opened the door and one of them said, Valerie Pallotta? Yes, I 
heard myself say through the ringing of my ears.
    Is your husband here? Yes. Gregory Pallotta? I vaguely 
heard my husband say yes. May we come in? May we come in? No, 
no, no, is what I wanted to say. I am very sorry to tell you 
that your son is deceased. No, this cannot be true. I thought 
he had been arrested. His PTSD was bound to get him arrested at 
some point. He had so much anger and so much pain. He is in 
jail. He is not dead. This cannot be.
    I knew in my gut that my son had ended his life before I 
even asked them the question. Our son was pronounced dead from 
a self-inflicted wound at 2:17 a.m., September 23, 2014, at the 
age of 25. His death certificate should have stated the cause 
of death as PTSD or traumatic brain injury, not from a self-
inflicted wound.
    Joshua Rodney Pallotta left behind a childless mother and 
father, countless friends and loved ones and his brothers in 
arms, whom he had trusted his life. The sleepless nights, the 
headaches, the physical pain, the anger, not eating, the 
nightmares; these are all signs of PTSD.
    Not only has PTSD taken the life of our son, but it has 
taken the life out of us. Our spirit left the day our son died. 
We lost our only child to something that should have been 
prevented. We used to have so much spirit. The light, that 
love, that spirit is gone and will be gone forever in us. We 
cry every single day.
    We are wracked with guilt every single day. My son asked me 
to borrow money and I thought the tough love route would be the 
way to go and I told him no. I had not talked to my son for 9 
months before he ended his life. It takes all that we have to 
get out of bed, after another night of not sleeping, because 
our minds race with thoughts of how we could have done things 
differently.
    Driving and doing everyday tasks are a challenge. We 
struggle to get through a shower without breaking down. We 
force ourselves to eat and to go to work. We just go through 
the motions.
    I forget which road I normally drive down. I have not 
cooked a meal since our son died. My husband went through a 
traffic light and did not know what color it was when he went 
through it. Just this past Saturday night, he was coming home 
and as he drove down our street it did not look familiar to 
him. He thought he was on the wrong street. He did not 
recognize it. We have been living on our street since 1998.
    This is our life. Our minds are at the funeral home, crying 
over our son's body as it lays cold. We are kissing him and 
hugging him and trying to wake ourselves up from this awful, 
horrible nightmare. Our minds are at the veterans' cemetery in 
Randolph, VT, the place our son was laid to rest, a place we 
have not yet been able to visit.
    Our minds are in Afghanistan wishing we could have been 
there to protect him, to shelter him from the pain he endured 
for 4 years. How can our son be dead from a self-inflicted 
wound, a wound caused by PTSD, invisible wounds nobody could 
ever heal, nobody could heal.
    Our son was deployed to a combat outpost in Afghanistan, 
COP Herrera. We had not realized how dangerous a location it 
was until August 22, 2010. I received a call from our son that 
day. Mom, I cannot talk. I am OK, but I cannot talk. You will 
find out soon enough. I just want you to know that I am OK. We 
are shutting down communications for now.
    Then I received a call from one of my friends, another mom 
from my son's unit. Two soldiers had been killed in action, 
Staff Sergeant Steven Deluzio from Connecticut, and Sergeant 
Tristan Southworth from Hardwick, VT. I only just found out 
that our son was standing right next to Tristan when he was 
killed. His brothers had to pull him away because he was in 
shock. He could not move. Our son's life, the lives of his 
brothers in arms and the lives of our families have changed 
forever. They changed forever that day.
    Our son was awarded the Army Commendation Medal with Valor 
that day for valorous achievement while assigned as a mortar 
assistant gunner for Third Platoon Alpha Company. His selfless 
service and dedication to duty were in keeping with the highest 
traditions of military service. Just 2 years later on August 
22, 2012, our son posted the following on his Facebook page:

          I do not know where to start. Southy and D were loved 
        by all people that knew them. It did not matter what 
        happened, those two would always have a smile on their 
        face. When they walked into a room, they had the power 
        to make everyone's day just a little better just with 
        their presence.
          They were truly the best people that I have ever 
        known, and they paid the ultimate sacrifice for the 
        freedom that so many people take for granted nowadays. 
        Not a day goes by that I do not replay this horrible 
        day in my head, always thinking what I could have done 
        differently, always thinking about why I am here and 
        these guys are not.
          Why am I so special to make it home. They had a hell 
        of a lot more going for them when they got back. Two 
        years ago today, the world lost two amazing men that 
        can never be replaced. Gone but never forgotten. Rest 
        in peace, Staff Sergeant Steven Deluzio and Sergeant 
        Tristan Southworth.

    He then wrote, ``Always wishing it was me instead of 
them.'' He lived with pain every single day, emotional, 
physical and spiritual. He saw their faces every single day. 
What our son and his brothers endured that year of deployment 
is something you would never wish on your worst enemy.
    The things they saw on deployment are burned into their 
heads; visuals that are not going away. Suicide bombers, seeing 
their limbs, scalps and a head just lying on the ground with 
the eyes open. A young boy who was doing yard work hit a 
Russian land mine. He was missing his face, an arm, and some 
fingers on one hand. This boy choked to death on his blood in a 
medevac. One of my son's best friends was his escort. A little 
girl who came in for treatment. She came in because her father 
and uncle had burned her feet so badly that she almost lost 
them. These are the visuals that our young men and women are 
seeing and coming home with.
    Our son was a casualty of war. Our son was a casualty of 
war just like Tristan and Steven. There were over 900 people at 
our son's funeral, 900 people. If you only knew. If that is the 
number of people affected by just one veteran's suicide, 
imagine the number affected by--now the number is 23 veteran 
suicides a day. Multiply 23 by 900.
    Our son lost his battle with PTSD and so did the rest of 
his family and friends. For the rest of our lives we will 
wonder if we could have done something different. Everyone 
always says, if there is anything you need, let me know. The 
only thing we need and wish for is to have our son back and we 
do not have the heart to tell them that that is not something 
they can give us.
    What we ask for now is an end to the bureaucracy in giving 
our veterans the resources they need so no other mom, dad, 
husband, wife, child, or loved one has to go through this 
tragedy. Thank you very much for this opportunity to speak.
    [The prepared statement of Mrs. Pallotta follows:]
              Prepared Statement of Valerie J. Pallotta, 
                  Mother of Veteran Joshua R. Pallotta
 Lyrics from the song ``A Soldier's Memoir'' by musician Mitch Rossell
Been home about six months now
But I still have my doubts
Well I'm not sure how I got here
Or how I'm gonna get out
My mama says I look the same
As I did before I left
But if she could see inside of me
It would scare her to death
I can still taste the powder
From the barrel of my gun
I can hear my sergeant screaming
``Run, soldier, run''
I can feel the backpack on my shoulders
God it weighed a ton
And I see death in every single thought
They taught me how to put that 
uniform on
I just can't get it off
Last Saturday they honored us
In a small parade downtown
And when they shot off those fireworks
I nearly hit the ground
And while they smiled and cheered 
for us
All I could do was stare
Cause part of me is here at home
And part of me is back there
I can still taste the powder
From the barrel of my gun
I can hear my sergeant screaming
``Run, soldier, run''
I can feel the backpack on my shoulders
God it weighed a ton
And I see death in every single thought
They taught me how to put that 
uniform on
I just can't get it off
Yeah there's no end in sight
Cause even though I'm home now
I'm still fighting for my life
I can still taste the powder
From the barrel of my gun
I can hear my sergeant screaming
``Run, soldier, run''
I can feel the backpack on my shoulders
God it weighed a ton
And I see death in every single thought
They taught me how to put that 
uniform on
I just can't get it off
Well the devil's won some battles
And he may win some more
But don't he know the American soldier
Will always win the war

    Good Morning Mr. Chairman, Ranking Member Burr and Members of the 
Committee. My name is Valerie Pallotta. It's been only eight weeks 
since we lost our son.
    The words above are lyrics to ``A Soldier's Memoir'' by musician 
Mitch Rossell. Our son Joshua's last text to his father was a link to 
this song. His last post on Facebook was ``I see death in every 
thought. They taught me how to put this uniform on; I just can't get it 
off.'' He sent this song to all of his friends and his loved ones. He 
wanted everyone to have a better understanding of what he was going 
through; what PTSD was doing to him, had done to him.
    25 years, five months and 20 days. That is the amount of time we 
had our son. In reality, it was 21 years, four months and one day 
because our son never really came home from Afghanistan.
    At 3:37 on the morning of September 23, 2014, my husband and I were 
awakened by a loud knocking at the door. As I looked out the window to 
see who was knocking at that hour, I saw two Burlington Police 
officers. My heart started to race as I knew it had to have something 
to do with Josh. `He's been arrested' was my first thought. My head 
started pounding and my ears started ringing. I felt like I was going 
to pass out. I opened the door and one of them said: ``Valerie 
Pallotta?''
    ``Yes.'' I heard myself say through the ringing of my ears. I tried 
to stop my heart from pounding so hard. I tried to stop shaking.
    ``Is your husband here?''
    ``Yes.''
    ``Gregory Pallotta?''
    ``Yes,'' I vaguely heard my husband answer.
    ``May we come in?'' `NO, NO, NO' I wanted to say. I was trying to 
stop the yelling in my head. `NO'.
    ``I'm very sorry to tell you that your son is deceased.''
    `NO! This can't be true. I thought he had been arrested. His PTSD 
was bound to get him arrested at some point. He had so much anger. So 
much pain. He's in jail. He's not dead. This can't be.'
    ``Did he kill himself?'' I knew in my gut that our son had ended 
his life before I asked the question.
    ``I'm afraid so.''
    `NO, NO, NO! This isn't happening. Please let me wake up from this 
nightmare and have everything be ok. Please.'

    We are still waiting to wake up. We are still waiting for this to 
be some cruel joke.
    Our son was pronounced dead from a self-inflicted wound at 2:17 AM, 
September 23, 2014, at the age of 25. His death certificate should have 
stated the cause of death as PTSD/TBI. Not from a self-inflicted wound.
    Joshua Rodney Pallotta not only left a childless mother and father, 
he left his grandparents, uncles, aunts, great uncles, great aunts, 
cousins, countless friends, former classmates, teachers, co-workers, 
and neighbors and just as importantly his brothers-in-arms with whom he 
had trusted his life.
    The sleepless nights, the headaches, the physical pain, the anger, 
not eating, nightmares; these are all signs of PTSD. Well, I'm sorry to 
say that these are also the effects of grief. Not only has PTSD taken 
the life of our son but it has taken the life out of us. Our spirit 
died the day our son died. We lost our only child that day to something 
that should have been prevented. We used to have so much spirit. The 
light, that love, that spirit is gone and will be gone forever in us. 
We hate this life; this life we have without our son. We cry 
Every.Single.Day. We are wracked with guilt Every.Single.Day. It takes 
all that we have to get out of bed, after another night of not 
sleeping, because our minds race with thoughts of how we could have 
done things differently. How we could have saved our son.
    Driving and doing everyday tasks is a challenge. We struggle to get 
through a shower without breaking down. We force ourselves to eat and 
go to work. We forget which roads we normally drive down. I haven't 
cooked a meal since our son died. My husband told me he went through a 
traffic light and didn't know what color it was when he went through. 
Just this past Saturday night, he was coming home and as he drove down 
our street it didn't look familiar. He thought he was on the wrong 
street. He didn't recognize it. We have been living on the same street 
since 1998.
    This is our life. This is our minds. Where are our minds? Our minds 
are at the funeral home less than two months ago; crying over our son's 
body as it lays cold. We are kissing him and hugging him and trying to 
wake ourselves and him up from this awful, horrible nightmare. Our 
minds are at the Veterans' cemetery in Randolph Vermont, the place our 
son was laid to rest by his brothers-in-arms; a place we haven't yet 
been able to visit because it is too painful. Our minds are in 
Afghanistan wishing we could have been there to protect him; to shelter 
him from the pain he was about to endure for the rest of his short 
life. This can't be true. I have been fighting for Veterans for almost 
5 years now! How can this be OUR son lying there dead from a self-
inflicted wound, a wound caused by PTSD, invisible wounds he couldn't 
heal. We couldn't heal.
    I'll never forget the day in 2009 when Josh came home and said: 
``Mom, I'm joining the National Guard and you can't stop me.'' After I 
picked my jaw up off the floor, I said: ``You know you're going to 
Afghanistan don't you?'' He said: ``Mom, that's why I'm joining. I want 
to protect my Country.'' I had so many emotions that day; pride, fear, 
love and gratitude for this selfless act our son felt he needed to do. 
After he took the Armed Services Vocational Aptitude Battery (ASVAB), 
the test that measures your aptitude in eight areas, he was told he 
scored high enough to choose whatever branch of service through the 
Guard he wanted. He chose Infantry. My heart sank. He was going to the 
front lines; the most dangerous of all places in war.
    I was filled with a rollercoaster of emotions. My baby, our only 
child was going off to war. I had to do something. I had to focus on 
what we could do to support our boys. How can we help him when he's at 
war with some of the most evil people on the planet? He was 20 years 
old. I was overcome with an unlimited drive and motivation to start 
something to give back, to support our boys, our men and women fighting 
for our Country. Somehow I guess I believed it was a way to still be 
there for him. If we could find a way to support our Troops and 
Veterans, indirectly we'd be supporting our Alpha Company boys, my boy. 
I did a lot of research early in 2009. When I came across Blue Star 
Mothers of America , I knew immediately that was the organization we 
needed to start in Vermont. The most intriguing aspect to me was that 
we could keep almost all of the money we raised in Vermont to support 
our Vermont Troops and Veterans. I brought the information to a Parent 
Network meeting, obtained the 5 signatures required to charter and was 
installed as Chapter President for the first Vermont Chapter of Blue 
Star Mothers of America.
    In June 2010, while our son was deployed, my position at the 
University of Vermont was eliminated. My supervisor knew that my son 
was in Afghanistan serving our country. Didn't she know that this job 
kept my mind off what was happening over there? I threw myself into our 
Blue Star Mothers chapter's work and in addition to that I started 
volunteering for Family Programs at Camp Johnson in Colchester Vermont. 
I spent hours working with the Director and his staff, trying to 
support our Veterans but in particular our young, single Soldiers. I 
supported the Yellow Ribbon program for other Units who were deploying, 
family members of Soldiers who were already deployed and some who were 
coming home. I thought we had it figured out. We were going to make a 
difference. We were going to help our boys. Or so I thought.
    We tried to send care packages to our boys. There were less than 
100 of them at our son's combat out post, COP Herrera. They were in 
such a dangerous and remote location in Rowqian Afghanistan that Josh 
told me not to bother to send packages, by the time they got them they 
would be home. We hadn't realized how dangerous a location it was until 
August 22, 2010. That day, I received a call from my son. ``Mom, I'm ok 
but I can't talk. You'll find out soon enough. I just want you to know 
that I'm ok. We're shutting down communications for now.'' Then I 
received the call from my friend, another Mom from my son's unit, two 
of the Soldiers who were with our boys had been killed; SSG Steven 
DeLuzio and SGT Tristan Southworth.
    Our son was awarded the Army Commendation Medal with ``Valor'' that 
day, 22 August 2010; for valorous achievement while assigned as a 
mortar assistant gunner for 3rd Platoon, Alpha Company. ``PFC 
Pallotta's actions against enemy combatants and ability as a mortar 
assistant gunner during combat operations contributed to the successful 
defeat of an enemy ambush. His selfless service and dedication to duty 
are in keeping with the highest traditions of military service and 
reflect distinct credit upon himself, 3rd Battalion, 172 Infantry 
(Mountain), Task Force Rakkasan and the United States Army.''
    The full narrative of the day that forever changed our son's life 
reads as follows:

