[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


  COMBATING THE CRISIS: EVALUATING EFFORTS TO PREVENT VETERAN SUICIDE

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

                                 HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         THURSDAY, MAY 12, 2016

                               __________

                           Serial No. 114-68

                               __________

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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
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both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
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                            C O N T E N T S

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                         Thursday, May 12, 2016

                                                                   Page

Combating The Crisis: Evaluating Efforts To Prevent Veteran 
  Suicide........................................................     1

                           OPENING STATEMENTS

Honorable Jeff Miller, Chairman..................................     1
Honorable Corrine Brown, Ranking Member..........................     3
    Prepared Statement...........................................    47
Honorable Timothy Walz, Member, Prepared Statement only..........    47

                               WITNESSES

Jacqueline Maffucci, Ph.D., Research Director, Iraq and 
  Afghanistan Veterans of America................................     4
    Prepared Statement...........................................    65

Joy J. Ilem, National Legislative Director, Disabled American 
  Veterans.......................................................     6
    Prepared Statement...........................................    67

Thomas J. Berger, Ph.D., Executive Director of the Veterans 
  Health Council, Vietnam Veterans of America....................     8
    Prepared Statement...........................................    73

Kim Ruocco, Chief External Relations Officer for Suicide 
  Prevention and Postvention Tragedy Assistance Program for 
  Survivors......................................................     9
    Prepared Statement...........................................    76

Maureen McCarthy, M.D., Assistant Deputy Under Secretary for 
  Health for Patient Care Services, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............    11
    Prepared Statement...........................................    81

        Accompanied by:

    Harold Kudler, M.D., Chief Consultant for Mental Health 
        Services, Veterans Health Administration, U.S. Department 
        of Veterans Affairs

    Caitlin Thompson, Ph.D., National Director for Suicide 
        Prevention, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

 
  COMBATING THE CRISIS: EVALUATING EFFORTS TO PREVENT VETERAN SUICIDE

                              ----------                              


                         Thursday, May 12, 2016

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[Chairman of the Committee] presiding.
    Present: Representatives Miller, Brown, Lamborn, Takano, 
Bilirakis, Brownley, Roe, Titus, Benishek, Ruiz, Huelskamp, 
Kuster, Coffman, O'Rourke, Wenstrup, Rice, Walorski, Walz, 
Abraham, McNerney, Radewagen, Zeldin, Costello, Bost.

           OPENING STATEMENT OF JEFF MILLER, CHAIRMAN

    The Chairman. The Committee will come to order. Good 
morning, everybody. Thank you for being with the Committee for 
today's Oversight Hearing entitled, ``Combating the Crisis: 
Evaluating Efforts to Prevent Veteran Suicide.''
    As the hearing title suggests, we are here this morning to 
discuss the ongoing veteran suicide crisis that, according to 
the latest data available from the Department of Veterans 
Affairs finds 22 veterans a day dying at their own hands.
    I am disappointed that the VA was not able to release 
updated veteran suicide statistics at this time for this 
hearing. I understand that the Center for Disease Control 
finally provided national data to VA in the middle of March. 
Considering the critical interest in updated veteran suicide 
data, I can't emphasize enough the need for VA to pursue their 
analysis with a sense of urgency.
    It is my fervent hope that the new data will show a 
reduction in the rate of veteran suicides as a result of the 
investments we have made in VA mental health care and suicide 
prevention. Regardless, I am hopeful that VA's witnesses today 
will be able to provide some more recent insights into the 
numbers of veteran suicides, and to shed some light on whether 
the efforts dedicated to this crisis are indeed making any 
impact.
    I recognize the challenges that VA, and indeed the American 
health care system as a whole faces in preventing suicides. The 
rates of suicides have risen significantly over the past 15 
years for almost every single demographic except for veterans, 
and I think that is due in large part to the hard work that VA 
health care providers do every day to extend helping hands to 
those most in need, but that is not to imply that the current 
rate is in any way acceptable.
    I continue to be concerned that, again, according to the 
latest data from VA that is admittedly dated, the number of 
veterans dying by suicide has not fallen despite significant 
increases in budget, in staff and programming for VA mental 
health care, and a number of targeted veteran suicide 
prevention initiatives. It is not enough for veteran suicide 
rates to remain stable, our work will not be over until veteran 
suicide rates are eliminated.
    There are many reasons a person may choose to take their 
own life, and there are many opportunities along the way for 
someone to step in and to intervene. VA should certainly be 
proud that veteran suicide rates have not risen along with 
rates in the general population, but there is clearly a deadly 
disconnect between the many services and supports that VA 
offers and the veterans that most need our help.
    Care, particularly for someone that is contemplating 
suicide, is not one-size-fits-all. And while suicide 
undoubtedly is a mental health issue, it is also much more than 
that. Eliminating veteran suicide all together will take a 
comprehensive approach to ensure that those most at risk have 
not only the care they need, but also a job, a purpose, and a 
system of support in place to help carry them through their 
struggles.
    Therefore, VA must adopt a suicide prevention strategy that 
recognizes the need for wraparound services, that treats 
patients as individuals, and embraces complementary and 
alternative approaches to care where appropriate.
    Furthermore, VA needs to better integrate a veteran and 
family perspective that incorporates the lessons learned from 
those who have been on the front lines of the fight against 
suicide, and can offer a personal perspective and a message of 
hope to those that are still struggling today.
    Last year, the Clay Hunt Suicide Prevention For American 
Veterans, or SAV Act, was signed into law. This law was named 
after a brave, 28-year-old Marine, Clay Hunt, who returned from 
battle against our enemies in Iraq and Afghanistan, but who in 
2011 lost his personal battle to the demons he brought home 
with him from those conflicts.
    The law included a number of provisions that I believe will 
help connect veterans in crisis with the care that they need 
both in VA, and in their communities that will provide valuable 
information about what programs are working for veterans in 
crisis, and assist VA in recruiting high-quality mental health 
professionals to treat veteran patients. Fully implementing the 
Clay Hunt SAV Act should be VA's highest priority.
    I look forward to discussing the Department's progress to 
date and hearing about how the implementation of that important 
legislation is helping VA's efforts to prevent suicide among 
our Nation's veterans. In Clay's memory and in the memory of 
the countless other veterans who have lost their lives to 
suicide, we have to do better.
    With that, I yield to the Ranking Member, Ms. Brown, for an 
opening statement that she may have.

       OPENING STATEMENT OF CORRINE BROWN, RANKING MEMBER

    Ms. Brown. Thank you, Mr. Chairman, for calling this 
hearing today.
    Strong oversight of the Department suicide prevention 
program remains a priority of this Committee. We are all aware 
of the often-cited statistics of 22 veterans a day committing 
suicide. We also note that VA reports in 2014 that there is a 
decreased rate of suicide among users of the Veterans Health 
Care System with mental health conditions. The question becomes 
how can we ensure ready access to safe, quality mental health 
services to veterans in need of care.
    I hope that the VA witnesses here today will be able to 
update us on those numbers, as much of the country was not 
included in previous estimates.
    My subject that concerns me relates to the new MyVA 12 
breakthrough priorities. I understand that addressing the 
suicide problem is not one of those. Increased access to health 
care, improving comprehensive and pension exams, continue to 
reduce homelessness, and transform the supply chains are all on 
the list, but specifically reducing suicide is not included. 
Given that suicide nationally is considered by some to be a 
public health problem, I believe VA should include suicide 
prevention as number one of MyVA priorities.
    I look forward to VA testimony on this and where suicide 
prevention fits into the 12 priorities. I still believe that 
suicide prevention should be one priority of their own, top 
priority.
    This hearing will also examine and implement the Clay Hunt 
Suicide Prevention for American Veterans Act, passed in the 
early days of the 114th Congress. This law focused the Nation 
on this terrible epidemic affecting veterans. This law requires 
that the Secretary of Veterans Affairs and the Secretary of 
Defense arrange for an outside evaluation of their mental 
health care and suicide prevention. It also requires any 
servicemember being discharged to have their case reviewed for 
any evidence of post-traumatic stress disorder or trauma, brain 
injury, or military sexual trauma.
    We have been at war for over 14 years, there are many 
veterans out there who do not engage the VA care system for 
purposes of mental health treatment, veterans from all era. 
Today the discussion should include how VA is going to reach 
out to these veterans.
    And I definitely want to say that one of the major 
problems, and I thank the VA for having the conference on 
suicide prevention that I was able to attend, but one of the 
points that was pointed out that many of the veterans, even 
though we have 22 a day, only three of them are involved in the 
system, and many of them are Vietnam veterans who when they 
returned home, wasn't received properly. So we need to figure 
out how we are going to reach out to these veterans and include 
them in the system.
    And with that, Mr. Chairman, I yield back the balance of my 
time.
    [The prepared statement of Corrine Brown appears in the 
Appendix]

    The Chairman. Thank you very much, Ms. Brown.
    With us this morning is Dr. Jackie Maffucci, the Research 
Director for the Iraq and Afghanistan Veterans of America; Joy 
Ilem, the National Legislative Director for the Disabled 
American Veterans; Thomas Berger, the Executive Director of the 
Veterans Health Council for the Vietnam Veterans of America; 
and Kim Ruocco, the Chief External Relations Officer for 
Suicide Prevention and Postvention for the Tragedy Assistance 
Program for Survivors.
    And we are also joined by Dr. Maureen McCarthy, VA's 
Assistant Deputy Under Secretary for Health for Patient Care 
Services, who is accompanied by Dr. Harold Kudler, VA's Chief 
Consultant for Mental Health Services, and Dr. Caitlin 
Thompson, VA's National Director for Suicide Prevention.
    Thank you all for being here today to testify before our 
Committee.
    Dr. Maffucci, you are recognized for five minutes.

                STATEMENT OF DR. JACKIE MAFFUCCI

    Dr. Maffucci. Thank you. Chairman Miller, Ranking Member 
Brown and Committee Members, on behalf of IAVA, thank you for 
the opportunity to share our views on this critical issue.
    In 2014, IAVA launched the Campaign to Combat Suicide, a 
result of our members continually identifying mental health and 
suicide as the number-one issue facing post-9/11 vets. This 
campaign centers around the principle that timely access to 
high-quality mental health care is critical in the fight to 
combat suicide.
    The signing of the Clay Hunt SAV Act into law was an 
important first step. We thank Richard and Susan Sulky for 
courageously inspiring us all to do the right thing, Congress 
for passing this legislation, and the VA for their commitment 
to fully implement the law.
    We knew it would take time, and we are pleased that we have 
been included in the process. We are committed to working with 
the VA, Congress and our VSO partners to progress both the SAV 
Act and new initiatives that are certain to follow.
    Personally, I have been working on this issue for about 
eight years and never in that time have I seen a movement 
around this issue so strong or a collective will so unified 
than in this last year. The conversations are moving to action, 
and it is our responsibility to make sure that this continues.
    So today I would like to focus on four specific areas 
critical to progress: access to care, interdisciplinary 
approach to care, supporting those most at risk, and the 
importance of research.
    In IAVA's annual member survey, over 80 percent of members 
with a mental health injury reported seeking care. This is an 
increase from our last survey. They continue to emphasize the 
role of the family and friends with over 75 percent who 
reported having a loved one suggest they seek help and, as a 
result, getting that help.
    For those in care, three of four of our members are using 
the VA. This year, we saw over 75 percent of those using VA 
mental health services report little to no scheduling 
challenges, which is up ten percent from last year and 
comparable with those using a non-VA clinician. The same number 
were also satisfied with that care. But with more help seekers 
comes more demand, and it is critical to ensure that the VA is 
properly resourced to provide this high-quality care.
    Efforts are under way with the Administration to bolster 
the VA workforce, recruiting medical students and improving 
curricula, but that is not enough. Beyond the challenge of a 
clinician shortage is the difficult task of hiring and 
retaining talent in the VA. The Federal hiring process is 
confusing and lengthy, at times deterring or rejecting 
qualified candidates; it must be made easier.
    The VA needs to fully understand why staff are leaving. 
They need to know how best to attract and retain talent, and to 
use updated staffing models and real-time data to establish 
where the need is. Climate surveys are showing that in large 
part, VA is losing staff because of noncompetitive salaries and 
low morale. We all play a role in workforce morale at the VA.
    We often forget to praise the dedicated staff who support 
VA's mission, some of whom are IAVA members. Our members have 
shared stories of the great work and dedication of these staff, 
relaying how these individuals saved their lives or cared for 
them in some of their hardest moments. We all must do our part 
to help celebrate what makes the VA good, while also focusing 
on how to make it better.
    Finally, we need to ensure that high-quality care exists 
outside VA. Just under 40 percent of the veteran population 
actually seeks care at VA, which means the current community 
clinical workforce needs to be equipped to support veterans and 
their families and our recent-ran report suggests this is not 
the case. It is not even common practice to ask a military 
history, this has got to change. But beyond asking about 
military histories, community care doctors need to know how 
best to provide treatment once they have the answer, and the VA 
and its academic partners are best equipped to lead this 
effort.
    But it is not just about mental health care. In February, 
IAVA and VVA called upon the Secretary to elevate the VA's 
Suicide Prevention Office, and we are pleased that that call 
was answered. While mental health is a major aspect of suicide 
prevention, it is not the only aspect. There are social factors 
that impact this as well.
    For the VA Suicide Prevention Office to truly take a public 
health approach to decreasing suicide, it must have impact 
wherever veterans and their dependents go. Within VA, this has 
to include VBA. So we ask Congress to ensure that the office, 
the Suicide Prevention Office is fully resourced through a line 
item on the budget, so that it can be certain to carry out its 
critical mission.
    We have also been focused on veterans with bad paper. This 
is a community that has been identified at high risk for 
suicide and homelessness. We can do something about this. IAVA 
urges passage of the Fairness for Veterans Act as part of the 
solution, but we also know that we together need to come up 
with a comprehensive solution with Congress, DoD and VA.
    And yet with all of this, we simply don't know enough yet, 
and this is where the research piece comes in. We know that 
suicide impacts seniors disproportionately, but we don't know 
why. We know that women vets have a high rate of suicide, but 
don't understand how best to intervene. This is why IAVA 
supports the House-passed Female Veterans Suicide Prevention 
Act, and calls on the Senate to take immediate action on the 
bill. We know that the post-9/11 generation are showing an 
increased risk, but are just starting to understand the risk 
factors to impact interventions.
    More research and evaluation is critical to developing 
these interventions. We simply cannot solve what we don't 
understand.
    The VA has a wealth of research and a wealth of data, and 
they need to call upon academics to partner with them. And so 
we are asking the VA to open up their data and invite academics 
to help be their army to look at this data and help us find the 
solutions.
    All veterans deserve the very best our Nation can offer. We 
look forward to working with Congress and the Administration to 
address these very real challenges with informed solutions.
    Thank you.
    [The prepared statement of Dr. Jackie Maffucci appears in 
the Appendix]

    The Chairman. Thank you very much, Doctor.
    Ms. Ilem, you are recognized for five minutes.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Mr. Chairman. We appreciate the 
opportunity to testify as well on this important issue.
    Over the past decade, VA has enhanced and promoted a 
comprehensive set of mental health services, including 
integration of mental health into primary care, and a goal of 
improving access, minimizing barriers and reducing stigma.
    Research shows early intervention and timely access to 
mental health care are key to improving quality of life, 
promoting recovery, obviating long-term health consequences, 
and minimizing the disabling effects of mental illness and the 
risk of suicide.
    In recent years, VA's mental health programs and suicide 
prevention efforts have been both praised and criticized. 
Outside sources have described the scope, depth and breadth of 
VA's multi-variant mental health approaches as superior to care 
in the private sector. Additionally, data shows that VA users 
have a lower suicide rate than veterans not using the VA Health 
Care System, as you have noted. However, there have been 
documented issues with access in the past, over-prescribing of 
medications and serious failures for some veterans, along with 
a call to action to do more to prevent suicide in this 
population.
    In our opinion, VA has two major challenges. One, to ensure 
it meets the diverse needs of an increasing number of veterans, 
enrolled veterans, who need specialized mental health services 
and, two, how to effectively outreach to veterans who are not 
using VA, but are in crisis or in need of help.
    Younger veterans indicate they prefer a variety of 
nontraditional therapies over medication, such as Web-based 
life coaching, yoga, meditation, and acupuncture. While VA is 
steadily increasing the availability of these non-medical 
approaches, there is still variability of access to 
complementary and alternative services across the system.
    This past weekend DAV, along with a group of community-
based organizations, sponsored a Spartan Weekend for ill and 
injured veterans, centered on the promise that they would not 
take their own lives without reaching out to someone for help. 
The event reached 1.8 million Facebook and other social media 
users, and resulted in a number of veterans reaching out for 
help for the first time.
    We believe these types of community events will be 
essential for connecting non-VA users to the mental health 
services they need.
    Another challenge VA faces is how to ensure veterans with 
war-related mental health issues get quality care in the 
community through the Choice program. While DAV prefers VA to 
be the provider of specialized mental health services whenever 
possible, immediate access to care is the most critical factor 
for a veteran in a mental health or emotional crisis.
    This group can particularly benefit from VA's peer-to-peer 
program, its expertise in treating PTSD, substance use 
disorder, and TBI, as well as the wraparound services and other 
post-deployment transition challenges they often face.
    If a veteran with mental health issues needs to access care 
in the community, we urge VA to routinely follow-up with the 
veteran to ensure the patient is receiving quality and 
effective care from a provider with expertise in treating 
veterans with war-related or sexual trauma.
    Another area we recommend VA put focus on is crisis 
management. When a veteran is experiencing a mental health 
crisis and asking for help, there must be ready access for 
mental health services. We are pleased in that regard that VA 
has been working to improve training and services through its 
crisis line and pilot new programs for peer specialists, who 
have been found to be very effective in helping to coach 
veterans into care and keeping them in care.
    Another area we urge focus on is women veterans. According 
to VA, the suicide rate is six times higher for women veterans 
compared to civilian women. Increased suicide rates are also 
reported among women who have experienced military sexual 
trauma. However, it is encouraging to learn that women veterans 
who use VA health services were 75-percent less likely to die 
by suicide than women veterans who did not use VA. This data 
suggests that VA's mental health programs for women, including 
suicide prevention efforts, are showing promise and positive 
results, and that a concerted focus on this subgroup of 
veterans should be continued.
    We do, however, suggest that there be improved access for 
women veterans to specialized in-patient and residential mental 
health programs to ensure recovery and effective reintegration. 
VA must ensure all of its mental health programs meet the 
unique needs of women, including safety and privacy concerns.
    In closing, we urge VA to continue its training and 
partnerships with the community providers, improving its mental 
health programs and research on suicide prevention, and to find 
innovative ways to engage all veterans who need specialized 
mental health services. We ask Congress to do their part as 
well, providing VA with the resources to address expansion of 
mental health programs, their recruitment challenges, staffing 
issues, and ongoing research.
    It is our hope that as a community, we can work together to 
ensure that any veteran who needs help can get it.
    Mr. Chairman, that concludes my statement. Thank you.
    [The prepared statement of Joy Ilem appears in the 
Appendix]

    The Chairman. Thank you.
    Dr. Berger, welcome, and you are recognized for five 
minutes.

                   STATEMENT OF THOMAS BERGER

    Mr. Berger. Thank you, Chairman Miller and Ranking Member 
Brown, and distinguished Members of the House Veterans' Affairs 
Committee.
    Vietnam Veterans of America thanks you for the opportunity 
to present our testimony regarding the Department of Veterans 
Affairs efforts to reduce suicide among the veteran population.
    The timing of this HVAC hearing is particularly important, 
as some of you may have read the recent National Center for 
Health Statistics report that found that suicides in the United 
States has surged to the highest levels in nearly 30 years, 
with increases in every age group except for older adults in 
the age group, both men and women, over the age of 75. The 
overall suicide rate has risen by 24 percent from 1999 to 2014, 
according to that report, and the increases were so widespread 
that they lifted the Nation's suicide rate to 13 per 100,000 
people, the highest since 1986.
    There is absolutely no doubt that this country is in the 
midst of a public health crisis with suicide and nowhere is 
that any more true than in the veterans community, as we 
learned back in February, 2013 with the VA's report on veterans 
who die by suicide. In particular, that report painted a 
shocking portrait of what is happening amongst our older vets, 
my cohort and those who served before me, because almost three 
quarters of the veterans who commit suicide, based on that 
report, are age 50 or older, according to that report.
    And even though suicide has become a major focus for the 
military over the last decade, most research by the Pentagon 
and the Veterans Affairs Department is focused on men, who 
account for more than 90 percent of the Nation's 22 million 
former troops, little has been done or focused on female 
veteran suicide until recently.
    According to an L.A. Times article in July, 2015--and by 
the way, I have to apologize, my written testimony says July, 
2016, I can't read into the future, and I need to get my auto 
correct fixed on my machine-- anyway, the suicide rates are 
highest among young female veterans for women ages 18 to 29. 
Veterans kill themselves at nearly 12 times the rate of non-
veterans.
    And according to that same Times article, amongst that 
cohort that was looked at, the suicide rate of female veterans 
closely approximate that of male counterparts, in effect, women 
vets at 28.7 per 100,000 versus 32.1 per 100,000 male vets.
    But we also can't forget, as the Chairman has alluded, that 
it is from that 2013 report that the figure of 22 veteran 
suicides per day is calculated. This number is suspect because 
of the data only representing numbers reported from 21 states 
from 1999 through 2011 and did not include states with massive 
veteran communities like California and Texas, which didn't 
report their suicides to the VA at the time.
    Therefore, VA calls for an updated veteran suicide report 
that includes data from all 50 states and U.S. territories, and 
also we strongly suggest that VA mental health services develop 
a nationwide strategy to particularly address the problem of 
suicides amongst our older veterans. Now, obviously I am 
speaking on behalf of our Vietnam Veteran-era group.
    At the same time, we understand it is very challenging to 
determine an exact number of suicides, but we have got to 
overcome the barriers, identify and overcome the barriers that 
prevent our servicemembers from seeking the help that they need 
and that they deserve.
    VVA is heartened in particular by the efforts the VA has 
made since February, 2016, including those efforts that were 
mentioned by Dr. Maffucci earlier. While these initiatives are 
laudable, VVA also believes strongly they cannot be fully 
successful without a significant increase in the recruitment, 
hiring and retention of VA mental health staff, as well as 
timely access to VA mental health clinical facilities and 
programs, especially for our rural veterans. And this Committee 
is in a position that can ensure that our veterans and their 
families are given access to the resources and programs 
necessary to stem the tide of veteran suicide.
    Once again, on behalf of VVA's national officers, board and 
general membership, thank you for your leadership and holding 
this important meeting, and I will be glad to answer any 
questions.
    [The prepared statement of Thomas Berger appears in the 
Appendix]

    The Chairman. Thank you.
    Ms. Ruocco, you are recognized.

                    STATEMENT OF KIM RUOCCO

    Ms. Ruocco. Chairman Miller, Ranking Member Brown and other 
distinguished Members of the Veterans' Affairs Committee, the 
Tragedy Assistance Program for Survivors, TAPS, thanks you for 
the opportunity to share stories from surviving family members 
of servicemembers and veterans who have died by suicide.
    These families are honored to have a voice in this process 
and they gain healing from the thought that this testimony in 
remembrance of their loved one may in fact save a life.
    My name is Kim Ruocco and I am Chief External Relations 
Officer for Suicide Prevention and Postvention for the Tragedy 
Assistance Program for Survivors. Following my husband's death, 
I joined together with Bonnie Carroll and TAPS to build a 
comprehensive peer-based support program for all those who are 
grieving a death of an active-duty servicemember or recent 
veteran who had died by suicide.
    TAPS' ultimate goal is to help these families of the fallen 
to rebuild their lives on a solid foundation of hope, healing, 
love, and a new sense of belonging after a death by suicide. 
TAPS presently has over 7,000 suicide survivors from the 
military and 700 survivors of military murder-suicide.
    For the purpose of today's testimony, I have gathered 
information from family members who have recently lost a 
veteran to suicide. Survivors of military suicide hold a wealth 
of information on the multiple factors that lead up to this 
kind of death. They are on the front lines of a servicemember 
or veteran's battle with PTS, DBI, mental illness, moral 
injury, and the multiple stressors associated with military 
life. They are witness to the challenges of stigma associated 
with mental health and the barriers to care for those who are 
suffering. Survivors of veteran suicide loss can provide us 
with a picture of potential impact of challenges within the VA 
system. Today's testimony is a summary of information gathered 
from these families.
    The first common theme was barriers to care. It is 
important to note that in each case, that I have highlighted 
the veteran was not in ongoing, consistent, evidence-based 
treatment at the VA. In most cases, the veteran struggled to 
get the care they needed in a timely fashion. In some cases the 
veteran himself or herself was the first barrier to good care 
because of their cultural beliefs, their stigma regarding 
mental health. This reluctance to share their true story, fear 
that they would not be believed or insistent that they need to 
push through and suck it up, in combination with institutional 
barriers, can become a perfect storm for those veterans that 
are suffering.
    Families of these veterans struggled to help their loved 
one and often became frustrated and overwhelmed with navigating 
the system. Many of them express frustration with the lack of 
their involvement in the assessment and treatment of their 
loved one. They claim that part of the veteran culture is to 
not complain or admit to emotional and physical pain, and to 
downplay how serious their issues actually are. Families feel 
strongly, if they were present for intakes and evaluations, 
they would have had a more accurate diagnosis and treatment 
plan. Most families state that it was difficult to get the 
veteran to go and agree to get help, and then when they did go, 
it was usually during a crisis period and there was long waits 
or inability to see someone at that time, or a misunderstanding 
of their struggles or a missed diagnosis.
    The second theme that was throughout all of our families' 
conversations was the quest for peer support. In each case, the 
family tells TAPS that the veteran only wanted to talk to 
someone else who had been there. The veteran had a lot of shame 
and guilt about the symptoms they were feeling, and thought 
that these symptoms were a weakness in them and not an illness. 
This false belief became a barrier to getting timely, 
appropriate treatment.
    Peer support can be used to build trust and eventually 
leads to an understanding that their symptoms are real and 
valid, and that there is treatment that works. Peers serve as a 
beacon of hope that those who are struggling could offer a 
roadmap to navigating the system.
    So here are our recommendations based on our findings. We 
have to increase the number of mental health providers that are 
trained in evidence-based best practices for treatments of 
these injuries and illness. At each contact, a veteran should 
be able to get appropriate mental health care in a timely 
manner, and this is especially true in crisis points like ERs, 
outpatient clinics and primary care.
    Two, the families would love to develop advocacy and 
information groups that can offer support and guidance for 
those who are supporting a veteran, so they can get answers.
    Number three, develop an avenue for family members to call 
for professional advice and get guidance on symptoms, 
treatment, and how to get their loved one into care.
    Four, make peer support specialists a line item. Peer 
support is an invaluable tool and reciprocal relationship that 
adds value to all involved. Peer support specialists can be 
used to reach out to these veterans where they are and build a 
bridge towards treatment and help them stay in treatment.
    And finally, five, increase incentives for and streamline 
process for peers to become mental health professionals. In the 
case of veterans, personal experience adds a level of trust and 
credibility that greatly increases the probability of a veteran 
seeking treatment and staying in treatment.
    Thank you so much for listening to us today. We have many 
families that came to me and would like their stories heard, 
and we have those available to you, if you would like to hear 
them in the future.
    Thank you very much.
    [The prepared statement of Kim Ruocco appears in the 
Appendix]

    The Chairman. Thank you very much for your testimony.
    Dr. McCarthy, you are recognized for five minutes.

               STATEMENT OF DR. MAUREEN MCCARTHY

    Dr. McCarthy. Good morning, Chairman Miller, Ranking Member 
Brown and Members of the Committee. Thank you for the 
opportunity to discuss the effectiveness of the Department of 
Veterans Affairs mental health programs and our efforts in 
preventing veteran suicide.
    I am accompanied by Dr. Harold Kudler, Chief Consultant for 
Mental Health, and Dr. Caitlin Thompson, National Director for 
Suicide Prevention.
    VA has developed the largest integrated suicide prevention 
program in the country. We have over 800 dedicated and 
passionate employees, including suicide prevention 
coordinators, Veterans Crisis Line staff, epidemiologists, and 
researchers who spend each day preventing suicide and caring 
for veterans.
    Our overarching strategy enhances veterans' access to high-
quality mental health care and implements upstream programs 
designed to help veterans before they consider suicide. 
Veterans who reach out for help must receive that help when and 
where they need it in a way that makes sense for each of them.
    We do have a good story to tell today, one in which we wish 
to share hope and progress, and in which we want all veterans 
to know that VA is here to help, but the rest of the story is, 
we still have work to do. We are pleased to share our progress 
and the opinions of others outside of VA about the quality of 
our efforts.
    On February 2nd, we hosted a summit on ``Preventing Veteran 
Suicide: A Call to Action,'' to bring together veterans, 
families, other Federal agencies, community partners, veteran 
service organizations, subject matter experts, Members of this 
Committee, and other key partners to enhance our work on 
suicide prevention.
    Powerful for so many attendees were the stories shared by 
veterans and their families. These stories truly resonated with 
us.
    Just as we don't prevent sudden cardiac death only when it 
is happening, we know that suicide prevention does not 
necessarily begin with our crisis line or other interventions 
when suicide is imminent. Our efforts are about hope, finding 
reasons for living, leading a high quality life, and developing 
strong, meaningful relationships. Engaging veterans in VA care, 
and in particular in our whole system of care, is a key part of 
prevention. Addressing their job concerns, substance abuse, 
homelessness, financial concerns, general medical health, and 
of course mental health are all important steps in preventing 
suicide.
    The Call to Action generated multiple recommendations and 
initiatives to strengthen VA's approach to suicide prevention. 
For example, a pilot project is underway to evaluate risk-
intervention strategies based on data that predict who would be 
at risk for suicide before these individuals reach a crisis.
    Also, VA continues to actively monitor suicide-related 
behaviors through our Suicide Prevention Applications Network. 
We are working to develop a dashboard that will allow us to 
identify possible clusters of suicide-related behaviors, and to 
trigger meaningful responses or interventions.
    VA remains committed to ensuring the safety of veterans, 
especially when they are in crisis. We do have universal access 
for 24/7 emergency care through our emergency departments and 
by VA's Veterans Crisis Line. The program continues to save 
lives and link veterans with effective ongoing mental health 
services on a daily basis.
    Preventing suicide also requires access to mental health 
care, as our partners on the panel have noted. Between 2005 and 
2015, the number of veterans who receive VA mental health care 
grew by 80 percent, a rate of increase more than three times 
that of the overall growth of VA users. This reflects VA's 
concerted efforts to engage veterans new to our system and 
stimulate better access to mental health services. We remain 
committed to eliminating the stigma associated with receiving 
mental health care. In 2007, we rolled out integrated mental 
health services in primary care clinics, which allow veterans 
to receive warm handoffs from their primary care team to a 
mental health provider present in the primary care clinic on 
that same day.
    VA has also moved to patient-centered community care, a 
centralized contracting mechanism, and has implemented the 
Choice program. We are addressing access through our efforts 
such as extended hours to help increase capacity and the hiring 
over 900 peer specialists, while expanding their role into 
primary care settings.
    We partner with more than 150 mental health organizations 
around suicide prevention. We recognize that we cannot do this 
alone, and we continue to develop and prioritize these 
partnerships.
    We are aware that some veterans are at an even greater risk 
of suicide. We have individual and group-specific interventions 
tailored to help these high-risk veterans. Of course, any risk 
for any veteran is one we must continue to address.
    VA has taken steps to implement each of the requirements of 
the Clay Hunt Suicide Prevention for American Veterans Act, 
including our Call to Action. VA has contracted with an 
independent third party to conduct evaluation of mental health 
and suicide prevention programs, we are collecting self-report 
outcome data from veterans newly receiving mental health care, 
we are working towards release of a Web site that provides 
easily accessible information about all the mental health 
services for veterans. Currently, the VA facility locator tool 
is accessible on several sites, including VA's home page. It 
includes contact and resource information for a variety of 
mental health programs.
    Mr. Chairman, the crisis of suicide among veterans 
mobilizes us to continuing and expanding upon the work we have 
done. We remain focused on providing the highest quality of 
care for our veterans while trying to understand more about 
precursors of suicide among veterans. We appreciate the support 
of Congress, those at this table and all partners in our 
mission, and we will be happy to respond to any questions you 
may have.
    Thank you.
    [The prepared statement of Dr. Maureen McCarthy appears in 
the Appendix]