          ``Private First Class Joshua R. Pallotta, United States Army, 
        heroically distinguished himself by exceptionally valorous 
        conduct in the face of enemy of the United States as a 
        Mortarman, Company A, 3d Battalion, 172d Infantry Regiment 
        (Mountain), COP Herrera, Paktya, Afghanistan on 22 August 2010, 
        during Operation Enduring Freedom. At approximately 1145 hours 
        on 22 August, PFC Pallotta's platoon was ambushed near 
        Mullafatee village, Paktya Province, killing one U.S. Soldier, 
        an Afghan Border Policeman and wounding two other ABP. The 
        mortar team of PFC Pallotta and SPC Gubic, moved to cover the 
        evacuation of the casualties. When the platoon began the 
        evacuation of the casualties, they were attacked a second time 
        and another U.S. Soldier was killed and one wounded. The 
        platoon was taking fire from a river bed 300 meters away and a 
        mountaintop roughly 500 meters away being engaged by at least 
        three enemy machine gun teams and two rocket propelled grenade 
        teams.
          ``PFC Pallotta, servings as the Assistant Gunner for the 
        mortar team, engaged targets with his M4 rifle until he was 
        told to move up into a position to engage the enemy with the 
        60MM mortar. With utter disregard for his own safety, PFC 
        Pallotta moved into the open and loaded rounds into the tube 
        for the mortar team gunner, SPC Gubic. PFC Pallotta continued 
        to prep and load rounds into the tube so his gunner could 
        engage targets, all the while taking enemy fire with rounds 
        landing next to and in front of their position. PFC Pallotta 
        called out targets for his gunner and assisted with ranging the 
        targets and calling out the most dangerous threats. PFC 
        Pallotta helped direct the mortar gunner in eliminating a 
        machine gun team, an RPG team, and dispersing a squad sized 
        element of dismounted troops in the river bed. The platoon was 
        then able to break contact and move down the hill toward the 
        Casualty Collection Point. PFC Pallotta proceeded to pull rear 
        security taking cover behind a small berm, continuing to engage 
        targets with his M4 while the element collected the casualties. 
        As the casualties were being moved downhill, PFC Pallotta broke 
        cover and ran to a litter and assisted with moving the casualty 
        to a secure casualty collection site.
          ``The platoon came under fire again while moving the 
        casualties from heavy machine gun fire and more RPG's. PFC 
        Pallotta again exposed himself to enemy fire in order to engage 
        targets with his rifle. This directly allowed for the litter 
        teams to move the casualties to the CCP. PFC Pallotta continued 
        to provide covering fire as the rest of the element moved to 
        the CCP, making himself one of the last to enter the safety of 
        the building serving as the CCP. Once inside the CCP, PFC 
        Pallotta moved to a position where he could provide security 
        for the flank of the element.
          ``PFC Pallotta's actions that day demonstrated bravery and 
        ability to act under fire and he greatly helped this platoon 
        break contact with the enemy to evacuate the wounded and 
        killed. PFC Pallotta's bravery and ability to act under fire is 
        without a doubt inspiring and upholds the finest traditions of 
        the Task Force Avalanche, 3rd Battalion, 172d Infantry 
        (Mountain), Task Force Rakkasan, and the United States Army.``

    Two years later to the day that our son's life, the lives of his 
brothers-in-arms and the lives of our families changed forever, our son 
posted the following on his Facebook page:

          ``I don't know where to start * * * Southy and D were loved 
        by all people that knew them. It didn't matter what happened, 
        those two would always have a smile on their face. When they 
        walked into a room, they had the power to make everyone's day 
        just a little better just with their presence. They were truly 
        the best people that I have ever known, and they paid the 
        ultimate sacrifice for the freedom that so many people take for 
        granted nowadays. Not a day goes by that I don't replay this 
        horrible day in my head * * * always thinking what I could have 
        done differently, always thinking about why I am here and these 
        two guys aren't. Why am I so special to make it home, they had 
        a hell of a lot more going for them when they got back * * * 2 
        years ago today, the world lost two amazing men that can never 
        be replaced. Gone but never forgotten. R.I.P SSG Steven DeLuzio 
        and SGT Tristan Southworth, KIA August 22nd, 2010. Rowqian 
        village, Paktya province, Afghanistan.

    He then wrote: ``Always wishing it was me instead of them.''

    He lived with pain every single day; emotional, physical and 
spiritual pain. He saw their faces every day. What our son and his 
brothers endured that year of deployment is something you would never 
wish on your worst enemy. The things they saw on deployment are burned 
into their heads; visuals that aren't going away. Suicide bombers, 
seeing their limbs, scalps and a head just lying on the ground with 
eyes open. A young boy who was doing yard work hit a Russian landmine 
and was missing his face, an arm, some fingers on the other hand * * * 
this boy choked to death on his blood in a med evac. One of our son's 
best friends was his escort. An afghan worker who filled their fuel 
tanks went up in flames because of static electricity; a little girl 
came in for treatment because her father and uncle had burned her feet 
so badly that she almost lost them.
    Our son was a casualty of war just like Tristan and Steven.
    I asked our son's brothers-in-arms to share their thoughts and 
frustrations so that I could share them in this testimony. One of them 
said he feels like heroine and opiate addiction takes priority, 
especially in Vermont. From his experiences with PTSD and TBI he feels 
like he's slowly deteriorating. He sleeps three hours a night if lucky. 
He hasn't slept in the same bed with his wife since returning home in 
2010. He's restless and has night terrors just about every night. He 
replays events from deployment and tries to figure out ways for them to 
save the men they lost. He's easily distracted at work by loud noises 
and hammering which causes him to leave his work area to let his heart 
slow down. He goes through this every single day. He and our son talked 
things out many times and kept each other going. They agreed to fight 
this ongoing battle together. Josh's unit had a pact, to fight this 
together. Our son's buddy was going to end his life a little over two 
months ago because ``I am just tired of the fight, the struggles, 
marriage issues, sleepless nights * * *'' The only reason he said he is 
here today to share his feelings is because of his 4 year old German 
shepherd and peer counseling with our son. Our son lost his fight. Now 
that our son is gone, how will his friends keep fighting?
    There is a strong feeling among Veterans that the counselors who 
work at the VA are only there to get a paycheck; they could care less 
about what is going on in the Veteran's mind or in their life. Many 
addressed the lack of compassionate counselors at the VA, counselors 
who spent time during their visits checking their watches. They are 
frustrated by lengthy intakes with no follow-up appointments and the 
over prescribing of medications. One said: ``What we as Veterans need 
is someone to talk to who can share some of the same experiences from 
past deployments or a counselor who has been in the military before and 
doesn't just feed us medication to mask our depression, anxiety, PTSD 
or anything else.'' Another said the therapist had to look through her 
notes to remember his name. The counselors don't relate to their 
situations. They act like it is an inconvenience and waste of time 
talking to the Veterans. They act like our Veterans are crazy and give 
them medications to mask their problems and make them feel like 
zombies.
    Some of the Veterans in our son's unit who admitted to having 
issues after deployment were sent to a Warrior Transition Unit (WTU) at 
Fort Drum, NY before coming home. They were isolated in the back of the 
barracks with no transportation and in the middle of nowhere. Why would 
you isolate a Veteran who admitted to struggling with PTSD or other 
issues? They lost cohesion. They lost unity. One Veteran told me he 
never heard from his Unit while at the WTU until they heard he was 
going to be discharged. He was then sent a letter with his next Drill 
dates. Our son told us he didn't admit to having issues when they were 
coming home because he just wanted to get home and see his family and 
friends.
    The process for Soldier Readiness Checks (SRC) that happens during 
Drill weekends needs to change. Veterans told me if you admit on the 
questionnaire that you are having an issue you are pulled out of the 
line and moved into another area. They feel exiled; singled out. The 
questionnaires at SRC and the VA are not accurate tools of assessment. 
Some Veterans aren't truthful when answering the questionnaires so this 
data being collected is not accurate. This is a broken system. Instead 
of singling out those who need help, treat them all as if they need 
help.
    I asked our son's brothers-in-arms how many have attempted or 
thought about suicide. 60% had attempted and 100% had thought about it. 
This is a problem. We're still talking about the same issues we've been 
talking about for years and nothing is getting better. It's getting 
worse.
    Everybody always asked: ``How's Josh?'' It was the same answer from 
me. ``Not good.'' It always ended there. Nobody asked: ``What can we do 
to help?'' Nobody followed up with him. His Outreach caseworker gave up 
on him. He told me he couldn't waste his time if Josh didn't want the 
help. Josh was not receptive to his visits so the caseworker gave up. 
His caseload was too high for him to keep spending time trying to help 
Josh if Josh wasn't receptive to him. He had other Veterans he needed 
to help, Veterans who wanted the help. Josh wanted the help; he just 
didn't know what he needed. Didn't his caseworker recognize this was 
the PTSD? Maybe he should have been assigned to another caseworker. 
Maybe his caseworker should have pushed our son more and not given up 
on him. He was a 21 year old male. The system is a broken system. There 
have to be checks and balances. There have to be more caseworkers in 
Veterans Outreach and Veteran Service Organizations. Josh fell through 
the cracks after being medically discharged. Nobody followed up with 
him. The signs were there. Our son's 4 year relationship with his 
girlfriend ended, he was in chronic pain and a job he finally found, 
that he liked, was ending due to the company closing. He felt like he 
was always taking one step forward and two steps back.
    Many administrators say that the resources are out there but the 
Veterans have to come to us. Despite this, many of our Veterans are 
still afraid to ask for help because of their pride. They are afraid to 
talk about feelings. They are afraid of repercussions for seeking help. 
They are asking for Vet to Vet counseling. They need to be heard. 
Rather than letting Veterans who served our Nation become ticking time 
bombs, listen to them. Give them what they are asking for.
    On February 9th, 2013, I attended via telephone, Senator Sanders 
Veterans' Advisory Council meeting. I raised the question of how our 
Soldiers, especially our single, younger Soldiers and Veterans would be 
supported. On March 20, 2013, this Senate Committee on Veterans' 
Affairs heard testimony regarding the same issues being addressed 
today. Instead of 22 Veterans committing suicide every day, that number 
has increased to 23 a day. Why are things getting worse as opposed to 
getting better? It's time for action. No more research. No more 
talking. Our Veterans deserve better. Our son deserved better.
    It is not just our Veterans who are affected by PTSD and Veteran 
suicide. The families and our community at large are affected. There is 
an increase in illness as our grief manifests itself physically and 
mentally. We lose days at work or at school as we grieve. We need to 
prevent this before another family goes through this tragedy.
    If you want to know how mental health and Veterans suicide affects 
Veterans and their families? This is how: broken relationships, debt, 
self-medicating due to poor services and a Fallen Hero by his or her 
own hand, brokenhearted family members and loved ones who will live 
with the guilt for the rest of their lives, wondering if they could 
have done something different, if they could have said one thing 
different that would have made a difference.
    We have lost our son forever. Our son lost his battle with PTSD and 
so did his family and friends. For the rest of our lives we will wonder 
if we could have done something different.
    There were over 900 people at our son's funeral. This number does 
not take into account the number of loved ones who weren't able to 
attend his funeral. If roughly 900 is the number of people affected by 
just our son's suicide, can you imagine the number of people affected 
by 23 Veteran suicides a day?
    As I close my testimony, I ask you, what would you do if you saw 
your loved ones struggling so much? What would you do if that was your 
child lying there * * * lifeless * * * because he or she could not take 
this fight any longer? Our son will never get married, never have 
children. We will never have grandchildren. Our only hope and prayer is 
that somehow, someway his death will be the catalyst to finally be the 
change to improve care for our Veterans.
    Everyone always says, if there is anything you need, let me know. 
The only thing we need and wish for is to have our son back and we 
don't have the heart to tell them that is not something they can give 
us.
    What we ask for now, is an end to the bureaucracy in getting our 
Veterans the benefits, resources and support they deserve so that our 
Veterans only focus can be on healing themselves and their families.

    My husband and I thank you for this opportunity, Mr. Chairman.

    Chairman Sanders. Thank you very much, Mrs. Pallotta.
    Sergeant Vanata.