    The Chairman. Thank you very much, Doctor. You talked about 
having contracted a review of your suicide-prevention programs 
and other outreach efforts. When do you expect to receive the 
final product from that review?
    Dr. McCarthy. So the contract is with the Enterprise 
Resource Performance, Incorporated, they have started their 
work. I think we are due to give you a report by August about 
what is happening with the report, but in two years their 
review will be complete.
    The Chairman. So it is a two-year program, but we get an 
interim report hopefully in August?
    Dr. McCarthy. Yes, sir.
    The Chairman. Okay. When we are on our summer work period.
    Dr. McCarthy. We will happily do it whenever is convenient.
    The Chairman. As soon as possible. Thank you.
    Can you also talk to us about the vacancies that exist, 
what your current vacancy rate is right now in health care? And 
then, I think it is important for the Committee to know and to 
understand what is the total time that it takes from 
recruitment all the way through to bringing a mental health 
provider on board right now at the VA.
    Dr. McCarthy. I have to say, I am not the person that knows 
the exact number of days it takes from recruitment. I can tell 
you the process and that it does likely take several months.
    When asked about the actual vacancy rate of psychiatrists, 
I believe Dr. Shulkin testified before this Committee we were 
at about 236. We are working--
    The Chairman. Out of how many? 236 out of?
    Dr. McCarthy. Harold, do you know the number of 
psychiatrists we have? I have it in my notes somewhere.
    Mr. Kudler. I believe it is about 800.
    Dr. McCarthy. About 800. And as we continued to hire and 
expand, some moved around and then we had vacancies. There is 
turnover in mental health. The psychologists, there is a lower 
rate of vacancy, I don't have the number.
    The Chairman. Go ahead and talk about the process of 
recruitment going all the way through to bringing somebody on 
board.
    Dr. McCarthy. So typically there is advertisement, people 
apply, often through USA Jobs. The applicants are reviewed, 
interviews are conducted. There is a credentialing process that 
is sensitive to how quickly information is imported into the 
credentialing process, it is usually a minimum of two weeks, 
but it can take up to a month or two depending on the delays. 
We have worked to streamline helping providers get the 
information they need in there relatively quickly. After that, 
an offer is made and a start date is given.
    I do not have the average time and I would be happy to get 
back with you on that.
    The Chairman. Okay. And we talked a little bit about the 
Clay Hunt--
    Dr. McCarthy. Yes, sir.
    The Chairman [continued]. --Suicide Prevention Act and 
according to the figures that I have, because of the enrollment 
period being extended, there have been almost a thousand 
veterans that have been enrolled into the VA Health Care 
System. What have you learned from those roughly 995 
individuals in regards to your outreach to them, and what can 
be done to provide more information about current programs?
    Dr. McCarthy. Thank you, sir. The question really is not 
just what we learn from them, but also other veterans as well 
that have chosen not to come and see us. What we learned also 
as part of the Call to Action, part of the Clay Hunt 
implementation, was people want us to make it easy for veterans 
who are leaving the military to enroll in VA health care.
    So we have worked with DoD, and we have begun a process 
currently ongoing with our Health Eligibility Office to try and 
decrease any barriers to help, that every person leaving the 
military have a health plan when they leave. We have done that 
especially already for people that have been engaged in mental 
health care, but now this is for all of them to have a health 
care plan when they leave.
    And so what we are looking at is not automatic enrollment, 
but essentially close to that. So that if they haven't chosen 
or indicated another health care system, we would like to 
decrease any bureaucracy or any barriers for them receiving 
health care and get them enrolled in VA very quickly.
    The Chairman. What are the biggest barriers that you have 
heard that they feel like they have to overcome to get into the 
system?
    Dr. McCarthy. On some level, there is a sense that some 
veterans do not understand that they are entitled to care. And 
for our vets who are post-9/11 who are leaving, there is that 
five-year eligibility window, there really should be no 
barrier. We have treated women veterans who said literally in a 
clinic, I didn't know I was eligible for services.
    And so we have to change our messaging to be more welcoming 
to all of our veterans. As much as we try, we have people at 
outreach events, our suicide prevention coordinators do five 
outreach events a month, we go to the welcome home and the 
yellow ribbon ceremonies and so forth, but something is not 
happening where people are not understanding that they are 
eligible or else they are choosing not to come.
    The Chairman. Thank you.
    Ms. Brown?
    Ms. Brown. I will go with the Committee and then I will go 
last. So the person, who is the first person?
    The Chairman. Mr. Takano?
    Ms. Brown. Yes.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. Chairman, I want to thank all the witnesses for your 
testimony, I also want to make a pitch to you, Mr. Chairman. 
Mr. Coffman held a wonderful reception for a group of people 
from Colorado that did a wonderful video, in which you are 
partly featured, and I hope that we can do something to 
encourage the Committee as a Committee to take the time to view 
that. It goes very deep into the topic of PTS. And I hope that 
you might, with encouragement, with help from Mr. Coffman and 
Mr. Perlmutter, do that.
    The Chairman. Why don't we do this, I will spring for the 
pizza and we will have a showing of that here in the Committee 
room in the very near future. I haven't seen it, but I 
understand it is very, very good.
    Mr. Takano. It is very good, very powerful. It is long, but 
I think it will give Committee Members other ideas that we need 
to follow and follow through on.
    The Chairman. Well, the director, Stefan Tubbs, is a very 
impassioned advocate.
    Mr. Takano. Well, certainly I intend to show it at events 
in my district, and it is a very bipartisan video.
    Anyway, I have some questions for, I believe it is the VA, 
about TAPS. I understand that TAPS is a big supporter of peer-
based counseling, and you recommended in testimony that peer 
support specialists should be a line item in the budget. What 
do you recommend that VA do better with regard to their peer 
support program?
    Ms. Ruocco. Well, I know there is about 900 out there now, 
but there needs to be more. We need more money to get that 
program built bigger, and to have them everywhere, because what 
our families told us, is that they had a lot of trouble getting 
their veteran to the VA. They had a lot of misconceptions about 
what would happen there, they don't understand treatment, they 
are afraid of treatment, they are afraid of being over-drugged. 
And so they would not go to the VA until they were in crisis, 
and then it is very difficult to get immediate mental health 
care when you are in crisis, where we would rather have them in 
the system before the crisis getting treatment.
    So these peer specialists have done everything from going 
and finding a homeless veteran, to bringing them to the VA and 
getting them into the system, to getting them housing, to 
sticking with them and describing what treatment is. To saying 
I went there, I had the same symptoms, I went there and I am 
better.
    So they can really be a bridge for all of this, because I 
think one of the biggest challenges is not getting our veterans 
who are suffering into good, evidence-based treatment for the 
things that they are suffering with these wars.
    And all of my cases are ones who fell through the cracks, 
they all died by suicide. And every one of them that I talked 
to had tried to go to the VA, had tried little places, but they 
didn't go until they were in crisis and then it was very 
difficult to get the treatment they want when they are already 
in crisis, and so many things had already interfered with their 
lives.
    Mr. Takano. Dr. Berger?
    Dr. Berger. I think it is misleading to say that, 
generalizing and say 900 peer-support persons have been hired, 
it makes it seem like they are all in mental health when that 
is not true. Okay? So I think we need some answers about how 
many peer-support people do we actually have in mental health.
    Mr. Takano. Is there a response to that question?
    Dr. McCarthy. So the number that we quoted are primarily 
mental health or they are part of the primary mental health 
integration program. So they are linked to being the ones that 
reach out and encourage the veteran to receive care.
    Mr. Takano. Do we need to fund this more, do we need to 
fund more? How much more do we need to fund it?
    Dr. McCarthy. Is that for me, sir?
    Mr. Takano. Yes.
    Ms. Ruocco. In my understanding, there is two pieces, 
right? There is the peer support specialists that are the 
training, but then there is also an avenue for peers to become 
mental health providers, right? That is two separate things. So 
having peers, veterans who have been there, get the training to 
be mental health counselors in the system is a win-win for 
both, because we are taking those veterans who had this 
experience and were able to use it to do good and to save other 
veterans.
    So it is two different tracks. We are talking about peer 
support specialists to go out in the community and get them 
into the VA, and we are talking about a streamline of getting 
peers, veterans trained in mental health to be counselors, two 
separate pieces.
    Mr. Takano. Okay. My question is, is there adequate funding 
and, if not, how much more do we need?
    Dr. McCarthy. I don't have that, but we would be happy to 
get back with you on that amount.
    Mr. Takano. Please. Thank you.
    Dr. McCarthy. Thank you. Could I just clarify the number 
that I gave as the number of vacancies? I am sorry, Chairman 
Miller.
    We currently have 5,500 on-board psychologists and 3,200 
on-board psychiatrists in VA. And so when I talked about 236 
vacancies, it is 236 out of 3,203.
    The Chairman. Okay.
    Mr. Lamborn, you are recognized.
    Mr. Lamborn. Thank you, Mr. Chairman, and thank you for 
having this important hearing today.
    Dr. McCarthy, the bill that we passed, the Clay Hunt 
Suicide Prevention Act for American Veterans, requires the VA 
to collaborate with nonprofit mental health organizations to do 
three things to improve the efficiency of suicide prevention 
efforts, to assist other nonprofit organizations to do a better 
job and to collaborate with these nonprofit organizations. What 
is the VA doing and how are these collaborative efforts coming 
along?
    Dr. McCarthy. So I did mention before our Call to Action 
summit that happened in February, that is one piece of it. We 
really brought a lot of people together, not for us to tell 
them, but for them to tell us what we really need to be doing, 
what we need to keep doing, what we need to do better, what we 
should do differently.
    More than that, we sponsor community mental health summits 
around the country and this is the fourth year of doing it. 
Each medical center sponsors a summit in which information is 
shared bidirectionally. Our homeless outreach folks have done 
that and mental health has been doing that. We have learned and 
we have shared, and it has been extremely productive for the 
collaboration.
    One other thing we have been doing is actually working with 
partners in the community who provide care. We realize that, 
especially as part of Choice, there are veterans that are out 
there receiving mental health care and we want them to have a 
warm welcome reception in the community, just like we want for 
them to have that at VA.
    We have developed in partnership with DoD a military 
competence training for providers. It provides up to eight 
hours of continuing medical education free for community 
providers or internally, for people to be able to understand 
the language, and about taking a military history. We have also 
lobbied to have a CPT code added for taking a military history, 
which is part of a reimbursement mechanism in the private 
sector, so that people will be encouraged and financially 
rewarded for doing that.
    Mr. Lamborn. Okay, thank you.
    And, Dr. Berger, I would like to ask you a question about 
research. And I think we all agree, there needs to be more 
research. You said that about 70 percent of veteran suicides 
are people, among males, is people of the age 50 and older and, 
according to your chart, 85 percent of male veteran suicides 
are age 40 or older.
    Mr. Berger. Well, sir--
    Mr. Lamborn. So my question is, my question is, let's say 
Vietnam-era veterans who served 40 to 50 years ago, let's say 
between '65 and '75, 1965 and 1975, tell us about the 
connection between that service and a suicide at the age of 70 
or something like that. And I understand probably every suicide 
is for unique and personal reasons, but what does research tell 
us about the connection there?
    Mr. Berger. Well, certainly there are risk factors that all 
veterans share. There is no denying it. But at the same time, 
as we age, there may be additionally risk factors added to the 
pool.
    For example, in the case of our older vets, it may involve 
insurance, health insurance kinds of things, if they are not 
enrolled in the VA in particular. There may be family issues 
that surface at that time. The structure in our lives changes, 
but at the same time, I am not aware of any focus, 
gerontological research on these different aged cohorts and 
which risk factors may be important at particular points in 
time.
    Mr. Lamborn. Thank you. And I appreciate the work of every 
one of you on the panel. Our hearts go out to those who have 
committed suicide at whatever age. And so thank you for your 
preventative work.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. Lamborn.
    Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman.
    And I wanted to thank Dr. Maffucci for bringing up the 
Female Veteran Suicide Prevention Act, and I am encouraging all 
of you to help in supporting this bill. We have a companion 
bill in the Senate, and I certainly would like to see this 
particular piece of legislation see it through. Because I think 
the focus, although Dr. Berger talked about, I believe you 
talked about an increase in being able to treat women veterans, 
I think it is really critically important that the VA is the 
expert, the absolute expert in this issue around suicide and 
particularly looking at best practices for both our male and 
female veterans, because I do think a female experience on the 
battlefield can be very different from a man's experience. So 
thank you for that.
    I also, you know, wanted to talk a little bit about the 
outreach. And I know that we have a transitional program to 
have a warm handoff when our veterans leave the service from 
the DoD to the VA, and I think that that is positive. I am 
curious to know how well that is going and what it looks like, 
but I think we have to actually dig back further.
    In other words, you know, it seems to me we should have 
medical professionals on the battlefield there. I think in 
terms of outreach with family members, I think we need to, for 
a veteran who is sent to the battlefield, who is potentially 
going to experience trauma, the family members should be 
trained and prepared, so on their reentry back, the family 
members need to know.
    And when we talk about older veterans, which for the first 
time today I am aware that the suicide rate amongst older 
veterans are going up, you know, we have got to figure out some 
kind of outreach in those cases as well.
    But I do think, you know, we train our men and women to go 
to the battlefield and be prepared to save their physicality 
and their physical health, but we also need to prepare them to 
survive their mental health as well. And so I think we have to 
go further back starting really at the beginning, so that 
people are knowledgeable and aware, and even the veteran can be 
aware of their own behaviors and help themselves.
    So I guess, you know, the question that I would like to get 
some answers from is, you know, really how this handoff 
situation from the DoD to the VA is really working. How do 
these handoffs take place, what are they looking like, and are 
we collecting some data on that to figure out if this kind of 
warm handoff is actually working?
    I open it up to anyone.
    Dr. Berger. I will jump right in here, at least from the 
perspective of what I know about it.
    You know, VVA has stayed away from using the term 
``seamless transition,'' because there is no such thing. I 
would only point out we have many, many cases where the 
transfer, quite frankly, there is no other way to say it, is 
screwed up, and it ends in the result, focusing on today's 
topic, in a veteran's suicide.
    For example, I am sure you have all heard, there is at 
least two or three cases in the last year or so of vets who 
were prescribed certain kinds of medication, and DoD for their 
mental health challenges, they get to the outside, those 
records weren't forwarded to the VA, or there was some kind of 
barrier or what have you. The VA gives a diagnosis, puts them 
on perhaps another complete set of mental health medications, 
and they can't cope and they take their own lives.
    Ms. Brownley. Dr. McCarthy, do you have any responses in 
terms of that response and how you believe the program is 
working? And if what Dr. Berger is saying is true, how do we 
rectify that?
    Dr. McCarthy. So I will be happy to respond to the 
medication parts, and I will turn it over to Dr. Thompson about 
the program, if that is okay. Thanks, Tom, for bringing that 
up.
    We have had an opportunity to look very closely in our 
cross-agency partnerships about this particular transition time 
and medications. And we have made it now so that all 
psychiatric and pain meds that would be prescribed in DoD could 
be prescribed in VA, and it is our expectation that the 
medications would continue seamlessly. However, the expectation 
is that the provider would do a safety review. So if, for 
instance, there are multiple drugs of the same class and too 
many, that at that point, they could be adjusted. But the 
expectation clearly is that this go well.
    We started, we have done two sets of chart reviews, 
actually looking at specifically transitioning veterans. Of a 
thousand veterans that we checked, I believe the number was 20 
that had a medication change that was not what we expected it 
to be. That is 20 too many. And so we have provided feedback to 
those providers who made that change, we have also increased 
our education program specifically about meds.
    But I would like Caitlin to talk about the transition 
program.
    Ms. Brownley. Well, my time has run out, but maybe we can 
follow-up.
    I yield back, Mr. Chairman.
    The Chairman. Thank you.
    Dr. Roe?
    Mr. Roe. I will yield my time to answer the question.
    Dr. Thompson. Thank you, sir.
    So we also have what is called the In Transition Program, 
which is a coaching model so that servicemembers who have 
difficulties with mental health are given a coach while they 
are still in service, who then help them and make sure that 
they have that transition point across to the VA. But we really 
take all of this extremely seriously, especially because we 
know, and for older veterans, but also for others, that those 
veterans who are going through transition in any way are at 
very high vulnerability for suicide risk.
    Mr. Roe. Thank you.
    I want to start by first of all thanking the VA. I think 
you all have, I think you do have the largest comprehensive 
mental health program in the United States and it is not 
perfect, but it is certainly better than it was seven years ago 
when I first got here, seven and a half years ago. There is no 
question the focus that the Congress have given and the VA has 
given has improved things.
    One of the things that is hard to do in suicide, first of 
all, as a practicing physician, was to identify those people 
who are at risk, because it is a silent demon you carry around 
and you don't share with anyone. And I think one of the things 
that we have learned today is, is that when patients, veterans 
do get into care at the VA, their suicide rate goes down. I 
think we have figured that out.
    Number two, I think we have also learned that the hiring 
process at the VA is ridiculously long and should be shortened 
for not just mental health, but other providers of health care. 
I think that has got to be shortened and I don't know what 
takes so long. I have hired multiple physicians in my career 
and it doesn't take that long. It is not that hard to do to do 
your background checks and so forth to find out what you need.
    I think the other thing that has been brought up, and what 
is confusing about this, is when you look at the data and I 
think the cohorts of people are different. For instance, us 
guys, Vietnam-era guys, that is a different cohort than the 
younger veterans that are leaving. And when you look at the 
suicide data from 2001 to '07, non-deployed veterans had 
suicide rates higher than deployed veterans, which is confusing 
for us. I mean, why does that happen? So I think more research 
is important.
    And I think one of the things that we have to do, the 
family and friends, there is no question, I looked at data 
years ago when I was in practice that showed that somebody who 
went to a psychiatrist had a higher rate of suicide than 
somebody who talked to their best buddy. So having a good 
friend to talk to someone and having someone, as you pointed 
out very clearly, I think you need to expand this program where 
you can touch a buddy that was in the service. Those of us who 
have served have a different look at things, a view of the 
world and so forth, and when you have somebody that has put 
their overalls on just like you have, it makes a big 
difference. And I think that is a program that works and it 
should be expanded.
    The other thing I want to encourage you to do at VA and 
outside the VA is good, good data, because without that you 
can't make the right decisions, you just cannot. And you can't 
group us all into one big group, you have got to look at 
different cohorts. We are female, younger veterans and older 
veterans like I am.
    So I will stop there and let anyone make a comment.
    Dr. McCarthy. So maybe I could mention the data analysis 
that is going on right now, because we are excited about this. 
This is very different from what we did in the past where we 
had to get data from the states and some states gave us data 
and some did not. We have worked with CDC and with DoD and have 
requested data on everybody that had been in the military or 
the VA between 1979 and 2015. And so we sent multiple discs 
with data that could be matched with the CDC data for suicide. 
And it is coming back to us, it is very raw. It involves a lot 
of individual checking and so forth. We so wanted to have the 
data to share with you at the hearing, we don't. We were told 
that it would be analyzed by the middle of the summer, and we 
promise we will get it to you as soon as we can.
    But we are really excited, because this is not state-
specific and it crosses ages, sexes and all those other kind of 
risk factors that we really want to be able to identify. And we 
want to make that data available to our academic partners in a 
transparent way, so others can help us understand the data.
    Mr. Roe. A few things that were said, and Dr. Berger 
pointed it out, that this 22, you just saying 22, well, that is 
probably not correct. Because if you look, it was just 21 
states, it probably isn't correct, and yet that is quoted all 
the time. That is why we need accurate data.
    And in the U.S., we are 50th in the world in suicide, and I 
am proud of the fact that we are really pointing it out, 
because it all comes down to one person. Look at all this data, 
it doesn't matter when you are the one person, the one patient 
out there, the one veteran or civilian that is contemplating 
taking their life. It is preventable. It is just like opioid 
addiction and deaths, those are preventable deaths if we pay 
attention.
    I yield back, Mr. Chairman.
    The Chairman. Thank you very much.
    Ms. Kuster, you are recognized.
    Ms. Kuster. Thank you very much, Mr. Chair. And thank you, 
Dr. Roe, for setting up my comments on the opioids, because as 
I sit and listen--and by the way, this is one of the best 
panels I have heard since we have been here, but as I sit and 
listen, there are so many corollaries. I am a co-chair of the 
bipartisan Congressional task force to combat the heroin 
epidemic, and we now have over 80 bipartisan members and we are 
passing 15 bills this week. And I want to commend my colleagues 
on both sides of the aisle and Jackie Walorski for her work on 
veterans. We passed yesterday the Promise Act. But there are so 
many corollaries and many of the same people, four out of five 
heroin users have a co-occurring mental health disorder, often 
undiagnosed and untreated.
    But I wanted to speak to you particularly, Ms. Ruocco. 
First of all, my condolences for your loss, but thank you for 
your courage.
    Ms. Ruocco. Thank you.
    Ms. Kuster. And a big part of this is about stigma, it is 
about mental health generally, and the stigma around mental 
health. So one piece that I want to convey to you is that we 
want to help, help you to be a leader on addressing stigma and 
particularly for veterans.
    In New Hampshire, I am very proud of a new program that we 
have that is called, ``Ask the Question,'' and we are using 
this across the state. This is way beyond the veteran 
community, this is our entire health care community, mental 
health community, every person that comes in contact with 
anyone who comes before them to ask the question, did you ever 
serve?
    My father was a World War II pilot. He was shot down, he 
was a POW for six months, no one ever asked him this question. 
He never talked about it until he was well into his 70s and it 
was only when my boys growing up started asking him all the 
questions. What was the plane like? What happened to you? What 
do you mean, what happened after you hit the ground? You know, 
tell this story.
    So I am curious about this peer support, because this is 
what one of my communities has just started for heroin use and 
it turns out that incredible psychological bond of someone who 
has been before you, and if you could talk more about how can 
we help you to grow that program.
    And then, just generally for any of the witnesses, how can 
any of us here help with the stigma and the support?
    And then just lastly, I really want to commend a candidate 
and I don't mean this to be partisan, to be honest, I don't 
even know his party, but this is in yesterday's Politico, ``One 
Candidate's Risky Bet Talking About his PTSD,'' he is running 
in Delaware and he is a veteran. And it is a risky bet, but the 
courage for you as a family member to come forward and for 
others to come forward I think is critical.
    Ms. Ruocco. Thank you so much. And I am from Massachusetts, 
so I am aware of that campaign and it is a great campaign.
    And we actually have all been speaking together, like 
Caitlin and I work a lot together on messaging with the 
Department of Defense, and one thing we have really talked 
about is, there is a need for all of us as a whole to change 
the messaging around the VA and around suicide.
    Ms. Kuster. Good.
    Ms. Ruocco. You know, that number 22 that has been going 
around, we had a suicide in the veteran population about five 
months ago who left a suicide note and in the suicide note 
said, I am going to be one of the 22 today, why should I even 
try? So having the negative messages out there that it is an 
epidemic, that there is 22 dying a day is increasing 
hopelessness in our veteran population and the feeling of 
helplessness and the feeling that treatment doesn't work. It is 
the biggest barrier to them getting real, good treatment with 
the demons that they are bringing with us from, you know, 
unresolved early childhood trauma and additional combat-related 
issues.
    So I think we need a campaign where we are all speaking 
with one voice about the people that are getting treatment, 
that treatment works, that more people are getting treatment 
and surviving than are dying by suicide. So that we can get 
those veterans out there really thinking, you know what, there 
are others that have gone through this, they have survived it, 
and they are doing well. Because we have amazing veterans in 
our communities that are doing unbelievable work, and we have 
peer-based programs all over the country like Red, White and 
Blue and Team Rubicon that are pulling these veterans together, 
are providing hope and are real beacons of who these veterans 
really are. They are loyal and they are smart and they are 
dedicated.
    So we have got to start a campaign that looks at that and 
talks about that, and stop focusing on the fact of how many 
have died. We have raised the awareness, we know it is a 
problem, let's get in the forums like this and fix the problem, 
but at the same time, get a message going out there that 
treatment works and it doesn't have to be that way.
    So I think that is really--
    Ms. Kuster. Well, my time is up. I am sorry, we will have 
to come back on another round. But I would just say, I saw the 
other night on television this Invictus that is going on this 
week--
    Ms. Ruocco. Yes.
    Ms. Kuster [continued]. --with the sports. It is so 
powerful, the hidden wounds of war. And this is part of what we 
are going through in the addiction community is anonymity has 
been such a big part of this, which is important for treatment, 
but for those on the other side to come out and start to tell 
their story--
    Ms. Ruocco. Yes.
    Ms. Kuster [continued]. --is so powerful. So thank you so 
much for being with us.
    Ms. Ruocco. So powerful. Thank you.
    The Chairman. Thank you very much.
    Dr. Benishek, you are recognized.
    Mr. Benishek. Thank you, Mr. Chairman. I too would like to 
thank you all for being here this morning.
    I just want to follow-up on something with Dr. McCarthy 
that has been bugging me since I have been around here. I don't 
know, I mean, is it emblematic of what is going on, is it a 
sign of the sincerity of the VA? But I have an issue with when 
you call the VA hospital and there is an automated message that 
says dial 1 for the pharmacy, dial 2 for the outpatient clinic, 
dial 3 for the OR, but if you have a mental health crisis, 
please hang up and dial a ten-digit number. Okay? Well, this is 
a pet peeve of mine. All right?
    And I have been working on this, and now only in my 
district they fixed that. All right? Because I have been on it 
all the time. But as of this morning, in Michigan, the Iron 
Mountain VA and the Saginaw VA have fixed it, but there are 
still three Medical Centers in Michigan that you have to hang 
up and dial an 800 number.
    Now, I brought this up in Committee a long time ago, and I 
am asking why this is not fixed. And they said, well, it will 
all be fixed in six months. Well, that was more than six months 
ago. And I would like to know why we just can't fix this right 
now? Why does this change take so long?
    You agree it should be fixed, right?
    Dr. McCarthy. Oh, sir, absolutely.
    Mr. Benishek. Is there anybody--
    Dr. McCarthy. I have good news. Do you want some good news? 
There are 12 VAs where you can press 1 and get directly 
connected from the Medical Center--
    Mr. Benishek. Twelve.
    Dr. McCarthy. Twelve, to the crisis line.
    Mr. Benishek. That is what I am telling you, that is not 
very many.
    Dr. McCarthy. Including Hawaii and a few other places, 
which is pretty great in terms of the technology. It is not all 
of them, and it should be all of them. And that is clearly in 
the works and--
    Mr. Benishek. Yeah, but you see, this is why I bring this 
up. Okay? Because to me this is something that should be just 
fixed automatically, without taking a year to do it. All right?
    So here we are talking about mental health crisis. All 
right? And you can't do this. Do you understand what I am 
saying? We have got all kinds of huge problems to solve in 
dealing with mental health patients and you can't fix this? It 
is outrageous. I mean, I am amazed by this.
    I mean, it hurts me, because these are blocking and 
tackling, this is solving the individual problems that veterans 
have when calling. This is a crucial thing. I mean, I have had 
individuals talk to me about this very problem, you know, and 
they try to kill themselves in the parking lot of the VA 
because they couldn't get help.
    So what I am trying to tell you in my comment here is that 
this is a blocking-tackling minor thing, these are the kind of 
things you have got to fix every day and not take a year to do 
it.
    So you are telling me that there are only 12 places in the 
country that this is actually occurring out of the hundreds of 
VA facilities around?
    Dr. McCarthy. It is my understanding it was 12 the last 
time I checked. I know that it is rolling out really quickly.
    Mr. Benishek. Is there somebody within the VA that is 
resisting this change that you are aware of?
    Dr. McCarthy. Oh, no. We have a rather old phone system, 
and we have a number of challenges with it, but I am not trying 
to--
    Mr. Benishek. Well, don't give me that. You have got the 
dial 1 for the pharmacy, it connects to the pharmacy just fine.
    Dr. McCarthy. Okay.
    Mr. Benishek. You know what I mean?
    Dr. McCarthy. Right.
    Mr. Benishek. So don't blame it on the phone system.
    Here is the other thing I want to know. When you dial this 
crisis line, I mean, a lot of people end up dialing the crisis 
line because that is the only place they can get a person, 
right? So what is the process for triaging people that call the 
crisis line who may not actually be in mental health crisis, 
but they are just trying desperately to talk to somebody at the 
VA?
    Dr. McCarthy. So let me let Dr. Thompson take that call, 
because she has worked there.
    Dr. Thompson. Thank you, sir. These are such important 
points and I do want to--by the end of the summer, all of the 
VAs will have rolled out the press 7, so that those press 7 
numbers get to the Veterans Crisis Line. The reason that they 
have to pilot it is because they have to know how many people 
will be available at the crisis line as they roll this out, 
otherwise there won't be enough people to answer those calls.
    Mr. Benishek. So right now, you are saying the 800 number, 
there is nobody there?
    Dr. Thompson. I am sorry, sir?
    Dr. McCarthy. No, sir, no.
    Mr. Benishek. Your answer makes me suggest that you are not 
rolling it out because you don't have people behind the scenes 
to do it.
    Dr. Thompson. No, we have to--that is to pilot things, in 
order to understand what the rollout is going to be, but I 
assure you that by the end of this summer all the VAs will be 
rolled out. But we absolutely understand--
    Mr. Benishek. That was what you said last year.
    Dr. Thompson [continued]. --and hear your concerns. This 
has taken longer than we had thought and--
    Dr. McCarthy. We personally tested it and--
    Mr. Benishek. What about the question I just asked about 
the--
    Dr. Thompson. Yes, sir. So when people--and I worked in the 
crisis line for five years--when people call the crisis line, 
there is a set of questions to ensure that the person isn't at 
immediate risk and needing somebody right away, which happens 
30 to 40 times a day where somebody needs that immediate help 
because they are in the process of dying by suicide, they can't 
commit to being safe. So but--
    Mr. Benishek. How many questions is it?
    Dr. Thompson. I mean, it varies as far as there are 
certainly a few questions that are important--
    Mr. Benishek. How long does it take?
    Dr. Thompson [continued]. --for a suicide risk assessment.
    Mr. Benishek. How long does it take?
    Dr. Thompson. To do a suicide risk assessment?
    Mr. Benishek. On the phone, yeah.
    Dr. Thompson. The immediate question is, are you safe right 
now, really, and that is an immediate question. And then there 
needs to be developed a rapport with the person who is calling. 
So many of the people that call, this is the first time--
    Mr. Benishek. All right, okay.
    Dr. Thompson [continued]. --they have called before--
    Mr. Benishek. I am out of time. Thank you.
    The Chairman. I will be glad to give you some more, if you 
need it.
    Dr. Thompson. And I am happy to keep answering the 
question, but--
    The Chairman. Well, unfortunately, I don't know your 
answers are what he is looking for, you know. I mean, to talk 
about a silly pilot on something as serious as this is just 
ridiculous.
    Mr. O'Rourke?
    Mr. O'Rourke. Thank you, Mr. Chairman.
    And, Mr. Chairman, I would like to begin by thanking you 
for bringing much needed attention and focus and accountability 
to this issue. I can't think of a more important issue for us 
to be working on, and I think that is reflected in your 
leadership. And I would just ask that we continue to keep the 
pressure, and the focus and our commitment to provide the 
resources and the oversight necessary to make progress on this 
issue. And I think to a person we are all there with you and 
the Ranking Member to maintain this as a priority.
    And I want to thank everyone who is part of the panel today 
from the VA and from the advocate community, for your help and 
focus, the information that you are bringing to this, so that 
we can make better decisions, so that we can hold ourselves and 
the VA accountable for making improvements.
    And I want to echo the Ranking Member's suggestion that, 
through you, Dr. McCarthy, this goes to the Secretary, he has 
12 wonderful priorities for transformation of the VA, not one 
of them is specific to reducing veteran suicide. And I authored 
a letter that the Ranking Member, Republicans and Democrats 
signed asking for just that. I would hate to have to do that 
legislatively. I think that is something that the Secretary can 
do and should do, and we will ask him through you to do just 
that.
    Until it is a stated priority, we are not going to see the 
changes that we need to see; we are not going to prioritize 
prevention, we are not going to move from pilot programs to 
full implementation of necessary interventions. I just believe 
in that wholeheartedly, and it needs to happen. And if we need 
to get the veterans advocate community behind that to create 
the political pressure and will to do that, then so be it, but 
let's not have to do that.
    One of the questions I have, is whether we will just use 
the 22 as our baseline statistic, 22 veterans a day taking 
their lives, if 17 of those veterans are not accessing VA care 
and if we believe that if they were to have access to VA care 
the outcomes would have been better, Dr. McCarthy, is the VA 
ready today in terms of capacity, number of providers, space, 
other considerations, to see those 17 veterans?
    Dr. McCarthy. That is a very thoughtful question. You know, 
what we have tried to do with the 17 is find other ways to have 
us reach out to them, and so we have this suite of mobile 
applications, we have worked on helping providers treat them 
and so forth. Space is a challenge.
    Mr. O'Rourke. So let me ask this, because I was really 
looking for a yes or no, and it sounds like the answer is no. I 
won't put words in your mouth. If the answer is in fact yes, 
tell me, but the answer it sounds like is no.
    What I want to know, and you may not be able to answer it 
today, so I will take it for the record, but I will ask it at 
the next hearing if I don't get it before then, I want to know 
what it will take to be able to see each one of those 17 
veterans, in terms of resources, in terms of planning, in terms 
of new facilities, in terms of agreements with community 
providers to take some of the pressure off the VA for what I 
would call non-core priorities. Arthritis is incredibly 
important to provide care for, so is diabetes, so is the flu, 
but if there is a community provider who can see veterans for 
those issues so that we can focus our hiring and our resources 
and our care for, as Dr. Roe said, an eminently preventable 
condition, suicidal ideation and ultimately suicide, then we 
should do that. I mean, we can prevent the loss of life. I 
can't think of anything more important for the VA to do.
    So my question to you and through you to the Secretary, and 
I think each of us wants to see the answer to this, what will 
it take to see each of those 17 veterans?
    Now, it sounds like we are going to have an updated number 
this summer.
    Dr. McCarthy. Yes.
    Mr. O'Rourke. And so the question follows, if that number 
is 25 and only four of those 25, we want to know what the other 
21 are going to do. So would you mind providing an answer, a 
full, detailed, accurate, honest answer to every Member of this 
Committee?
    Dr. McCarthy. I would be happy to do my best to get that 
answer to you, sir.
    You know, I took it when you asked me the question, did we 
have the capacity internally, and we do not have that capacity 
internally. When you mentioned community providers, we do have 
a network of community providers, but we are not up to speed 
with a hundred percent of them in that position.
    So, yes, we will take your question, and I promise you, we 
will give you the answer to the best of our ability.
    Mr. O'Rourke. Thank you.
    I yield back.
    The Chairman. Thank you.
    Mr. Huelskamp?
    Mr. Huelskamp. Thank you, Mr. Chairman. I appreciate the 
opportunity to follow my colleague Mr. O'Rourke, who has done 
tremendous work on this, bringing it to the attention of the 
Committee and recognizing the difficulties in his area, which 
are not just there, but thank you.
    And I want to follow-up a little bit more on those 
questions you mentioned and the network of community providers. 
Can you describe how the Choice program has worked in terms of 
mental health care and meeting the needs of rural areas like 
mine and elsewhere across the country?
    Dr. McCarthy. So let me start with the Choice program. I 
can talk about the community care that was provided and the 
number of appointments that have been provided by Choice. I am 
going to speak in somewhat round numbers, but in fiscal year 
2013 we had over 16,000 appointments in the community, in 
fiscal year 2014, 24,000. Fiscal year 2015, we had 31,000 in 
the community and over 3.4 thousand through Choice.
    The Choice program has grown, this year we have over 18,000 
so far, and there are a number that haven't yet been attributed 
to the year that when people were doing the review. So the 
Choice program is growing, and we are grateful for that, and I 
know our veterans are.
    Mr. Huelskamp. And the numbers on Choice, do you know which 
those are based on, waiting too long versus distance 
requirements?
    Dr. McCarthy. That, sir, I do not know.
    Mr. Huelskamp. Okay. And do you have a general figure on 
the waiting time for those, and how do you calculate that in 
this particular situation?
    Dr. McCarthy. So our under secretary has asked us to 
rethink access and how we talk about wait times and to do that 
in a veteran-centric way. He said really the only important 
measure of wait time is the veteran's satisfaction with how 
quickly they have been seen. And so that is the direction we 
are moving toward in calculating how we are doing with access. 
We have an online kind of--or a kiosk means, I am sorry, in 
which we will assess veterans each day as they are in our 
system, and did they get the care they needed when they felt 
they needed it.
    And a similar question, we have what we use is the SHEP 
survey, and other health services systems ask the same 
questions as part of the CAP survey, but that question is, was 
the care available to you when you needed it? And that really 
is how we need to think about access in a veteran-centric way.
    We want to be transparent, sir, and we just feel like as we 
have gone through all the descriptions of create date, desired 
date, you know, all those other descriptors, we have managed to 
confuse a lot of people, and really the most important person 
we want to satisfy is the veteran. And so our measures will--
    Mr. Huelskamp. Well, in this situation, it is certainly not 
like other items in health care. We are dealing with suicide, 
obviously a very serious matter. I am not saying the others are 
not.
    So what is the number? I heard the long description and how 
difficult. If you call and push 7, and you are one of the lucky 
12 VAs--you don't have to dial the crisis hotline, how long 
does it take for you to see a mental health care provider? And 
do you not have that number or tell us.
    Dr. McCarthy. So first of all, if you press 7 or you call 
the crisis line, that gets you to the crisis line where an 
assessment is made; "Is this an urgent situation?", just as was 
asked before. If the veteran is in urgent need and the veteran 
calls or comes to the medical center, our expectation is that 
that veteran is seen that day. Okay, they come to our emergency 
room, they are seen that day. An urgent need is seen that day.
    However, if they come to a place like a community-based 
outpatient clinic and it is, you know, after hours or something 
and the clinic is closed, we need to understand urgency there. 
Our expectation is that the medical center, the parent medical 
center has an emergency room where that person could be seen. 
Urgent, same day.
    Mr. Huelskamp. But what if you are 200 miles away?
    Dr. McCarthy. So then, if you are working through the 
crisis line, the expectation is that the crisis line assists 
you with getting the care you need, reaching out either to the 
medical center, or to the suicide prevention coordinators in 
the medical center to arrange for that care. Urgent, the 
expectation.
    Mr. Huelskamp. But, again, a little more. And these are 
limited circumstances, but in rural areas, I don't think you 
have the network in my area that you certainly have elsewhere. 
What do they do? I am just curious and maybe it is individual 
circumstances, each one of these probably, obviously is, but 
what do they do? When they are 200 miles away, they call the 
hotline, you say it is an urgent situation, what do you do 
next?
    Dr. McCarthy. So Caitlin, who has worked the hotline, will 
explain this.
    Dr. Thompson. Yes, certainly. And this happens all the 
time. The crisis line has received calls from people who are in 
the middle of lakes. And so, you know, you get that emergency 
personnel immediately to that person. If the VA is 200 miles 
away, they are going to immediately go to the closest facility, 
and all of that is coordinated between the crisis line and the 
local officials.
    Mr. Huelskamp. Local officials? I am sorry to get into 
this, but unless the Choice program is working well, which in 
some cases it is not, you are just going to call--who would you 
call?
    Dr. Thompson. So I think we may be talking about a couple 
of different things, but in terms of imminent situation, 
someone says I am feeling suicidal, the Veterans Crisis Line 
will get them to whoever is available at that moment, the 
closest person, and then they can coordinate that care 
afterwards.
    Mr. Huelskamp. And I appreciate it. I am sorry, Mr. 
Chairman. Rural areas, and this is not just with veterans, 
this--where is the network? And I would be curious in the State 
of Kansas and elsewhere, show me who you would call, because I 
doubt that you have a network up that you could pick up the 
phone and say I know who to call out in the middle of western 
Kansas. And again, we are 200, 300 miles away, and in every 
other care, they are expected to drive until we did the Choice 
program.
    So we could have some follow-up and discussion in my 
particular area, what do they do? Because I am hearing from 
veterans, I am hearing from folks that are active duty as well, 
what do they do?
    Dr. Thompson. Yes.
    Mr. Huelskamp. And, you know, the phone is not working in 
these emergent situations and long term as well, what do you do 
after that?
    Dr. Thompson. Exactly.
    Mr. Huelskamp. What do you do, you know, two months later 
and you are in some type, and there is not much of a network 
there?
    Dr. McCarthy. And that is the crux of suicide prevention, 
so I will look forward to talking and follow-up.
    Mr. Huelskamp. Okay. Thank you, Mr. Chairman. I apologize.
    The Chairman. Thank you.
    Miss Rice, you are recognized.
    Ms Rice. Thank you, Mr. Chairman.
    I am going to direct this question to Ms. McCarthy. I have 
heard from many veterans who separated from the military with 
what is called an other-than-honorable discharge, we all know 
that, that was their designation, and these veterans are often 
the ones who are the most difficult to reach out to, because 
depending on the discharge, they are not able to access many VA 
services like health care, housing or employment help.
    The VA's characterization of the discharge process is, we 
all know, very messy. It often takes years before a decision is 
made on whether or not a veteran can have a reclassification so 
that they are eligible for these benefits.
    And I want to just take a moment to thank our colleague 
Mike Coffman for introducing the Veteran Urgent Access to 
Mental Health Care Act, to ensure that all veterans, regardless 
of their discharge designation, can access the care they 
desperately need before something tragic happens. I mean, it 
seems to me that that is about as big a red flag as you can 
have for someone who might have suicidal issues because of that 
designation.
    So what I want to know is, what is the VA doing 
specifically to increase outreach to this most vulnerable 
population of veterans with other than honorable discharges? 
Have you researched if there is a connection between that 
designation of other than honorable discharge and suicide or 
attempted suicides?
    And I think your ability to kind of improve the 
characterization of discharge process is limited, because I 
know it is, you know, either Air Force or the specific wing, 
but what, if anything, have you done to address this issue?
    Dr. McCarthy. So thanks for the question.
    Let me start by saying that it is indeed a problem, and we 
have identified it certainly in partnership with IAVA. We have 
been working on trying to come to a solution. That is partly 
why we wanted to make sure, first of all, the mobile apps are 
all available. There is this whole suite of things where people 
can get help. They don't need to be enrolled as veterans, and 
yet they have access to these kinds of tools, the use of 
meditation, coaching for PTSD and so forth, online-type tools 
which can help them with their symptoms, help them identify 
them and then help them with the treatments.
    We have vet centers which are able to follow a different 
set of rules for eligibility. Any Vietnam veteran seen, I 
believe, before 2004 at the Vet Center, and then all combat 
veterans are eligible for services at the Vet Center. There 
are--80 percent of the employees they are veterans themselves. 
And they can actually provide counseling for people regardless 
of the kind of discharge. And they also provide some counseling 
to active duty military.
    As part of the Choice Act, we were asked to open our doors, 
and for active duty services members with MST, and some of them 
are coming to the vet centers for that kind of care.
    Ms. Rice. What about the connection between the designation 
and suicides or attempted suicides?
    Dr. McCarthy. I--
    Ms. Rice. Do you have that number or no?
    Dr. McCarthy [continued]. I don't have that. I think IAVA 
has that number.
    Ms. Rice. Okay.
    Dr. Maffucci. So there has been a study done that suggests 
that those with bad paper are two times more at risk for 
suicide. And so this is one piece why IAVA has been so focused 
on this issue. There was a recent report out by Swords for 
Plowshares and some others that partnered on that report that 
estimates 125,000 post 9/11 vets with bad paper. Now, not all 
of these are going to fall into that category of needing mental 
health, but certainly some of them will. And for some of these, 
these are individuals who might have been received that 
discharge status due to symptoms of an undiagnosed mental 
health illness or injury.
    And so this is why we have certainly urging passage of the 
Fairness for Veterans Act, but we are also calling for--we all 
need to come together. DoD--this is a DoD, VA, Congress and the 
VSOs and MSOs. There needs to be a comprehensive plan. We have 
been--over the last few years, there have been pieces that have 
been getting to the solution, but we haven't gotten near to 
that solution.
    The other challenge is that many of the community providers 
out there, many of the community programs base their 
eligibility off of the definition and the eligibility 
requirements at VA. So even those programs that could 
potentially be helping these individuals aren't available to 
them.
    The vet centers are fantastic. Our members are constantly 
holding them up as a top resources, resources they go to, 
resources they recommend. And one of the things we would like 
to see done is an assessment of the vet centers, how they are 
being used. Are there enough of them? Are they under utilized? 
Are they over utilized? And how can we expand them if they are 
being--if there is that demand there, because they certainly 
are not just for those with bad paper, but for families as 
well. I mean, their criteria is much more broad than the VA and 
they can do a lot more.
    Ms. Rice. Ms. Ruocco, if I can just make a comment. I 
applaud you. I would imagine how difficult it must be for you 
to get past what must have been enormous anger, and for you to 
be able to deal with that and be sitting here and be such an 
advocate. I was at an event last night with an organization 
called PenFed. And they support obviously our veterans, but 
also last night, one of the caregivers for a veteran was given 
an award. And it was the mother of a servicemember who was 
severely wounded in his service. And I think it is time that 
we, you know, maybe focus on help to caregivers as well--
    Ms. Ruocco. Absolutely.
    Ms. Rice [continued]. --because it is an enormous 
population that we ask a lot of and you sacrifice an enormous 
amount, and I thank you very much. Thank you, Mr. Chairman.
    MS. Ruocco. Well, thank you for that.
    The Chairman. Thank you very much. Mr. Coffman, you re 
recognized.
    Mr. Coffman. Thank you, Mr. Chairman. Appreciate the 
comments of Congresswoman Rice on this important issue of 
veterans being discharged under other than honorable conditions 
and being denied access to mental health care from the VA. 
Combat veterans with multiple tours of duty, who, I think in a 
very unfair way, for particularly the United States Army to 
conduct a reduction in force through singling out combat 
veterans who might have some disciplinary issues, oftentimes, 
we believe related to post-traumatic stress disorder, and that 
are discharged without any access to VA mental health care, is 
a recipe for problems in and of itself. And so this legislation 
and I know many of the Members here, Mr. O'Rourke, Mr. Walz, 
Mr. Zeldin and others are co-sponsoring this legislation. But 
we absolutely need to get that done. And I want to thank IAVA 
for being really a catalyst on this very important issue.
    Let me just pivot to--I have a real concern that we have 
had testimony before this Committee before concerning a drug-
centric therapy and form of treatment, modality of treatment. 
And in fact, we had testimony of veteran suicide where I think 
a former servicemember was given a cocktail of drugs in 
response to treatment. And then moved, relocated, the 
prescriptions ran out, was unable to navigate the bureaucracy 
of VHA to get those prescriptions refilled. And given the 
powerful nature of some of those drugs, took his own life.
    And then, I think we have had testimony as well--well, in 
fact, I was with Congressman Lamborn in his district in 
Colorado Springs where we had testimony from parents of a 
Marine who had served tours of duty, I think in Iraq and 
Afghanistan, had left the service, went to the VA for mental 
health care. They gave him a very powerful drug that part of 
the directions on the drug were it required constant 
monitoring. He was not monitored. He subsequently took his 
life.
    And so I just think that this reliance on these very 
powerful drugs is a shortcut to treatment by the VA. And I 
think it is costing veteran lives, and I want you to respond to 
that.
    Dr. McCarthy. So, you know, I am not prepared to talk about 
individual situations, but I would be happy to talk about our 
expectation. When we had learned about some of these problems 
with people moving, we have made it really clear the 
expectation is that the meds continue, and that any barriers to 
that be broken down so that the meds would continue. So we 
appreciate that having been brought to our attention. And it is 
certainly our hope and our expectation that that particular 
problem is not occurring at this time.
    As far as treatments go, the evidence based treatments for 
PTSD in particular include cognitive behavioral therapy, 
prolonged exposure therapies, all therapies that do not involve 
medications. And it is really important that the right kinds of 
treatments are used. As a provider, a psychiatrist, who has 
treated veterans with PTSD, I know that often the despair and 
the frustration and the impatience that you see when you talk 
to a veteran leads you to think I have got to do something. And 
I think that leads to people at times making choices about meds 
that they might not otherwise make. Let me try this, let me try 
that. You know, there is no single pill that is a cure for 
PSTD.
    Mr. Coffman. Well, it becomes a pill to get up in the 
morning and a pill to go to bed at night.
    Dr. McCarthy. Right. And--
    Mr. Coffman [continued]. And a pill for this and a pill for 
that.
    Dr. McCarthy [continued]. And that's why--
    Mr. Coffman [continued]. And I think it has a very adverse 
cumulative effect. Let me also just mention that I think it has 
been brought--I think that it has been raised by this panel 
about the vacancies in the VA in terms of mental health 
providers being hired by VHA.
    We had a very good roundtable with the leadership of VHA in 
this room not that long ago. And one thing that was interesting 
that was raised, in that was how difficult it is for somebody 
who wants a job, and the VA to navigate how long it takes to 
get accepted by the VA, and how long it takes to get placed by 
the VA, and how significant the attrition rate is by those who 
start the process and those who simply can't afford to finish 
the process. And so it has been raised that it is a function of 
compensation. I contend that it is part of this bureaucracy 
that needs to be cleaned up. Mr. Chairman, I yield back.
    The Chairman. Thank you. Mr. Walz, you're recognized.
    Mr. Walz. Thank you, Mr. Chairman. And thank you to all of 
you for being here. And to the VA thank you on the Clay Hunt 
bill is near and dear to many in this room, not just up here or 
there, but those sitting behind you. And I appreciate the VA's 
not just approaching to fulfill the letter of letter of the 
law, but the spirit of the law. And for that you should be 
thanked and I am grateful.
    Also I think the things that have been spoken by my 
colleagues talking about veteran health care in a vacuum 
outside of health care in general is the wrong way to go about 
this. I think in that lies an opportunity. We know the VA can't 
fix this alone. We know the private sector can't fix it alone. 
And certainly the veteran and the families can't fix it alone. 
That gives us the opportunity to find new ways to partner, new 
ways to deliver care, new ways to use best practices to move 
those things forward.
    And I will echo what Mr. O'Rourke, the Chairman and the 
Ranking Member all said, and if I can add my word to this. It 
is obvious you have elevated this to the highest level. I think 
VA in general has to. When we see a list of 12 priorities, my 
suggestion is this better be near the top. That is why my 
constituents are asking for.
    And in that I ask the question, I think we are asking, we 
have been tracking this very closely, this legislation, and 
there is no doubt in my mind that the willingness to implement 
it is there and it is happening. My question though is, it 
seems like the coordination might be something. And Dr. 
McCarthy, I don't question it, I just wonder and I ask you is, 
do we need to elevate VA suicide prevention office to the 
Office of the Secretary, is that the first step we need to do 
on this, just so that coordination is tighter?
    Dr. McCarthy. So thank you for that question. We are in the 
process of reorganizing the suicide prevention office and 
raising it higher in the organization right now, and increasing 
the number of staff, as well as the resources. When we talked 
about elevating it, at one point we did talk about a separate 
line item in the budget would effectively elevate it as well. 
But in any case, what we very much know is that it needs to 
report higher in the organization.
    DoD has elevated it to the level of the Secretary. I'm not 
sure that is what we are going to do. Dr. Caitlin Thompson is 
our suicide prevention coordinator and we are having her report 
through the Under Secretary for Health, Dr. Shulkin. And I 
think that's an important place, given that in that position 
she will have the opportunity to reach across the aisle to VBA 
and effectively partner with DoD as we--
    Mr. Walz. Well, I certainly don't want us to interfere with 
the organizational structure down to that level, but I 
certainly do want everyone to know that, Dr. Thompson, I would 
like you to open up your office door to the Secretary on this 
one if that is what it takes to do this. That is what we are 
trying to do. And I would segue a little bit here to this next 
one. I think all of you have hit on this. It is the people we 
are not reaching, I think that is--I mean you do a wonderful 
job when we get them in. I think that is what many of the 
Members here are focused on.
    New York Times reported on Clay Hunt's unit himself that 
that unit and the Minnesota National Guard, we are seeing 
clusters. We have got to get better at predicting these 
clusters and when they are happening. And I know that is tough 
stuff that you are all working on.
    But I would say, and I ask about this, and the Chairman and 
the Ranking Member, all of you looking at this from a 
coordinated broader perspective, but there have been several 
mentions of groups that are actually doing this--of trying to 
get that coordination there, Team Rubicon and Jake Wood who 
served as battle buddy with Clay, those folks.
    I would humbly request that we do something where we bring 
them in, sitting right where you are, to talk about how they 
are doing this, because there are groups like Team Rubicon and 
Ride Recovery and I mention, I am not singling out, these are 
folks that I have looked at, worked with, looking for evidence-
based results on this. And the question that Mr. Huelskamp 
brought up is really good about building that network.
    There is a headstrong group up in New York you may be 
familiar with working with Cornell University, they partner 
with the San Diego VA. And they said the San Diego VA is 
fabulous about saying ``We can't handle all these. You guys 
need to help them.'' They built a network of the top 
psychiatrists and mental health people in the country. They are 
getting almost immediate care. It is incredibly cost efficient 
and they are out there and doing it. So that was our vision of 
the Clay Hunt. That was the vision of where these groups are 
at.
    And I know Dr. Robrad (?) and the Centerstone people that 
operate in the Tennessee/Indiana areas. So I ask all of you, 
these are out there, they are doing it. Certainly what works 
for veterans is what works. We have to be evidence-based. We 
have to be cost conscious on how we will be delivering these. 
But the purpose of the Clay Hunt bill was get that peer to 
peer, get that out in the community. Do you feel it is 
happening? How much do you work with these groups? You know, 
you mention the names. We hear Team Rubicon. I just ask all of 
you quickly. I would like them to be here, because I think that 
model is a working one.
    Dr. McCarthy. We fully agree and we do reach out. We are 
partnering with our folks at the table here often, and in 
addition with partners in the community. So yes.
    Ms. Ruocco. I would say that there are some really amazing 
things happening all over the country.
    Mr. Walz. Amazing.
    Ms. Ruocco. Like in Massachusetts the home-based program, 
which is taking in, educating, giving free treatment. And then 
there is like Vets for Warriors, who is peer based 24/7 call-
ins. Those people are really, you know, bridging those gaps. So 
we have got to look at those, I think you are right, bring them 
in, what is working and really give them some funding to really 
expand.
    Mr. Walz. It goes back into that VA is the medical home--
    Ms. Ruocco. Yes.
    Mr. Walz [continued]. --of the coordinating center with Dr. 
Thompson. But using those groups almost rapidly and seamlessly.
    Ms. Ruocco. And support.
    Dr. Berger. Both Dr. Maffucci and I, in February, called 
for a strengthening of that coordination. And in fact, okay, 
Dr. Carolyn Clancy was named co-chair of the National Alliance 
for Suicide Prevention. Okay. And as a Member of the executive 
committee, there could be some stronger efforts by our VA 
partners in pushing that message out because they have got all 
those connections with some of the groups, most of the groups 
that you mentioned.
    Mr. Walz. They are building networks. I know my time is 
over. I just think there is a golden opportunity here. And it 
is not a critique on this. I think this is moving in a 
direction that many of us wanted to see. The seamless use, the 
building the networks, the reinforcing that. You are going to--
we can streamline the hiring, we can do all that, that is not 
going to make all the difference though. Those folks are out 
there. So I thank you. Thanks, Chairman.
    The Chairman. Mr. Zeldin, you're recognized.
    Mr. Zeldin. Well, thank you, Mr. Chairman. Dr. McCarthy, so 
I served four years on active duty. I have been in the Reserves 
since 2007. I have lost more people I have known in the service 
due to PSTD, than I have in combat. And it has impacted my home 
county pretty hard. I represent Suffolk County. We not only 
have the highest veterans population of any county in the 
state, we are second highest of any county in the country.
    And there was some conversation earlier pretty much in your 
opening statements you were getting at peer support. And I just 
want to get an idea of what kind of a model you may be 
considering, if not doing already, as far as peer support 
groups.
    Dr. McCarthy. So I would like to turn to Dr. Kudler to 
describe this.
    Dr. Kudler. Thank you. VA has been hiring and training peer 
support specialists. It doesn't even--the 990 or so we have, 
doesn't include about 100 Global War on terror and outreach 
workers at vet centers, at the 300 vet centers around the 
country. And we train them to run groups, we train them to be 
in waiting rooms, to look for people who are agitated and 
anxious, and that includes primary care, as well as mental 
health. In some places, in emergency departments for instance, 
at the Phoenix VA, now has a peer support person in the ED to 
kind of hang out and wait for people who maybe--might want to 
walk out before their wait time ends.
    And we are training them to do therapy. We are training 
them to help support clinical work like compliance with 
medication, to call people up and help. And by the way, we also 
have a lot of peer volunteers who work with us in veterans 
justice outreach who work with people who are involved in the 
criminal system, which is a place you find a lot of people who 
will not go to a doctor, but end up funneling down into the 
Nation's largest mental health system, our prisons and jails. 
And VA has become an incredibly active partner in reaching that 
population, largely through peers.
    Mr. Zeldin. And I do understand that your peer specialists 
do a lot, and more so than I would have list obviously, because 
you are intimately familiar with it. But I do understand that 
your peer specialists do a lot of that. But I am getting 
feedback that there aren't as many peer support groups as 
necessary.
    Dr. Kudler. I think you are right. And I think VA can be in 
many ways the hub that can help generate more peer support. The 
Clay Hunt Act asked us to partner with community peer programs 
where they existed, and we are doing that and following the 
Clay Hunt Act in trying to enlarge on what Clay Hunt asked for.
    But I think we could be doing more. We have developed a 
peer support specialist training that, I think we could be 
sharing with other groups. And I would like to see that happen. 
I think particularly for Guard and Reserve. I have been in 
Suffolk County. I am from Queens. But I have worked with 
military members and reserve units there, and I think that peer 
support could be key in dealing with them.
    Mr. Zeldin. Yeah. Peer support is important. I had real 
training in the peer support groups. In Suffolk County we are 
one of over a dozen counties in New York State, we have 
something called the PFC Joseph Dwyer Program. We will put 8, 
10, 12 veterans in one room because people feel isolated and 
alone. They don't realize that someone around the block is 
going through what they are going through. So it is tearing 
apart families. People at work may not understand. Friends 
don't understand. So it is very important to create that peer 
group setting.
    Also a lot of people may live at a distance from a VA 
hospital, so having support groups out in the community is 
incredibly important. One of the things that I have noticed 
while serving on this Committee, we have had many 
representatives from the VA come before this Committee.
    I have only been on--this is my first term in Congress. I 
have only been able to experience this a little over year. A 
lot of the opening statements that we hear from the VA 
representatives are telling the Committee about everything that 
is working, to create this picture of the VA as if it is 
perfect. And we all know it is not. And what was stated by Dr. 
McCarthy was, I want to be transparent, ``want to be 
transparent.''
    And what we hear from our constituents with regard to 
veteran crisis line, calling a patient advocate and getting a 
voicemail, in some cases not getting a call back. The Denver VA 
hospital construction project last year there was a last minute 
bailout where obviously the fiscal situation could have been 
brought to this Committee's attention earlier, a backlog of 
appeals where a backlog of claims is reduced, just creating a 
backlog of appeals.
    We hear constituents with individual cases where their 
ducks are lined up, paperwork is in order and they are still 
waiting. We read the USA Today report a few weeks ago where 
supervisors are instructing employees to falsify wait time 
lists. I would just--one observation from one freshman members 
of this particular Committee, I think in the effort of wanting 
to be transparent, it would be very helpful if when you were 
coming to the Committee right out of the gate you are telling 
us what needs to be fixed as opposed to this Committee having 
it to pull out of you. I yield back.
    The Chairman. Mr. McNerney?
    Mr. McNerney. I thank the Chairman. This is a difficult and 
humbling subject, so I tread on it carefully. I am going to 
ask--I am going to direct most of my questions to you, Dr. 
Maffucci. But I ask anyone else on the panel to jump in if they 
have answers. Dr. Maffucci, you referred to the Clay Hunt Save 
Act as a step in the right direction. What specifically in that 
law is working that we can expand upon?
    Dr. Maffucci. So as I alluded to in my testimony, this year 
has really been the foundation. We have been--the VSO community 
has been included in conversations with VA about how do we do 
this right, because it is one thing to do it, but it is--and 
our intention was always not to just get a law passed, it was 
to make sure that it was implemented correctly.
    So I think certainly going through the evaluations process, 
I previously worked in the Pentagon, worked for DoD and I was 
on the Army's Suicide Prevention Task Force for about two and a 
half years. And the Army went through this. And it took them a 
good three or four years to kind of process, figure out how to 
go through evaluating their mental health programs. It is 
something that is not done within the mental health worlds. 
There are no standards that are required. There are no metrics 
that are standardized. And so it makes these kinds of program 
evaluations really challenging. But our vision for the Clay 
Hunt Save Act was that to ask the VA to step up and set those 
standards and work with DoD to do that, because DoD has those 
same requirements.
    So I am really, I think we are really excited about the 
evaluations piece. Certainly with the loan repayment program 
for psychiatrists, we were hoping that that would get 
implemented more quickly. I understand there has been some 
challenges with changing the law basically to allow that. But I 
think that too, noting that one of the challenges to VA hiring 
is the low salaries. The more that the VA can provide those 
incentives and can match the private sector, if you will, the 
more competitive they can be to bring in those professionals. 
So that was another piece that we are really excited about.
    And then certainly the partnerships. Up until recently, up 
until Secretary McDonald came into leadership at VA, 
partnerships was not a word that the VA uttered. And so that in 
and of itself over the last two years is immense. And we hope 
to see that term and the implementation of what that term is, 
we are really working to make sure that those partnerships 
expand in a really innovative way.
    We have seen a lot of really positive interaction between 
VA, IAVA, the others at this table. It is going to take time. 
And unfortunately that is just the way it is. But I think we 
all feel, if I can speak for the others on the panel, we all 
feel that we are moving in the right direction, that the 
momentum is there, the motivation is there. There is a 
different energy and we are doing this. Like I said in my 
testimony, we have stopped talking about it, we are actually 
doing things.
    Mr. Zeldin. Well, one of the things we--the buzzwords these 
days is evidence-based. And, of course, suicide it is very 
difficult to get sort of trials or anything like that. But data 
sharing can be extremely important, not only in this issue, but 
with regard to post-traumatic stress and traumatic brain 
injuries. What are the obstacles we are facing with regard to 
data sharing, anyone on the panel?
    Dr. Maffucci. So one of the challenges, which as a taxpayer 
doesn't make sense to me, is that most of the data that is paid 
for with taxpayer dollars is not shared. This is actually, I 
believe I heard Dr. Shulkin commit the VA to actually opening 
up the VA's vaults. And in sharing that, they figure out how to 
make sure that the data that the VA holds is shared across the 
research community. These are dollars that have already--the 
taxpayers have already put forward to get that research, to get 
that data. And I can--I promise you that there are other 
researchers out there that are just chomping at the bit to get 
at it and to help and to do their part.
    Mr. Zeldin. Are the HIPAA laws part of the--
    Dr. Maffucci. I think that is part of the concern is the 
HIPAA. And how do you go--how do you balance needing to know 
certain information with also protecting the patient's 
identity. So that is certainly a challenge. But I would also 
say in my own personal opinion I think there is--HIPAA is often 
called upon as like the scary elephant in the room, right.
    Mr. Zeldin. Right.
    Dr. Maffucci. When people want to--when people are worried 
about data sharing for whatever reason, often HIPAA is the 
primary reason put forward. And the law itself often gets 
interpreted wrong.
    Mr. Zeldin. Mr. Chairman, perhaps we could assemble a group 
of experts to decide how to use data sharing and not violate 
HIPAA intent.
    The Chairman. Absolutely, great idea.
    Mr. Zeldin. I yield back.
    The Chairman. I appreciate it. Ms. Radewagen, do you have 
any comments?
    Ms. Radewagen. Thank you, Mr. Chairman. First of all, all 
of this information has been tremendously useful and I want to 
thank you all for being here today. I also wanted to associate 
myself with Mr. Coffman and Ms. Rice's concerns about the other 
than honorable discharged veterans. We do have a couple of 
cases back in my home district about that. And one veteran is 
in such bad shape his heart has become enlarged. He was in 
Afghanistan and Iraq and he was court martialed. So we are 
trying to work some kind of things out. I also have a brother 
who is a disabled veteran from Vietnam, he has got mental 
health problems big time. And VA prescribes tons and tons of 
pills. And so I understand the importance of it.
    But I have a quick question for Ms. Ruocco. And it has to 
do with family and survival involvement. Do you think VA does a 
sufficient job supporting the surviving family members of 
veterans who have died by suicide? And if not, how can VA 
improve in that area? There are all these problems that the 
veterans are going through, their families are going through 
the same thing.
    Ms. Ruocco. Right. Actually, in the past, you know, as far 
as TAPS, our mission statement was mostly focused on active 
duty servicemembers who died by suicide. But we have just 
expanded that and we are just working on a memorandum of 
understanding with the VA to bring in surviving families right 
to the tragedy assistance program for survivors where we can 
provide them, you know, very comprehensive care right from day 
one and get them, you know, feel--getting the kind of care they 
need, peer support as far--and also connected to trauma 
support, counseling, you know, any kind of benefits issues, 
anything like that. So, yes, we are moving in a direction where 
we are doing better about that.
    What we hear from our families is they would like to be 
more involved before there is a death, and because they feel 
like they are at home struggling with veterans that are very 
sick and just don't know how to get them into treatment, don't 
know how to convince them to go to the VA, don't know how to, 
you know, where to go to ask for advice, where to get support 
for that. So I think there is a real need for the VA to work 
closer with families on providing them access to professionals 
who can guide them and peers who can support the process.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you very much. Dr. Abraham, you're 
recognized.
    Mr. Abraham. Thank you, Mr. Chairman. This is a most 
important hearing. I thank you for having it. When I was 
fortunate enough to be put on this Committee about a year and a 
half ago, the first day we were told that 22 veterans were 
committing suicide and that if 17 of those could get into the 
VA system then we could certainly reduce that. And we hear 
these same numbers today. And you feel the frustration up here 
on the dais and I am sure in your arena too. The frustration is 
palpable because we understand that, yeah, we are dealing with 
a bureaucracy, but come on, we have got to do better than this, 
because when we--like you said, Dr. Maffucci--we need more 
assessment and we need planning.
    But I guarantee if I gave you guys at the table right now a 
legal pad and a pencil, in two hours you could come up with a 
plan, you know how to fix this. And I know that this probably 
goes above your level as to the implementation and the move, 
but it is not like we are dealing with bronchitis here. We are 
dealing with lives every day.
    Somebody, I think it was Mr. Huelskamp, brought up the 
Choice Program. I have got physicians that in my district, in 
my state that have tried to get into the VA system. They are 
just dead in the water literally as far as getting movement. 
And these are physicians that are in good standing with their 
state medical boards, they graduated from accredited 
universities and they have no criminal activity. And that is 
all you need. And you can do that in a matter of 30 seconds on 
a computer now to bring these people in and get some help in 
the community, because I know the VA and the DoD is 
overwhelmed.
    And, Dr. Berger, you mentioned that DoD and VA are not 
still talking to each other on electronic health matters. And 
if they duplicate a medicine from one doctor to another or if 
they give them medicine that has an intersection, yeah, you 
have got some very serious problems very quicky.
    Our Chairman made a comment that, you know, why a pilot 
program when we are talking about this phone system? We know 
the Secretary and certainly his supervisors under him have the 
ability to move manpower to wherever that need is. So why do we 
need a study to study a study and why do we need a pilot 
program? Let's try something, because what we have tried since 
I have been here hasn't been too sporting. And we are dealing 
with people's lives every day.
    So, again, you know, the frustration, we need to quit 
talking and we need to do something productive here. Ms. 
Radewagen mentioned the families. And I would say, well, we 
talk about HIPAA, you know, that big elephant in the room that 
you can't, you know, share what size clothes you wear that day 
with somebody. When that veteran comes in, because I have run 
medical practices all my life and, you know, I understand HIPAA 
compliance, but I also understand HIPAA what it takes to put 
that name on a form. If you explain to that veteran when they 
come in what--whoever they list on the HIPAA form can access 
their information, they could have in 90 times out of 100 they 
are going to say put them on the list. Call them.
    And we know there is four physicians down here, five 
physicians up here. Those on the dais that aren't physicians, I 
guarantee you they are more intelligent than I am, that they--
we understand that family is the first person or the first unit 
that recognizes when this veteran is in a bind. These are the 
ones that can reach out. And we have got to incorporate them. 
You guys have got to get them in the VA system better so that 
they can help. And when they do see an instance they can call 
and not get a recording. And again, just comments, I will take 
any, you know, comments you have. Ms. Ruocco?
    Ms. Ruocco. Yes, thank you for that. That is really 
important. One of the things that we worry about is that, you 
know, all my families told me that they wish they would have 
had evidence-based treatment for the injuries and illnesses 
that they had. And so, yes, while the Clay Hunt Act has 
incentives for psychiatrists, psychiatrists give medication. 
They don't do evidence-based treatment for PTSD. So we have got 
to get the time and the providers to give the treatment that 
these guys need, these men and women that are coming back with 
these kinds of injuries. We have to have the time, the space, 
and the professionals, you know, middle level mental health 
providers that are actually doing treatment and we have got to 
have incentives for that as well.
    Mr. Abraham. Thank you. Dr. Berger, do you have any 
comment?
    Dr. Berger. I think my colleague, Kim, is right on with it. 
But I would also like to say that I think there needs to be 
more effort at coordination. This is a national public health 
problem and veterans are a big part of it and we can focus on 
that. But what is important is the VA needs to take the 
leadership role in this, in coordinating this. They have got 
practices, they have got standards, et cetera. Do it. I know it 
is going to burden Harold's shop and Dr. McCarthy's shop. Let's 
find the money so that we can bolster the resources there to do 
it. Let's do it.
    Mr. Abraham. Thank you, Chairman. I yield back.
    The Chairman. Dr. Wenstrup?
    Mr. Wenstrup. Thank you, Mr. Chairman. I appreciate you all 
being here today. I found it interesting today when you talked 
about that number 22. And we have heard that over and over and 
over again. And with my limited psychology background, which is 
an undergraduate degree, negativity over and over again is not 
helping in this situation. Created awareness, which was very 
much needed, but it doesn't help. And I hope we take a turn in 
the other direction, not only VA, but in the public in general. 
And I also found it intriguing and hopeful that as more people 
get into care the rate drops and that is the bottom line.
    Another interesting point is it is not really just being 
deployed, it is the non-deployed. And what you just mentioned, 
Dr. Berger, has been weighing on my mind all along, because 
just in my neighborhood where I grew up, middle class, upper 
middle class, three families have had suicides, they went to 
good schools. You know, the things that you would think would 
be the underlying factors they committed suicide. So it is not 
just in the military. Now, as you said, the military can lead 
on this with the opportunity to do that. But this is more than 
that.
    You mentioned the HIPAA restrictions, if you will. And Dr. 
Tim Murphy, who is a Navy veteran, psychologist, Member of 
Congress, has a very good bill, I believe. It is out and I 
would encourage you to take a look at it and weigh in on it 
from the standpoint of being able to engage the family more 
readily. And I think that will help us not only at the VA, but 
also in society.
    So, you know, you don't see many suicides taking place in 
theater, they happen after. You know, my feeling as a veteran 
when you are in theater you are engaged, you are a part of 
something big, you are important, you have a purposes. And I 
think that when that purpose is taken away and you find 
yourself with nothing to do, that is when you become more 
vulnerable. We have put a lot of it on, oh, you were in combat. 
But we are seeing you weren't in combat. So did we predetermine 
the cause erroneously and now we are starting to get it? Is it 
important that we get people involved with part of something 
positive? And that is probably the case on the civilian side 
too. So I would love for you to weigh in on those thoughts. And 
I really appreciate you all being here today.
    Dr. McCarthy. So could I just start? I so appreciate what 
you said, Dr. Wenstrup. I think you are 100 percent on target. 
What I was trying to communicate earlier is we need to approach 
it in the same way we approach preventing heart disease. You 
know, it is not like it starts in the ICU that we focus on 
prevention. And the same is true, it doesn't start with our 
crisis line and it doesn't start in that urgent situation all 
the time. Sometimes it does. But we really need to take the 
steps ahead of time. And it is not just for veterans and not 
just for military, but it is for everybody.
    And increasing awareness is really important and making it 
a discussable issue is also really important, because the 
loneliness that comes from the stigma and the fear about 
getting treatment is a big piece of it. So we agree with you 
and we are happy to work--we have partnered with other Federal 
agencies, SAMHSA and CMS and so forth also to address this, 
because it is a national crisis. It is not just veterans, but 
it is veterans included.
    Dr. Kudler. May I add if I might? Just yesterday at the 
Invictus Games, which were mentioned earlier, it was announced 
that VA is partnering with Give an Hour and their Change 
Direction Program. Prince Harry also made a video about Change 
Direction. The idea is to develop basic mental health literacy 
for all Americans. It is not surprising that veterans like all 
Americans don't have words for their feelings and don't know 
where to go when they have a mental health problem, and don't 
know if they should even speak about it, since obviously nobody 
else speaks about it. So we are partnering to create a national 
rollout of a mental health literacy program, which we believe 
will help this generation and future generations, not just 
veterans, but all Americans.
    Dr. McCarthy. And I would just like to add to that. With 
the repeated number of times from various people on the panel 
spoke about the peer programs, whether that is the necessity 
for peer family connections, as well as that veteran 
connection, and not just being in the VA, but expanding that 
program that works so well in the VA out into the community, 
into the chat rooms, you know, into the various places where 
veterans are in colleges and, you know, other locations so that 
they can bring them in, because you can have the best system in 
the world and the greatest programs and services, but if you 
can't get them there, if they don't feel, you know, why is it 
important and understand the treatment works, you know, you 
have lost right at the beginning.
    Ms. Ruocco. Right. We know that, you know, it is a sense of 
purpose and a sense of belongingness are protective factors for 
suicide. And so, you know, that is one of the big losses that 
the military have when they get out and go into the communities 
and they struggle. Where do I belong? What is my purpose in 
life? So these peer groups within the communities are really 
important. At TAPS we have good grief camps at every one of our 
national events. And we match active duty military or veterans 
with a child who has lost a parent or a sibling to suicide or 
other deaths in the military. Out of that comes a new sense of 
purpose where I can mentor this child of a fallen comrade, 
right.
    And they also find a new sense of belongingness with other 
mentors, where we keep them connected with one another. And so 
out of those pages and connecting them we see people become at 
risk, but they are connected to other people, they have a place 
where people notice that and connect them with care. And so 
building those kinds of things all over the country is what is 
going to help support what the VA is doing.
    Mr. Wenstrup. Prevention is always wonderful if we can do 
it. And I think we are getting some signs on what will work. 
Dr. Berger?
    Dr. Berger. You have already heard my comments about VA 
taking a leadership role. But in a larger sense, and it maybe 
shows my scientific nerdiness, you can't manage what you don't 
measure. And so just a number of people passing through a 
program does not tell you whether the program works or not.
    Mr. Wenstrup. Agreed.
    Dr. Berger. So--
    Mr. Wenstrup. Yes.
    Dr. Maffucci. So I just wanted to add from our own members 
survey we know that our members, so 80 percent, over 80 percent 
have told us that they have experienced transitioning 
challenges. And the top three challenges that have been 
identified, number one is loss of identity or purposes. Two is 
finding or keeping employment. And we actually know from our 
survey that for those who took part, 65 percent did not have a 
job when they left the military, so again tying back into a 
loss of purpose. Jobs often give us purpose. Careers give us 
purpose. And then finally the third one was mental health 
concerns.
    So we do know within our population some of the pieces, or 
at least within our membership, some of the pieces that are 
challenging within transition. And it is a start: the peer 
support programs, getting individuals connected while they are 
still on base. The installation access last year was huge for 
DoD to allow these programs and partnerships to come on base. 
One of the things that DoD has not provided and I don't believe 
is tracking from my inquiries is how that is being utilized: 
what installations, who is coming to the installations, what 
does that look like? And that would be really important too to 
understand how you connect people to RWB, to Rubicon, to the 
organizations here before they even leave that installation.
    Mr. Wenstrup. Well, thank you. My time is expired. I 
appreciate it.
    The Chairman. Thank you very much. Final questions from the 
Ranking Member, Ms. Brown.
    Ms. Brown. Thank you, Mr. Chairman. And this has been a 
very informative session. I have got to thank you very, very 
much, very educational. And I want to make a couple of comments 
and then I want to turn it over to you to answer some questions 
that I didn't really hear the answers to. First, My VA 12 
breakthrough priorities. I think that's wonderful. But it 
should be something on top of it as far as I am concerned 
pertaining to suicides, because that is--when we tackle 
homelessness, when we were able to engage the mayors and the 
community and the VA took the lead, I mean we brought that 
down. And I think we can do the same with VA as the leadership.
    And so the veterans crisis hotline have come under 
scrutiny, have had some problems. It has been realigned. And I 
met with the team and I felt that they are on the right track. 
The vet centers, everybody knows they do an excellent job. 
Those, you should have the peers in all of the vet centers in 
my opinion, the peer to peer and then the training of the VA 
counsel suicide is different from that peer to peer. But the 
vet centers is to me in the community and they do an excellent 
job.
    I haven't heard enough about the female veterans. I have 
had several forums with them. They have said, and we are coming 
up with the Women's Veterans Memorial that we go every year. 
But they are not educated to what services are available. I 
don't understand why the women get such a fallout. But they 
don't know what services are available and they don't really 
view them as a part of when they get out as a part of the 
system. So we really need to do some work in that area.
    And I do want to hear about the Vietnam veterans, because 
when I went to this conference, that is the one area that stood 
out saying that the Vietnam veterans are one of the highest 
groups committing suicide, because when they came back they 
didn't feel integrated, appreciated. And so we need some 
special reach out for them.
    And the last thing I want to mention is as we--one way to 
get additional professionals is to work with the colleges and 
give scholarships in that area. And to me that is the key, to 
give those scholarships, not just for psychiatrists, but social 
works and other areas. Everybody don't have to be a doctor to 
give assistance. And, of course, I--you know, to get assistance 
that maybe you need a doctor, but some of us may need the entry 
level to be referred to a doctor. So with that I want to hear 
from everybody.
    Dr. McCarthy. So I will start on this end and then we will 
keep going. We have gotten very loud and clear the message 
about the 12 priorities, so thank you for communicating that 
very effectively. We agree the crisis line has been 
reorganized. And we are really pleased that there will be a 
total of 343 responders employed by the crisis line. We 
definitely feel like that is moving in the right direction. And 
the alliance of that group is in the right place.
    Thanks for celebrating our vet centers. We are very proud 
of them and they are very key partners for all of us. Regarding 
women vets, we need to do better. We need to have a welcoming 
environment. We need--we have heard from them what sometimes is 
perceived as less than welcoming. We need to fix what that is. 
But in addition, we welcome all the help in getting the word 
out about VA is there for them. We have a communications 
campaign, I Serve Too, VA is there for you too. You know, we 
have done a lot with images and so forth to include women 
veterans, but it is not enough. We also are looking at how 
inclusive we are in treatment programs and research studies and 
everything else.
    The Vietnam vets, the Secretary rolled out a 50-year 
celebration campaign. And we have been awarding a number of 
vets welcome home medals recognizing their 50 years of service, 
including some of our own employees who teared up in ways I 
have never seen. It has taken us way too long to say welcome 
home as a Nation. And, you know, we do that individually, but 
to have the 50-year anniversary be a reason to do it has been a 
really important thing.
    We agree with you about colleges and scholarships. I will 
pass this to the rest of the panel.
    Ms. Ruocco. Hi. Thank you so much. You know, one thing I 
hear from the families all the time is that they worry how 
their loved one died will kind of be what people focus on and 
they will forget how they lived and served. Many of our 
families and in my testimony there are some stories of those 
families where they went into the military and they were 
healthy and strong. They did several tours and it wasn't until 
after they had that exposure and that trauma that they started 
to get in trouble and having drinking and other issues that 
then got them less than honorable discharges or other things. 
So we really have got to look at, you know, what are we asking 
these human beings to do? Let's provide them the kind of mental 
health care that they deserve after all these exposures.
    Another challenge that we have had is the vet centers are 
awesome and they do really good counseling for our family 
members. But you have to have been in a combat zone to go to 
the vet center. So where there, once again, is another fall 
through the cracks. If we have a servicemembers, and we know in 
the active duty 50 percent of the people who die by suicide 
have never been in combat. They are struggling with other 
things and they may have been held back from combat because of 
their struggles. They are not eligible for vet center care. So 
we have got to look at those people who don't fit into those 
things and really fill in those gaps as well. Thank you.
    Dr. Berger. Thank you, Congresswoman, for your questions 
and your comments related to Vietnam vets, so I will limit my 
comments to them, to us. As you know, back in March the 
Secretary issued or the VA publically announced nine 
initiatives to deal with suicide. And one of those, I quote the 
VA itself ``Using predictive modeling to guide early 
interventions for suicide prevention.'' They need, as I said 
earlier, to develop a nationwide strategy to address the 
problems of suicides among our older veterans. As I said 
earlier, there are many risk factors that we share with our 
younger colleagues, but what is it that sets us apart and makes 
us take our lives more frequently, according to the 2013 data.
    Ms. Ilem. I would just comment that VA has made tremendous 
progress on women veterans issues and attention from the 
committee on women veteran's issues. A number of hearings have 
been held, bills have been introduced. And I think one of the 
things that is borne out by the research that VA has done on 
women veterans is that once you get them in the VA they are 
doing, you know, much better off. They are much better off, 
they are getting the services that they need. But it is 
addressing that issue of how do you get those from other 
military eras? We know that VA did a tremendous outreach 
program for Operation Enduring Freedom/Operation Iraqi Freedom 
veterans. And it resulted in a much higher rate of those 
veterans coming in and being seen and be part of the system. 
But how do we get those other eras of veterans, women veterans, 
who have felt neglected, have felt isolated and could really 
benefit from VA services? So I think an outreach program to 
them, specifically targeted based on just what has been 
successful in VA, would be a really--would be tremendous for 
those people.
    Dr. Maffucci. So IAVA has been preparing to really roll out 
our campaign focused around women veterans. Last year our 
research department did an eight-city tour meeting with some of 
our women veteran members, as well as a survey that were sent 
out beyond our membership to really kind of try to understand 
what the challenges are. From myself my first question was are 
the challenges that women veterans face different from their 
male compatriots or are they the same? And if they are the same 
then what do we do if they are different, what do we do? And I 
think one of the women that I spoke with in one of the focus 
groups summed it up the best, where she said, ``Our challenges 
are the same, but the resources aren't tailored to women and 
the women veterans are having challenges finding the 
resources.''
    A few things that I really pulled out from the survey 
findings and from those conversations that I wanted to share, 
our members, our women veterans they self-identify. They are 
proud to be veterans. But they are also tired of defending the 
fact that they are veterans to the Nation at large. Being 
asked, being challenged and then when they come out and they 
tell people that they are veterans, and having a look of 
disbelief or a question. All right, this is a cultural change 
first and foremost. And it is a cultural change not just at VA, 
it is the Nation. We all need to recognize that women are 
growing in the forces, they are growing in the veteran 
community, they are serving and they are serving right next to 
the men that are enlisting as well.
    On the topic of peer support, that was something that our 
survey showed women really want other women in peer support 
programs. It is a concern that we have had just looking across 
the peer support program that already exists and understanding 
are minority groups represented, to what degree, are we making 
sure that the populations that peers are available to peers? 
This is something that we are going to keep working on, because 
it is so critical, both within VA, but also outside of VA to 
create that network of peer support so that women can find 
other women, share their stories and know they are not alone.
    The other piece is just the research piece is critical. And 
it is not just VA. Across the Federal agencies there is not a 
requirement to look at programs and look at gender analysis and 
look at age analysis and look at some of the other covariants 
that occur when you want to understand a program is working. It 
is past time that the Federal agencies at large start to 
recognize it is not just about that big picture. We have got to 
start understanding the populations within the population at 
large.
    The Chairman. Thank you very much, Members. Thank you to 
our panelists for being here today. I would ask that unanimous 
consent that all Members will have five legislative days with 
which to revise and extend their remarks and add any extraneous 
material. And with that this hearing is adjourned.

    [Whereupon, at 12:28 p.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

          Prepared Statement of Corrine Brown, Ranking Member
    Thank you, Mr. Chairman, for calling this hearing today.
    Strong oversight of the Department's Suicide Prevention Programs 
remains a priority of this Committee. We are all aware of the often 
cited statistic of 22 veterans a day committing suicide.
    We also know that VA reported in 2014 that there is decreased rates 
of suicide among users of the Veterans Health Care System with mental 
health conditions.
    The question becomes how do we ensure ready access to safe, 
quality, mental health services for veterans in need of care?
    I hope the VA witnesses here today will be able to update us on 
these numbers, as much of the country was not included in previous 
estimates.
    One subject that concerns me relates to the new MyVA 12 
breakthrough priorities. I understand that addressing the suicide 
problem is not one of them. `Increase access to healthcare', `improve 
the compensation and pension exam', `continue to reduce homelessness' 
and `transform the supply chain' are all on the list, but specifically 
reducing suicide is not included. Given that suicide, nationally, is 
considered by some to be a public health problem, I believe VA should 
include suicide prevention as one of their MyVA priorities.
    I look forward to VA's testimony on this and where suicide 
prevention fits into the 12 priorities. I know that the urgency of this 
issue is not lost upon the VA. VA leads the nation in service related 
mental health treatment, and rightfully so.
    The Suicide Data Report of 2012 was published by the VA partially 
as a result of the 2007 Joshua Omvig (AHM-vig) Veterans Suicide 
Prevention Act. This law was a positive first step in addressing what 
was then a burgeoning epidemic of suicides in the veteran community. It 
required, among other things, the VA to establish a comprehensive 
program for suicide prevention among veterans. Additionally, it 
required the creation of a suicide prevention counselor at each VA 
medical facility, who are responsible to engage in outreach to 
veterans. Finally, this law required VA to set up a toll-free hotline.
    Mr. Chairman, this hearing will also examine the implementation of 
the Clay Hunt Suicide Prevention for American Veterans Act. Passed in 
the early days of the 114th Congress, this law focused the nation on 
this terrible epidemic affecting veterans of the current cohort.
    This law requires the Secretary of Veterans Affairs and the 
Secretary of Defense to arrange for an outside evaluation of their 
mental health care and suicide prevention programs.
    It also requires any service member being discharged to have their 
case reviewed for any evidence of Post-Traumatic Stress Disorder or 
Traumatic Brain Injury or Military Sexual Trauma.
    We have been at war for over 14 years. There are many veterans out 
there who do not engage the VA health care system for purposes of 
mental health treatment, veterans from all eras. Today, the discussion 
should include how VA is going to reach these veterans, what better 
ways can be used to ensure access to quality mental health care, and 
finally, once veterans are engaged, how do we keep them engaged. It is 
time to think outside the box and tackle this very pervasive problem.
    Thank you, Mr. Chairman and I yield back the balance of my time.

                                 
                     Prepared Statement of Tim Walz
    I think these two articles are especially pertinent in light of the 
discussion we are having today in the committee. As a community, as a 
nation, and as members of the House Committee on Veterans Affairs, we 
need to fully understand the occurrence of clustering in units and work 
to prevent these deaths. I look forward to further discussion on the 
ways we can reach Veterans who are not receiving the care and benefits 
they have earned and deserve.
     Suicide hits hard among the ranks of Minnesota National Guard
A father's despair over his son's death in Iraq drives home a suicide 
    crisis for Minnesota National Guard.
By Mark Brunswick Star Tribune

APRIL 2, 2016 - 7:48AM

    Kim Schmit knew her husband was in trouble, that much was clear.
    It had been seven years since the Willmar couple's 26-year-old son, 
Josh, had been killed by a roadside bomb in Iraq while serving in the 
Army. Greg Schmit, an 18-year member of the Minnesota National Guard, 
had found it particularly hard to adjust.
    Out of guilt and grief, his life had dissolved into a series of 
unproductive counseling sessions at the VA. A medley of medications for 
anxiety, depression and sleeplessness now frequently left him either 
lethargic or irritable. Contributing to his despair, he contended that 
the Guard had been unsupportive after Josh's death and that a few 
commanders had conspired to ruin his career and have him fired.
    Late on a July night last year, Kim would later tell authorities, 
she was awakened by her husband struggling for breath next to her. She 
spotted the prescription bottles. All were empty. Within minutes, Greg 
Schmit, the by-the-book supply sergeant, was rushed to the hospital in 
a futile attempt to save his life.
    ``I tried with Greg,'' Kim Schmit said, ``but I wasn't enough to 
keep him going.''
    Few organizations have felt the crisis in military suicides more 
than the Minnesota National Guard. In the past five years, more of its 
members have died by suicide than all but one state Guard in the 
country. Minnesota's Guard is the 10th largest state Guard by size. But 
when it comes to suicide, its 27 deaths rank second only to 
Pennsylvania's 30.
    By comparison, the state of Minnesota overall ranks 41st in the 
country in the rate of suicides per 100,000 people.
    Asked if the Minnesota Guard has a suicide problem, Command Sgt. 
Major Douglas Wortham, the Guard's top enlisted soldier, said simply: 
``One life lost to suicide is too many.''
    Guard leaders say they can't explain why only the Pennsylvania 
Guard has recorded more suicides. Stressors in everyday life - job 
loss, financial difficulties, relationship and mental health issues and 
substance abuse - more than Guard service are likely contributing 
factors, they say.
    ``We see our soldiers two days out of the month, but the community, 
the churches, their employers, they get to see them those other 28 days 
out of the month,'' said Maj Ron Jarvi, program manager for the 
Minnesota National Guard Resilience Risk Reduction & Suicide Prevention 
Office.
    Changes in record keeping - Guard units did not keep uniform 
records on suicides until recently - could also account for the high 
number. So, too, could a possible ``contagion'' effect, where suicide 
might be considered more acceptable the more it happens around you.
    ``With each suicide you have an increased pool risk of suicide,'' 
said Melissa Heinen, suicide prevention coordinator for the Minnesota 
Department of Health, who has worked closely with the Guard. ``The more 
suicides you have, the more that becomes a more normalized option.''