 STATEMENT OF VINCENT VANATA, MSGT, USMC (RET.), COMBAT STRESS 
           RECOVERY PROGRAM, WOUNDED WARRIOR PROJECT

    Mr. Vanata. Chairman Sanders, Ranking Member Burr, and 
Members of the Committee, thank you for the opportunity to 
speak to you today regarding mental health care and suicide 
prevention. I proudly served in the U.S. Marine Corps for 22 
years, including 8 years overseas and a combat tour in Iraq.
    My wife Jona also served in the Marines for 4 years and we 
both have assisted other veterans and their families who are 
struggling to receive effective mental health care in rural 
Wyoming. We understand deeply the challenges of reintegration 
for those with combat-related mental health issues, both as 
mentors for many other warriors and families, and from our own 
difficult journey.
    In my written statement, I talked about the struggles we 
have had transitioning from active duty to civilian life and 
the challenges of accessing mental health care in rural 
Wyoming. But I want to focus my oral statement on a program 
through the Wounded Warrior Project's Combat Stress Recovery 
Program, called Project Odyssey.
    Project Odyssey brings veterans together with other combat 
veterans on outdoor rehabilitative retreats that promote 
healing. For us, it worked. For many warriors, like Jona and I, 
such peer-connection is often the first step toward engagement 
in treatment. The experiences I gained from Project Odyssey 
helped me work through challenges related to my combat stress 
and PTSD and improved my mental attitudes and outlook while 
encouraging me to build new skills, connect with peers, and 
find support.
    I have lost three fellow warriors, three friends, all to 
suicide this year. Two of these men survived combat without any 
physical wounds. One of them saved lives on the battlefield as 
a Navy corpsman, probably the bravest man that I have even 
known.
    Still, no one knows why they took their own lives. There 
were no signals, no warnings. All three were receiving mental 
health treatment through the VA. As to whether it was 
satisfactory treatment, I am not sure and I am not placing 
blame on the mental health professionals or on the prescribed 
medications, nor am I placing any blame upon these warriors for 
taking their own lives. The fact remains they are dead and any 
one of their deaths may have been preventable.
    When I returned home from Iraq, we were told to take some 
time off and decompress. We received no guidance or direction 
about what decompressing meant. In my case, I took some leave 
and traveled home to Cody to be with my family. I went from a 
combat zone to Cody, WY, in 3 days.
    As I walked down Main Street the next day with my two 
children holding my hands, I heard gunshots. I put each child 
under my arm and I ran for cover with them. My daughter yelled, 
``It is OK, it is OK, Daddy. It is only the gunfighters.'' The 
gunfighters put on a show every day for the tourists in town. 
As I looked around, I saw people on the street looking at me as 
if I had done something wrong.
    When I returned to Twenty Nine Palms of California and 
processed out of the Marine Corps, I received no counseling, no 
guidance, nothing to consider about the precautions of 
returning from combat and transitioning back to civilian life.
    I had received the required transition assistance program, 
or TAP training as they call it, before my deployment. But it 
did not give me any critical information on returning to 
civilian life after a combat deployment. Within 24 hours I was 
back in Anytown, USA, just another retired Marine.
    I struggled on my own for years until in 2012, I reached 
out to the Wounded Warrior Project at the urging of the mother 
of a soldier I know. She told me Wounded Warrior Project was in 
tune with post-9/11 veterans and I should give it a try. I 
contacted Wounded Warrior Project and seamlessly was brought 
aboard as an alumnus.
    In the summer of 2012, I attended a Project Odyssey retreat 
in Telluride, CO. There, I was able to connect with 15 other 
warriors and, for the first time, realized I was not alone. 
Interacting with these warriors, who were experiencing the same 
feelings I was, was such a breath of relief--something that no 
medication could ever provide.
    Since then I have been active with Wounded Warrior Project 
and have attended many different events. These events provided 
me with the opportunities to forge lifelong friendships with 
other veterans I would have never met otherwise. It is through 
these events and friendships that I have been able to regain a 
sense of honor and empowerment.
    Me and my wife's experiences with Project Odyssey and as 
peer mentors illustrate how important peer support is in 
assisting veterans and their families. Whether we are engaging 
with a veteran and helping them to see that he is not alone, or 
encouraging him to seek treatment, it is a proven method of 
assisting veterans and their family members in healing from the 
wounds of war.
    Thank you again for the opportunity to speak with you today 
about mental health care and I am also happy to answer any 
questions that you might have.
    [The prepared statement of Mr. Vanata follows:]
   Prepared Statement of Vincent Vanata, Master Sergeant USMC (Ret.) 
                            and Jona Vanata
    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee: We are honored to have the opportunity to speak to you today 
regarding mental health care and suicide prevention.
    I proudly served in the United States Marines for 22 years, 
including 8 years overseas and a combat tour in Iraq. My wife Jona also 
served in the Marines for 4 years and we both have participated in 
Wounded Warrior Project's (WWP) Project Odyssey program and work as 
peer mentors with the organization, assisting other veterans and their 
families who are struggling to receive effective mental health care in 
rural Wyoming. We understand deeply the challenges of reintegration for 
those with combat-related mental health issues, both as mentors for 
many other warriors and families, and from our own difficult journey. 
Project Odyssey, part of WWP's Combat Stress Recovery Program, brings 
warriors together with other combat veterans on outdoor rehabilitative 
retreats that promote healing. For many warriors, such peer-connection 
is often the first step toward engagement in treatment. The experiences 
I gained from Project Odyssey helped me work through challenges related 
to my combat stress and PTSD and improved my mental attitudes and 
outlook while encouraging me to build new skills, connect with peers, 
and find support.
                     a warrior's road to recovery--
                          vinny's perspective
    I've been retired from the Marine Corps for 11 years. When I 
retired, I had just returned from deployment. I spent 2 weeks 
``reintegrating'' and then joined our family in rural Cody, Wyoming. 
The closest base to us is located 400 miles away in Cheyenne, Wyoming.
    I look back upon my career as a great one. Each day, we Marines 
woke up and faced the reality that we could be going into harm's way. 
We viewed the world as an inherently dangerous place and our military 
was the first line of defense to preserve our way of life. We accepted 
the dangers associated with live fire training, operating aircraft, 
tanks, etc. We were able to mitigate those dangers with prudent safety 
practices, good training, and accepted risk management.
    But when we went to combat the inherent dangers increased and the 
mitigation decreased. I believe that anyone who goes into harm's way 
and experiences combat comes back a different person. It is not like a 
video game. People are actually trying to kill you. You don't get to 
press the reset button. Yet, the unit I was with only lost one man 
throughout phases one and two of Operation Iraqi Freedom.
    Flash forward to 2014, I've lost three fellow warriors to suicide. 
Two of these men survived combat without any physical wounds, one of 
them saved lives on the battlefield as a Navy corpsman. Still, no one 
knows why they took their own lives. There were no signals or warnings. 
All three were receiving mental health treatment through the VA. As to 
whether it was satisfactory treatment, I'm not sure. I am not placing 
blame on the mental health professionals or on the prescribed 
medications, nor am I placing any blame upon these warriors for taking 
their own lives. The fact remains they are dead and any one of their 
deaths may have been preventable.
    When I returned to CONUS, we were told to take some time off and 
decompress. We received no guidance or direction about what 
decompressing meant. In my case, I took some leave and travelled home 
to Cody to be with my family. I went from a combat zone to Cody, 
Wyoming in three days. As I walked down Main Street the next day, with 
my two children holding my hands, I heard nearby gunshots. I put each 
child under my arms as I ran for cover. My daughter yelled, ``It's OK, 
it's only the gunfighters'' (the gunfighters are a group of actors who 
put on shows for tourists each day in the downtown area). As I looked 
around, I saw the people on the street looking at me as if I had done 
something wrong.
    Shortly thereafter, I returned to 29 Palms, CA and processed out of 
the Marine Corps. I received no counseling, no guidance, nothing to 
consider about the precautions of returning from combat and 
transitioning back to civilian life. I had received the required 
transition assistance program training before my deployment. But even 
if I had the training after I returned, it still did not give me any 
critical information on returning to civilian life after a combat 
deployment. Within 24 hours I was back in Anytown, USA, a retired 
Marine.
    I did what was expected and eventually found a job in law 
enforcement as a peace officer. When I took the required psychiatric 
evaluation for employment I was able to pass, but the doctor commented 
that I was ``guarded.'' He stated this was not atypical for a person 
who had recently been in combat. As time went on I was exposed to 
scenes in civilian law enforcement not very different from the military 
or combat. I witnessed traumatic car wrecks where people were maimed, 
saw dead bodies. The hypervigilance, distrust, and violence that 
surrounded me exacerbated all the feelings I had since returning from 
my deployment. In 2004, at the urging of my wife, I sought treatment 
from the Veterans Administration to explore the issues I was 
experiencing. Quite frankly, I thought I was fine--it was everyone else 
who had issues.
    The nearest VA hospital to us is 120 miles away. However, there is 
a contracted civilian community based outpatient clinic (CBOC) 22 miles 
away. The social worker I met with at the CBOC told me that I was her 
first post-9/11 veteran and she was unsure how to proceed. The primary 
care provider I was assigned told me I probably had PTSD and prescribed 
anti-depressants, but they triggered nightmares and sleepless episodes. 
No formal intake or assessment was ever completed. After a while I 
stopped attending sessions and sought care from a private medical 
provider.
    In 2007, I went through some very stressful experiences which led 
me back to the VA to seek treatment. I periodically attended counseling 
sessions until I reached a point where I felt I could cope again, then 
stopped. In 2011, I again went through a very stressful event, looking 
back, it was a crisis point. So, I sought out treatment and found the 
same social worker at the CBOC who I had seen years before. By that 
time, she had received training in PTSD and post-9/11 veterans. She 
referred me to a psychiatrist who I felt had a solid grasp on PTSD 
treatment. Both professionals were right on target with a course of 
treatment. Since then, I have attended regular weekly counseling 
sessions and periodic appointments with a psychiatrist in Sheridan, WY 
via teleconference, because that's 120 miles away. When that doctor 
retired, I began teleconferencing sessions with a provider in Casper, 
WY (210 miles away). I've never met either doctor in person.
    It seems as though the doctors at the CBOC have become more 
familiar with post-9/11 veterans and have worked with the VA to provide 
acceptable medical care. However, the VA care at the hospitals in 
Sheridan, WY and Cheyenne, WY has been disappointing. While considering 
inpatient treatment for PTSD in Sheridan, I visited the facility and 
was taken aback by the scene--akin to ``One Flew over the Cuckoo's 
Nest.'' I refused to enter the treatment facility. I understand a new 
facility has been completed, but I haven't yet been able to visit it.
    At the VA, one has to advocate for oneself to receive treatment. 
There is a lack of patient management from the beginning of a 
consultation. For example, I had an adverse reaction to a medication 
and was unable to contact my doctor. I could not drive to the emergency 
room at the VA 120 miles away, and I was afraid of stopping the 
medication and going cold turkey. After reading about it online, I made 
the decision to stop the medication. When I was contacted five days 
later, the doctor's nurse told me the doctor was going to prescribe a 
drug to counteract the negative side effects I was experiencing, but 
that medication interacted with something else I was taking. When I saw 
my doctor a month later he tried to prescribe the same medication which 
initially gave me the adverse reaction. He hadn't even read my chart 
prior to seeing me. While I hold no ill will against the doctor, I 
wonder if an overburdened system is at fault for requiring the doctor 
to see too many patients, without enough time to carefully review 
individual cases.
    In 2012, I reached out to WWP at the urging of the mother of a 
soldier I know. She told me WWP was in tune with post-9/11 veterans and 
I should give it a try. I contacted WWP, and seamlessly was brought 
aboard as an alumnus. In the summer of 2012, I attended a Project 
Odyssey retreat in Telluride, Colorado. There, I was able to connect 
with 15 other warriors, and for the first time, realized I was not 
alone. Interacting with these warriors, who were experiencing the same 
feelings as I was, was such a breath of relief--something which no drug 
could ever provide. Since then I have been active with WWP and have 
attended many different events. These events have provided me with 
opportunities to forge lifelong friendships with other veterans I would 
have never met otherwise. It's through these events and friendships 
that I've been able to regain a sense of honor and empowerment.
    Through this journey, my wife and I have felt we needed to give 
back to our community. We knew that there were other veterans in our 
community who would benefit from the same interaction I had with my 
fellow brother and sister veterans. My wife and I became peer mentors 
through the training offered by WWP. Since then we have been able to 
touch the lives of veterans and spouses alike.
    My wife and another spouse started a local support group called 
Wives of Warriors (WOW). My wife has also reached out to the spouses of 
Vietnam-era veterans and started another support group for those women. 
As for myself, I have been able to talk with many veterans 
individually. Having been in their shoes, I can help them by providing 
information about resources available to them, connecting them with 
local assistance, and most times, just listening.
    Another milestone was the ability of my wife and me to attend a 
Couples Project Odyssey in Truckee, California. The interaction with 
other couples experiencing similar and unique circumstances opened our 
eyes to the problems we all were experiencing. We were also able to 
bond with some of those couples and continue our parallel journeys 
together. This year we were honored to have become couple peer mentors 
and attended our first Project Odyssey as couple peer mentors. Our 
experience was one of the most fulfilling opportunities we've had since 
becoming affiliated with WWP.
    While working with veterans as a peer mentor I've observed and 
heard various stories regarding others' experiences. Some veterans feel 
a distrust toward the VA due to their past, negative experiences 
seeking care, conversations with others, and media reports. Some feel 
like they are lumped into a category, rather than being treated as an 
individual. Many veterans have indicated that some doctors are quick to 
push medications instead of exploring other options or alternative 
treatments. These veterans fear the long term or negative effects of 
medication, that the medications won't work, or that the VA providers 
won't treat them if they refuse to take the recommended medications.
    Some veterans have had successes with the VA treatment. For 
example, a 26 year-old former Marine I know returned from Iraq and 
bounced from job to job. He became dependent on alcohol and pain 
medication, and was incarcerated in Montana and Wyoming numerous times. 
Finally, he was facing a felony charge. He regressed to a point where 
he felt his life was meaningless and began to ponder suicide. He 
formulated a plan to end his life. Had he not spoken to his father, a 
former Marine, he would have become a statistic and a memory to his 
friends and families. He was admitted into a VA hospital, treated for 
chemical dependency, PTSD, and later placed in a halfway home. After 
going to a community college, he now attends the University of Wyoming 
as an engineering student with a 4.0 GPA. His felony was expunged and 
he enjoys the freedoms he enlisted to defend. His story was a success 
only because he had the courage to admit he was contemplating suicide, 
after being turned away from treatment at the VA emergency room once 
before. I spoke with his father last week, who questioned why the VA 
had initially turned his son away. If this father was not there for his 
son, had he not pressed his son about what happened at the emergency 
room, he would not have taken him back to the VA hospital and 
encouraged him to tell the truth about what he was going to do to 
himself.
    From my perspective, it seems the VA was not prepared to deal with 
the numbers of returning veterans. This, coupled with the unique nature 
of these wars and the advancements of battlefield medicine, brought so 
many veterans home in need of medical care, both physical and mental.
    One of the biggest challenges facing the VA and many veterans' 
service organizations today is how to reach post-9/11 veterans in rural 
communities. Veterans living in rural areas face unique obstacles 
getting engaged with the VA. Distance is a huge factor for many 
veterans. Many times, driving to a VA involves driving long distances, 
sometimes in treacherous weather conditions. Often, those rural areas 
have no public transportation as an alternative. Just getting to a DAV 
van can be a hundred mile drive. An alternative to trying to get 
veterans to engage with the VA could be the VA trying to engage with 
the veteran. That might involve VA personnel or State Veteran Service 
Officers going out to meet with the veteran to speak with them about 
the services offered, such as the Caregiver Program does in our area. I 
realize the VA has mobile Vet Centers, but effectively getting the word 
out about their deployment in an area is challenging, at best.
    Me and my wife's experiences as peer mentors and the profound 
impact it's had on our lives and on those with whom we've worked 
illustrate how important it is in assisting veterans and their 
families. Whether we're just engaging them and helping them see that 
they are not alone, or encouraging them to seek treatment, it's a 
proven method in assisting veterans and their family members in healing 
from the wounds of war.
  the toll of combat-related mental health challenges on the family--
                           jona's perspective
    When Vinny returned from his deployment, we expected the same 
husband and father to walk in the door and resume where we left off. 
Right away we could tell that he was not the same, he seemed closed 
off, emotionless, and apathetic. He seemed as if he could not engage 
with us like he did prior to leaving. Though we were all making an 
effort to aid with the reintegration, it would take years before we 
made any strides in truly understanding the effect combat has on the 
entire family.
    My children were 12 and 13 when their father returned from 
deployment. We were not prepared, in any way for what to expect. We had 
no tools to deal with the PTSD or the TBI from which he was suffering. 
We went to family counseling in our area, which turned out to be a 
disaster and only made things worse. The counselor did not recognize 
the effects of PTSD on a family and really didn't know how to assist 
us. The stress especially took a toll on our daughter, who we took to 6 
different local counselors. We were even advised to have her 
institutionalized. She was finally diagnosed with secondary PTSD when 
she was 16. This came as a huge blow for us, but it also helped us 
begin to truly understand PTSD and the effect it has on family members. 
I was diagnosed a year later. Prior to my diagnosis, I was on 7 
medications for anxiety, depression, sleeping issues--I felt like I had 
been in combat! Looking back, if we had still lived on a military base, 
not been so isolated, or had been surrounded by other military 
families, we likely would have been able to identify the symptoms more 
quickly and not have suffered so much pain. After the diagnosis we all 
began to learn tools to help each other heal.
    Our family did not ask to be broken; we did not ask to suffer the 
pains of war that immersed us. In a rural setting it is difficult to 
find mental health professionals who know how to identify PTSD or 
secondary PTSD. There was no counseling available for families through 
the VA at that time. I am thankful for the child psychiatrist we found, 
who took the time to listen, but it took us several very challenging 
years to find a provider, and they were located 90 miles away and in 
another state.
    For the first 6 years post-deployment, I was mourning the death of 
my husband. It seemed like the man who came back to us was not the man 
who had left us in January 2003. He was physically and emotionally 
changed and all my children and I desired was the husband and father we 
once knew. I learned the hard way, suffered in silence, and suffered 
alone in desperation.
    I was a member of a support group, Families on the Frontline, that 
I helped form when my husband deployed. In the beginning, I was the 
only member who had a spouse deployed; the others were parents, 
grandparents, sisters, etc. of servicemembers. We supported those 
deployed and the families left behind. Over the years, during the 
meetings, I would ask other members, ``How is your son/daughter 
doing?'' The response was always, ``Oh s/he's just fine, sleeping well, 
ready to go back, etc.'' I felt alone, like my veteran was the only one 
having issues. Their servicemembers were living in other states or had 
returned to their home base and were telling their families that 
everything was fine. I realize now that this is the survival attitude 
most veterans and family members take on. If we can just get through 
this hour, this day, this week maybe things will get better, maybe we 
will be able to handle these injuries. We are taught as military 
families to always adapt and overcome. However, a few years later, 
these other families finally began to reveal the issues their loved 
ones were experiencing.
    Once our children graduated college and left home, my husband and I 
were alone in the house and still trying to overcome the physical and 
mental wounds of war and the challenges they presented. I have to be 
honest, in pure desperation, I have been--as we say in the military--in 
the dark places. I considered taking my own life. The emotional pain 
and the desperation that we would never find any help was overwhelming. 
The thought of never having a stable family or marriage again was 
daunting. I am a Marine, I know how to be tough and be a hard charger, 
never surrender. One of the main reasons I was able to carry on was the 
fact I had a constant stream of family members and veterans coming to 
us, seeking help. We were in so much pain ourselves, but what kept me 
going was that I was helping other veterans. This engagement, being 
needed, kept us moving forward.
    We know several veterans in our area who have sought out mental 
health care and felt like the social worker providing the services just 
did not understand the military culture and the culture of war. For two 
of the veterans I am concerned about, it has been over 8 years since 
their first experience at the CBOC--they never returned for care. I 
know they are in pain, their families are suffering, and they are self-
medicating with alcohol.
    I have heard this often--from my family and from those with whom I 
work as a peer mentor--the long wait for a returned phone call from a 
doctor or nurse, the follow through with referrals, waiting for a 
prescription at a local pharmacy when the VA fails to mail a 
medication--these are all exacerbating the anxiety, the anguish, and 
the other symptoms of PTSD or mental health issue. When there are 
constant walls they run into, they feel like they are groveling for 
their benefits. After so many failures it's hard to encourage them to 
return for mental health care.
    We have had it ingrained in us, ``Hurry up and wait.'' ``Hurry up 
and wait'' doesn't work when you have a fellow veteran who is suicidal, 
who shows up at the VA hospital, but due to pride, does not say the 
magic words: ``I am suicidal.'' Because those magic words aren't 
spoken, he is turned away, brought to a homeless shelter for some 
reason, but because there is no bed available, he is turned away again. 
Why does it have to be at a crisis point, why does it have to be at the 
point of the veteran being so close, so desperate that he no longer 
wants to suffer and only then will he be considered for care?
    In all wars terrain is very important. If we are fighting in a 
jungle we train in jungle warfare, if we are fighting in the desert, we 
do the same. The battle that families face in rural areas continues on, 
we have very few weapons or resources, so we use what we have, survival 
instincts in an environment that does not have the resources needed for 
us to effectively heal. Unfortunately many veterans and their families 
have fallen and lost the battle, families are being by divorce and 
suicide.
    I have engaged with hundreds of warriors through WWP events. I know 
for a fact that engagement and peer support has saved lives! I have met 
over 30 warriors who have confided in me that at one point they were at 
the point they were going to take their lives. One stopped because he 
was afraid his children were coming home from school and he didn't want 
them to find him. Another had a plan to take his life when his wife and 
daughter went to the commissary. He had a complete plan laid out, but 
then a fellow veteran called, engaged him, and assured him the VA would 
help. Another had the gun and was ready, but then his dog laid his head 
on his lap and he changed his mind.
    We have found such healing, power, strength, and sense of 
acceptance from meeting with our fellow veterans and family members 
through WWP. We know what works, we have seen huge transformations and 
strides, not just with veterans but with the whole family. I know VA 
has adopted a peer support model in some places, but unfortunately I am 
not aware that it has been implemented in Wyoming. While I am 
encouraged VA is adapting their services to meet the mental health 
needs of this generation, for those of us in rural areas, we are still 
waiting for a comprehensive approach to engaging veterans and their 
families in mental health care. Every veteran is unique and mental 
health care has to engage them where they are, whether that is through 
traditional counseling, or through peer support, outdoor retreats, or 
other modalities.

    Chairman Sanders. Thank you very much, Sergeant Vanata.
    Dr. Ritchie.

 STATEMENT OF ELSPETH CAMERON RITCHIE, M.D., COL, USA (RET.), 
 CHIEF CLINICAL OFFICER, DISTRICT OF COLUMBIA'S DEPARTMENT OF 
                         MENTAL HEALTH

    Dr. Ritchie. It is very hard to speak about a report after 
hearing the testimony from Mrs. Pallotta and Mrs. Selke. I will 
try, but I want to acknowledge your pain and suffering.
    I would also like to say that I am an Army combat veteran 
myself and that is perhaps one of the most important 
credentials. I am here as a member of the Institute of Medicine 
report and I will talk to that report briefly. I also wanted to 
share some of the things that I think will make a difference 
that the VA can do that have not really been talked about 
before.
    First of all, the brief version of the IOM report for the 
Veterans Affairs part of it--because there is a DOD part, too--
is that there are a lot of very good people trying really hard 
to provide care and the results are mixed. Yet, we actually do 
not know the results because they are not well measured. We do 
not know who is getting better and why. This is not a problem 
unique to the VA, but it is a major issue.
    Now, we have briefed the VA on it and they have listened 
and I can go into more detail about the recommendations. You 
have them in the written testimony. Another big part of it that 
you all have heard a little bit about is the civilian providers 
are not familiar with military culture. The VA has begun to be. 
We really need to work on the civilian providers.
    In my other capacity, actually in Washington, DC, we have a 
SAMHSA policy academy, DOD, VA, military family members group 
which is one of the things we are working on. So, that is a 
tremendous issue.
    Let me come to some of the specific recommendations that I 
would like to make, not in my IOM capacity, but as a long-term 
Army psychiatrist and seeing them now through my other work.
    First of all, the VA does not know enough about who is 
suiciding. You heard that here.
    The military launched the Suicide Event Report shortly 
after 2001, got fielded really in 2005, and they know a lot 
about who suicides and why. I am pleased to hear about the 
Behavioral Health Autopsy. There needs to be more resources in 
the VA to learn who is suiciding.
    Second, servicemembers need to be screened for what type of 
deployments they were on. Many of our soldiers and sailors and 
others went to, for example, detainee operations. Michael 
Little, who is in the back of this room, is one of the ones I 
have talked to quite a bit. He tells me that he has lost ten of 
his friends from suicide, and if you come from working at Abu 
Ghraib or Guantanamo Bay or the detainment facility in Bagram, 
you do not necessarily get a whole lot of pats on the back. And 
we need to recognize that kind of service as well.
    Third, we need to recognize toxic exposures. It was Agent 
Orange from Vietnam, now there is a medication called 
Mefloquine or Lariam that causes psychiatric side effects in 
some people. We do not really know who, why, when. The VA needs 
to be screening for exposure to Lariam, Mefloquine, and other 
toxic agents. We have actually met with the VA and talked to 
them about that.
    The subject of complementary and alternative medicines came 
up quite a bit here. I am a big proponent of that, either as a 
bridging therapy, because many people do not like medications, 
they do not like, ``the evidence-based'' psychotherapies. 
Unfortunately, we do not really know who they work on and why.
    The VA has a great research portfolio. I would love to see 
them do more systematic research, areas like acupuncture, 
stellate ganglion block, which is an anesthetic technique that 
has been shown to help with post-traumatic stress disorder in 
some people--we do not know who and why--yoga. I am very 
involved with dogs, canine therapy, equine therapy. We need to 
have more research to see what works and who it works for.
    I would like to close my remarks with a concept that has 
been alluded to here that we have not really heard too much 
about, which is the concept of moral injury. This concept has 
been around, actually, since Vietnam, but we are seeing it more 
and more. It is related to post-traumatic stress disorder; it 
is not quite that. A lot of it has to do with survivor guilt.
    Ma'am, when you were talking about the images that are 
burned in people's brain, people they have killed or they have 
seen killed, in some ways it is an existential anguish. I 
believe that that really is a contributor to suicide and we do 
not often enough recognize it.
    I will close my remarks there. Thank you all very much for 
what it is that you are doing. This is just critically 
important.
    [The prepared statement and recommendations of Dr. Ritchie 
follows:]
 Prepared Statement of Elspeth Cameron Ritchie, MD, MPH, Colonel, U.S. 
   Army (Ret.), District of Columbia Department of Behavioral Health 
 Clinical Professor of Psychiatry, Georgetown University and Member of 
the Committee on the Assessment of Ongoing Efforts in the Treatment of 
  Posttraumatic Stress Disorder, Institute of Medicine, The National 
                               Academies
    Good morning Mr. Chairman, Ranking Member Burr, and Members of the 
Committee. Thanks to Senator Sanders, Senator Burr, and Members of the 
Committee on Veterans' Affairs, for your concern about veteran's 
health.
    My name is Elspeth Cameron Ritchie. I am a long-time Army 
psychiatrist now serving as the chief clinical officer for the District 
of Columbia's Department of Mental Health. Before retiring from the 
Army in 2010, I spent the last five of my 24 years in uniform as the 
top advocate for mental health inside of the Office of the Army Surgeon 
General. Before that, I served in other leadership roles including the 
psychiatry consultant to the Army Surgeon General at the Department of 
Defense Health Affairs. I trained at Harvard, George Washington 
University, Walter Reed, and the Uniformed Services University of the 
Health Sciences. I am a professor of psychiatry at the Uniformed 
Services University of the Health Sciences--the U.S. military's medical 
school--in Bethesda, MD; I am also a clinical professor of psychiatry 
at Georgetown University. I am here before you today because of my 
experience as a volunteer serving on the Institute of Medicine (IOM)\1\ 
Committee on the Assessment of Ongoing Efforts in the Treatment of 
Posttraumatic Stress Disorder. I will address the issues on Post 
Traumatic Stress Disorder as revealed by the IOM committee, however, 
any remarks I make regarding suicide will be my personal opinion as the 
Committee did not address issues of suicide in its study.
---------------------------------------------------------------------------
    \1\ The National Academy of Sciences, National Academy of 
Engineering, and the Institute of Medicine of The National Academies 
were chartered by Congress in 1863 to advise the government on matters 
of science and technology.
---------------------------------------------------------------------------
    Posttraumatic stress disorder (PTSD) is one of the signature 
injuries of the U.S. conflicts in Afghanistan and Iraq, but it affects 
veterans of all eras. It is estimated that 7 to 20% of servicemembers 
and veterans who served in Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF) may have the disorder. PTSD is 
characterized by a combination of mental health symptoms--re-
experiencing of a traumatic event, avoidance of trauma-associated 
stimuli, adverse alterations in thoughts and mood, and hyperarousal--
that last at least a month and impair functioning.
    PTSD can be lifelong and pervade all aspects of a servicemember's 
or veteran's life, including mental and physical health, family and 
social relationships, and employment. It is often concurrent with other 
health problems, such as depression, Traumatic Brain Injury (TBI), 
chronic pain, substance abuse disorder, and intimate partner violence. 
The Department of Defense (DOD) and the Department of Veterans Affairs 
(VA) provide a spectrum of programs and services to screen, diagnose, 
treat, and rehabilitate servicemembers and veterans who have or are at 
risk for PTSD.
    The 2010 National Defense Authorization Act tasked the IOM with 
assessing those PTSD programs and services. The IOM conducted the study 
in two phases; the Committee members directed the literature searches, 
requested data from the DOD and the VA, and visited nine military 
medical facilities and six VA medical facilities. I will discuss the 
Committee's findings.
                       ptsd management strategies
    PTSD management in DOD appears to be local, ad hoc, incremental, 
and crisis-driven with little planning devoted to the development of a 
long-range, population-based approach for the disorder by either the 
Office of the Assistant Secretary of Defense for Health Affairs or any 
of the service branches. Each service branch has established its own 
prevention programs, trains its own mental health staff, and has its 
own programs and services for PTSD treatment.
    VA has a more unified organizational structure than DOD and is able 
to ensure a more consistent approach to the management of PTSD in its 
medical facilities. However, there are few data to indicate that PTSD-
related performance measures are being met, although improving mental 
health care is one of VA's major initiatives in its strategic plan.
    Although the DOD and VA are coordinating strategic efforts such as 
the DOD/VA Integrated Mental Health Strategy and the National Research 
Action Plan for Improving Access to Mental Health Services for 
Veterans, Servicemembers, and Military Families, those activities have 
not proven to be sufficient to determine whether PTSD management is 
improving or whether a population-based approach is being used to reach 
and treat all servicemembers and veterans in need of care for PTSD. 
Furthermore, current DOD and VA strategic efforts do not necessarily 
encourage the use of best practices for preventing, screening for, 
diagnosing, and treating for PTSD and its comorbidities, and do not 
extend to ensuring continuity of care as servicemembers transition from 
active duty to veteran status.
                      leadership and communication
    DOD leaders at all levels of the chain of command are not 
consistently held accountable for implementing policies and programs to 
manage PTSD effectively. In each service branch, there is no 
overarching authority to establish and enforce policies for the entire 
spectrum of PTSD management activities. A lack of communication among 
mental health leaders and clinicians in DOD can lead to the use of 
redundant, expensive, and perhaps ineffective programs and services 
while other programs, known to be effective, languish or disappear.
    VA leadership engagement in PTSD management among sites varies 
resulting in different types and quality of PTSD programs and services. 
Although the VA central office has established policies on minimum care 
requirements and guidance on PTSD treatment, it is unclear whether VA 
leaders adhere to the policies or encourage staff to follow the 
guidance.
                        performance measurement
    DOD and VA do not collect data to identify best practices 
throughout the spectrum of their PTSD programs and services, although 
there are some initiatives to do so. Given that DOD and VA are 
responsible for serving millions of servicemembers, families, and 
veterans, it is surprising that no PTSD outcome measures of any type 
for psychotherapy or pharmacotherapy are consistently used or tracked 
in the short or long term (with the exception of the VA Specialized 
Intensive PTSD Programs). Without tracking outcomes neither department 
knows whether it is providing effective, appropriate, or adequate care 
for PTSD. Reliable and valid self-report measures are available and 
could be used to monitor progress, provide real-time response 
information to providers and patients, and guide modifications of 
individual treatment plans. VA is in the process of expanding its 
electronic health record to capture the types of psychotherapy that 
patients are receiving, but the revised record still will not include 
regularly administered outcome measures. Most veterans who have PTSD do 
not receive care in VA specialized PTSD programs, so their treatments 
and outcomes are unknown.
                      workforce and access to care
    DOD and VA have substantially increased their mental health 
staffing--both direct care and purchased care. However, staffing 
increases do not appear to have kept pace with the demand for PTSD 
services. Staffing shortages can result in clinicians not having 
sufficient time to provide evidence-based psychotherapies readily and 
with fidelity. The lack of time to deliver psychotherapy with fidelity 
is reflected in the fact that in 2013 only 53% of OEF and OIF veterans 
who had a primary diagnosis of PTSD and sought care in the VA received 
the recommended eight sessions within 14 weeks. Provision of evidence-
based treatments also implies refraining from providing services or 
programs that lack an evidence base or whose evidence base has been 
deemed ineffective by recent research. The size of the VA and DOD 
workforces will be influenced by how efficiently and effectively staff 
use their time to deliver the most effective assessments and treatments 
in a patient-centered approach. Although expanding the number of staff 
to meet needs may be necessary, it may also be possible to achieve 
equal or better results with more efficient use of existing staff and 
by having existing staff use the most effective programs and services.
    Neither department appears to have formal procedures for evaluating 
the qualifications of purchased providers, mechanisms to determine the 
best purchased care provider for an individual patient, or a 
requirement that those providers give referring providers updates on 
patients' progress. Having standards, procedures, and requirements for 
direct care and purchased care providers will help to ensure that they 
are trained in evidence-based treatments that are consistent with VA/
DOD Clinical Practice Guideline for Management of Post-Traumatic 
Stress, understand military context and culture, measure the progress 
of patients in treatment on a continuing basis, and, in the case of 
purchased care providers, coordinate with patients' DOD or VA referring 
providers regularly. DOD and VA have expanded training in evidence-
based psychotherapies for all mental health staff. However, the 
training is not required for purchased care providers in either 
department.
                        evidence-based treatment
    DOD and VA have expended considerable effort to develop, update, 
and disseminate the VA/DOD Clinical Practice Guideline for Management 
of Post-traumatic Stress. The guideline provides algorithms for 
choosing an evidence-based treatment for PTSD, addresses comorbidities, 
describes approaches for engaging patients in treatment, and discusses 
the evidence on first-line and other psychosocial therapies and 
pharmacotherapies.
    However, mental health care providers in both departments do not 
consistently provide evidence-based treatment in spite of policies that 
require that all servicemembers and veterans who have PTSD receive 
first-line treatments, such as cognitive processing therapy and 
prolonged exposure therapy. It is unclear what PTSD therapies most 
servicemembers or veterans receive in any treatment setting and whether 
their symptoms improve as a result. DOD and VA are also integrating 
complementary and alternative therapies into some of their specialized 
PTSD programs, but the interventions need to be studied to establish 
their evidence base and to ensure that their use does not deter 
patients from receiving first-line, evidence-based treatments.
               central data base of programs and services
    DOD does not have a central database of PTSD programs and services 
that are available throughout the service branches. Without such a 
database, it is impossible to compare programs and services, to 
identify the ones that are effective and use best practices, and to 
recognize the ones that need improvement or should be eliminated. Most 
of the specialized PTSD programs in the service branches were developed 
and implemented locally. As a result, clinicians and other mental 
health care providers have no resource that provides information on 
programs (for example, type, location, admission criteria, and 
treatment modalities) to which they might refer servicemembers who need 
specialized PTSD care, or that might serve as models for new programs 
at their facility.
    Although the VA prepares an annual report on its specialized PTSD 
programs, that report does not include all PTSD treatment settings, 
such as general mental health clinics and women's health clinics. 
Furthermore, the report does not contain any descriptive information on 
program elements and does not appear to be widely used.
    All stakeholders, including families and direct and purchased care 
providers, would benefit from ready access to a routinely updated 
database in which programs are described and evaluated according to 
standardized measures. Existing resources, such as the National Center 
for PTSD, could be leveraged to develop more comprehensive information 
about VA-wide PTSD programs and services (not just specialized ones) 
and, in a collaborative effort, include those of DOD.
                           family involvement
    DOD has a variety of resources to assist servicemembers and their 
families and others in learning about PTSD, its diagnosis and 
treatment, and its impact on family and friends. Many support services 
are available to servicemembers and their family members in military 
installations and personnel in those programs and services are trained 
to recognize early symptoms of PTSD, provide nonclinical supportive 
care, and refer servicemembers and their families to appropriate 
professional care.
    VA also has resources for families of veterans who have PTSD, such 
as the National Center for PTSD. Some veterans have expressed their 
interest in and preference for having their partners involved in their 
PTSD treatment and the need for support groups for those partners. 
However, there is no formal VA-wide program for engaging family members 
in the veterans' treatments, for providing psychoeducation in a 
facility, or for establishing support groups for family members. In 
several VA mental health programs, veterans who have PTSD and their 
partners and children receive couple or family therapy from 
professional clinicians. VA, including Vet Centers, provides peer 
counselors and peer support groups that help to engage veterans in 
treatment, reduce stigma, and promote empathy, but data on the number 
of veterans who seek treatment as a result of peer counseling or who 
participate in support groups are not available. Vet Centers also 
provide counseling services for family members.
                          research priorities
    There can be substantial barriers to conducting PTSD research 
within and between the departments and in collaboration with academic, 
government organizations, and private partners. To date, there does not 
appear to have been a systematic effort by either department to 
identify those barriers and mechanisms to overcome them. Nevertheless, 
DOD and VA are funding broad PTSD research portfolios and are working 
collaboratively with the National Institutes of Health and other 
organizations to fill research gaps (for example, developing the joint 
National Research Action Plan for Improving Access to Mental Health 
Services for Veterans, Servicemembers, and Military Families for 
improving access to mental-health services), but much work remains to 
be done.
    DOD and VA are spending substantial time, money, and effort on the 
management of PTSD in servicemembers and veterans. Those efforts have 
resulted in a variety of programs and services for the prevention and 
diagnosis of, treatment for, rehabilitation of, and research on PTSD 
and its comorbidities. Nevertheless, neither department knows with 
certainty whether those many programs and services are actually 
successful in reducing the prevalence of PTSD in servicemembers or 
veterans and in improving their lives.
                                suicide
    As previously mentioned, I am here today in several capacities: as 
a former IOM Committee member on PTSD, and as a retired career Army 
psychiatrist and subject matter expert on military suicide. This part 
of the testimony is from my professional experience in military and 
veteran mental health and suicide issues and does not reflect the 
collective opinion of the IOM.
    The military has made a comprehensive effort to understand the 
dynamics of those who kill themselves while on active duty. That 
information is obtained in a variety of ways including suicide event 
reports, which help to inform suicide prevention efforts. The suicide 
numbers are still stubbornly hard to reduce, but the rate among active 
duty troops is beginning to flatten.
    Far less is known about the reasons for suicide in reserve troops 
who kill themselves while not on active duty or on suicides in 
veterans. The numbers of Guard and reservists, including IAs or 
individual augmentees, who are killing themselves is still unacceptably 
high, and moreover we do not know why they are doing it.
    For example, it's important that we also focus on the needs of our 
``Non Traditional Deployers.'' Members who deploy in support of 
missions like Detainee Operations have often been forgotten. This 
includes a large contingent of Navy Sailors who deployed to GITMO, Iraq 
Theater Interment Facilities and Afghanistan Interment Facilities. They 
received very little training in the jobs they were asked to preform, 
and came back to even less demobilization support.
    Now would be the time to identify these members and study them, so 
we can identify what the training they went through was like, how they 
were treated in theater, and how they were received once they returned 
home. It would be good to compare these servicemembers with 
servicemembers who have been trained in the Military Correction Officer 
programs, and see how they favor during the same deployment 
environments.
    The suicide rates among these sailors have continued to increase 
since 2010, and it is my thought that these rates may rise over the 
coming year with the IA's going away with the ending of the war. These 
sailors have been able to suppress their mental injuries by continuing 
to deploy and with that no longer being an option, it is likely that 
psychological symptoms will start to set in, and send most of them into 
a shock.
    The numbers of veteran suicides are widely cited as 22 per day. 
However, as compared with suicides among active duty military, almost 
nothing is known about what precipitates self-injury among veterans. 
Anecdotally, I think that younger veterans are killing themselves in a 
pattern similar to that of active duty members, in other words over 
relationship and occupational difficulties. The pattern in older 
veterans appears to be more similar to the civilian population, with 
depression and substance abuse as key culprits.
    To the best of my knowledge, the VA's suicide epidemiological 
office has two people. Thus the first of my recommendations is to 
better resource the efforts to understand who is killing themselves and 
why so that the risk of this tragedy can be reduced.
    A second recommendation is to better screen veterans for exposures 
to a number of potentially toxic agents, including Mefloquine (an 
antimalarial), which has been associated with psychiatric symptoms and 
suicide. Fifty years after the beginning of the Vietnam War, and 
twenty-three years after the first Gulf War and the so-called Gulf War 
illness, the military has dramatically stepped up their screening as 
troops re-deploy home. But this is not yet uniformly done in the VA.
    I turn now to the direction of research into PTSD treatment and 
suicide prevention. The VA has certainly been a leader in the former 
area. I would like to see them continue in that capacity, with a focus 
on expanding the evidence-base for the so-called cadre of complementary 
and alternative medicines (CAM) or integrative therapies. These CAM 
treatments include medical acupuncture, yoga, mindfulness, stellate 
ganglion block, and canine and equine therapy. For many of these CAM 
therapies, the evidence-base is promising but insufficient to guide 
changes in standard clinical treatment paradigms for PTSD. Given the 
well-documented low rate of effectiveness in existing evidence-base 
therapies (less than 30% overall) and the epidemic of PTSD in our 
military and veteran populations, it is an imperative that VA and DOD 
invest in research for new and innovative therapies with preliminary 
data showing favorable outcomes in PTSD symptom reduction.
    It is important to keep in mind that many patients are already 
using these CAM strategies, some through established medical clinics 
and others through the internet or other non-traditional means. Based 
on preliminary published data as well as anecdotal patient 
testimonials, we know that some patients benefit greatly from these CAM 
therapies, but we do not yet know who which types of patients benefit 
most or why. DOD has begun doing some research on these innovative 
approaches, but it does not have the sophisticated ability to conduct 
clinical trials with the same capacity as VA does.
    Finally, I would like to close with a concept that is important for 
all listening to understand: ``moral injury.'' ``Moral injury'' is not 
a psychiatric disorder but a condition imposed by war, often related to 
the act of killing or of seeing others die. Servicemembers who have 
served in prisons, such as Guantanamo Bay and Abu Ghraib may be at 
highest risk. As a psychiatrist who has treated countless patients with 
PTSD, I believe that the related shame and guilt contribute to 
substance abuse, divorce, and suicide, but again there is not yet 
adequate research. I would encourage the VA--as well as the military 
and civilian community--to acknowledge and discuss these almost 
existential concepts with patients.