The new reality

    On a snowy Friday morning, more than 70 soldiers file into a 
classroom at the Minnesota National Guard Armory in Cottage Grove. At 
first it seems like just another meeting during just another drill 
weekend.
    But as Capt. Tony Hodgkins takes the podium, it quickly becomes 
clear it is about something deeper. Hodgkins, the unit commander, asks 
the soldiers how many have experienced someone close to them feeling 
suicidal. Nearly half raise their hands.
    This is the new reality of the National Guard, where suicide 
prevention has become not only a priority, but a necessity. In the last 
eight years, Hodgkins tells the group, about 40 members of the 
Minnesota Guard have taken their lives.
    Most have been men. The average age of victims was 26 - much 
younger than the middle-aged males in the general population who kill 
themselves. The most common cause of death - a self-inflicted gunshot.
    Some, such as the 41-year-old Guard member who shot himself while 
sheriff's deputies pleaded with him, had been deployed, police reports 
and other documents show. But fewer than half - 17 of 41 - had been 
deployed or seen combat experience.
    In 2015, a 27-year-old full-time member of the Honor Guard at Fort 
Snelling who had never been deployed killed himself in his apartment 
within two weeks of being told he was failing Officer Candidate School. 
The year before, a 21-year-old Guardsman killed himself after drinking 
heavily and arguing with friends. He died 10 days after joining the 
Guard and before he was scheduled to ship out to boot camp.
    In an effort to address the issue, the Guard has taken steps in 
recent years to ensure that each Minnesota unit has a resilience leader 
trained to identify common stressors and recommend resources. Each unit 
also has scheduled an annual block of suicide prevention training that 
includes role-playing and videos.
    The Guard also is employing new techniques and technologies - using 
Internet resources and social media connections - to reach out to 
soldiers.
    ``We live by soldier's creed and warrior's ethos and after it's all 
said and done and we stand at attention and declare these things we've 
memorized, it really just means we're here for each other,'' Hodgkins 
tells the group. ``At least we're supposed to be.''
    On this winter morning, soldiers are assigned to the 204th Area 
Medical Support Co., whose mission is to provide health support to Army 
units wherever they are deployed, including the battlefield. Staff Sgt. 
Mandie McGinnis, one of the unit's suicide intervention officers, takes 
the lead.
    ``I want you to take your masks off if you are having a bad day,'' 
she urges the class. ``Somebody can help talk you through it and find 
the light at the other side.''
    Leaders hand out cards outlining suicide risk factors, along with a 
card listing suicide-prevention hot line numbers. Each soldier is given 
a gun lock. McGinnis also leads a role-playing session where she steps 
on a table and pretends to be thinking about jumping off a bridge. 
Several soldiers in the class volunteer to step forward to talk her out 
of it.
    McGinnis, whose regular Guard job is in medical supply, and several 
other unit members recently started a Facebook page to help soldiers in 
need. It is a resource for nearly any type of support. The page, Battle 
Check, is available only to current and former service members. As 
evidence that it is filling a need, it now has more than 2,500 members 
nationwide. As the Friday morning session winds down, 1st Sgt. Brent 
Ambuehl, the senior enlisted member of the unit, addresses the group.
    ``The scariest thing for me as part of a command team is suicide,'' 
he says. ``That's the 11th-hour call that I fear the most. Losing a 
soldier in your ranks to something that is this preventable is plain-
out scary. This is a group effort here and we all need to take care of 
each other.''

`Pins and needles'

    Even with all the Guard's prevention efforts, the death last summer 
of Greg Schmit illustrates the stark difference between how things work 
in training and what actually plays out in real life.
    In response to Schmit's death, the Guard told the Star Tribune that 
it ensured that he had access to mental health, family survivor 
specialists and spiritual counseling; and that his behavior - even 
before his son's death - was ``inconsistent with standards of military 
order and discipline.''
    But his wife and others believe the Guard's treatment of Schmit 
after his son was killed contributed to his grief and ultimately, his 
death. Five years before Schmit took his life, after a series of 
increasingly tense workplace confrontations and accusations of 
disrespect and insubordination, his commanders had fired him from his 
full-time job as a supply sergeant at the Willmar armory.
    ``It reminded me of a soldier who was injured laying on the 
battlefield and they were stepping over him, letting him bleed out,'' 
Kim Schmit said recently.
    As the Guard moved closer to firing him, it sought insight about 
his behavior from the soldiers he worked with. More than a dozen wrote 
letters of support. But several claimed Schmit used Josh's death as an 
excuse for behavior they described as unsettling.
    One first sergeant wrote that Schmit, who had made some enemies, 
had been told many times before and after his son's death, ``to change 
his behavior,'' according to paperwork Kim Schmit provided to the Star 
Tribune. ``Now when he is told to change his behavior, his response is 
how people are out to get him because his son died.''
    Another complained of walking on ``pins and needles'' on the 
anniversary of Josh's death, and of feeling threatened because Schmit 
had access to weapons.
    One supportive soldier wrote that many people felt Schmit ``needs 
to get over it and move on with his life'' and were ``getting sick of 
him using his son's death as an excuse to have an outburst.'' Yet, he 
added, others recognized Schmit ``will never get over the loss of his 
son, and he has the right to grieve his son.''
    In November 2010, the Guard cited seven incidents over the previous 
two years in which Schmit was accused of disrespect, insubordination or 
failure to obey orders, including a 2009 letter of reprimand in which 
he was docked three days' pay. It also listed four incidents before 
Josh's death to show what it called ``the prolonged and continued 
nature of your anger problems.''
    A month later, Schmit made a passionate plea to stay in the Guard 
and ``continue to serve my country, bring stability to my family, and 
honor the values and way of life (of) Joshua, and many like him, who 
paid the ultimate sacrifice to protect.''
    The following March, Major Gen. Richard Nash, head of the Minnesota 
Guard, signed the letter dismissing Schmit. The letter, officially 
called an ``Involuntary Separation Care Plan,'' offered the names of 
resources for support.
    ``I encourage you to take advantage of these resources to assist 
you through this difficult time,'' Nash's letter said.
    That same month, Schmit attempted suicide for the first time. He 
would tell doctors that he remembered waking up after taking an 
overdose of pills and being angry that he had survived.
    Asked about how it felt it responded to the situation, the Guard 
said in a recent written response: ``After Sgt. Joshua Schmit's death - 
even with sympathetic and caring leaders and full access to counseling 
- Staff Sgt. Greg Schmit continued his behavior, resulting in 
progressive nonjudicial punishment and ultimately termination of his 
employment.''
    Veterans advocate Trisha Appeldorn, director of the Kandiyohi 
County Veterans Services Office and an acquaintance of the Schmits, 
learned about Greg Schmit's struggle after he asked her to help him 
fill out paperwork. She said she was stunned by how he was treated.
    ``Anyone would be shocked,'' she said. ``A father loses his son in 
Iraq and basically gets booted out of the National Guard two years 
before he could retire. In my opinion, it was just sort of a raw 
deal.''

Emotionally `stuck'

    After being dismissed from the Guard, Schmit's condition worsened. 
He was treated briefly at a hospital in Pueblo, Colo., then entered the 
Warrior Transition Battalion at Fort Riley, Kansas. It was one of 
several programs set up by the Army to help wounded soldiers transition 
back into the military or to civilian life.
    He was medically discharged from the Army in 2013 due to headaches, 
depression and post-traumatic stress.
    More than 1,000 pages of notes from the Minneapolis and St. Cloud 
VAs that Kim Schmit obtained document his slide. The reports are 
dominated by words such as ``resentment,'' ``unresolved anger,'' and 
``hopelessness.''
    Greg Schmit told of having vivid word-for-word conversations with 
Josh in his dreams, described flashbacks of seeing his son's dead body 
and discussed the once-a-week panic attacks that put pain in his chest 
and blinded his eyes.
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    An excerpt from Gregory Schmit's VA patient file.

    In one meeting with a VA staff psychiatrist, Schmit admitted that 
he was emotionally ``stuck.'' In a 2013 session for medication 
management and supportive therapy, he spoke of having regular 
nightmares and feelings of worthlessness. He also told the doctor he 
would attempt suicide if he knew it wouldn't hurt other people.
    Two years later, after more counseling failed to help, Greg Schmit 
killed himself. The cause of death was listed as intentional multiple 
drug overdose, with a secondary cause listed as major depression and 
post-traumatic stress disorder. He was 56.
    Schmit was buried alongside his son at Fairview Cemetery in 
Willmar. Because he had been fired, the Guard no longer considered him 
a member at the time of his death. Nor does it consider Schmit to be 
one of its suicide victims.
    ``The circumstances surrounding the Schmit family are tragic,'' the 
Guard said recently, when asked to respond to his death, adding that 
its ``thoughts and prayers . are with the Schmit family.''
    Kim Schmit, meanwhile, has been left to shoulder the deaths of two 
soldiers: a son killed just 10 days before he was to come home and a 
husband who blamed himself for the loss. She said her son, like his 
father, ``wanted to play the Army game.'' Greg encouraged Josh to 
enlist and when Josh died, Greg ``thought he killed his son in a 
roundabout way.''
    Not long ago, Kim Schmit's co-workers at a St. Cloud medical clinic 
bought a stone slab that features laser etchings of pictures of Greg 
and Josh hoisting beers. The photos were taken when the family visited 
Josh in Germany for his wedding.
    The slab sits prominently inside Kim Schmit's home. The inscription 
reads: ``You are now free and our tears wish you luck.''
      In Unit Stalked by Suicide, Veterans Try to Save One Another
Members of a Marine battalion that served in a restive region in 
    Afghanistan have been devastated by the deaths of comrades and 
    frustrated by the V.A.

By DAVE PHILIPPS - SEPT. 19, 2015

    After the sixth suicide in his old battalion, Manny Bojorquez sank 
onto his bed. With a half-empty bottle of Jim Beam beside him and a 
pistol in his hand, he began to cry.
    He had gone to Afghanistan at 19 as a machine-gunner in the Marine 
Corps. In the 18 months since leaving the military, he had grown long 
hair and a bushy mustache. It was 2012. He was working part time in a 
store selling baseball caps and going to community college while living 
with his parents in the suburbs of Phoenix. He rarely mentioned the war 
to friends and family, and he never mentioned his nightmares.
    He thought he was getting used to suicides in his old infantry 
unit, but the latest one had hit him like a brick: Joshua Markel, a 
mentor from his fire team, who had seemed unshakable. In Afghanistan, 
Corporal Markel volunteered for extra patrols and joked during 
firefights. Back home Mr. Markel appeared solid: a job with a sheriff's 
office, a new truck, a wife and time to hunt deer with his father. But 
that week, while watching football on TV with friends, he had 
wordlessly gone into his room, picked up a pistol and killed himself. 
He was 25.
    Still reeling from the news, Mr. Bojorquez surveyed the old 
baseball posters on the walls of his childhood bedroom and the sun-
bleached body armor hanging on his bedpost. Then he took a long pull 
from the bottle.
    ``If he couldn't make it,'' he recalled thinking to himself, ``what 
chance do I have?''
    He pressed the loaded pistol to his brow and pulled the trigger.
    Mr. Bojorquez, 27, served in one of the hardest hit military units 
in Afghanistan, the Second Battalion, Seventh Marine Regiment. In 2008, 
the 2/7 deployed to a wild swath of Helmand Province. Well beyond 
reliable supply lines, the battalion regularly ran low on water and 
ammunition while coming under fire almost daily. During eight months of 
combat, the unit killed hundreds of enemy fighters and suffered more 
casualties than any other Marine battalion that year.
    When its members returned, most left the military and melted back 
into the civilian landscape. They had families and played softball, 
taught high school and attended Ivy League universities. But many also 
struggled, unable to find solace. And for some, the agonies of war 
never ended.
    Almost seven years after the deployment, suicide is spreading 
through the old unit like a virus. Of about 1,200 Marines who deployed 
with the 2/7 in 2008, at least 13 have killed themselves, two while on 
active duty, the rest after they left the military. The resulting 
suicide rate for the group is nearly four times the rate for young male 
veterans as a whole and 14 times that for all Americans.
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    The deaths started a few months after the Marines returned from the 
war in Afghanistan. A corporal put on his dress uniform and shot 
himself in his driveway. A former sergeant shot himself in front of his 
girlfriend and mother. An ex-sniper who pushed others to seek help for 
post-traumatic stress disorder shot himself while alone in his 
apartment.
    The problem has grown over time. More men from the battalion killed 
themselves in 2014 - four - than in any previous year. Veterans of the 
unit, tightly connected by social media, sometimes learn of the deaths 
nearly as soon as they happen. In November, a 2/7 veteran of three 
combat tours posted a photo of his pistol on Snapchat with a note 
saying, ``I miss you all.'' Minutes later, he killed himself.
    The most recent suicide was in May, when Eduardo Bojorquez, no 
relation to Manny, overdosed on pills in his car. Men from the 
battalion converged from all over the country for his funeral in Las 
Vegas, filing silently past the grave, tossing roses that thumped on 
the plain metal coffin like drum beats.
    ``When the suicides started, I felt angry,'' Matt Havniear, a 
onetime lance corporal who carried a rocket launcher in the war, said 
in a phone interview from Oregon. ``The next few, I would just be 
confused and sad. Then at about the 10th, I started feeling as if it 
was inevitable - that it is going to get us all and there is nothing we 
could do to stop it.''
    For years leaders at the top levels of the government have 
acknowledged the high suicide rate among veterans and spent heavily to 
try to reduce it. But the suicides have continued, and basic questions 
about who is most at risk and how best to help them are still largely 
unanswered. The authorities are not even aware of the spike in suicides 
in the 2/7; suicide experts at the Department of Veterans Affairs said 
they did not track suicide trends among veterans of specific military 
units. And the Marine Corps does not track suicides of former service 
members.
    Feeling abandoned, members of the battalion have turned to a 
survival strategy they learned at war: depending on one another. Doing 
what the government has not, they have used free software and social 
media to create a quick-response system that allows them to track, 
monitor and intervene with some of their most troubled comrades.
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    Their system has made a few saves, but many in the battalion still 
feel stalked by suicide.
    ``To this day I'm scared of it,'' said Ruben Sevilla, 28, who 
deployed twice with the 2/7 and now works for a warehouse management 
company called Legacy SCS near Chicago. ``If all these guys can do 
that, what's stopping me? That's what freaks me out the most. I haven't 
touched a gun since I got out of the Marine Corps because I'm afraid 
to.''
    The morning after Manny Bojorquez tried to shoot himself in 2012, 
he opened his eyes to sunlight streaming in his window and found the 
loaded gun on the floor. Through his whiskey headache, he pieced 
together that his gun had jammed and that he had passed out drunk.
    A week later, he stood alongside more than a dozen other Marine 
veterans at Mr. Markel's funeral in Lincoln, Neb. The crack of rifles 
echoed off the headstones as an honor guard fired a salute.
    Mr. Bojorquez offered his condolences to Mr. Markel's mother after 
the funeral. He thought about how life seemed increasingly bitter. The 
thrill of combat was gone. Only regrets and flashbacks remained.
    Mr. Markel's mother pressed something into Mr. Bojorquez's palm at 
the funeral, a spent brass shell casing from the honor guard. Promise 
me, she said to him, that you will never put your mother through this. 
Mr. Bojorquez promised.
    That began a three-year odyssey in which the deaths of his friends 
weighed on Mr. Bojorquez, who tried repeatedly to get help from 
Veterans Affairs but ultimately gave up.
    ``I was lost then. I still am kind of lost,'' he said in a recent 
interview. ``I was just trying to look for something that wasn't there. 
I was trying to look for an answer that I don't have - that no one 
does.''
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    He was wearing a bracelet etched with the names of four Marines: 
one who died on the battlefield and three who died by their own hands 
at home.

`The Forgotten Battalion'

    In Afghanistan, after the men of the 2/7 realized the scope of 
their mission, they began calling themselves ``the Forgotten 
Battalion.''
    In the spring of 2008, they deployed from their base at Twenty-Nine 
Palms, Calif., to an untamed stretch of Afghanistan surrounding the 
city of Sangin.
    Their job was to pacify a Taliban stronghold the size of 
Massachusetts that had never been controlled by coalition troops, or 
anyone else. Opium poppies grew in fields as vast as those of corn in 
the Midwest. Roads were pocked with the rusting hulks of Soviet tanks 
destroyed in a different war.
    The Marines were spread out in sandbag outposts, hours from 
reinforcements, and often outnumbered. With the Pentagon focused on the 
surge in Iraq, equipment was scant. There was no dedicated air support, 
few mine-sweeping trucks, often no refrigeration. The only reliable 
abundance was combat.
    ``Machine guns, mortars, rockets, RPGs, I.E.D.s, constant fighting. 
It was like the Wild West,'' said Keith Branch of Austin, Tex., who was 
a 20-year-old rifleman who patrolled a village called Now Zad.
    In that village alone, two Marine platoons fired more than 2,500 
mortar rounds, called in 50,000 pounds of explosives from aircraft and 
killed 185 enemy fighters, battalion documents show.
    Many of the Marines had deployed to Iraq just eight months before. 
At least two had been shot by snipers and one was hit by a grenade in 
Iraq, but they were redeployed to Afghanistan anyway. All three later 
killed themselves.
    The I.E.D.s, or improvised explosive devices, plagued patrols. The 
first convoy arriving in Sangin hit two. In the next two weeks, an 
I.E.D. hidden in a bicycle killed a medic, an I.E.D. packed in a 
culvert killed three Marines in a Humvee, and an I.E.D. discovered in a 
dirt lane killed a specialist trained to defuse the explosives.
    Manny Bojorquez spent the tour in a village called Musa Qala, where 
repeated offensives failed to drive out the Taliban.
    One evening his squad was patrolling single file across a field 
when the enemy ambushed it on two sides. As the squad sprinted for 
cover, Mr. Bojorquez watched a bullet hit a Marine in front of him, who 
crumpled to the dirt. Mr. Bojorquez and another Marine grabbed the 
bleeding man and dragged him to a ditch.
    Pressed against the ground, readying his machine gun, Mr. Bojorquez 
looked over and saw his teammate Corporal Markel laying down fire - 
with a steady grin on his face. Together they showered the surrounding 
fields and houses with bullets, providing cover for a medic. But the 
enemy pressed harder, another Marine was hit and the outnumbered squad 
had to pick up and run.
    ``It's funny. I was never scared. You just act. But it stuck with 
me,'' Mr. Bojorquez said.
    By the end of the deployment, 20 Marines in the battalion had been 
killed and 140 had been wounded. Many lost limbs. Some were badly 
burned; others were so battered by blasts that they can scarcely 
function day to day.
    Others returned unscathed, but unable to fall in with civilian 
life. Members of the battalion say what they brought home from combat 
is more complex than just PTSD. Many regret things they did - or failed 
to do. Some feel betrayed that the deep sacrifices made in combat seem 
to have achieved little. Others cannot reconcile the stark intensity of 
war with home's mannered expectations, leaving them alienated among 
family and friends. It is not just symptoms like sleeplessness or 
flashbacks, but an injury to their sense of self.

Where to Call for Help

The Department of Veterans Affairs maintains a hotline for veterans in 
    crisis that operates 24 hours a day. Call 1-800-273-8255 and press 
    1. Online, visit veteranscrisisline.net/chat, or send a text 
    message to 838255.
    ``Something happens over there,'' said Mr. Havniear, whose best 
friend from the battalion tried suicide by cutting his wrists after 
returning home, but survived. ``You wake up a primal part of your brain 
you are not supposed to listen to, and it becomes a part of you. I shot 
an old woman. I shot her on purpose because she was running at us with 
an RPG. You see someone blown in half, or you carry a foot. You can 
try, but it is hard to get away from that.''
    After Mr. Bojorquez returned home, he started having a recurring 
nightmare. He was patrolling with his squad when bomb blasts killed 
everyone but him. As the dust cleared, he looked up to see enemy 
fighters surging forward. He often sat up in bed, thinking he was 
choking on his own blood.

One Mission's Toll

    Beginning in 2005, suicide rates among Iraq and Afghanistan 
veterans started to climb sharply, and the military and Veterans 
Affairs created a number of programs to fight the problem. Despite 
spending hundreds of millions on research, the department and the 
military still know little about how combat experience affects suicide 
risk, according to suicide researchers focused on the military.
    Many recent studies have focused on whether deployment was a risk 
factor for suicide, and found that it was not.
    The results appeared to show something paradoxical: Those deployed 
to war were actually less likely to commit suicide. But critics of the 
studies say most people deployed in war zones do not face enemy fire. 
The risk for true combat veterans is hidden in the larger results, and 
has never been properly examined, they assert.
    ``They may have 10 times the risk, they may have 100 times, and we 
don't know, because no one has looked,'' said Michael Schoenbaum, an 
epidemiologist at the Centers for Disease Control and Prevention.
    The men of the 2/7 overwhelmingly see a tie between combat and 
their suicide problem. Not only were all of the men who committed 
suicide young infantrymen who struggled with experiences of killing and 
loss, they say, but it is possible to trace one traumatic moment 
forward and see how those involved are now struggling.
    Noel Guerrero and Manny Bojorquez were best friends in the 
battalion. As two Mexican-Americans from the Southwest, they bonded in 
infantry school over a love of Mexican hot sauce. In Afghanistan, they 
would share bottles sent from home.
    On one mission, Mr. Guerrero, then a 20-year-old lance corporal, 
was a machine-gunner atop a truck at the lead of a supply convoy. He 
said he was good at finding I.E.D.s and over six months had spotted 
almost a dozen that the battalion was able to avoid. But one day, the 
truck hit a big one, and the explosion flung him against his gun 
turret.
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    Mr. Guerrero crawled from the smoking vehicle, his head spinning. 
He watched his sergeant's Humvee roll in to help. Then suddenly, 
another blast swallowed the sergeant's truck in smoke. The truck shot 
up 10 feet and came down with a crash, falling to its side. Then, 
chaos. The driver was trapped and screaming, with his arm caught under 
the wreckage. A medic in the back was pinned by a seat crushed against 
the truck's ceiling. The sergeant was dead.
    Before Mr. Guerrero could get to his feet to help, enemy fire 
started thudding into the ground around him. He spotted his machine gun 
in the dirt, where it had landed after being blown out of the truck, 
and with his vision still blurred, he began to return fire.
    Two other Marines, Cpl. Jastin Pak and Lance Cpl. Tanner Cleveland, 
scrambled into the wreckage. Mr. Pak crouched over the driver, 
shielding him until a line of Marines could lift the truck enough to 
free his arm. Mr. Pak and Mr. Cleveland emerged covered with blood, 
clutching the wounded, then went back for the remains of the sergeant. 
The platoon was out of body bags, so they stuffed the sergeant's 
remains into a sleeping bag.
    When it was all over, Mr. Guerrero picked up a cigarette that had 
been blown out of one of the trucks and lit it. After he exhaled, he 
noticed it was spotted with blood. He smoked it anyway.
    Since that day, Mr. Guerrero has blamed himself for the ordeal and 
has tried to kill himself three times. Mr. Cleveland, 26, of Chicago, 
also tried suicide, and Mr. Pak, of Oceanside, Calif., hanged himself 
in November.
    ``You come back and try to be a normal kid, but there is always a 
shadow on you, a dark shadow you can never take away,'' Mr. Guerrero, 
now 28, said in an interview at his home in San Diego.
    ``Now, when I meet someone, I already know what they look like 
dead. I can't help but think that way. And I ask myself, `Do I want to 
live with this feeling for the rest of my life, or is it better to just 
finish it off?' ``

Lacking Data on Suicides

    The first few suicides struck the men of the battalion as random. 
It was only over time that they came to see the deaths as a part of 
their war story - combat deaths that happened after the fact.
    Cpl. Richard McShan died first. He had survived a truck bomb in 
Iraq before deploying to Afghanistan. Four months after they returned, 
in the spring of 2009, he put on his dress uniform after an argument 
with his girlfriend and shot himself in his driveway.
    In December 2009, Pfc. Christopher G. Stewart hanged himself from a 
door in his barracks.
    In April 2010, Shawn Jensen, a sergeant who had just gotten out of 
the Marines and moved home to rural Washington State to work in 
construction, shot himself during an argument with his girlfriend and 
mother.
    The Marines tended to chalk up these first suicides to foolish 
impulses or prewar problems. Then came the death that shook the 
battalion, and prompted many to ask whether something was wrong not 
just with the men who killed themselves, but with them all.

Battalion Suicides

    Thirteen Marines who deployed with the Second Battalion, Seventh 
Marine Regiment to Afghanistan in 2008 later killed themselves. All 
were young, low-ranking infantry troops.
    APRIL 1, 2009
    Cpl. Richard McShan, 23

    DEC. 23, 2009
    Pvt. Christopher G. Stewart, 21

    APRIL 3, 2010
    Sgt. Shawn Jensen, 27

    MARCH 31, 2011
    Cpl. Clay Hunt, 28

    JULY 1, 2012
    Cpl. Jeremie Ross, 25

    OCT. 6, 2012
    Cpl. Joshua Markel, 25

    DEC. 9, 2012
    Lance Cpl. Ufrano Rios Jimenez, 23

    JAN. 18, 2013
    Cpl. Luis Rocha, 23

    APRIL 12, 2014
    Cpl. Elias Reyes Jr., 27

    OCT. 6, 2014
    Lance Cpl. Tyler Wilkerson, 27

    NOV. 2, 2014
    Cpl. Joseph Gellings, 29

    NOV. 5, 2014
    Sgt. Jastin Pak, 27

    MAY 30, 2015
    Lance Cpl. Eduardo Bojorquez, 25

    Cpl. Clay Hunt had been a sniper in the battalion. After he got out 
of the Marine Corps in 2009 after his second tour, his disenchantment 
with the war grew, and he sought treatment from Veterans Affairs for 
depression and PTSD.
    He became an outspoken advocate for young veterans, speaking openly 
about his problems and lobbying for better care for veterans on Capitol 
Hill. In 2010, he was featured in a public service message urging 
veterans to seek support from their comrades.
    At the same time, Mr. Hunt was fighting to get adequate care at the 
V.A., encountering long delays and inconsistent treatment, according to 
his mother, Susan Selke of Houston.
    Friends said Mr. Hunt had felt directionless. ``There is so much 
isolation and lack of purpose. We came home from war unprepared for 
peace, and we've had to find a new mission,'' said Jake Wood, who was 
also a sniper in the 2/7. ``He struggled to do that.''
    Mr. Hunt shot himself in his apartment in Texas in March 2011. He 
was 28.
    After years of lobbying by his family and veterans' groups, 
Congress in February passed the Clay Hunt Suicide Prevention for 
American Veterans Act, which provides additional suicide prevention 
resources for Veterans Affairs.
    ``When he died, all the guys, we couldn't understand it,'' said 
Danny Kwan of San Gabriel, Calif., an ex-corporal who served two tours 
with Mr. Hunt. ``He had done exactly what he had been fighting 
against.''
    At the time of Mr. Hunt's suicide, Mr. Kwan was fresh out of the 
Marines. One night when he was drunk and despondent over a recent 
breakup, he put a gun to his head and pulled the trigger. He jerked the 
gun away as it fired, sending the bullet through a wall.
    ``At the last moment I decided I wanted to live,'' Mr. Kwan said. 
``We all have our demons. Some more than others.''
    No one knows whether the battalion's suicide rate is abnormally 
high or a common trait of fighting units hit hard by combat, because no 
one monitors troops over time. In an era of Big Data, when algorithms 
can predict human patterns in startling detail, suicide data for 
veterans is incomplete and years old by the time it is available. The 
most recentdata is from 2011.
    The Department of Veterans Affairs and the Pentagon say they have 
introduced a new system, called the Suicide Data Repository, that is 
faster and more complete.
    But Dr. Harold Kudler, chief mental health consultant to the 
department, said the military and V.A. did not share information that 
could allow the monitoring of combat units over time.
    ``Might that be a good idea? It might be a good idea,'' he said. 
``But it's not in our ability to achieve. It's not our mission.''

A Pact to Help

    In December 2012, Marines from the 2/7 converged on a small town in 
the Central Valley of California for another funeral. A former radioman 
named Ufrano Rios Jimenez had killed himself with a shot to the heart.
    Mr. Rios had lost a leg in Afghanistan. Once home, he struggled 
with PTSD. But he gave up on treatment at the V.A. and turned to 
alcohol, painkillers and eventually heroin, according to his former 
girlfriend, Allison Keefer. After the suicide of a friend from the 
battalion, Jeremie Ross, in July 2012, he quit work and slipped into a 
deep depression.
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    At the funeral, Mr. Bojorquez stood with the others from the 2/7 as 
they shook their heads and discussed what to do. A battle-hardened 
former corporal named Travis Wilkerson spoke up.
    Once a fearsome team leader in a deadly sector of Sangin, he was 
now working as a night manager at a sandwich shop. He was one of 
several men from the battalion who had changed their lives radically in 
search of peace, growing a bushy beard and taking a vow of nonviolence.
    ``Real talk, guys, let's make a pact, right here,'' Travis 
Wilkerson said. ``I don't want to go to any more funerals. Let's 
promise to reach out and talk. Get your phones out, put my number in. 
Call me day or night. I'm not doing this again.''
    His twin brother, Tyler Wilkerson, who had served in the same 
platoon, stood next to him. After the Marines, he had become a Buddhist 
and joined Greenpeace. He said he agreed.
    Then a three-tour former corporal named Elias Reyes Jr. stepped 
forward. He had a long ponytail and a degree in philosophy from the 
University of California, Los Angeles. He was hoping to attend medical 
school.
    Enough of this, he said. One by one, the others joined the pact.
    Just over a year later, Mr. Reyes killed himself. In combat, he had 
been flattened by explosions several times and seen friends maimed and 
killed.
    Back home, he was getting counseling at the V.A., family members 
said, but faced delays and struggled to find a therapist who he felt 
understood him. In April 2014, he hanged himself in his apartment.
    ``He was very religious, a Catholic,'' his sister, Margarita Reyes, 
said. ``To do what he did, he must have been in so much pain.''
    News of his death was one more in a mounting pile of problems for 
Tyler Wilkerson.
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    After the Marines, Tyler Wilkerson, also a Californian, became part 
of a commandolike team of Greenpeace protesters. The job combined his 
love of tactical missions and his vow of nonviolence.
    But in March 2013, he was arrested after he and others trespassed 
to unfurl giant banners that accused Procter & Gamble, the household 
products company, of destroying rain forests.
    In the months that followed, his girlfriend broke up with him and 
Greenpeace fired him, leaving him alone with wartime memories that he 
had tried to escape.
    He fatally shot himself in October 2014, a few weeks before he was 
to stand trial for the Greenpeace action.
    ``He felt like he had lost everything,'' Travis Wilkerson said. 
``He said his life looked like this endless mountain he couldn't see 
the top of.''
    Other deaths soon followed.
    A month later, a mortar man who had served three tours at war, 
Joseph Gellings, killed himself at his home in Kansas.
    He had tried mental health treatment at the V.A., but gave up after 
delays and other frustrations, according to his longtime girlfriend, 
Jenna Passio. Instead, she said, he drank and became reclusive. She 
eventually left him, taking their daughter.
    After their breakup, he posted to Facebook, ``I'm done with life.'' 
Other Marines texted and called to check on him.
    ``Disregard guys, everything is fine,'' he replied.
    A short time later he shot himself in the head as Ms. Passio looked 
on in horror. Realizing he was only wounded, he went into a bathroom in 
his home and shot himself again.
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    As the news rocketed across Facebook the next day, Mr. Cleveland, 
who had tried suicide, thought, ``It's to the point now where it's 
like, `Who is next?' ``
    It was the friend who had helped Mr. Cleveland pull body parts from 
a smoldering Humvee in Afghanistan, Jastin Pak. Three days after Mr. 
Gellings's death, Mr. Pak, 27, hanged himself from a pine tree in the 
mountains west of his home.
    On his desk, Mr. Pak left a completed ``stressful incident form'' 
that the veterans hospital in San Diego gave him on his initial visit a 
few days before. It asked him to list events from combat that were 
causing him anguish. He filled two pages, starting with the killing of 
an older man in Iraq who had been unarmed and finishing with placing 
the remains of the dead sergeant into a sleeping bag.