    In closing, I would like to thank you for inviting me to testify 
before this Committee. I appreciate the work of the Senate Committee on 
Veterans Affairs. On behalf of the IOM PTSD committee members, I thank 
you for your trust in our ability to assist you with this important 
work for our Nation's veterans. I know from my service on the IOM 
committee that the Nation's scientists are happy to serve, and look to 
you for guidance on how we can be of most assistance to you and the VA 
and the DOD in addressing this difficult issue. I look forward to 
answering any questions you might have regarding the IOM's PTSD report. 
Attached to my testimony are the IOM committee's recommendations. Any 
questions you might have regarding suicide will be my opinion as the 
Committee did not address that issue as it was not part of their 
statement of task as outlined in the legislation.
                                 ______
                                 
                                Addendum
 Treatment for Posttraumatic Stress Disorders in Military and Veteran 
               Populations, Final Assessment (IOM, 2014)
                            RECOMMENDATIONS
                       ptsd management strategies
    Recommendation A: DOD and VA should develop an integrated, 
coordinated, and comprehensive PTSD management strategy that plans for 
the growing burden of PTSD for servicemembers, veterans, and their 
families, including female veterans and minority group members.
                      leadership and communication
    DOD and VA leaders at the national and local levels set the 
priorities for PTSD care for their respective organizations. Authority, 
responsibility, and accountability for PTSD management needs to begin 
at the central office level--at the level of the assistant secretary of 
defense for health affairs and the VA under secretary for health--and 
extend down to facility leaders and unit leaders. Leadership 
accountability can help ensure that information on PTSD programs and 
services is collected and that their success is measured and reported. 
Effective leadership extends to supporting innovation in new processes 
and approaches for treatment for PTSD.
    Recommendation B: DOD and VA leaders, who are accountable for the 
delivery of high-quality health care for their populations, should 
communicate a clear mandate through their chain of command that PTSD 
management, using best practices, has high priority.
                        performance measurement
    To better assess the success of their PTSD programs and services, 
DOD and VA should have a performance management system that includes:

     The use of standard metrics to screen for, measure, and 
track PTSD symptoms and outcomes throughout DOD and VA. The departments 
should work with the National Quality Forum to endorse consensus 
performance measures for both clinical measures and quality indicators.
     Health information technology that documents a patient's 
PTSD treatments and progress such that the data can be aggregated at 
the provider, program, facility, service, regional, and national 
levels.
     Performance measures to inform and improve the system via 
integrated feedback loops, which should be used by leaders at all 
levels to evaluate and improve PTSD management.
    Recommendation C: DOD and VA should develop, coordinate, and 
implement a measurement-based PTSD management system that documents 
patients' progress over the course of treatment and long-term follow-up 
with standardized and validated instruments.
                      workforce and access to care
    Recommendation D: DOD and VA should have available an adequate 
workforce of mental health care providers--both direct care and 
purchased car--and ancillary staff to meet the growing demand for PTSD 
services. DOD and VA should develop and implement clear training 
standards, referral procedures, and patient monitoring and reporting 
requirements for all their mental health care providers. Resources need 
to be available to facilitate access to mental health programs and 
services.
                        evidence-based treatment
    Recommendation E: Both DOD and VA should use evidence-based 
treatments as the treatment of choice for PTSD, and these treatments 
should be delivered with fidelity to their established protocols. As 
innovative programs and services are developed and piloted, they should 
include an evaluation process to establish the evidence base on their 
efficacy and effectiveness.
                           family involvement
    Recommendation G: DOD and VA should increase engagement of family 
members in the PTSD management process for servicemembers and veterans.
                          research priorities
    The Committee identified the following as major foci of future 
PTSD-related research:

     Increasing knowledge of how to overcome barriers to 
implementation, dissemination, and use of evidence-based treatments to 
improve their accessibility, availability, and acceptability for 
patients and their families.
     Increasing understanding of basic biological, 
physiological, psychological, and psychosocial processes that lead to 
the development of more and better treatments for PTSD.
     Developing markers to identify better approaches for PTSD 
prevention, diagnosis, and treatment.
     Understanding the heterogeneity of PTSD presentations and 
predicting responses to treatment for them in different populations and 
at different times in the course of the disorder.
     Preventing the development of PTSD before and after trauma 
exposure.
     Developing and rigorously assessing new interventions and 
delivery methods (pharmacological, psychological, somatic, 
technological, and psychosocial) for both PTSD and comorbidities.
     Identifying effective care models, establishing evidence-
based practice competences, and developing methods to enhance effective 
training in and implementation and dissemination of them.
    Recommendation H: PTSD research priorities in DOD and VA should 
reflect the current and future needs of servicemembers, veterans, and 
their families. Both departments should continue to develop and 
implement a comprehensive plan to promote a collaborative, prospective 
PTSD research agenda.

    Chairman Sanders. Thank you, Dr. Ritchie.
    Mr. Smith.

        STATEMENT OF BLAYNE SMITH, EXECUTIVE DIRECTOR, 
                    TEAM RED, WHITE AND BLUE

    Mr. Smith. Chairman Sanders, Ranking Member Burr, 
distinguished Members of the Committee, and our distinguished 
guests here today, it is really my honor to be here to talk 
about this incredibly important topic and to represent our 
55,000 members at Team Red, White and Blue. We are hoping that 
we can be a part of the solution.
    Before we get into any solutions, I think it is worth 
taking some time to actually understand the challenge a bit 
better. We know that the physical, emotional, and psychological 
wounds of war affect a significant percentage of our veterans 
and they have to be addressed. Conditions like post-traumatic 
stress and traumatic brain injury have justifiably moved into 
the spotlight and are oft-cited as the culprits for many 
veteran challenges.
    We acknowledge that, but we would like to submit that there 
are additional challenges that may play just as significant a 
role for many veterans, and that includes very common things 
like survivor's remorse, guilt and depression, and even just 
the loss of identity and purpose and comradery that comes with 
taking off the uniform and transitioning to civilian life.
    So, we want to craft solutions that address the full 
spectrum of the challenge and, whenever possible, proactively 
get at those challenges. We also think it is important to 
understand the people that are involved here. As has been 
stated many times this morning, every veteran is not the same.
    Our organization, while we were building ourselves back in 
July 2012, conducted a representative survey and study of 
veterans in which we asked them what they wanted. We asked them 
what they needed and wanted in order to build an organization 
that could address those wants and needs. And what they told us 
they wanted was connection to their community. They told us 
they wanted comradery, they wanted opportunities to continue 
serving, and they wanted meaningful relationships. So, that is 
what we have gone about trying to craft at Team Red, White and 
Blue.
    The next thing I will state is that the solution requires 
empathy, not just sympathy. It really requires a deep 
understanding of our veterans and their families and their 
needs. So, we have to provide local, consistent, and inclusive 
opportunities for veterans and their families to interact with 
one another, but maybe more importantly, with members of their 
community who are not veterans.
    One of the things we know is that stress and anxiety and 
depression and divorce and guilt, those are not veteran-centric 
issues. These are human issues that just happen to be 
experienced by veterans as well. So, if we can build meaningful 
connections between veterans and the members of their 
community, we can create understanding and we can create trust. 
Then we can move veterans toward the potentially life-saving 
treatments that they may need, because also what has been 
stated here this morning is that it does not matter what our 
capacity for acute care is if we cannot move veterans toward 
that care. That is a critically important step. The engagement 
and the outreach piece is absolutely critical.
    So, at Team Red, White and Blue, our job is to build those 
connections in the community and we choose to do it primarily 
through physical social activities. We do that because we know 
that it works. So, why does it work so well? I think it is 
clear that physical exercise is great for your physical health. 
We all understand that.
    It has also been well-documented in recent studies that 
physical activity, even moderate exercise, does great things 
for mood, reduction of anxiety, and reduction of stress. It is 
even cited in some cases that exercise can be as effective as 
some antidepressants or even counseling when combating 
depression.
    But I will tell you that I think the most compelling 
argument for physical exercise is that in addition to improving 
physical health and mood, it is an extremely efficient vehicle 
for developing genuine relationships. We know that shared 
accomplishment and accountability, even shared hardship through 
exercise and challenges, builds a bond very rapidly and creates 
great understanding amongst people.
    We have also found this team concept to be very, very 
attractive amongst veterans, especially of the younger 
generation. At Team Red, White and Blue we do not ask them to 
identify themselves as wounded or broken. We just offer them an 
opportunity to be a part of a new team, perhaps to help other 
veterans, and they really come out in droves. I think the 
results have been remarkable and we measure them.
    Over the past 2 years, our membership has exploded by more 
than tenfold to now more than 55,000 members and we grow by 
about 700 members every week. We have gone from about ten local 
chapters to nearly 120 and those chapters host over 800 
activities and generate almost 10,000 quality veteran 
interactions every single month.
    Those outputs, I think, are interesting but the outcomes 
are actually more compelling. In a recent survey of about 4,400 
of our members, we have learned that our programs are having a 
profound impact. Our members indicated that their health is 
improving, they have more meaningful relationships, and they 
have a stronger sense of purpose and identity.
    For example, 94 percent of active Team Red, White and Blue 
members report feeling part of something bigger than 
themselves, and that is really important. Similarly, 61 percent 
of active Team Red, White and Blue members report feeling less 
down, depressed, and hopeless.
    Additionally, veterans have more people they can turn to 
for emotional support, they are more involved in their local 
community, they have more programs they can turn to for 
resources, and they have a greater sense of brotherhood or 
sisterhood in their lives.
    Last, I would say that our programs are effectively 
connecting veterans to their civilian counterparts. A majority 
of our veterans, nearly 75 percent, report sharing the 
challenges they face as a veteran with the civilian members of 
their community. I think that is remarkable. And of equal 
importance, 75 percent of our civilian members state that they 
have a better understanding of both the challenges veterans 
face and the strengths that veterans bring to their community, 
which is also very important.
    So, while we are committed to measuring these outcomes, I 
think that ultimately our organization is about people. I would 
like to share a couple of quotes if I have time. I really 
believe that if Ian had been involved in this group, he would 
be alive today.

          ``Team Red, White and Blue helped me make friends 
        when I moved to Virginia. It also allowed me to connect 
        with the people I worked so hard to save. This is 
        suicide prevention and life enrichment in its most 
        simple and clear manner.''

And that comes from a very strong lady sitting behind me. Her 
name is Rebecca Morrison and her late husband tragically took 
his own life in 2012.

          ``PTSD and alcohol dependence were killing me, 
        physically, mentally, and socially. My will to live was 
        completely broken. Physically I was a wreck, mentally I 
        was all over the place. Severe depression and anxiety 
        ruled my life. Fast forward to April 2013 when I found 
        Team Red, White and Blue. This is the point that my 
        life definitely changed. I found what was missing since 
        I left the Army. Genuine people and brotherhood and 
        comradery, people who understand me.''
          ``Now I have lost 60 pounds and I reap the physical 
        and mental benefits of consistent exercise. I have 
        taken back my life and I have overcome the challenges 
        the PTSD. I have regained self-esteem and confidence. I 
        am now part of a wonderful group of friends and a very 
        large extended family that genuinely care about me and 
        I care about them, also.''

That comes from an Army veteran named Sean MacMillan. He lives 
in central Pennsylvania. He now leads our chapter there and is 
working every day to help hundreds of veterans like him.
    Thanks for giving me this time. I look forward to answering 
any of your questions and helping in any way that I can.
    [The prepared statement of Mr. Smith follows:]
        Prepared Statement of Blayne Smith, Executive Director, 
                        Team Red, White and Blue
                      understanding the challenge
    The physical wounds of war are quite real and require dedicated 
attention and care. However, the invisible wounds of war affect a 
significant percentage of our Veteran population and must be addressed. 
Conditions such as post-traumatic stress and traumatic brain injury 
(TBI) have justifiably moved into the light are oft cited as the 
culprits for Veteran challenges. While these conditions are serious, we 
submit that there are additional, perhaps overlooked, causes for the 
difficulty in transitioning from military-member to civilian. For many 
Veterans, survivors' remorse and guilt can be debilitating. For others, 
the loss of purpose, identity, and camaraderie can be devastating and 
greatly inhibit a smooth reintegration process.
                        understanding the people
    It is critically important to understand Veterans' needs and 
preferences when creating support programs, rather than simply giving 
them what we think they need. That is why Team RWB conducted a 
representative study of Veterans in July 2012. The study was extremely 
informative and uncovered Veterans' true wants and needs: connection to 
community, physical activity, camaraderie, opportunities to serve, and 
meaningful relationships.
    We also discovered that Veterans generally fall into one of three 
groups. We call them: Connection-seekers, Family-focused, and Driven. 
Interestingly, Connection-seekers and Driven have very complementary 
needs. While about 25% of Veterans are seeking connection, mentorship, 
and belonging (Connection-seekers); another 25% are actively looking 
for opportunities to lead, coach, mentor, and matter (Driven). The 
remaining 50% are generally getting along quite well and will join only 
if the experience adds value to their life (Family-focused). Armed with 
this knowledge and understanding, we went about creating a model that 
would actually give Veterans what they were asking for.
              the solution requires empathy, not sympathy
    In order to provide Veterans with what they are seeking, we know 
that we need local, consistent, and inclusive programs that foster 
authentic interactions. We need to connect Veterans to other Veterans, 
and perhaps more importantly, non-Veterans within their communities. 
When people truly know each other, they build trust. Trust creates 
genuine, supportive relationships, and those relationships are the 
foundation upon which a healthy, happy, productive life can be built.
    While post-traumatic stress, head injuries, depression, and anxiety 
can be challenges for Veterans, these are not ``Veteran issues.'' These 
are human issues, experienced by many Americans. In most cases, 
Veterans and non-veterans have many more similarities than they do 
differences. This is easily discovered once we establish authentic 
relationships with one another. Our job at Team RWB is to create the 
conditions for these relationships.
                  why physical activity works so well
    It is clear that exercise improves physical health. Servicemembers 
learn the benefits of maintaining a rigorous fitness regimen from the 
time they conduct initial training. However, we now know that physical 
activity, even moderate exercise, can also significantly improve mood, 
reduce stress, and limit anxiety. Some studies (Otto/Smits) show 
exercise to be as effective as common anti-depressants and counseling 
at combatting depression.
    In addition to improving health and mood, physical activity is an 
extremely efficient vehicle for building authentic relationships. 
Shared accomplishment, accountability, and even shared hardship are 
powerful drivers of connection and friendship. This team concept is 
very attractive to Veterans because (unlike therapy) on a team, 
everybody contributes and everybody benefits. Team RWB members will 
generally tell you that they are participating in order to support 
their fellow Veteran, and that is just fine. We do not require them to 
identify themselves as in-need or wounded or broken. At Team RWB, we 
don't rank-order suffering or injury. Put more positively, we don't 
rank-order ``deserving.'' We simply provide Veterans an opportunity to 
be part of new team, to engage in positive activities, and to support 
their community.
                           remarkable results
    Team RWB's model of delivering local, consistent, and inclusive 
opportunities for positive involvement is clearly resonating with 
Veterans and community members alike. Over the past two years, total 
membership has increased almost tenfold (to over 55,000) and is 
continuing to grow at a rate of 700 signups per week. We have gone from 
10 local chapters to nearly 120, hosting over 800 activities and 
facilitating more than 10,000 unique veteran interactions per month.
    While these outputs tell part of the story, the outcomes are even 
more compelling. In a recent survey of 4,438 members, we learned that 
our programs are having a profound impact. A significant majority of 
members reported living richer lives since joining the organization. 
They indicated improved health (physical, mental, and emotional), more 
meaningful relationships, and a stronger sense of purpose and identity. 
Moreover, while outcomes were generally positive, those who are active 
in the organization consistently reported much higher levels of 
enrichment than those who identified themselves as less active.
    For example, nearly half (45%) of ``less active'' TRWB Veterans 
felt part of something bigger than themselves, but the percentage 
jumped to 94% for those Team RWB Veterans who defined themselves as 
``active.'' Similarly, 61% of active Team RWB Veterans felt that they 
were ``less down, depressed, or hopeless.'' While 57% of our ``less 
active'' members said they benefited from the opportunity to share 
their personal journeys, an astonishing 86% of ``active'' members found 
these experiences to be beneficial to them. Additionally, Veterans have 
more people they can turn to for emotional support (57%), they are more 
involved in the local community (60%), they have more programs they can 
turn to for resources (64%), and they feel an increased sense of 
brotherhood/sisterhood in their lives (66%).
    Last, Team RWB programs are effectively connecting Veterans to 
their civilian counterparts. A majority of Veterans (73% among active 
members) reported sharing the challenges they face as a veteran with 
civilians, and 87% demonstrated the strengths they have as a Veteran to 
civilians. Of equal importance, 75% of civilian members stated that 
they better understand both the challenges and strengths of Veterans in 
their communities.
                           we can save lives
    Suicide is most often the result of deep despair, a total loss of 
hope. We can proactively address this challenge by ensuring that 
Veterans are connected to a supportive community with programs that 
provide a sense of purpose, identity, and camaraderie. Once we've 
handled engagement and connection, we can more efficiently deliver the 
potentially live-saving resources that some Veterans need. I would like 
to close my testimony with short quotes from two of our members.

          ``I really believe that if Ian had been involved with this 
        group that he would be alive today. Team Red, White, and Blue 
        helped me make friends and feel connected when I moved to 
        Virginia. It also allowed me to connect with the people I work 
        so hard to save. This is suicide prevention and life enrichment 
        in the most simple and clear manner.''--Rebecca Morrison, who's 
        late husband Ian tragically committed suicide in 2012

          ``PTSD and alcohol dependence were killing me physically, 
        mentally, socially, and spiritually. My will to live was pretty 
        much broken. Physically--I weighed over 230 pounds and could 
        not run a mile without gasping for air. My blood pressure was 
        through the roof, and my cholesterol was sky high. Mentally--I 
        was all over the place. Severe depression and anxiety ruled my 
        life.
          Fast forward to April 2013 when I found Team RWB. This is the 
        point that my life definitely changed. I found what I had been 
        missing since I left the Army. Genuine people. The brotherhood. 
        The camaraderie. People who understand me * * *. Now I am down 
        to about 170 pounds. I reap the physical and mental benefits of 
        consistent and challenging exercise. I have taken my life back, 
        and overcome the challenges associated with PTSD. My mental 
        health has never been better. I have regained my self-esteem 
        and self-confidence. I now have a wonderful group of friends 
        and a very large extended family that genuinely cares about me 
        (and I care about them as well).''--Sean MacMillen, Army 
        Veteran

    Team RWB is committed to enriching the lives of Veterans and their 
families. We are honored to be part of the discussion and welcome the 
opportunity to provide any additional insight or assistance on the very 
serious matter.