Failed Therapy

    After the eighth suicide in the battalion, in 2013, Mr. Bojorquez 
decided he needed professional help and made an appointment at the 
veterans hospital in Phoenix.
    He sat down with a therapist, a young woman. After listening for a 
few minutes, she told him that she knew he was hurting, but that he 
would just have to get over the deaths of his friends. He should treat 
it, he recalled her saying, ``like a bad breakup with a girl.''
    The comment caught him like a hook. Guys he knew had been blown to 
pieces and burned to death. One came home with shrapnel in his face 
from a friend's skull. Now they were killing themselves at an alarming 
rate. And the therapist wanted him to get over it like a breakup?
    Mr. Bojorquez shot out of his seat and began yelling. ``What are 
you talking about?'' he said. ``This isn't something you just get 
over.''
    He had tried getting help at the V.A. once before, right after Mr. 
Markel's funeral, and had walked out when he realized the counselor had 
not read his file. Now he was angry that he had returned. With each 
visit, it appeared to him that the professionals trained to make sense 
of what he was feeling understood it less than he did.
    He threw a chair across the room and stomped out, vowing again 
never to go back to the V.A.
    In recent years, suicide prevention efforts by the Department of 
Veterans Affairs have focused on encouraging veterans to go to its 
hospitals for help, but a bigger problem could be keeping them there.
    In interviews, many Marines from the battalion said they received 
effective care at the V.A. But many others said they had quit the 
treatment because of what they considered long waits, ineffective 
therapists and doctors' overreliance on drugs.
    Six of the 13 Marines from the battalion who committed suicide had 
tried and then given up on V.A. treatment, discouraged by the 
bureaucracy and poor results, according to friends and relatives.
    A 2014 study of 204,000 veterans, in The Journal of the American 
Psychiatric Association, found nearly two-thirds of Iraq and 
Afghanistan veterans stopped Veterans Affairs therapy for PTSD within a 
year, before completing the treatment. A smaller study from the same 
year found about 90 percent dropped out of therapy.
    The therapies, considered by the department to be the gold standard 
of evidence-based treatments, rely on having patients repeatedly 
revisit traumatic memories - remembrances that seem to cause many to 
quit. Evaluations of the effectiveness of the programs often do not 
account for the large number of patients who find the process 
disturbing and drop out.
    Dr. Kudler of the Department of Veterans Affairs said data showed 
that 28 percent of patients drop out of PTSD therapy, but that most 
veterans stay in treatment and report improvements.
    He added that dropout is an issue in all mental health care, not 
just among veterans, and that the department was constantly trying to 
provide alternative types of therapy, like meditation.
    Craig J. Bryan, a psychologist and an Iraq war veteran, said that 
``the V.A. has done more to try to prevent suicide than anyone has done 
in the history of the human race.'' Mr. Bryan, who runs the National 
Center for Veterans Studies at the University of Utah, added: ``But 
most veterans who kill themselves do not go to treatment or give up. 
They are not interested. That is the challenge.''
    Mr. Bojorquez tried the system one more time out of desperation. 
After the spate of suicides in 2014, he called and said he needed help. 
The V.A. had him see a psychologist and psychiatrist.
    He told them that he wanted therapy but no drugs. Too many friends 
had stories of bad reactions. One, Luis Rocha, had taken a photograph 
of all his pill bottles right before shooting himself.
    ``We get it, no drugs,'' he recalled them saying. But on his way 
out, after scheduling a return appointment in two months, he was handed 
a bag filled with bottles of pills. He calmly walked to his car, then 
screamed and pounded the steering wheel.
    He wanted to get better, so he started taking the medications - an 
antidepressant, an anti-anxiety drug and a drug to help him sleep - but 
they made him feel worse, he said. His nightmares grew more vivid, his 
urge to kill himself more urgent.
    After a few weeks, he flushed the pills down the toilet, determined 
to deal with his problems on his own.

Fighting the Label

    Increasingly, members of the battalion felt that at home, as in 
Afghanistan, they were still the Forgotten Battalion. So they looked 
for help from the people they counted on in Afghanistan: their fellow 
Marines.
    In November, Mr. Branch, who was completing a degree in social work 
in Texas, posted a request on Facebook asking the others to enter their 
addresses in a Google spreadsheet. That way, if a Marine in Montana was 
worried about a friend in Georgia, he could look on the spreadsheet and 
find someone nearby to help.
    ``All of us are going through the same struggle,'' Mr. Branch, now 
28, said in an interview. ``If we can get someone there that a guy can 
relate to, we hope it will make all the difference.''
    The spreadsheet is part of a wider realization among young veterans 
that connecting with other veterans - whether through volunteering, 
sports, art or other shared experiences - can be potent medicine.
    One battalion member started an organic farm intended to help 
veterans heal by growing food. Another leads trips to bring together 
veterans with PTSD. Mr. Wood, 32, the former sniper, founded a national 
network of veterans, called Team Rubicon, that provides volunteer 
relief work after natural disasters.
    ``We did it because we really wanted to help others,'' said Mr. 
Wood, of Los Angeles. ``We soon realized it would help us, too.''
    Less than two weeks after the Google spreadsheet was created, a 
text message popped up on the phone of a Marine veteran named Geoff 
Kamp. It was just after 11 p.m. on a Wednesday in November.
    Mr. Kamp, who had turned in early to be up for his shift with the 
Postal Service, reached for the phone next to his bed, read the text, 
turned to his wife and said, ``I'm going to be gone for a while.''
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

    An hour earlier, a 27-year-old Marine veteran, Charles Gerard, had 
changed his Facebook profile photo to an image of a rifle stuck in the 
dirt, topped with a helmet - the symbol of someone killed in action. In 
a post, he wrote: ``I can't do it anymore.''
    After surviving an ambush in Afghanistan where several Marines were 
injured, Mr. Gerard said, he was treated for PTSD by the Marine Corps. 
But when his enlistment ended in 2011, so did his therapy. He tried to 
continue at the V.A., but long delays meant it was two years before he 
got any treatment, and even then, he said, he found it ineffective.
    He moved back to rural Indiana and worked at factories, but his 
anger frayed ties with his friends and family. News that comrades from 
the battalion had killed themselves pushed him deeper into despair. The 
night he changed his profile picture, his girlfriend had left him.
    Within minutes, the battalion's response system kicked in. Mr. 
Havniear in Oregon spotted the Facebook post and called a Marine in 
Utah who had been Mr. Gerard's roommate. They called Mr. Gerard 
immediately but got no answer. Mr. Gerard was parked in his pickup by a 
lake outside of town with a hunting rifle in his lap.
    Desperate to head off another death, they opened the Google 
spreadsheet and found Mr. Kamp, 90 minutes away. Within 10 minutes, he 
was in his truck, speeding north through the late autumn corn stubble.
    Mr. Kamp had never met Mr. Gerard. But he, too, had been injured in 
a firefight, and been dogged by guilt and anger afterward.
    ``Every one of the guys that's died, I see myself in them,'' he 
said later in an interview at his home. ``It's like you are always just 
one bad day away from that being you.''
    At the lake, Mr. Gerard propped his rifle against his head, closed 
his eyes and pulled the trigger. There was a click, then nothing.
    He took a deep breath and checked the chamber. It was loaded, but 
the round was a dud.
    He decided the universe was telling him it was not his time to die. 
He tossed his remaining ammunition in the lake and drove home.
    A few minutes later, Mr. Kamp knocked on the door.
    They talked on the couch most of the night about relationships, 
work, mortgages, combat, guys who did not make it home and the cold 
feeling after Afghanistan that you are alone even when surrounded by 
other people.
    ``We'll make it through this,'' Mr. Kamp told him.
    Mr. Kamp eventually called the sheriff's office for help, took the 
rifle for safekeeping and stayed until paramedics took Mr. Gerard to 
the veterans hospital in Indianapolis.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    In March, members of the group used their informal network to 
intervene with another battalion member in Louisiana. The jury-rigged 
system is far from ideal, they said, but they are determined to make it 
work.
    Mr. Gerard's experience shows, however, that the system is only as 
good as the V.A. treatment it is intended to connect to. The night he 
went to the psychiatric ward at the Indianapolis veterans hospital, he 
said, he waited and waited for a doctor to see him. After 24 hours, he 
gave up and checked himself out.
    ``There was no one there for me,'' Mr. Gerard said in a quiet voice 
during a recent interview at his home after a 12-hour night shift at an 
auto plant.
    He looked pale and gaunt, a far cry from the tan and muscular 
Marine in photos from Afghanistan. Garbage and unwashed dishes were 
piled up around him. The curtains were drawn.
    He crushed out a cigarette. The V.A.? ``I've had nothing to do with 
them since,'' he said.

A Lifesaving Call

    After swearing off the V.A., Manny Bojorquez turned increasingly to 
friends for support. Late-night calls and texts with guys from the 
battalion seemed to help more than therapy ever did.
    He reconnected with Mr. Guerrero, who still shared his love of 
Mexican hot sauce. The machine-gunner was living in California, in his 
last year of college, and he had a baby boy.
    ``The guys we served with, they are the only ones we can really 
talk to,'' Mr. Bojorquez said in an interview.
    But in November, Mr. Bojorquez got a text from Mr. Guerrero that 
upended everything. ``I don't think I can do this life anymore,'' it 
said.
    Mr. Guerrero had never mentioned it to others, but he still 
believed his sergeant's death was his fault. If only he had yelled a 
warning. Or spotted the I.E.D. He was getting therapy and medication 
for his depression, but still often woke up with a deep dread, as if he 
were sitting at the principal's office, waiting to be punished. Every 
day, he wore a bracelet etched with the sergeant's name.
    That night, Mr. Guerrero had been watching television with his wife 
after church when something snapped. He crumpled to the floor and 
backed into a corner, crying, ``I'm sorry, I'm sorry.''
    He had not smoked since the Marines, but pleaded with his wife to 
go out and buy cigarettes. The panic and guilt were so excruciating 
that he decided the only relief was to kill himself. He went onto his 
porch with shaking hands to text Mr. Bojorquez to say goodbye.
    Mr. Bojorquez called immediately. Mr. Guerrero picked up, sobbing, 
but after a few words hung up.
    A fear had crept over Mr. Bojorquez over the last year that he was 
doomed to watch his friends die one after another until he was the only 
one left. At times, he saw it as another reason to kill himself. But it 
was also motivation to break the pattern.
    He knew he had to call 911, but hesitated. The call might land Mr. 
Guerrero in a psychiatric ward or ruin his marriage, already strained. 
Worse, if the police barged in, his friend might go berserk. Someone 
could get hurt. But what choice was there?
    The police pounded on the door just as Mr. Guerrero put a handful 
of pills into his mouth. He spent the next few weeks in a private 
inpatient treatment program for PTSD.
    It was far from a cure. He said he was still deeply depressed and 
ashamed. He still slept on the couch instead of in his wife's bed, and 
he was not speaking to his parents. But he was alive.
    Six weeks later, Mr. Bojorquez drove out to visit him in San Diego. 
The 911 call had not broken their friendship, but it had broken the 
long silence in which neither mentioned what he had brought home from 
war.
    They greeted each other in a hug. During a lunch at a nearby 
taqueria, Mr. Bojorquez talked about the night he had put a gun to his 
head. Mr. Guerrero talked about watching his sergeant's Humvee explode 
and being so rattled afterward that he did not care that his cigarette 
was flecked with blood. They stayed long after the lunch crowd cleared 
out.
    ``This is good - us here like this,'' Mr. Guerrero told his friend. 
``It's the times when I'm alone that I fear.''
    They had found small ways to rebuild their lives. Mr. Guerrero had 
become a rabid marathoner and was leading the youth band at his church. 
Mr. Bojorquez was studying to join the United States Border Patrol and 
playing on a softball team with his brother.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    At dawn the next morning, Mr. Guerrero took Mr. Bojorquez on his 
favorite run to the top of a mountain behind his house. He had placed 
an old metal ammunition box at the top, where Marines could leave 
letters and sign their names. He dedicated it to the men of the 
Forgotten Battalion.
    As they clambered up the trail, they talked about how hard it was 
to find balance.
    ``The death of my brothers consumes me,'' Mr. Guerrero said between 
breaths. ``It gives me this dark energy. I don't know what to do, so I 
run. I run all the time. I pray I never run out of trails to run.''
    It was five winding miles to the summit. When they reached it, the 
two stood side by side catching their breath and looking out at the 
dawn spreading over the ocean. Mr. Bojorquez hung his arm over his 
friend's shoulder. Hummingbirds zipped through the pink light.
    Mr. Guerrero broke the silence.
    ``I'm glad I got to share this with you,'' he told his friend. ``I 
wish I could bring the whole battalion up here.''

Correction: September 23, 2015

    An article on Sunday about the high number of suicides among a 
Marine battalion that served in Afghanistan misidentified the 
association that sponsored a 2014 study of 204,000 veterans on post-
traumatic stress disorder. It is the American Psychiatric Association, 
not the American Psychological Association.
    The Department of Veterans Affairs maintains a hotline for veterans 
in crisis that operates 24 hours a day. Call 1-800-273-8255 and press 
1, go to veteranscrisisline.net/chat, or send a text to 838255.
    A version of this article appears in print on September 20, 2015, 
on page A1 of the New York edition with the headline: A Unit Stalked by 
Suicide, Trying to Save Itself.

                                 
            Prepared Statement of Jacqueline Maffucci, Ph.D.
    Chairman Miller, Ranking Member Brown and Distinguished Members of 
the Committee:
    On behalf of Iraq and Afghanistan Veterans of America (IAVA) and 
our more than 425,000 members, thank you for the opportunity to share 
our views on the Department of Veterans' Affairs efforts to reduce 
suicide among veterans.
    In 2014, IAVA launched the Campaign to Combat Suicide. This was a 
result of our members continually identifying mental health and suicide 
as the number one issue facing post-9/11 veterans in our annual 
membership survey. This campaign centers around the principle that 
timely access to high quality mental health care is critical in the 
fight to combat veteran suicides.
    The signing of the Clay Hunt SAV Act into law was an important 
first step to addressing this. We thank you for your support of this 
legislation, the VA for their commitment to fully implement this law 
and Richard and Susan Selke for courageously uniting us all to do the 
right thing. We knew it would take time to do so correctly and we've 
been pleased that the VA's Mental Health Service team has included us 
in that process. While progress has seemingly been slow, we expected 
that this first year would be spent laying the foundation to implement 
the law and identifying funds to do so. We look forward to continuing 
to be a part of the implementation while working with the VA and 
Congress to continue working towards progress on this issue with new 
initiatives.
    I'd like to focus today on four specific areas that IAVA feels are 
critical to this progress: Access to Care; Interdisciplinary Approach 
to Care; Research; and Supporting Those Most at Risk.

Access to High Quality Mental Health Care

    IAVA's Rapid Response Referral Program connects veterans and their 
family members to quality resources. Mental health and suicide 
challenges are among the top three issues our team is responding to.
    In our most recent annual membership survey, over half of the 
respondents reported having a mental health injury and over 80 percent 
reported seeking care for that injury. For over 75 percent, the impact 
of a loved one suggesting they seek help made a huge difference and 
resulted in them finding that help. For IAVA this is a good news story. 
More of our members are seeking help, and the role of family and 
friends taking that first step is huge.
    For those in care, three out of four are using the VA. And this 
year, we saw over 75 percent of those using VA mental health report 
little to no challenges scheduling an appointment, up 10 percent 
compared to last year and comparable with those using a non-VA 
clinician. The same number were also satisfied with that care.
    The challenge associated with growing awareness of service-related 
mental health challenges and this improved care is an increase in 
demand for high quality mental health care rising both in- and outside 
of the VA. It is critical to ensure that the VA is properly resourced 
to provide high quality mental health care; a challenge made even more 
difficult by the dwindling supply of mental health professionals.
    Efforts are underway to bolster the number of mental health 
professionals. The Secretary is carrying out the ever important task of 
recruiting medical students into the VA. Joining Forces has been 
critical in urging medical schools to improve curricula to ensure that 
that these students are better equipped to care for veterans and their 
families. But that's not enough.
    Beyond the challenge of a clinician shortage is the difficult task 
of hiring and retaining talent in VA. A recent VA OIG report that 
looked at hiring and loss rates of VA psychologists found that a 
significant percentage of the total gains from hiring was offset by 
losses. \1\ The VA needs to fully understand and address the reasons 
that staff leave and how to best attract and retain new talent. They 
need to do so with the knowledge of where the demand is for those 
professionals using updated models and real time data.
---------------------------------------------------------------------------
    \1\ Office of the Inspector General, Department of Veterans 
Affairs. OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages. Washington D.C: Department of Veterans 
Affairs, 2015.
---------------------------------------------------------------------------
    The federal hiring process can also be confusing and lengthy, which 
can deter candidates. And the VA itself, particularly in today's 
climate, can be a challenging place to work. We often forget to praise 
the talented and dedicated staff who sacrifice in service of the VA's 
mission, some of whom are IAVA members themselves. IAVA members have 
shared stories with me of the great work and dedication of these staff, 
telling me how these individuals have saved their lives or cared for 
them in some of their hardest moments. We all must do our part to help 
celebrate what makes the VA good while also focusing on how to make it 
better.
    Finally, we need to ensure high quality care outside the VA as 
well. Just under 40 percent of the total veteran population seek care 
at the VA, which means the current community clinical workforce needs 
to be equipped to support veterans and their families. A recent RAND 
report estimates that only eight percent of community mental health 
providers are prepared to address the mental health needs of this 
population. \2\ It is not even standard practice to ask if a patient is 
has served in the military. This has got to change. New Hampshire is 
leading the way with its campaign, ``Ask the Question.'' But beyond 
asking the question, providers need to know how best to provide 
treatment once they have the answer. The VA and its partners 
(particularly its academic partners) are best equipped to lead this 
effort.
---------------------------------------------------------------------------
    \2\ Tanielian, Terri, Coreen Farris, Caroline Batka, Carrie M. 
Farmer, Eric Robinson, Charles C. Engel, Michael Robbins and Lisa H. 
Jaycox. Ready to Serve: Community-Based Provider Capacity to Deliver 
Culturally Competent, Quality Mental Health Care to Veterans and Their 
Families. Santa Monica, CA: RAND Corporation, 2014.

---------------------------------------------------------------------------
Interdisciplinary Approach to Care

    But suicide prevention is not just about mental health care. In 
February, the VA hosted a Suicide Prevention Summit, and IAVA and 
Vietnam Veterans of America were both invited to speak. Together, we 
called upon the Secretary to elevate the VA's Suicide Prevention Office 
from Clinical Operations under Mental Health Services in VHA to the 
Office of the Secretary, at the same level that DOD places the office 
in its structure. Our reasoning is simple: while mental health is a 
major aspect of suicide prevention, it is not the only aspect. There 
are social factors that can also impact these actions, factors such as 
employment, finances and social supports. This is why IAVA has been so 
focused on employment initiatives, defending the new GI bill and 
creating a network of support among our members. Many of us have heard 
the tragic stories of Clay Hunt, Daniel Somers and other veterans who 
have died by suicide. Often these stories highlight not just the mental 
health challenges, but the challenges these individuals faced seeking 
care and obtaining VA benefits. The Suicide Prevention Office has to 
exist at a higher level, where it could impact both VHA and VBA. We are 
pleased that the Secretary has answered our call. We ask Congress to 
ensure that this office is fully resourced through a line-item on the 
budget so that it can be certain of its funding to carry out the 
critical mission with which it is tasked.

The Need for Research

    We simply don't know enough, yet, about suicide within the veteran 
population. We know that suicide impacts seniors disproportionately, 
but we don't know why. We know that the women have a high rate of 
suicide, but don't understand how best to intervene. We know that the 
post-9/11 generation is showing an increased risk, but are just 
starting to understand the risk factors that can really help us impact 
interventions. More research is critical to developing interventions. 
We cannot solve what we don't understand.
    IAVA, and anyone serious about understanding the current state of 
veteran suicide, are frustrated that the Joint Suicide Data repository 
has not been fully utilized. That data can be critical in understanding 
and preventing suicide and there is no reason to not share it with the 
researchers and scientists outside the VA who can bring additional 
resources to analyzing it. Similarly, we want to see the VA's Coming 
Home study finally launched. Data from this study will help us to 
understand the transition home and define what is unique to military 
service from a health outcomes perspective.
    A greater understanding of the unique challenges facing subgroups 
of vets is why IAVA supports the House-passed Female Veterans Suicide 
Prevention Act (H.R. 2915/S. 2487). This legislation will be critical 
in identifying the mental health and suicide prevention programs and 
services that work for women veterans. We have called on the Senate to 
take immediate action on the bill.

Supporting Those Most at Risk

    Finally, as a community we must provide care for those most at 
risk. Veterans with bad paper have a higher risk of suicide and 
homelessness and yet often do not have access to care. A recent report 
estimated there are 125,000 post-9/11 veterans with bad paper. \3\ It 
is likely that for some, their discharge status was a result of 
symptoms experienced from an undiagnosed mental health injury. The 
current system does not make it easy to identify these individuals and 
get them into care. This must change. IAVA urges passage of the 
Fairness for Veterans? Act (S.1567/H.R.4683) as part of the solution, 
but we also recognize that there must be a broader solution identified 
through a collaborative effort between the VSO/MSO community, Congress, 
DoD, and VA. Suicide prevention efforts are most effective when we can 
identify an at risk population and provide targeted solutions to 
support this population. We've identified one of these populations and 
we know what they need. It's negligent not to take action.
---------------------------------------------------------------------------
    \3\ Underserved: How the VA Wrongfully Excludes Veterans with Bad 
Paper. San Francisco, CA: Swords to Plowshares, 2016.
---------------------------------------------------------------------------
    In some cases, the answer might lie within the Vet Centers. This 
resource continues to be highly praised among IAVA's member population. 
We recommend a comprehensive assessment of the role the Vet Centers 
play in supporting veteran and family mental health. This is a critical 
resource and fills a specific need, particularly for veterans who may 
less inclined to seek services at the VA health centers, are seeking 
care with their family or are not eligible for VA care. We want to 
ensure that it is being fully utilized.
    All veterans deserve the very best our nation can offer. We look 
forward working with you and the Administration to address these very 
real challenges with informed solutions.
            Statement on Receipt of Grants or Contract Funds
    Neither Dr. Maffucci, nor the organization she represents, Iraq and 
Afghanistan Veterans of America, has received federal grant or contract 
funds relevant to the subject matter of this testimony during the 
current or past two fiscal years.

                                 
                   Prepared Statement of Joy J. Ilem
    Chairman Miller, Ranking Member Brown and Members of the Committee:

    On behalf of DAV (Disabled American Veterans) and our 1.3 million 
members, all of whom are wartime injured or ill veterans, I am pleased 
to present our views at this hearing, related to the effectiveness of 
the mental health and suicide prevention programs of the Department of 
Veterans Affairs (VA), future actions that may be needed to reduce 
suicide among high-risk veteran populations, including women veterans 
and veterans who are not currently enrolled in or accessing VA 
services, and the progress VA has made implementing the Clay Hunt 
Suicide Prevention for American Veterans (SAV) Act, Public Law 114-2.
    In last week's Washington Post, Harvard Psychology Professor 
Matthew Nock, a noted researcher on suicide, published a column worth 
considering on the topic before the Committee today. Professor Nock 
concluded in describing the present state of knowledge about suicide:
    There are many well-intentioned prevention programs out there, but 
we have very little data on which ones work and which ones don't. .[W]e 
have no programs backed up by evidence from randomized controlled 
trials, the highest standard, showing that they stop people from ever 
attempting suicide. Our best bet for preventing suicide is to ramp up 
research and hopefully shed more light on this troubling phenomenon.
    According to the Centers for Disease Control and Prevention (CDC), 
suicide is not a health care problem but rather, a public health and 
societal problem. The World Health Organization states that suicide is 
the 10th leading cause of death in the United States and worldwide more 
than 800,000 people commit suicide every year. The CDC recommends 
adoption of a public health model to best deal with conditions that 
might lead to suicidal ideation. For these reasons DAV is pleased that 
VA has adopted a modified public health model in its attempt to improve 
suicide prevention efforts in the veteran population.
    Public health uses a population approach to improve health on a 
large scale. A population approach means focusing on prevention efforts 
that impact groups or populations of people as a whole, versus 
treatment of individuals. Second, public health focuses on preventing 
suicidal behavior or even ideation, before it ever occurs (primary 
prevention), and addresses a broad range of risk and protective 
factors. Third, public health holds a strong commitment to increasing 
understanding of suicide prevention through science, so that we can 
develop new and better approaches and solutions. Finally, public health 
values multi-disciplinary collaboration, which brings together many 
different perspectives and experience to strengthen the solutions for 
many diverse communities.

VA Mental Health and Suicide Prevention Programs

    The Vietnam War and the more recent lengthy wars in Iraq and 
Afghanistan have taken a toll on the mental health of the military 
service branches, and veterans who have returned from these operations. 
Combat stress and often severely disabling combat-related mental health 
readjustment are prevalent among Vietnam veterans and our newest 
generation of warfighters from Operations Enduring Freedom/Iraqi 
Freedom/New Dawn (OEF/OIF/OND) veterans.
    Unique aspects of deployment, including the frequency and intensity 
of exposure to violence, injury and death, asymmetrical warfare from 
urban to desert to jungle environments, and suffering through or 
witnessing the reality of war, a truism from World War II until today, 
are strongly correlated with the risk of chronic post-traumatic stress 
disorder (PTSD) and other mental health sequalae. While veterans who 
served in Iraq and Afghanistan make up only a fraction of the VA 
patient population, they are absorbing a significant proportion of VA's 
specialized mental health resources. Since the wars began 15 years ago, 
over 2.7 million service members have deployed, more than 1.9 million 
are now veterans eligible for VA health care, and about 1.2 million 
have actually obtained VA care in some form. More than 57 percent who 
have received VA health care received a mental health diagnosis, 
prominently including PTSD. As of the end of 2015, VA was compensating 
nearly 830,000 veterans from all war eras for PTSD.
    Applying lessons learned from prior wars, VA mounted efforts at 
early identification and treatment of behavioral health anomalies in 
enrolled OEF/OIF/OND veterans by instituting system-wide mental health 
screenings, adding new counseling and clinical sites, and conducting 
wide-scale training in evidence-based psychotherapies. While these are 
positive steps and VHA has made progress in disseminating knowledge 
about evidence-based treatment that does not guarantee implementation 
of such treatments. For these reasons we recommend VA collect 
information on the use of evidence-based psychotherapies to ensure 
system-wide availability of such services.
    Over the past decade the VA Office of Mental Health has promoted a 
comprehensive set of mental health services, while VA facilities were 
seeing a significant increase in the number of veterans seeking care. 
VA has integrated a mental health presence into primary care in its 
Patient Aligned Care Team (PACT) model, with a goal of minimizing 
barriers to this specialized care, and aimed at reducing stigma. From 
FY 2008 to March 2014, VA provided more than 3.6 million Primary Care-
Mental Health Integration (PC-MHI) clinic visits to more than 942,000 
veterans. Also, VA provided specialty mental health services to more 
than 1.5 million veterans in fiscal year (FY) 2014.
    The Government Accountability Office (GAO) and others have 
identified key barriers that deter veterans from seeking mental health 
care, including stigma, lack of understanding or awareness of the 
potential for improvement, lack of child care or transportation, and 
work or family commitments. Research shows early intervention and 
timely access to mental health care are key to improving quality of 
life, promoting recovery, obviating long-term health consequences, and 
minimizing the disabling effects of mental illness -and the risk for 
suicide.
    In recent years, VA's mental health programs, including its suicide 
prevention efforts, have been both praised and criticized. 
Nevertheless, the Committee should note that VA offers an array of 
mental health services that is unparalleled in any other health system 
or individual institution in the country. The scope, depth, and breadth 
of VA's multivariate approaches deserve recognition. However, as noted 
above, VA's most significant challenge is to ensure that the dozens of 
developed models used in evidence-based care (many of which emerged 
from VA's own intramural research) are uniformly available in every 
Veterans Integrated Service Network-a situation that also has been 
criticized by both internal and external observers. Variability is the 
result of a number of factors including insufficient staff levels; 
archaic human resources operations governing personnel recruitment; 
availability of specialized practitioners, and lingering VA 
organizational and cultural challenges. DAV believes VA is making good-
faith efforts to address the problems that are within its control, but 
Congress and the Administration need to do their part to ensure VA has 
the legislative authority, tools and resources to solve these specific 
problems.
    VA increased staffing of new mental health providers following a 
2012 Office of Inspector General (OIG) report on the Veterans Health 
Administration, titled ``Review of Veterans' Access to Mental Health 
Care'' (http://www.va.gov/oig/pubs/VAOIG-12-00900-168.pdf). In fact, VA 
has the highest number of mental health providers in an integrated 
health care system (over 5,200 employed practitioners) with specific 
expertise and training in post-deployment-related mental health 
conditions, such as PTSD. These practitioners are reinforced by 
investigators in VA's Research and Development Service, as well as the 
unique asset of the VA National Center for PTSD. VA is able to 
coordinate comprehensive primary and specialty care services for 
veterans with substance-use disorders, traumatic brain injury (TBI), 
and other co-occurring disorders that are tailored to meet veterans' 
complex health and mental health needs.
    The goal of increasing staffing was to shorten waiting times for 
access to mental health services, and address numerous known barriers 
to care. However, it is unclear if all enrolled veterans are receiving 
the types of services they want or need-when and where they need them. 
Veterans, especially younger veterans, indicate they would prefer a 
variety of new services over medication, such as web-based life 
coaching and skills-building tools, intensive evidence-based therapies, 
as well as non-medical/non-traditional therapies, such as complementary 
and alternative medicine (CAM) options (i.e., yoga, meditation, 
acupuncture, Tai Chi). While VA is steadily increasing the availability 
of these new non-medical approaches, there is variability across the 
system related to access to CAM services.
    In addition to the PACT approach, VA uses Patient-Centered 
Community Care (PCCC) in mental health to maximize utilization of 
integrated health services when enrolled veterans are unable to access 
direct VA care. DAV prefers VA to be the provider of these specialized 
services whenever possible, but immediate access to care is the most 
critical factor for a veteran in a mental health or emotional crisis. 
However, we believe VA should properly triage and make a determination 
for every patient based on the unique findings in each case, and 
develop a mental health treatment plan that meets the veteran's needs, 
whether in-house, in the community, or in a hybrid arrangement. A 2014 
report by the RAND Corporation indicates that only 13 percent of 
evaluated mental health providers (not limited to VHA providers) met 
study criteria for readiness to provide veteran-friendly, high-quality 
care. According to RAND, providers working within the VHA or a military 
setting were more likely than others to meet the criteria, which may 
raise questions for some about increasing the use of non-VHA care. The 
report recommends conducting better assessments of civilian provider 
capacity, assessing the impact of trainings in cultural competency on 
provider capacity, expanding access to effective trainings in selected 
evidence-based approaches, and facilitating providers' use of evidence-
based approaches.
    Mr. Chairman, DAV has previously testified that, in most cases, 
sending veterans with war-related mental health issues out of the 
system is not the answer. This group can particularly benefit from VA's 
expertise in treating PTSD, substance-use disorders, TBI and other 
post-deployment transition challenges. Giving a card to a veteran with 
mental health challenges and leaving him or her to search for services 
in the community, absent VA care coordination, increases the risks for 
these vulnerable veterans. If veterans with mental health issues need 
access to care outside of the VA system, we urge VA to have routine 
follow-up with the veteran to ensure the patient is receiving quality 
care from a provider with expertise in treating veterans.
    Over the years, VA has received both praise and criticism for its 
suicide prevention efforts and mental health services. Some veterans 
have undoubtedly fallen through the cracks and others have testified 
before Congress that VA's suicide prevention efforts were inadequate, 
describing barriers in access to care and the lack of time for 
clinicians to provide intensive evidence-based treatments for those who 
do access care. Veterans and family members have testified before this 
committee on several occasions talking about horrible failures in the 
system and the need to do more to ensure we do not lose another veteran 
to suicide. I am sure those failures weigh heavy on the many dedicated 
and compassionate VA mental health providers and program directors who 
are responsible for serving our nation's veterans. But more 
importantly, what can be done to ensure that any veteran who needs help 
gets it?
    Continued evaluation of the system and a goal of continuous 
improvement is essential. We are pleased that VA has placed special 
emphasis on suicide prevention through an aggressive anti-stigma and 
outreach campaign, and has launched services for veterans involved in 
the criminal justice system. Peer Specialists, mental health consumer 
councils, and family and couples counseling services have also been 
evolving and spreading throughout VA. We have also been encouraged that 
VA has extended clinic hours for patients, placed VA staff on college 
campuses and at universities. VA's web-based self-help resources and 
mobile apps have been very popular and VA's coaching into care campaign 
focused on assisting family members and friends to get veterans the 
help they need has logged thousands of calls.
    A 2010 progress report on the National Strategy for Suicide 
Prevention described the VA as ``one of the most vibrant forces in the 
U.S. suicide prevention movement, implementing multiple levels of 
innovation and state of the art interventions, backed up by a robust 
evaluation and research capacity.'' More recently, Psychiatric 
Services, a peer-reviewed journal of the American Psychiatric 
Association, published a report showing that the quality of mental 
health care provided by VA is superior to that provided to a comparable 
population in the private sector.
    According to the study, ``in every case, VA performance was 
superior to that of the private sector by more than 30 percent. 
Compared with individuals in private plans, veterans with schizophrenia 
or major depression were more than twice as likely to receive 
appropriate initial medication treatment, and veterans with depression 
were more than twice as likely to receive appropriate long-term 
treatment.'' The authors concluded that ``findings demonstrate the 
significant advantages that accrue from an organized, nationwide system 
of care. The much higher performance of the VA has important clinical 
and policy implications.''
    VA's current suicide prevention efforts based on a public health 
framework, has three major components: (1) surveillance, (2) risk and 
protective factors, and (3) intervention. Suicide prevention 
interventions aim to reduce risk factors and/or enhance protective 
factors that have been identified; interventions may target high-risk 
groups or individuals, identified based on known risk factors. Easy and 
quick access to care is a protective factor against suicide, and recent 
laws have included provisions aimed at increasing veterans' access to 
VA-provided or VA-funded care, including mental health care.
    VA policy requires that mental health care be made available 24 
hours per day in VA facilities or at local community hospitals; that 
new patients referred for mental health services receive an initial 
assessment within 24 hours and a full evaluation appointment within 14 
days; and that follow-up appointments for established patients be 
scheduled within 30 days of initial contact. Likewise, VA has extended 
its care through tele-mental health capabilities so the veteran can 
more easily receive needed services. A full-time suicide prevention 
coordinator is assigned to each VA medical center and large community-
based outpatient clinic. The coordinator is responsible for tracking 
high risk veterans (all attempters, and patients with serious suicidal 
ideation or others clinically determined to be at risk for suicide) as 
well as tracking appointments and coordinating enhanced care. The 
extent to which these policies are in practice broadly should continue 
to be a major oversight concern of this Committee. The one area we 
recommend VA put more focus on is crisis management. When a veteran is 
experiencing a mental health crisis and asking for help, there must be 
ready access to a mental health specialist and/or specialized program. 
Other areas VA should focus on include negative perceptions and 
concerns veterans may have about VA care, and challenges in scheduling 
appointments. VA should utilize its peer specialists to follow up with 
veterans waiting for care. According to VA, peer-to-peer interactions 
have been extremely helpful to the patient and treating clinicians.
    In November 2011, VA launched an award-winning, national public 
awareness campaign called Make the Connection, which is aimed at 
reducing the negative perceptions associated with seeking mental health 
care and informing veterans, their families, friends, and members of 
their communities about VA resources (www.maketheconnection.net). As of 
July 2015, the campaign has had over 8.8 million website visits, 
227,909 uses of the VA resource locator, 12 million video views, and 
more than 33 million Facebook comments, shares, and post likes.
    The Veterans Crisis Line is another successful component in VA's 
suicide prevention efforts. However, despite the measurable success 
with answered calls, dispatched emergency services and referrals to 
care, service problems were identified earlier this year in a VA Office 
of Inspector General report. Specifically, complaints included some 
calls going unanswered, lack of immediate assistance, delayed arrival 
of emergency services, and difficulty using the call line during a 
crisis. Continued evaluation and program improvement is needed. For 
these reasons, we are pleased that an outside evaluation of the VA's 
mental health care system is now underway, as mandated by the Clay Hunt 
SAV Act, to be completed by the end of fiscal year (FY) 2017. Going 
forward, these evaluations will be continued on an annual basis.
    Challenges also persist in suicide surveillance including 
timeliness of data, consistent classification of deaths as suicides, 
and the accuracy of information reported. Addressing these gaps is not 
a responsibility of VA but more so of the states' vital records 
agencies, coroners and medical examiners. These units of state and 
local government are under no federal mandate to report all suicides to 
any federal agency, including VA or even the CDC.
    It is widely believed that inconsistent reporting of suicides 
across jurisdictions, as well as underreporting of suicides in general, 
limit the effectiveness of surveillance efforts. Classification of a 
death as a suicide requires a determination that death was both self-
inflicted and intentional. Also, suicides may be underreported when the 
manner of death is misclassified as ``undetermined'' or ``accidental'' 
(e.g., poisonings or single-occupant automobile accidents). 
Additionally, each jurisdiction (state, city, Indian Tribe, or 
territory) governs its own rules for investigating deaths, leading to 
variability not only in classification but in reporting.
    Based on these findings, the GAO has recommended the VA implement 
processes to improve the completeness, accuracy, and consistency of 
data reported to the VA's Behavioral Health Autopsy Program (BHAP) 
system, and in particular, that VA rely more on outside data sources 
(e.g., the DOD) to identify decedents as veterans if they are not 
enrolled in the agency's numerous services and benefits programs.