    Chairman Sanders. Mr. Smith, thank you very much for your 
testimony. Members of the panel, thank you all for your 
excellent testimony.
    Let me start with Mrs. Selke and Mrs. Pallotta. Please 
answer this in any way that you want. Thinking back about the 
experiences that your sons went through, what recommendations 
would you make to the VA as to how they could have responded 
better to the needs of your sons? If the Secretary was sitting 
here right now, what should they have done that would have 
prevented the tragedy? Mrs. Selke, do you want to begin?
    Mrs. Selke. I think in Clay's case, I do not know that I 
can pinpoint any one particular thing, there was buildup; the 
difficulty in navigating the VA from the month that he left the 
service and started accessing VA care. That was summer of 2009 
and that was just when the new G.I. Bill was going into effect. 
He was very delayed in getting his benefits to start school.
    Chairman Sanders. So, he had to deal with the bureaucracy 
and the delays of getting benefits which were important to him?
    Mrs. Selke. He did.
    Chairman Sanders. As I recall, he also had difficulty 
holding down a job because of----
    Mrs. Selke. Exactly. During that summer, he was working in 
a bike shop and because of his panic attacks, he would have to 
leave to go outside to collect himself often. He just had to be 
let go because it was interfering. So, that is when he realized 
he needed to make an appeal on his disability benefits as well. 
So, he was battling to get his education benefits in place as 
well as dealing with that.
    In making that appeal for his disability benefits, that is 
when the VA lost his file and he had to re-create the medical 
records for the previous 2 years, since the time he had been 
diagnosed with post-traumatic stress in order to make that 
appeal. So, really from day one when he got out, he began 
experiencing the difficulty of just navigating through the 
system.
    As far as the medical part of it, again, I said in my 
testimony, predominantly the medication was the way that he was 
dealt with. It was very difficult.
    Chairman Sanders. It sounds like he never received a warm 
hand that said, relax, we are with you, we are going to get you 
through this. We are going to get you through the benefits 
issue, we are going to get you through the mental health thing, 
we are here for you.
    Mrs. Selke. Right.
    Chairman Sanders. It sounds like he did not get that.
    Mrs. Selke. I look back and realize now how proactive Clay 
was, how determined he was that these were the benefits 
promised to him. He needed them and he was going to do what it 
took to get those. And it makes me realize how many others are 
out there that may not have tried as hard. There are so many 
that just say, I give up, I am just not going to fool with it, 
I give up.
    The medication was a real stumbling block for him. It was 
very frustrating to know that he needed help in some way. He 
knew he was not functioning the way that he should be. And yet, 
the place that he felt was his comfort zone, the place that he 
had been promised would take care of him as a veteran, there 
just did not seem to be very many options other than the 
medication route, and that just proved to be very difficult for 
him.
    When he came back to Houston in those last really 10 weeks, 
before he saw the psychiatrist it just is uncanny how something 
can go wrong. It seems like something goes wrong so fast, but 
there is a buildup, and there is something that is the tipping 
point. For him I think it was his interaction with VA, with 
medication, he saw that psychiatrist.
    I know they testified earlier about different health care 
professionals and mental health care professionals. He saw 
three or four people before he ever got to the psychiatrist. 
Well, he had been treated for PTSD for 3 years, so to start 
back over and have to go through all that intake, or whatever 
the term is, was very frustrating.
    I did not tell this part in my testimony. When he saw the 
psychiatrist and he asked to be prescribed the medication that 
he had been on while he was active duty, which was Lexapro--
because that had worked for him with the least amount of side 
effects--when he left active duty and went to VA, he was not 
given that drug. He was changed to a generic version of another 
drug, Celexa.
    Those drugs are so specific. I mean, it takes a long time 
to find one that works and when you do, it is just 
incomprehensible to me that if it is documented, it is in your 
records that finally you found one that worked, and just 
because you transfer out and are under VA care, then you are 
told, well, we do not prescribe that right off the bat. We are 
going to do this.
    So, when he came back and saw that psychiatrist, he said, I 
would like to be put back on that because it worked better for 
me, which he agreed and wrote the prescription. Then, Clay goes 
to the pharmacy at the VA and waits 2 hours. In addition, he 
had sleeping problems and he was given a prescription for 
Ambien.
    So, he goes to the pharmacy and learns they do not stock 
Lexapro because at that time there was not a generic. He was 
told, we can get this for you, but we will have to send it to 
you by mail. It should reach you within 10 days. So, he left 
with a prescription for Ambien, nothing for anxiety, no 
antidepressant, being told it would come in the mail within 10 
days.
    He was so--in his voice when he called, which I said in my 
testimony that he called and said, I cannot go back there--he 
was just very dispirited. It was sort of like, I have fought 
for everything and now here I go with another battle, another 
hurdle to jump over. It seems unnecessary. Just looking back, 
some of that just seems unnecessary.
    The medication for malaria that was brought up by someone, 
Clay's unit, he was part of 2-7 in the Marines, and one of his 
comrades called us a couple of--well, last week and he was just 
distraught. He said, we have lost--that combat in 2008 in 
Afghanistan, that 2-7 group, they lost 20 in combat and they 
have now recently lost their 20th to suicide.
    He was just beside himself. He knew that Richard and I were 
involved in proactively trying to seek better help for them and 
they are struggling. They are worried about each other and I 
cannot even fathom those numbers. He brought up the malaria 
medication. He said, we are wondering, because they were all--
they called it Malaria Monday. They would be given the pill on 
Mondays every week, and evidently there were side effects that 
were not fun.
    But we have worried about Ambien. As we were meeting other 
families who had lost loved ones to suicide, veterans to 
suicide, it has been uncanny how many of them have been on 
Ambien. It just is worrisome.
    Chairman Sanders. My time has long expired, but I wanted to 
ask Mrs. Pallotta the same question. Thinking back.
    Mrs. Pallotta. Thank you. I think Josh went through the 
same things that Clay did with the bureaucracy. Josh actually 
was only in the Guard for a few years. He joined in 2009 
because he knew he was going to Afghanistan and he went right 
to basic training; then they went right to deployment.
    When he was over there he got some back injuries along with 
the PTSD. So, for him to try to get treatment for his back, he 
had to drive an hour-and-a-half to White River Junction in his 
Jeep Wrangler and then an hour-and-a-half back, which he did 
not do because he could not deal with the pain.
    He was on medications which, in fact, the VA has since sent 
us more automatic refills since he has been deceased.
    I try to not--I try to go back and figure things out. What 
went wrong, what could we have changed? I know the fight for 
his disability was an extremely agonizing process and he was 
still only diagnosed at 65 percent.
    He was medically discharged from the Guard in February, I 
believe, and I have since talked to buddies that he was 
deployed with, and every single one of them that I have talked 
to has said, we do not want the medications; we feel like 
zombies. We do not want counselors who are checking their 
watches while we are in our counseling session. We do not want 
a counselor to have to look through my file to find out what my 
name is.
    Josh, fortunately, had a great counselor and he actually 
had started going back to counseling a few weeks before he 
ended his life. He was making headway. He had financial 
difficulties. He ended his 4-year long relationship with his 
girlfriend, which he described to his father as feeling like a 
weight had been lifted off of his shoulders. He had a job that 
he really liked. He was working in a deli in downtown 
Burlington, but they were closing. He felt like it was three 
steps forward and four steps back.
    Going back, I do not know what one thing could have changed 
or what we could have done different. I think, as one of his 
buddies who was with him said, I think Josh just gave up the 
fight and I think it was a little too late. He had a veteran 
outreach worker who gave up on him. He did not want the help, 
so he said, I have got other veterans who want the help, so--
yeah. Thank you.
    Chairman Sanders. Thank you very much. I have gone way, way 
over my time so you take as much time as you need, Senator 
Johanns.
    Senator Johanns. That is no problem because your comments 
are so incredibly compelling. Again, I thank you for being 
here. So, much of what you say is what we hear when we sit down 
with veterans, and all of us have had round table meetings with 
spouses and loved ones and family members and veterans 
themselves. They kind of walk us down through this same 
horrific challenge that they face.
    But I must admit, I was very moved a year or so ago when a 
veteran described to me the experience of separating, 
separating from friends that had held them up on the worst day 
of their life and on and on, and then all of a sudden it is 
just not there.
    Sergeant, you talked about going from combat and 3 days 
later walking down a street in Cody. And again, it is such a 
shock to put yourself in that position and think, oh, my Lord, 
how do you do that? Let me ask the two of you, if there would 
have been a support system of fellow veterans, do you think 
that would have been helpful?
    If, literally, on the day of separation somebody would have 
said, you know, you are going back to wherever home is, here is 
a name and a phone number. You need to touch base because this 
is a group of people who have gone through what you have gone 
through and experienced what you have experienced. Would that 
have made any difference?
    Mrs. Pallotta. I will speak personally for Josh's 
experience. Being in the National Guard is much more difficult, 
I think, and I am not saying this against anybody in the active 
military. Being in the National Guard, when they came home from 
their 2010 deployment they had 3 months off. Then, they came 
together at a Yellow Ribbon event. These were 20-year-old males 
who had not seen each other in 3 months. They went out and they 
got hammered. That was the way that they coped. This was the 
first time they had seen each other and been together in 3 
months.
    I believe that if the reintegration process was different 
where they were mandated to be together as part of drill or 
group therapy and if it happened immediately after they had 
come home from deployment, I think that it would have made a 
huge difference.
    Because a lot of them in my son's unit, there was a huge 
leadership changeover after they came home and they lost that 
unity and they lost that cohesion and they lost that 
brotherhood--the guys who were next to them the whole time, who 
had watched their backs the whole time.
    I mean, my son was aware of group therapy, but I think it 
needed to happen sooner, as opposed to being on an active duty 
military base where you have that atmosphere and that culture 
right there 24/7. The National Guard, they are trying to fit 
into their civilian life. I think they have tried some peer 
support groups at the Vet Centers and the VA, and my son 
contemplated it, but I think it was a little too late.
    Senator Johanns. Too late.
    Mrs. Pallotta. I think it needed to happen when they came 
home from deployment.
    Senator Johanns. That is a good point.
    Mrs. Pallotta. Thank you.
    Mrs. Selke. I would add that prior to leaving the service, 
if there is more of a, I do not know if you call it a 
debriefing or what. We do a great job of training up front to 
make wonderful, you know, wonderful soldiers and Marines out of 
all of these young men and women, and then when it is time to 
leave, time for getting out, our understanding is that it is a 
very brief process of getting out.
    Something that developed actually as a result of Clay's 
death, at his funeral or at his memorial service, several of 
his fellow Marines were there and they realized that there were 
three from his unit that lived within 15 miles of Clay. He did 
not know that; they did not know that. None of them knew that 
the others lived that close to each other, and these were guys 
who literally served together.
    So, on the plane on the way back to L.A., Clay's best 
friend, Jake Wood (who went on to found Team Rubicon), Jake and 
William McNulty came up with the idea of a mobile app for their 
phones. It is in place. It is called POS REP, P-O-S R-E-P, 
which stands for Position Reporting in the military.
    How it works is, as a veteran, when you get out you choose 
to join this group which is a mobile application so that, say, 
while Clay was in Houston, had that app been available, he 
would have been able to register himself and log in to see that 
there were other veterans around him. Maybe not necessarily 
ones that he knew, but it seems that that would be just--I do 
not understand why the VA does not grasp that technology and 
offer that, because this generation, they live on their phones, 
you know, with the technology. It just would be so simple to 
do.
    For Clay to come back to Houston, which is where he grew 
up, to feel so alone and, like you say, feel so isolated, 
things like that; there are things that we can do, that we can 
do better. I do not understand the pushback.
    Senator Johanns. I am out of time, too, but Sergeant, just 
because you talked about your experience, and there was a point 
at which you found others who were going through the same 
experience. You said, my goodness, I am not alone out here. 
What is your reaction to what I have been talking about and 
what these two mothers are talking about? If veterans could 
somehow be joined together, do you think that would make a 
difference here?
    Mr. Vanata. I truly believe that bringing veterans together 
from similar experiences gives them a sense that they are not 
alone, that they have somebody they can talk to. They can talk 
about the things that have occurred in their life that they 
could never, ever say to a counselor or say to a psychiatrist. 
They can joke, they can laugh about things they have seen, 
things they have done that people on the outside might say is 
really inappropriate.
    But, they both understand. And it is a way of rationalizing 
things and giving them an informal support system that they can 
always look to, to talk to each other. I have a good friend in 
Cody. He is retired Army, I am a retired Marine. We could not 
have less in common in that respect. Yet, we rely upon each 
other. It might be a quick text message, it might be a quick 
phone call, something along those lines. I know it helps me and 
I know it helps him.
    I think it would be beneficial. And the dynamics of those 
who separate from the military after doing 4 years, 3 years, 
whatever it is, and those who retire from the military after 
doing 20-plus years, those dynamics are different. But having 
somebody within your peer group available, I think it would be 
beneficial.
    Senator Johanns. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Johanns.
    Senator Moran.
    Senator Moran. Chairman, thank you. You know, I suppose the 
takeaway for me in listening to what has been said is that too 