High-Risk Veteran Populations Including Those Not Enrolled or Accessing 
    VA Care, and Women Veterans

    The veteran population is currently estimated at 21.7 million 
individuals. Of these, only 31 percent of all veterans use the VA 
health care system (6.7 million users). Based on this fact, it will 
continue to be a challenge for VA to provide successful outreach to 
veterans that do not use VA but who may need VA's specialized mental 
health services. There have been several examples highlighted in the 
media about military units that have suffered losses to suicide without 
veterans getting any help in the VA or in the private sector. This past 
weekend, to contribute to the ongoing suicide prevention efforts for 
our nation's veterans, DAV along with a coalition of non-profits 
sponsored a ``Spartan Weekend'' for ill and injured veterans, which 
centered on the promise that they would not take their own life without 
reaching out to someone for help. The goal is to help isolated veterans 
reconnect with their battle buddy, unit members and other veterans who 
may need care. The event reached 1.8 million Facebook and other social 
media users and resulted in a number of veterans reaching out for help.
    Meeting the unique needs of women veterans has been a priority for 
DAV. According to VA, over the past decade, there has been a 154 
percent increase in the number of women veterans accessing VHA mental 
health services. Women veterans comprise 9 percent of the total veteran 
population but constitute the fastest growing veteran sub-population. 
Since 2000, the number of women veterans using VA health care has more 
than doubled. VA offers a comprehensive array of mental health and 
specialized post-deployment mental health services to women and VA's 
Uniform Mental Health Services Handbook requires that mental health 
services be provided as needed to women veterans at an equivalent level 
to that of their male counterparts system-wide, and that providers be 
capable and competent to meet the unique needs of women.
    VA conducts annual, comprehensive assessments of suicide deaths 
that occur among veterans using VA health services. These assessments 
evaluate gender differences in suicide rates. According to VA, suicide 
rates among women veterans have increased in recent years, yet are 
lower than suicide rates among male veterans. VA continues to conduct 
important research to identify risk factors and patterns of suicide in 
veterans, including those that may be linked to gender. In one recent 
study, VA researchers found rates of suicide to be higher among women 
who report having experienced military sexual trauma (MST), contrasted 
with those who did not.
    VA partnered with 23 states to report information from death 
certificates on veteran deaths by suicide to learn more about patterns 
and rates. Recently, this effort allowed VA researchers to evaluate 
preliminary estimates of suicide rates, including those who do and 
those who do not use VA health care services. These estimates were 
based on information for the years 2000 through 2010 and include 
gender-specific information, including:

      Suicide rates were nearly six times higher in women 
veterans than in civilian women.
      Suicide among all women veterans was 34.6 per 100,000 in 
2010. This rate increased 40 percent since 2000, from 24.7 per 100,000.
      The suicide rate among male veterans was 36 per 100,000.

    In 2010, women veterans who used VA health services were 75 percent 
less likely to die by suicide than women veterans who did not use VA 
health services. This data suggests that VA's mental health programs 
for women, including suicide prevention efforts, are showing a positive 
impact. VA also found that for women veterans, there is a greater 
likelihood of using firearms as the method of suicide, (i.e., women 
veterans who die by suicide are 18 percent more likely than civilian 
women to use firearms as the instrument of death). Furthermore, the 
firearm suicide rate among women veterans has increased faster and to a 
greater degree than suicide rates among women veterans using other 
methods. This type of gender-specific data collection can aid VA in 
improving mental health services for our women veterans.
    As documented in DAV's 2014 report, Women Veterans: the Long 
Journey Home, women's military and wartime deployment experiences and 
reintegration processes are inherently different from those of their 
male counterparts. Research indicates that both men and women may 
develop PTSD as a response to combat exposure, but women are more 
likely to manifest depression as a co-occurring disorder. Women are 
less likely than men to display anger and resort to substance use. 
Women are more likely to develop depression, or an eating or anxiety 
disorder, but without a diagnosis of PTSD. Findings also show that when 
women return from deployment, the camaraderie and support from their 
male peers is often short-lived, resulting in isolation for many. 
Studies have shown that peer support is important to a successful 
transition, but women report they often cannot find a network of women 
who can relate to their military or wartime service.
    While VA is recognized for its longstanding expertise in 
specialized mental health and post-deployment mental health services, 
it has struggled to establish system-wide access to gender-specific 
group counseling, residential treatment, and specialty inpatient 
programs to serve women. Improved access to these programs is essential 
for recovery and effective reintegration, therefore VA must ensure all 
outpatient and residential programs have environments that can 
accommodate women with safety, privacy, and respect. Existing programs 
should be re-evaluated to ensure they are appropriately tailored to 
meet the unique mental health care and post-deployment transition 
challenges women experience in serving in war.

Update on the Clay Hunt SAV Act, Public Law 114-2

    The Clay Hunt Suicide Prevention for American Veterans (SAV) Act 
included provisions to:

      Extend for one year the existing five-year post-discharge 
period of open eligibility for VA health care for combat veterans 
covering illnesses that have not been medically proven to be related to 
their military service;
      Increase access to mental health care by creating a peer 
support and community outreach pilot program including an interactive 
website of available resources;
      Create a pilot program to repay loan debt of psychiatry 
students for VA recruitment purposes; and
      Conduct an annual evaluation of VA mental health and 
suicide prevention program.

    Based on our understanding, VA is still working to implement most 
of the provisions in the Clay Hunt SAV Act. The VISNs have been chosen 
for establishing a community peer outreach network, developing website 
resources is in progress, the educational loan language is still 
pending in the regulatory process and the RFP or Request for Proposals 
for the Independent Evaluation has gone out.

DAV Recommendations

      DAV urges Congress and the Administration to ensure ample 
resources are provided for VA mental health programs, including 
comprehensive treatment for serious mental illness and sexual trauma, 
readjustment counseling, peer-to-peer programs, promotion of evidence-
based treatments for post-traumatic stress disorder, and specialty 
substance-use disorder services to provide effective mental health care 
for all veterans needing such services.
      VA should continually strive to improve access and 
services for veterans in crisis and those seeking VA primary mental 
health care and specialized programs. VA should continue its targeted 
outreach, anti-stigma, and early intervention efforts, and routine 
screening for new veterans returning from wartime deployments.
      VA should continue research in mental health to study 
gaps in care and develop best practices in screening, diagnosis, and 
treatment for post-deployment readjustment, as well as studies focused 
on understanding and reducing suicide in the veteran population.
      VA should conduct health services research on effective 
stigma reduction, differences in gender readjustment, suicide 
prevention, and treatment of acute co-occurring PTSD, mild traumatic 
brain injury, and substance-use disorders in combat veterans.
      VA should increase innovative programs such as telehealth 
for increasing access to gender-sensitive mental health treatment 
programs for women veterans.
      VA should develop a standardized approach to transition 
women with serious mental health deficits, including those who have 
experienced sexual assault, from DOD to VA care.
      Congress should expand the authority for the VA 
Readjustment Counseling Service's women veterans retreat program. The 
VA Office of Research and Development should study the program to 
determine its key success factors, its effectiveness as an alternative 
treatment regimen, and whether it can be replicated in other settings.

Closing

    Despite obvious improvements, it is clear that more progress needs 
to be achieved by VA to fulfill the nation's obligations to veterans 
who are challenged by serious and, in some cases, chronic mental 
illness-particularly in all eras of war veterans, including younger 
veterans who are confronted by post-deployment repatriation and 
transition challenges. Currently, there is a pressing need for timely 
access to mental health services for many returning injured and ill 
veterans, particularly in early intervention services for veterans with 
substance-use disorders, and for evidence-based treatments for those 
with PTSD, suicidal ideation, depression and other consequences of 
combat exposure. If these symptoms are not readily addressed at onset, 
they can easily compound and become chronic and lifelong. Delays or 
failures in addressing these problems can result in risky behavior, job 
and family disintegration, incarceration, homelessness, and suicide.
    DAV appreciates the efforts made by VA to improve the safety, 
consistency, and effectiveness of mental health care programs for all 
veterans. We urge VA to continue research on suicide prevention efforts 
and finding innovative ways to engage all veterans. We also appreciate 
that Congress continues to provide funding to VA in pursuit of a 
comprehensive set of services to meet the mental health needs of 
veterans, in particular veterans with wartime service who present post-
deployment readjustment needs. To this end, we urge the Committee's 
continued oversight of VA's progress in fully implementing its Mental 
Health Strategic Plan.
    Chairman Miller and Members of the Committee, this concludes my 
statement. DAV appreciates the opportunity to provide this testimony, 
and I would be pleased to address any of the topics discussed in this 
statement.

                                 
             Prepared Statement of Thomas J. Berger, Ph.D.
    Chairman Miller, Ranking Member Brown, and Distinguished Members of 
the House Veterans Affairs Committee, Vietnam Veterans of America (VVA) 
thanks you for the opportunity to present our testimony regarding the 
Department of Veterans Affairs (VA) efforts to reduce suicide among the 
veteran population. We should also like to thank you for your overall 
concern about the mental health care of our troops and veterans.
    The timing of this HVAC hearing is particularly important as a 
recent National Center for Health Statistics report found that suicide 
in the United States has surged to the highest levels in nearly 30 
years, with increases in every age group except older adults (i.e., 
declining for only one age group: men and women over 75). The rise was 
particularly steep for women where the suicide rate for middle-aged 
women, ages 45 to 64, jumped by 63 percent over the period of the 
study, while it rose by 43 percent for men in that age range, the 
sharpest increase for males of any age. It was also substantial among 
middle-aged Americans, whose suicide rates had been stable or falling 
since the 1950s. The overall suicide rate rose by 24 percent from 1999 
to 2014, according to the report, and the increases were so widespread 
that they lifted the nation's suicide rate to 13 per 100,000 people, 
the highest since 1986. There is absolutely no doubt that this country 
is in the midst of a public health crisis with suicide.
    Nowhere is this more true than in the veterans community as we 
learned back in February 2013 from the VA's report on veterans who die 
by suicide. This report painted a shocking portrait of what's happening 
among our older vets (see chart below) ----
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


Almost three-quarters of veterans who commit suicide are age 50 or 
    older according to this report.

    And even though suicide has become a major issue for the military 
over the last decade, most research by the Pentagon and the Veterans 
Affairs Department has focused on men, who account for more than 90% of 
the nation's 22 million former troops. Little has been known about 
female veteran suicide until recently.
    According to an LA Times article in July 2016, the suicide rates 
are highest among young female veterans--for women ages 18 to 29, 
veterans kill themselves at nearly 12 times the rate of nonveterans. 
And, according to the Times same article, among the cohort of nearly 
174,000 veteran suicides in 21 states between 2000 and 2010, the 
suicide rate of female vets closely approximates that of male 
counterparts--i.e., women vets 28.7 per 100,000 vs 32.1 per 100, 000 
male vets.
    However, we must not forget that it is from the VA's 2013 report 
noted above that the figure of 22 veteran suicides per day is 
calculated. This number is suspect because the data only represent 
numbers reported from 21 states from 1999 through 2011 and did not 
include states with massive veteran communities, like California and 
Texas which didn't report suicides to the VA at that time.
    If the media are going to focus on this number, they need to make 
sure that they are targeting the right generation because according to 
the report, the majority of veteran suicides are committed by Vietnam-
era veterans, yet the media is surprisingly quiet on this point. 
Therefore, VVA calls for an updated veteran suicide report that 
includes data from all 50 states and U.S. territories, and also 
strongly suggests that VA mental health services develop a nationwide 
strategy to address the problem of suicides among our older veterans - 
particularly Vietnam-era veterans. To do so, the VA should seriously 
consider the establishment of an Advisory Board of key VA stakeholders 
involved in suicide prevention, education, treatment, and research.
    VVA understands that it is very challenging to determine an exact 
number of suicides. Some troops who return from deployment become 
stronger from having survived their experiences. Too many others are 
wracked by memories of what they have experienced. This translates into 
extreme issues and risk-taking behaviors when they return home, which 
is one of the reasons why veteran suicides have attracted so much 
attention in the media. Many times, suicides are not reported, and it 
can be very difficult to determine whether or not a particular 
individual's death was intentional. For a suicide to be recognized, 
examiners must be able to say that the deceased meant to die. Other 
factors that contribute to the difficulty are differences among states 
as to who is mandated to report a death, as well as changes over time 
in the coding of mortality data. Nevertheless, according to the 
American Foundation for Suicide Prevention, in more than 120 studies of 
a series of completed suicides, at least 90 percent of the individuals 
involved were suffering from a mental illness at the time of their 
death. The most important interventions are recognizing and treating 
these underlying illnesses, such as depression, alcohol and substance 
abuse, post-traumatic stress disorder and traumatic brain injury. Many 
veterans (and active duty military) resist seeking help because of the 
stigma associated with mental illness, or they are unaware of the 
warning signs and treatment options. These barriers must be identified 
and overcome.
    To be fair, VVA recognizes that over the past year, the VA has 
developed a number of strategies to reduce suicides and suicide 
behaviors in the veterans' community since HVAC's Oversight 
Subcommittee July 2010 hearing entitled ``Examining the Progress of 
Suicide Prevention Outreach Efforts at the VA''. These efforts have 
included a February 2016 announcement that improvements to enhance and 
accelerate progress at the Veterans Crisis Line were made by moving the 
Veterans Crisis Line into VA's Member Services under a director with 
extensive clinical social work background, and that by the end of this 
year, every veteran in crisis will have their call promptly answered by 
an experienced VA responder. That will mean non-core calls will be 
directed appropriately to other VA entities that can best address their 
questions or concerns and presumably, will eliminate the hundreds of 
``dropped'' calls we have all read about. VA also committed to increase 
staff at the Veterans Crisis Line Center.
    Then on March 8, the VA also publicly announced changes to be made 
to its suicide prevention programs, including:

    1. Elevating VA's suicide-prevention program with additional 
resources to manage and strengthen current programs and initiatives;

    2. Meeting urgent mental health needs by providing veterans with 
the goal of same-day evaluations and access by the end of calendar year 
2016;

    3. Establishing a new standard of care by using measures of 
veteran-reported symptoms to tailor mental health treatments to 
individual needs;

    4. Launching a new study, ``Coming Home from Afghanistan and 
Iraq,'' to look at the impact of deployment and combat as it relates to 
suicide, mental health, and well-being;

    5. Using predictive modeling to guide early interventions for 
suicide prevention;

    6. Using data on suicide attempts and overdoses to guide strategies 
to prevent suicide;

    7. Increasing the availability of naloxone rescue kits throughout 
VA to prevent deaths from opioid overdoses;

    8. Enhancing veteran mental health access by establishing three 
regional tele-mental health hubs; and

    9. Continuing to partner with the DoD on suicide prevention and 
other efforts for a seamless transition from military service to 
civilian life.

    While these initiatives are laudable, VVA also believes strongly 
that they cannot fully succeed without a significant increase in the 
recruitment, hiring, and retention of VA mental health staff, as well 
as timely access to VA mental health clinical facilities and programs, 
especially for our rural veterans. This committee must ensure that our 
veterans and their families are given access to the resources and 
programs necessary to stem the tide of veteran suicide.
    Once again, on behalf of VVA's National Officers, Board, and 
general membership, thank you for your leadership in holding this 
important hearing on a topic that is literally of vital interest to so 
many veterans, and should be of keen interest to all Americans who care 
about our nation's veterans. I shall be glad to answer any questions.
                      VIETNAM VETERANS OF AMERICA
                           Funding Statement
                              May 12, 2016
    The national organization Vietnam Veterans of America (VVA) is a 
non-profit veterans' membership organization registered as a 501(c)(19) 
with the Internal Revenue Service. VVA is also appropriately registered 
with the Secretary of the Senate and the Clerk of the House of 
Representatives in compliance with the Lobbying Disclosure Act of 1995.
    VVA is not currently in receipt of any federal grant or contract, 
other than the routine allocation of office space and associated 
resources in VA Regional Offices for outreach and direct services 
through its Veterans Benefits Program (Service Representatives). This 
is also true of the previous two fiscal years.
    For Further Information, Contact:
    Executive Director for Policy and Government Affairs
    Vietnam Veterans of America.
    (301) 585-4000, extension 127

                                 
                    Prepared Statement of Kim Ruocco
    Tragedy Assistance Program for Survivors (TAPS) is the national 
organization providing compassionate care for the families of America's 
fallen military heroes. TAPS provides peer-based emotional support, 
grief and trauma resources, grief seminars and retreats for adults, 
`Good Grief Camps' for children, case work assistance, connections to 
community-based care, and a 24/7 resource and information helpline for 
all who have been affected by a death in the Armed Forces. Services are 
provided to families at no cost to them. We do all of this without 
financial support from the Department of Defense. TAPS is funded by the 
generosity of the American people.
    TAPS was founded in 1994 by Bonnie Carroll following the death of 
her husband in a military plane crash in Alaska in 1992. Since then, 
TAPS has offered comfort and care to more than 50,000 bereaved 
surviving family members. For more information, please visit 
www.TAPS.org
    TAPS currently receives no government grants or funding.

Kim Ruocco

    Kim Ruocco is presently the Chief External Relations Officer for 
Suicide Prevention and Postvention for the Tragedy Assistance Program 
for Survivors (TAPS). Ms. Ruocco is an international public speaker who 
has a unique combination of personal and professional experience, 
education and training that provides a comprehensive understanding of 
suicide prevention and postvention. Ms. Ruocco has been the keynote 
speaker at many national events, most notably the Department of Defense 
(DOD)/Department of Veterans'Affairs(VA) Suicide Prevention Conference, 
VA Suicide Prevention Month, The LOSS team conference, AAS/AFSP Healing 
Conference, IAVA Clay Hunt announcement and multiple USMC, Army, ANG 
and Navy safety stand downs. She has appeared in multiple media outlets 
including CNN, Fox News, Al Jazeera, NPR and NBC radio. She has been 
the topic of many magazine articles including Men's Health, Christian 
Science Monitor, Stars and Stripes and Marine Times. Ms. Ruocco is 
regularly quoted in national newspapers articles on the topics of 
Suicide, Military Culture, Mental Illness, PTSD and VA and DOD policy 
matters.
    Ms. Ruocco has been instrumental in raising awareness using the 
voices of military suicide survivors. She developed suicide survivor 
panels that testified in multiple venues including the DOD/VA suicide 
prevention task force, National Action Alliance and DOD/VA conferences. 
She assisted in the development of the Department of Defense Suicide 
prevention Office (DSPO) Postvention Toolkit, and was a reviewer for 
the current national strategy for postvention. Ms. Ruocco assisted in 
the development of the USMC's ``Never Leave a Marine Behind'' program 
and is a participant in the training video. She was the Family Liaison 
Contact for the USMC/AAS psychological autopsy research project that 
provided key prevention information for the USMC. She and her sons are 
also lead participants in the Sesame Street ``When Families Grieve'' 
video which is distributed internationally to families who have a 
recent death. Ms. Ruocco regularly briefs the DSPO and Navy on the 
family perspective of risk factors and gaps in service. She has also 
testified before the Senate Committee on Veterans' Affairs and is 
considered a subject matter expert for suicide pre and postvention.
    Ms. Ruocco has developed comprehensive, peer-based programs that 
offer comfort and care to all those who are grieving the loss of a 
service member to suicide. She created a team of peer-professionals who 
provide care and comfort to nearly 5000 survivors of military suicide. 
The most impactful of these services is the TAPS Annual Survivors of 
Suicide Loss Seminar, which offers hope and healing to thousands of 
survivors, and provides a camp and military mentoring for the children 
of the fallen. Her programming has been ground breaking in the field of 
postvention and has been incorporated into many civilian postvention 
programs.
    Ms. Ruocco is currently the co-lead on the National Action Alliance 
Military and Family Task force and a member of the National Expert 
Advisory Panel for Research.
    Ms. Ruocco holds a BA in Human Services and Psychology from the 
University of Massachusetts and a Masters degree in Clinical Social 
Work from Boston University. She is also the surviving widow of Marine 
Corp Major John Ruocco, who died by suicide in 2005.
    Chairman Miller, Ranking Member Brown, and other distinguished 
members of the Veterans Affairs Committee, the Tragedy Assistance 
Program for Survivors (TAPS) thanks you for the opportunity to share 
the stories of surviving family members of service members and veterans 
who have completed suicide and to offer suggestions on how to prevent 
other families from suffering the same tragedy. We are appreciative of 
the work this subcommittee has done in the past to improve benefits for 
the survivors of those who have made the greatest sacrifice for our 
country.

How TAPS Helps Survivors

    The Tragedy Assistance program for Survivors (TAPS) is a national 
organization providing compassionate care for the families of America's 
fallen military heroes. TAPS provides peer-based emotional support, 
grief and trauma resources, grief seminars and retreats for adults, 
``Good Grief Camps'' for children, casework assistance, connections to 
community-based care, and 24/7 resource and information helpline for 
all who have been affected by a death in the Armed Forces. Services are 
provided to families and battle buddies at no cost to them. TAPS does 
all of this without financial support from the Department of Defense 
(DoD or the Department of Veterans' Affairs (VA). TAPS is funded by the 
generosity of the American people.
    Bonnie Carroll, following the death of her husband in a military 
plane crash in Alaska in 1992 founded TAPS. Since then, TAPS has 
offered comfort and care to more than 50,000 bereaved family members 
worldwide.

TAPS Special Care for the Survivors Whose Loved Ones Complete Suicide

    My name is Kim Ruocco and I came to TAPS seeking support in 2006 
following the death of my husband, Marine Corp Major John Ruocco. John 
died by suicide after suffering for years with untreated depression and 
PTSD. He was an attack helicopter pilot who flew 75 combat missions in 
Iraq and died three months after he returned. When John died, I was 
overcome with emotions and questions. I was desperate to talk to others 
who had experienced this kind of loss. I had a lot of questions like 
``How do I tell my two boys, who were 8 and 10, that their Dad made it 
safely back from combat and then took his own life?'' I had questions 
about spirituality and increased risk for my children and myself and a 
need to know why someone dies by suicide. I realized that a death by 
suicide required a different kind of grief journey than other military 
deaths.
    In 2007 Bonnie Carroll and I developed a comprehensive Suicide Loss 
Survivor Program. The program is divided into three parts:

      POSTVENTION-postvention is prevention. Those who are 
exposed to suicide, especially those who were intimately connected to 
the deceased, are at higher risk of suicide themselves. Postvention is 
an intervention that provides care to all those who are grieving a 
death by suicide in hopes of decreasing risk and providing a path to 
healing. TAPS has developed a program that allows peer professionals to 
connect immediately with new survivors. New survivors are offered peer 
based support, resources and referrals to trauma care and seminars 
designed specifically for healing after suicide.
      INTERVENTION-survivors of traumatic loss are at increased 
risk for suicide, mental health disorders and addiction. Whether killed 
in action, illness, accident or suicide, survivors may be at risk for 
suicide. TAPS staff is trained in Applied Suicide Intervention Skills 
Training (ASIST). This training allows our staff to identify those at 
risk and connect them with the care they need.
      PREVENTION-with each suicide comes a story of a service 
member or veteran who did not survive his or her injury or illness. 
These stories provide us with an extraordinary amount of information 
that can be used in prevention efforts. TAPS has been the voice of 
suicide survivors for over a decade. Information from our survivors has 
informed policy and protocols for each of the services as well as the 
DOD and VA. We are grateful to be asked once again to testify on behalf 
of these surviving families.

Surviving Family Members of Military Suicide Share Their Stories

    One of the largest growing populations in our TAPS family is our 
surviving families of military suicide. TAPS presently has over 7000 
suicide loss survivors and 700 survivors of murder-suicide. We average 
3 to 4 new suicide survivors everyday.
    For the purpose of today's hearing, I would like to focus on the 
suicide loss population within TAPS. Survivors of military suicide hold 
a wealth of information on the multiple factors that lead up to a death 
by suicide. They are on the front lines of a service member's or 
veteran's battle with PTSD, mental illness, moral injury and the 
multiple stressors associated with military life. They are witness to 
the challenges of stigma associated with mental health and the barriers 
to care for those who are suffering. Survivors of veteran suicide loss 
can provide us with a picture of the potential impact of challenges 
within the VA system. Today's testimony is a summary of information 
gathered from our survivors' journeys. I have narrowed it down to two 
prominent and consistent themes.