often we hear the stories. Certainly I, as a member of 
Congress, have heard stories of the bureaucracy, the delays, 
the pushback, the lack of welcome and guidance that needs to 
take place in a department that is designed and created to take 
care of veterans.
    We hear the stories of the bureaucracy and the culture 
there. The takeaway from what I hear you all saying is the idea 
that we just cannot write that off. You cannot say, well, that 
is just the VA. That is just the way the system works and we 
are going to have to figure out how to--I do not know how many 
times I hear about how we have to help, you know, somebody 
navigate the system.
    The system ought not be something that requires navigation. 
It ought to be something that works. I would just tell you that 
I am quite certain that the testimony and your circumstances 
and being here, this cannot be anything that--I know you do not 
want to be here, you do not want to be in these circumstances, 
but there is a benefit to telling the story, because the 
reminder is that while we hear this stuff about the bureaucracy 
of VA, the consequences are something that we are not so 
readily aware of, as we heard from you today.
    My point--I do not think I said it very well--but the point 
being that there can be no excuse. There can be no just kind of 
understanding that, well, that is the way the VA works; because 
if that is true, people's lives are lost. So, thank you for 
telling your stories, as difficult as that is.
    Does anyone have the sense, any of our witnesses here, have 
the sense that anything is changing at the VA, that it is 
different than it was 6 months ago, different than it was in 
2011? Or what you all are telling us is what a soldier 
returning today experiences in the process?
    Sergeant.
    Mr. Vanata. Sir, when I retired and had returned from Iraq 
in 2003, I went to see a counselor at the urging of my wife 
because she felt something was not right, and she was right on 
target. When I went to that counselor, she told me that I was 
the first veteran that she had spoken to from post-9/11 and she 
really did not know how to approach it.
    Senator Moran. This was a counselor at the VA?
    Mr. Vanata. Well, it was through contracted care. It was at 
a CBOC. She referred me to a psychiatrist and a primary care 
physician. The primary care physician said, well, I think you 
have PTSD. He did not go through any kind of an assessment; 
zero. The psychiatrist said, well, yeah, I think the doctor, 
your primary care physician, is correct. You have got PTSD. And 
then they started throwing drugs at me.
    Well, that lasted for about 3 months and then I turned them 
off for about 6 years. When I went back in 2011, it was very 
apparent that they had gone through a steep learning curve; 
that they now understand that there is a lot involved in this. 
I was directed to a doctor in Sheridan, WY, at the VA there 
through telehealth, and she was topnotch. I think she was on 
the leading edge of PTSD treatment.
    Unfortunately, she has retired, but she really--she had it 
in hand. She knew what was going on and it was not through her 
experience with Vietnam veterans, but it was her experience 
with post-9/11 veterans and getting up-to-date on the latest 
and somewhat unconventional treatments.
    Senator Moran. Well, Sergeant, the question then becomes, 
is the problem that we do not know what to do or that we have 
not connected the veteran with the people who do know what to 
do?
    Mr. Vanata. I think it is an issue of not connecting. Where 
I live, I live in a very rural part of the country. To the VA, 
to the hospital, it is 120 miles. If it is snowing, that 3 
hours just converts into 5 hours since I have got to go around 
a mountain range. And you have a lot of guys returning back to 
the United States who are just not connecting because the VA is 
not near.
    A lot of guys have this mind set: there is nothing wrong 
with me, it is the rest of the world that is screwed up. There 
is no outreach. So, from my perspective, the VA is not engaging 
with these returning veterans and letting them know what is 
available, whatever their situation may be, and how to overcome 
obstacles and challenges that they may be facing.
    Senator Moran. And that is where, in part, the technology 
that has been described here comes into play. It is where your 
organization comes into play. I think both the doctor and----
    Dr. Ritchie. We are both raring to jump in here. So, I 
think the short answer to your question is, it depends. When, 
as part of the IOM Committee, when we went out and looked at a 
number of different VAs, we found really highly-variable 
conditions. There were some terrific VAs who were doing on-the-
edge treatment for post-traumatic stress disorder and traumatic 
brain injury, and then there were some others that were not.
    Senator Moran. What is the difference? What is the cause of 
that? Why is there such a difference between two different 
places?
    Dr. Ritchie. Some of them are where they are placed. So, 
for example, the Palo Alto VA right outside of San Francisco, 
you have got a lot of people who want to come to Palo Alto, who 
want to work there. You have got other VAs that are in more 
rural areas, have a tougher time. Part of it is the attitude of 
the staff, though.
    I would like to say, just personally--again, I am a 
veteran, I am retired--I tried to get my comp and pen exam, 
compensation and disability exam. I am a retired colonel. I 
have good friends who work at the Washington VA. I work down 
the street from the Washington VA. Yet, it took me about 2 
years to get my physical completed and done. And I know the 
system. Then, by the way, I could not get any disability 
because I have a job and make too much money. But that is fine; 
I do not need it.
    So, if you are somebody who is struggling-- people who are 
having more problems, they would not answer the phone. So, 
there are still a lot of roadblocks.
    Senator Moran. Well, that was an interesting thing for me 
to learn, is that we sometimes separate the benefits side from 
the health care side of the VA, and what I heard in the 
testimony of one of the moms is the consequences of the backlog 
had a terrible consequence on their son's life. It was one of 
those additional impediments of being stuck.
    We segment oftentimes: this is a health care issue, this is 
a benefits issue. There is a consequence.
    Mr. Smith. So, I think there is another point to be made 
here which was pointed out earlier--that we need to get as far 
upstream of this as we possibly can. I served in Iraq and 
Afghanistan in very challenging conditions, lost friends, 
people that worked under my command, and I received mental 
health care from the VA in Tampa, FL, which is, I think, an 
exemplary facility. In fact, the Tampa director is now in 
Phoenix trying to work there.
    They work very closely with our organization, they are very 
progressive, and so I think it is dependent upon the leadership 
and where you go geographically. And I think DOD has a role to 
play here. I do not want to gloss over this because I came back 
from Afghanistan in 2009 after a horrific deployment.
    You must take a post-combat health assessment survey and I 
answered every one of the bad questions affirmatively. You 
know, did you kill people? Yes. Did you see people killed? Yes. 
Did you fear for your life? Yes. I answered all of those 
affirmatively and so did every guy in my detachment. Yet, we 
were not made to go see a mental health professional, which we 
should be because the stigma there is challenging, especially 
for barrel-chested, bearded Special Forces guys. They are not 
going to go see somebody. If we were all made to go, we would 
have.
    The reference into VA from DOD could have been very 
critical there in both benefits and health care with regard to 
the backlog. So, I think it is incredibly important that we 
make those organizations work together.
    Senator Moran. Thank you. Thank you all.
    Chairman Sanders. Thank you, Senator Moran.
    Senator Boozman.
    Senator Boozman. Thank you, Mr. Chair. Again, I really do 
appreciate all of you being here testifying. As I said in my 
opening statement, you that have been directly involved, there 
is just simply no substitute for you being here. I know it is 
difficult to talk about these things, but we really do 
appreciate it.
    The only thing I would like to know, having three daughters 
that are grown and just having three kids--Mrs. Selke and Mrs. 
Pallotta, you all were in difficult situations, you know, 
dealing with loved ones, with children that were struggling. 
Were you able to get some help as far as knowing how to deal 
with that situation? How did you personally cope in that 
regard----
    Mrs. Pallotta. Well----
    Senator Boozman [continuing]. Because, you know, we have 
got a situation now that if a wounded warrior comes back and he 
has lost a leg or this or that and is in a dire situation 
there, then loved ones could step in and we can direct them as 
to do this or that, provide training. But this is a different 
injury.
    Mrs. Pallotta. It is different and what is ironic--that is 
not even the right word, but I actually was very instrumental 
in chartering the first Blue Star Mothers of Vermont chapter 
and I was a chapter president for 2 years. We were all moms 
from a parent network that started when our boys were getting 
ready to deploy. I say boys because it was infantry and there 
were no women in their unit.
    We had active duty, all branches of the military. The work 
that we do for veterans is to support our veterans by giving 
them financial support, cook meals for veterans in transitional 
housing. We have two in Vermont that we support. And I do not 
know, because I should have. I saw the signs. I worked with 
veterans as part of this organization for over 3 years and I 
still could not save my own son.
    So, I do not know the answer to that. I do know that what 
is frustrating as a parent is there are no support services for 
parents.
    Senator Boozman. That is really what I wanted to know.
    Mrs. Pallotta. We have a Vet Center and they were very 
accommodating to me a few weeks before my son died, because I 
was really struggling with it. But because he was not currently 
being seen at the Vet Center, technically they could not see 
me. The VA would not see me. As a mother of a 20-something 
young male soldier, it is really difficult for us to provide 
support to them and get support for ourselves.
    So, to answer that question, I do not know. I saw the 
signs. We saw the signs. And as an only child--but, you know, 
to use the term again, there is no rule book for it. There is 
no--I do not know. I mean, if I knew the answer to that, we 
probably would not be sitting here. I probably could have saved 
my son.
    Mrs. Selke. I do not know how it can be accomplished, but 
the lack of education about post-traumatic stress disorder or 
traumatic brain injury or what to expect when your veteran 
comes home. You talk about being discharged and leaving the 
military and all of a sudden you are back in a small town and a 
totally different culture.
    As a parent, you have lived through two deployments. You 
have lived through your child, who is a 28-year-old scout 
sniper, survived two wars, and then they come home and they 
are--even if they are open about it, you do not know what to do 
as a parent other than encourage them to get help.
    As a parent, I felt as well that the VA would be the source 
of that help for him because they know about war, they know 
what he had dealt with. As far as educating us, I never really 
thought about that until we started doing this kind of work, to 
think, Who could we have asked? Where could we have gone as a 
resource to say, our son has been diagnosed with this; is there 
anything we need to know to look out for?
    I think as a parent, too, these are strong young men and 
women. The people they want to protect the most are their 
family. Clay did not want to worry us, and I think there were 
times when he would put on a good face as in, I am a tough 
Marine, I can handle this, I know what to do.
    As a parent, maybe you are fooling yourself. What you want 
to believe is that they are going to be OK, that there are 
educated, qualified people taking care of whatever it is that 
they need medically. So, an education piece, as military folks 
are transitioning out, for families--I am not sure how that is 
accomplished--would be very helpful.
    Senator Boozman. Thank you very much. Thank you, Mr. 
Chairman.
    Chairman Sanders. Thank you, Senator Boozman. Well, this 
has been a very important hearing. I just want to thank all of 
the panelists for being here, and especially the moms for doing 
what we know has been very, very difficult. I think you are 
here to make sure other families do not experience what you 
have experienced, and I think you have helped us very much in 
doing that.
    To everybody else, thank you for the great work that you 
all are doing. With that, the panel is concluded.
    [Whereupon, at 1:34 p.m., the hearing was adjourned.]
                                ------                                

 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
 Mrs. Susan Selke, mother of Clay Hunt, a deceased Marine Corps combat 
                                veteran
    Question 1. Mrs. Selke, thank you for your deeply moving testimony. 
My question for you is when your son sought services from the VA, did 
he have to provide additional documentation to substantiate claims for 
exposure to situations that could be linked to PTSD?
    Response. I appreciate the question from Senator Brown. 
Unfortunately, I don't know the answer. Clay was diagnosed with PTSD 
during active duty in 2007. He separated from the Marines in 2009 and 
began going to the VA in Los Angeles. I don't know if they asked for 
additional information or if they based his care on his active duty 
medical records.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
       Mrs. Valerie Pallotta, mother of Vermonter Joshua Pallotta
    Question 1. Mrs. Pallotta, thank you for your deeply moving 
testimony. My question for you is when your son sought services from 
the VA, did he have to provide additional documentation to substantiate 
claims for exposure to situations that could be linked to PTSD?
    Response. From my recollection Josh did have to provide additional 
documentation to substantiate his claim for PTSD. I know that he went 
through a series of disability tests.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
   MSgt Vanata, USMC (Ret.), Combat Stress Recovery Program, Wounded 
                            Warrior Project
    Question 1. In your testimony you mentioned that the doctor in 
Wyoming never even had the chance or the time to really review your 
chart when you sought services. I am curious, when you were filing for 
help, obtaining counselling, or anytime thereafter, were you required 
to submit additional information to corroborate your exposures to PTSD 
or TBI while serving in Iraq?
    Response. [No response was received.]
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
   COL Elspeth Cameron Ritchie, USA (Ret.), Chief Clinical Officer, 
           District of Columbia's Department of Mental Health
    Question 1. Colonel Richie, in your study you mentioned that ``most 
veterans who have PTSD are not receiving care in VA specialized PTSD 
programs.'' Given your experience in the Army, at the D.C. Department 
of Mental Health, and the Institutes of Medicine, do you believe the 
DOD is doing enough to sharing information about a servicemember's 
potential exposure to PTSD and TBI causal events with the VA and the 
transitioning servicemember? What more could be done by the DOD to 
share corroborative evidence with the VA?
    Response. [No response was received.]

                            A P P E N D I X

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      Report of Citizens Commission on Human Rights International
      
      
      
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