Barriers To Care

    We know from research that treatment works and that those who are 
in the care of the VA have a lower rate of suicide. In each case of a 
TAPS family whose loved one died by suicide, the veteran was not 
enrolled in a consistent, effective, evidence based treatment at the 
VA. In most cases the veteran struggled to get the care they needed in 
a timely fashion. In some cases the veteran himself became the first 
barrier to good care because of their cultural beliefs and stigma 
regarding mental health. This reluctance to share their true story, in 
combination with institutional barriers, can become the perfect storm 
for a veteran who is suffering. Families of these veterans struggled to 
help their loved one and often became frustrated and overwhelmed with 
navigating the system. Many of them expressed frustration with the lack 
of their involvement in assessment and treatment. They claim that part 
of the veteran culture is to not complain or admit to emotional or 
physical pain and to downplay how serious the issues actually are. 
Families feel strongly that if they were present for intakes and 
evaluations there would have been a more accurate diagnosis and 
treatment plan. Additionally these families long for a network of peer 
support where they could share information ideas about what helped and 
offer support to one another.
    Here are some stories from TAPS families whose service member or 
veteran faced barriers to care:

PCS Edward Michael Gilkes

    ``Eddie'', was stationed at Ft Benning Ga. training to be an 
Airborne soldier. Just before graduation he was accidently blown up by 
a claymore mine. He spent two years in and out of Army hospitals trying 
to recover from debilitating migraine headaches, blurred vision, 
ringing in his ears and nausea. Despite his pain and multiple doctor 
visits, Eddie never gave up trying to reach his dreams. He attempted to 
complete Ranger training three times but in each case he failed due to 
his ongoing medical issues.
    In May of 2012, Eddie was honorably discharged from the Army 
following a medical board review. He was not given a disability rating 
or sequential pay. Eddie moved in with his parents because he could not 
afford to live on his own. He spent one year waiting to be assessed for 
care by the VA. During this time he was riddled with pain and started 
to lose hope that he would ever get better. When his assessment was 
complete, Edward waited another 6 months for an appointment with the 
doctor. At the appointment he was given painkillers, a brain scan and 
was told to come back in 3 months. Edward returned in 3 months and 
waited all day in the waiting room. At the end of the day he was told 
that he would have to reschedule because there was no longer time to 
see him. The next appointment he could get was 2 months away.
    During this period Edward was also waiting for a disability rating 
from the VA. His diagnosis was TBI and PTSD along with chronic pain 
related to the training accident. Despite documentation of all these 
conditions, disability was denied with one of the reasons being that he 
``had not had enough visits with the VA.'' Eddie became so frustrated 
and hopeless that he gave up trying to get care from the VA. He began 
looking for a job and was hired to work on the pipeline. This work was 
very difficult for him. He had to take frequent breaks because of his 
pain and he had difficulty concentrating. Co-workers often had to cover 
for him. After a little over a year, he was laid off. Eddie moved in 
with his brother and applied for unemployment but his spirit was 
broken. On October 26th, 2015 PCS Edward Michael Gilkes died by 
suicide. He left a note saying ``I have no purpose in life.''

CPL Kevin Schranz

    Kevin was a Marine Corp machine gunner who served two combat tours 
in Afghanistan. During his second tour he received a couple of minor 
injuries from explosions. He experienced ringing in his ears and a 
minor eye injury that could develop into a more significant injury in 
the future. He was honorably discharged in 2014. He and his wife moved 
to Connecticut where he enrolled in college and he tried to transition 
to the civilian world. During this time Kevin began to have some 
anxiety and sleep problems. He told his wife that he had seen some 
``intense things'' and couldn't get them out of his mind. Kevin started 
counseling at the Vet Center and put in a VA claim for his eye injury, 
tinnitus and anxiety.
    Kevin's wife, Abby says her husband became more anxious and 
paranoid. He started to be afraid to be alone and carried his gun with 
him. She encouraged him to go to the VA and be assessed for PTSD. Abby 
says that her husband ``trusted the system'' and was anxious to find 
out ``what was wrong with him.'' Kevin did go to the VA and was tested 
for PTSD. Months later Kevin was denied benefits for his eye injury and 
was told that he did not have PTSD. This finding was devastating to 
Kevin. He said to his wife that this was just a problem with him. He 
wrote a letter to his wife stating that everyone would be better off 
without him. He also left a suicide note that said, in part ``This is 
my own fault, this is not a PTSD problem so please do not politicize 
it.'' Abby looked at his records, after he died, and was surprised to 
see that he denied many of the issues that she witnessed him having, 
such as driving recklessly. Abby expressed regret that she was not 
involved in the assessment. She also wished her husband was immediately 
enrolled in the VA and given treatment for his combat exposure without 
having to ``prove'' he was sick.

Sgt. Raymond Burnside

    Ray was a Special Ops medic for the Army. He had one tour in Iraq 
and another in Afghanistan. Ray enlisted right out of high school when 
he was just 18 years old. He was determined to do something important 
with his life and also wanted to avoid ending up like his Dad, who was 
a veteran who died by suicide in the early 90s. Ray was honorably 
discharged from the Army in 2012. He claimed that he was fine and did 
not need help with the things he had seen and done in combat. His mom 
was concerned because she could see that he was drinking a lot and 
seemed to isolate himself frequently. Ray started school but found it 
very challenging. He would tell his Mom that no one understood him and 
he would get really angry at things the professors would say. He seemed 
more and more agitated and angry and his drinking increased. He dropped 
out of school and went on what his mom described as ``a quest to fit in 
and calm his emotions.'' At one point he disappeared saying he was 
going to join the French foreign legion. He came back weeks later 
saying that he was so drunk that he lost his way. His friends and 
family became very concerned about him. They asked if he might be 
suffering from PTSD and he would respond, ``No, I am just a loser, it 
is all my fault.''
    In July of 2014 Ray was finally convinced to go to the VA. He went 
by himself saying, ``I can handle it.'' Ray returned home, after his 
first visit, enraged. He said that they treated him like he was just 
trying to get attention. He said that he was told that he is not as bad 
as other guys they had seen. Ray told his family that this is exactly 
what he feared that he wouldn't be believed and that people would think 
he is weak and making up his symptoms. His family felt helpless. They 
wondered if Ray had shared just how bad his symptoms were because he 
had so much shame about them. For the next couple of years Ray would 
self-medicate with alcohol and periodically become suicidal. His mom 
would call the VA asking for help and didn't know how to get the help 
her son needed. Once she was able to get him committed to inpatient 
care but he left after three days saying he couldn't ``be confined like 
that because it brought him back to a place he didn't want to go.'' The 
day before Ray died he cut his wrist very badly. His Mom found him 
trying to stitch it closed by himself. She convinced him to go to the 
ER only by convincing him that they could tell the hospital that he cut 
his arm on a broken window. They went to the VA emergency room and he 
was stitched up and released. He went home and began drinking. By the 
next day he was saying that he was going to kill himself. His mom was 
desperate to save him and was able to convince him to get in the car 
with her. Unfortunately at a stop sign he jumped out of the car and 
ran. He was found hours later, hanging in a hotel room.

PEER-BASED SUPPORT

    In each case the family tells TAPS that their veteran only wanted 
to talk to someone who has ``been there.'' The veteran had shame and 
guilt about the symptoms they were feeling and thought these symptoms 
were a weakness in them, not an illness. This false belief became a 
barrier to getting a good assessment and to finding appropriate 
treatment and staying in treatment. Peer support can be used to build 
trust that eventually leads to an understanding that their symptoms are 
real and valid and that there is treatment available that works. Peers 
serve as a beacon of hope for those who are struggle and can offer a 
road map on navigating the system.
    The Fisher family shared their thoughts about how peer-based 
support could have helped their son Fritz.

Fritz Fisher

    Fritz Fisher was a Marine veteran who had served two tours in Iraq 
and was honorably discharged from the Marine Corp in 2004. Fritz was a 
field operator in Iraq and had to leave mid tour because his commitment 
was up. He married Amanda soon after discharge from the Marines. Within 
days of his discharge he experienced extreme guilt for leaving his 
buddies in a war zone and had nightmares and flashbacks related to his 
tour. Amanda encouraged him to go the VA and get assessed. At first he 
refused saying, ``I need to suck it up'' and ``it wouldn't look good.'' 
Fritz resisted care and at the same time his symptoms continued to 
escalate. He was having angry outbursts and panic attacks. He self-
medicated with alcohol which just increased his problems. Finally 
Amanda was able to convince him to go to the VA. According to Amanda, 
it took two years for Fritz to get a PTSD disability rating of 30% and 
many months to see a doctor. When he finally saw the doctor, he was 
given medication and not offered counseling for his emotional pain and 
PTSD. Fritz dropped out of treatment telling his wife that it wasn't 
helping and he didn't feel better. In 2010 Fritz became a government 
contractor and deployed back to Iraq. He told his wife that this would 
help him and that it is where he feels most comfortable. In 2011 Fitz 
returned from Iraq and started having problems. He had chest pain and 
panic attacks. He was drinking and smoking marijuana to ease his 
symptoms. He didn't want to go back to the VA because ``he didn't just 
want to be drugged like my buddies.'' Amanda was desperate to help him 
but didn't know how. Their life became a cycle of anxiety, angry 
outbursts, addiction and crisis. When Fritz was in crisis Amanda would 
take him to the VA ER. She states that many times they would wait all 
day and sometimes not get an appointment. On several occasions Fritz 
stormed out yelling ``no one gives a shit.'' In 2012 Fritz had hit rock 
bottom. He had started huffing air dust. He became suicidal and called 
his parents. His parents drove and picked him up. They also did not 
know how to help him so they drove him to the VA. They were told they 
would see him when they could fit him in. They waited for several hours 
and Fritz stormed out. Fritz only tried to get treatment one more time 
before his death. He went to a civilian, mental health provider and 
they told him that he needed to go to the VA. Fritz over-dosed on air 
dust on October 2, 2014. His wife wishes that her husband had more peer 
support to encourage treatment and normalize his symptoms. She also 
wishes she had a place to get answers on how to help him.
    A veteran recently told me ``I was homeless and living out of my 
truck when I met my peer support specialist 3 years ago. He helped me 
in all areas of my life and I am proud to say that tomorrow I am 
closing on a home.''

Recommendations

    1.Increase number of mental health care providers who are trained 
in evidence based best practice for treatment of injuries and illnesses 
related to these conflicts. At each contact a veteran should be able to 
get appropriate mental health care in a timely manner. This is 
especially crucial for entry points during crisis, such as emergency 
rooms and outpatient clinics.

    2.Develop family advocacy and information groups that can offer 
support and guidance to those who are supporting a veteran.

    3.Develop an avenue for family members to call for professional 
advice on how to help their loved one.

    4.Make peer support specialist a line item. Peer support is an 
invaluable tool and a reciprocal relationship that adds value to all 
involved. Peer support specialist can be used to reach out to veterans 
where they are and build a bridge toward the professional mental health 
care they need. Peer professionals can be used in numerous impactful 
ways including navigating paper work, running support groups, 
normalizing symptoms and validating that treatment works.

    5.Increase incentives for and streamline process for becoming a 
peer mental health professional. In the field of social work we often 
say ``there is no better clinician than one who has personal experience 
and professional training''. In the case of veterans, personal 
experience adds a level of trust and credibility that greatly increases 
the probability of a veteran seeking treatment and staying in 
treatment.

    We hope you will consider our recommendations as you consider the 
ways that the Department of Veterans Affairs can reach out and help 
those veterans who are contemplating suicide. Our families shared their 
stories so that all may learn and identify what brought their loved one 
to take their lives. TAPS stands ready to work with you to end this 
national epidemic.

                                 
               Prepared Statement of Dr. Maureen McCarthy
    Good morning, Chairman Miller, Ranking Member Brown, and members of 
the Committee. Thank you for the opportunity to discuss the 
effectiveness of the Department of Veterans Affairs (VA) mental health 
programs. I am accompanied by Dr. Harold Kudler, Chief Consultant, 
Mental Health Services, and Dr. Caitlin Thompson, National Director, 
Suicide Prevention, Veterans Health Administration.
    VA has developed the largest integrated suicide prevention program 
in the country. We have over 800 dedicated and passionate employees, 
including Suicide Prevention Coordinators, Veterans Crisis Line staff, 
epidemiologists, and researchers, who spend each and every day solely 
working on suicide prevention efforts and care for our Veterans. Our 
overarching strategy is based on enhancing Veterans' access to high-
quality mental health care and implementing upstream programs designed 
to help prevent Veterans from even considering suicide. 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 terms that 
they value.

Preventing Veterans Suicide - A Call to Action

    The Department of Veterans Affairs (VA) hosted a summit on 
``Preventing Veterans Suicide - A Call to Action'' on February 2, 2016, 
to bring together Veterans, families, other Federal agencies, community 
providers, subject matter experts, and other key partners to enhance 
our work on suicide prevention. VA continues to partner with more than 
150 non-Federal mental health organizations around suicide prevention. 
Alongside these partners, we remain strongly committed to preventing 
Veteran suicide. We recognize that we can't do this alone, and we 
continue to develop and prioritize these partnerships.
    Powerful for so many attendees were the stories shared both by 
Veterans and by families. The families of Clay Hunt and Daniel Somers 
have testified before this committee with us several years ago. What 
they shared then and in other settings and again at our Call to Action 
truly has been an extremely powerful and compelling message to us. We 
see them and other families as essential partners to help us continue 
to think through and develop our services.
    In addition, we heard from two extraordinary Veterans, Mr. John 
Heitzman and Mr. Brent Rice, during the Call to Action. They told their 
stories of falling into significant crises and seriously considering 
suicide. They then spoke about the power of connecting with VA Suicide 
Prevention Coordinators and VA clinicians who were integral in helping 
them to recover and lead fulfilling and healthy lives. All these 
stories were videotaped and are available through the following links: 
Veteran - John Heitzman - YouTube and Veteran- Brent Rice - YouTube
    The message from these Veterans was one that truly resonated with 
us. Just as preventing death from heart attacks does not begin in the 
Intensive Care Unit, likewise suicide prevention does not necessarily 
begin with our Crisis Line or our interventions when suicide is 
imminent. Instead, it's about finding hope, leading a high-quality 
life, developing strong, meaningful relationships, and celebrating our 
reasons for living. Engaging Veterans in VA care, and particularly in 
our whole system of care, is a key part of prevention. Also engagement 
with communities is essential. Just like preventing death from heart 
disease involves our efforts in promoting healthy living, addressing 
risk factors, intervening when blood pressure or lipid profiles signal 
problems, there are precursor steps we continue to take to prevent 
suicide. Focusing on the social aspects of Veterans lives, working to 
advocate for their benefits, to assist them with jobs and functioning 
in those jobs, screening for signs of depression to include screening 
for substance use disorders, Post-traumatic Stress Disorder which is 
strongly associated with substance use and dependence, Military Sexual 
Trauma, and Intimate Partner Violence, intervening with our Justice 
Outreach System, preventing homelessness, and providing a system of 
medical care for Veterans,--all of these are significant interventions 
in VA which are part of our comprehensive suicide prevention program. 
That is the message these two Veterans who spoke so eloquently 
communicated.
    The summit generated a series of very clear recommendations for VA. 
One frequently voiced recommendation was for VA and the Department of 
Defense (DoD) to partner on improving the transition from military 
service to civilian life. This builds upon the Presidential Executive 
Action of August 26, 2014, requiring DoD to automatically enroll all 
service members identified as having a mental health problem into DoD's 
inTransition program and, upon separation from the military, provide a 
warm handoff to VA care or community care. Research demonstrates that 
the time of transition out of military service is a time of significant 
stress and increased health risk for service members and their 
families. This includes being a time of increased risk for suicide.
    VA research has indicated that rates of suicide among those who use 
VA services have not shown increases similar to those observed in all 
Veterans and the general U.S. population. This research suggests that 
an improved healthcare transition between DoD and VA could help 
mitigate suicide risk as well as other increased risks of morbidity. 
Focusing on this transition would advance the Departments to a 
proactive population health approach focused on prevention through 
early engagement. To accomplish this, VA must facilitate transitioning 
service members' enrollment in VA health care.
    The Call to Action summit generated multiple additional 
recommendations and initiatives to strengthen VA's approach to Suicide 
Prevention. Significantly, a pilot project is underway to evaluate risk 
intervention strategies based on data that predict who would be at risk 
for suicide before these individuals reach a crisis. Also, VA continues 
to actively monitor suicide related behaviors through the Suicide 
Prevention Applications Network (SPAN). We are working to develop a 
dashboard that will allow ongoing surveillance to support the 
identification of possible clusters of suicide-related behaviors and to 
trigger meaningful responses or interventions. We are also working 
towards establishing a new standard of suicide prevention care by 
analyzing measures of Veteran-reported symptoms to tailor mental health 
treatments to individual needs.
    On April 8, 2016, VA leadership strategized to elevate and enhance 
the Suicide Prevention Program, in order to ensure that VA is able to 
fulfill ongoing and new suicide prevention initiatives. Plans are 
underway to elevate VA's Suicide Prevention Program with additional 
resources and a new reporting structure in order to strengthen current 
programs and initiatives.
    In addition, to continue our commitment to preventing deaths, 
intentional or inadvertent, from opioid overdoses, every VA facility 
provides naloxone, which prevents death by overdose. More than 20,000 
kits have been provided to Veterans across VA. Veterans and families 
have been instructed in their use. Educating VA physicians about the 
importance of ensuring patients only have access to medications they 
need is essential to decreasing overprescribing.

Veterans Crisis Line

    VA is committed to ensuring the safety of Veterans, but especially 
when they are in crisis. We have universal access for 24/7 emergency 
care through our Emergency Departments and VA's Veterans Crisis Line 
(1-800-273-TALK (8255), press 1, and www.veteranscrisisline.net). We 
know that when we diagnose and treat people, they get better. August 
2015 marked 8 years since the establishment of VA's Veterans Crisis 
Line (VCL), which has expanded to include a Chat Service and texting 
option for contacting the Crisis Line. The program continues to save 
lives and link Veterans with effective ongoing mental health services 
on a daily basis.
    The Military Crisis Line has also been added, branded to reach 
active duty service members. Since 2007, the VCL has answered over two 
million calls, nearly 490,000 of those during the last fiscal year. VCL 
has made over 267,000 chat connections and communicated with over 
48,000 texts. VCL initiated the dispatch of emergency services to 
callers in imminent suicidal crisis over 11,000 times last year and 
over 57,000 times total. Finally, the VCL provided over 340,000 
referrals to a VA Suicide Prevention Coordinator (SPC) ensuring 
Veterans are connected to local care.
    To address this increased demand, many steps are currently 
underway. First among these is an increase in responders to 310 Full 
Time Employee Equivalent . Since January 1, 2016, VCL has brought on 29 
administrative personnel to augment areas such as analytics, knowledge 
management, quality assurance, and training. In addition, 38 new 
responders have been brought on board during this same period of time, 
with another 23 in active and ongoing recruitment. New responders are 
also receiving newly developed training that will allow them to provide 
the best experience and services to Veterans. This training includes 
approximately 20 modules, both in person and online, on a wide variety 
of topics in crisis intervention, substance use disorders, Screening, 
Brief Intervention, and Referral to Treatment (SBIRT), motivational 
interviewing, and suicide prevention. In addition, training is now 
being implemented onsite by dedicated training staff who are all former 
VCL responders.
    The Veterans Crisis Line continues to uphold their extraordinary 
commitment to Veterans in crisis, demonstrating a 97% satisfaction 
rating, reported by Veterans who call the VCL and complete an end-of-
call survey. In an effort to further improve the quality of the Veteran 
experience at VCL, Quality assurance processes have been initiated. 
These began April 3 with the selection of six dedicated silent 
monitors. This along with recruitment of a Quality Management Officer 
expected to be on board by May 15, 2016 will bring VCL in line with 
Quality Management processes that are considered best in industry 
practices

Expanding Mental Health Services

    While focusing on suicide prevention, we know that preventing 
suicide for the population we serve does not begin with an intervention 
as someone is about to take an action that could end his or her life. 
We are aware of how we work to prevent fatal heart attacks. We must 
similarly focus on prevention, which includes addressing many factors 
that contribute to someone feeling suicidal. We are aware that access 
to mental health care is one significant part of preventing suicide. VA 
is determined to address systemic problems with access to care in 
general and to mental health care, including substance use disorders in 
particular. VA has recommitted to a culture that puts the Veteran 
first. To serve the growing number of Veterans seeking mental health 
care, VA has deployed significant resources and increased staff in 
mental health services. Between 2005 and 2015, the number of Veterans 
who received mental health care from VA grew by eighty percent. This 
rate of increase is more than three times that seen in the overall 
number of VA users over the same time period. This reflects VA's 
concerted efforts to engage Veterans who are new to our system and 
stimulate better access to mental health services for Veterans within 
our system. In addition, this reflects VA's efforts to eliminate 
barriers to receiving mental health care, including the stigma 
associated with receiving mental health care and treatment for 
substance use disorders.
    Easing the way Veterans receive care from mental health providers 
also has allowed more Veterans to receive care. VA Telemental Health 
innovations provided more than 380,000 encounters to over 122,000 
Veterans in 2015. Telemental Health reaches Veterans where and when 
they are best served. VA is a leader across the US and internationally 
in these efforts. VA's MaketheConnection.net, Suicide Prevention 
campaigns, and the Posttraumatic Stress Disorder (PTSD) mobile app 
(which has been downloaded over 208,000 times) contribute to increasing 
Mental Health access and utilization. VA has also created a suite of 
award-winning tools that can be utilized as self-help resources or as 
an adjunct to active mental health services and substance use 
disorders.
    Additionally, in 2007, VA began national implementation of 
integrated mental health services in primary care clinics. Primary 
Care-Mental Health Integration (PC-MHI) services include both co-
located collaborative functions and evidence-based care management, a 
telephone based modality of care. By co-locating mental health 
providers within primary care clinics, Veterans are able to be 
introduced same day by their primary care team to a mental health 
provider present in the clinic, thereby reducing wait times and no show 
rates for mental health services. Additionally, integration of mental 
health providers within primary care has been shown to improve the 
identification of mental health disorders and substance use disorders 
and increase the rates of treatment. Several studies of the program 
have also shown that treatment within PC-MHI increases the odds of 
attending future mental health appointments and engaging in specialty 
mental health treatment. Finally, the integration of primary care and 
mental health has shown consistent improvement of quality of care and 
outcomes, including patient satisfaction. The PC-MHI program continues 
to expand and through December 2015, has provided over 5.5 million PC-
MHI clinic encounters, serving over 1.3 million individuals since 
October 1, 2007.
    These efforts align with VA's interagency activities including the 
Cross Agency Priority (CAP) Goals and expanding VA mental health policy 
and practice. We anticipate that demand for VA mental health care, 
including treatment for substance use disorders, will continue to grow 
as active duty personnel separate from service. Importantly, in an 
effort to help Veterans who have not enrolled in VA for care, these 
applications are important lifelines to understanding their symptoms 
and helping them to overcome other barriers to care.

VA Mental Health Services and Suicide Prevention for Women Veterans

    VA conducts annual, comprehensive assessments of suicide deaths 
that occur among Veterans using VA health services. These assessments 
evaluate gender differences in suicide rates. While the suicide rate 
among women Veterans are lower than the rate in male Veterans, suicide 
rate among women Veterans have increased in recent years.
    Providing high-quality care specific to women Veterans is a 
priority and VA offers a full continuum of mental health services to 
women Veterans. Evidence-based therapies for PTSD, including prolonged 
exposure and cognitive processing therapy, have been shown to decrease 
suicidal ideation. These treatments are available at every VA medical 
center. Women Veterans have access to comprehensive mental health 
services at every VA medical center. VA has residential and inpatient 
programs that provide treatment to women only or, that have separate 
tracks for women and men. These residential and inpatient programs are 
considered regional and/or national resources, not just a resource for 
the local VA facility. VA remains committed to ensuring that 
appropriate services are available to meet the treatment needs of women 
(and men) Veterans who have experienced Military Sexual Trauma (MST) 
and may be at risk for suicide.

Breakthrough Outcomes for 2016

    We are looking to achieve three breakthrough outcomes for 2016. 
First, we remain focused to increasing access to health care. When 
Veterans call for a new mental health appointment, they receive a 
suicide risk assessment and immediate care, if needed. Veterans already 
engaged in mental health care identifying a need for urgent attention 
will speak with a provider the same day. Second, we will modernize our 
Contact Centers, including the Veterans Crisis Line. Veterans will have 
a single toll free phone number to access the VA Contact Centers, know 
where to call to get their questions answered, receive prompt service 
and accurate answers, and be treated with kindness and respect. By the 
end of this year, every Veteran in crisis will have his or her call 
promptly answered by an experienced responder at the Veterans Crisis 
Line. Third, we will staff critical positions. VA is looking to achieve 
significantly improved critical staffing levels that balance access and 
clinical productivity. This will increase the rate at which positions 
are filled.
    Timely access to mental health care for our Veterans is of utmost 
importance to VA. We acknowledge that we have work to do in this area, 
and we are constantly working to increase access. We are in 
partnerships with other Federal agencies, community providers, and 
through the use of tele-mental health, we are increasing access. There 
are many entry points for mental health care, including 168 VA medical 
centers, 1,035 Community Based Outpatient Clinics and Outpatient 
Services sites, 300 Vet Centers providing readjustment counseling, 80 
Mobile Vet Centers, a national Veterans Crisis Line, VA staff on 
college and university campuses, and a variety of other outreach 
efforts.

Community Provider Pilot Program

    In 2013, 12 VA Medical Centers (VAMCs) developed agreements with 24 
Community Mental Health Clinics (CMHCs) across the country to establish 
Community Mental Health (CMH) pilots. These pilots were created in 
response to section 3(a) of Executive Order 13625, ``Improving Access 
to Mental Health Services for Veterans, Service Members, and Military 
Families,'' which focused on the creation of ``Enhanced Partnerships 
between the Department of Veterans Affairs and Community Providers'' 
designed specifically to decrease wait times and assist in areas where 
VA has faced challenges in hiring and placing mental health providers. 
Pilot sites were able to select a model of care to best meet the needs 
of local Veterans. All sites used one of two broad approaches: 
Community Care or VA telemental health (TMH), with most sites choosing 
to provide Non-VA care to Veterans. Non-VA care uses community 
providers that are paid by VA. TMH care utilizes technology to deliver 
mental health services via modalities such as video conferencing and 
allows for real-time (or ``synchronous'') encounters between health 
care providers and patients who are not in the same location. During 
the VA/Community Mental Health Care Pilot partnerships, TMH services 
enabled Veterans to receive care at designated community clinics that 
were closer to their homes than the nearest VA medical facilities or 
clinics.
    VA and CMHC staff worked together in determining roles and 
responsibilities within each pilot partnership. Partnerships using 
telemental health required space, equipment, a technician, and a 
protocol for handling emergencies (e.g., a Veteran becoming distressed 
during a TMH session). For Non-VA care partnerships, there were other 
responsibilities that needed to be addressed: coordination of care 
(between VA and CMHCs), billing, and payment. While some pilot site 
VAMCs developed strong systems for coordinating care, monitoring 
patients, and billing, other sites, especially smaller ones, 
experienced challenges in these areas.
    Evaluation of the pilots included both gathering data from not only 
Veterans about their experiences, but also from key staff at each of 
the participating Veterans Integrated Service Networks (VISN) and VA 
Central Office (VACO) and a review of key documents associated with the 
pilots. Results from follow up surveys indicate that Veterans were very 
satisfied with the services they received via these pilots. When the 
pilots concluded, each participating VAMC was allowed to determine 
whether to continue the partnership.

Additional Efforts to Improve Access

    VA has also moved to Patient Centered Community Care, a centralized 
contracting mechanism, and has implemented the Veterans Choice Program. 
Regardless of how such care is provided, the growing need for mental 
health services for Veterans will increase the need for efficient 
leveraging of Non-VA community providers when access to care is not 
available within the VA system of care. VA is rising to the challenge 
through its Community Mental Health Summit program which engaged over 
11,000 individuals at 144 sites in FY 14 and continues annually to 
bring together DoD, VA, State, and Community providers and stakeholders 
for vital conversations at the local level.
    VA and DoD developed a joint Military Cultural Competence Training 
Program as part of the Integrated Mental Health Strategy which is now 
housed on the public facing TRAIN website, vha.train.org, and which, to 
date, has provided free training to over 2,000 providers. Whether 
mental health care is delivered directly by Non-VA mental health care 
providers, through TMH care at Non-VA sites, or any other means, it is 
critical for VA to continue to provide Veterans with access to high 
quality mental health care in coordination with other VA services.
    In addition, VA is addressing access through the following efforts:

      Veteran-centered operating hours: Extended hours help 
increase capacity when space is limited and improve the match between 
available staff hours and the needs of Veterans who are employed or 
have other competing responsibilities during day-time hours.
      Leveraging trainees and fellows: These professionals 
provide substantial amounts of clinical care under the direct 
supervision of appropriately licensed and privileged mental health 
staff. Training programs also provide ready access to well-qualified 
candidates for recruitment into vacant positions.
      Support staff, adjunct professions, and peer support 
staff: VA has hired over 900 peer specialists and is developing a pilot 
program in response to the President's August 2014 Executive Actions to 
expand the role of peer specialists into primary care settings.

    VA's efforts to increase access to mental health care for Veterans 
face many challenges. These include overcoming stigmas that Veterans 
may associate with seeking care for mental health, the need to address 
co-occurring substance use disorders, and fears that associated medical 
records documenting their care may have an adverse impact on their 
lives. Additionally, VA struggles to attain and retain a sufficient 
mental health workforce capacity, establish a competency-based 
practice, and have adequate systems to support improving care 
nationwide. In the face of these challenges, we continue to focus our 
efforts on ensuring Veterans receive timely access to mental health 
care.

Hiring Practices

    In 2012, VA began a two-part hiring initiative under Executive 
Order 13625 issued in August 2012. The first part focused on recruiting 
1,600 new mental health professionals, 300 new non-clinical support 
staff (such as scheduling clerks), and filling existing vacancies as of 
June 2012. The second part was the hiring of 800 peer specialist 
positions by December 31, 2013. As a result of this initiative, VA 
hired approximately 5,300 new clinical and non-clinical mental health 
staff. VA hired 932 peer specialists as well. The Government 
Accountability Office found that VAMC officials reported local 
improvements due to the additional hiring, such as more evidence-based 
therapies offered, mental health care provided at new locations, and a 
variety of benefits provided by the new peer specialists such as 
modeling effective coping, engaging Veterans who are resistant to 
discussing mental health issues, and providing peer-to-peer counseling.
    VAMC officials also cited several challenges to hiring mental 
health care providers such as pay disparity with the private sector, 
competition among VAMCs, the lengthy hiring process, lack of space and 
support staff, and an underlying nationwide shortage of mental health 
professionals. VA has increased its mental health hiring through 
outreach events at medical schools, through Mental Health professional 
groups and other means of active recruitment in order to develop the 
workforce needed to meet the needs of our Veterans who need mental 
health care. At a national level, VA outpatient mental health staff 
totals increased from 11,138 full-time equivalents in 2010 to more than 
14,000 in FY 2015. Over the same time period, the number of Veterans 
receiving outpatient mental health care increased from 1,259,300 to 
more than 1,600,000.
    The recent rapid growth in the number of Veterans seeking mental 
health treatment in VA has posed challenges in the area of staffing. In 
Figure 1 below, the solid black line shows the growth in numbers of 
Veterans using mental health services, from 897,600 in 2005 to more 
than 1,600,000 in 2015. The number of patients is expressed in terms of 
hundreds to show staff and patient numbers on the same graph. For 
example, 10,000 on the vertical axis represents 1,000,000 patients and 
10,000 full time equivalents employees (FTEs).
[GRAPHIC] [TIFF OMITTED] T5157.012


    This graph also shows the growth in numbers of mental health 
clinical staff, measured in terms of the FTE providing outpatient and 
inpatient treatment. Consistent with a shift to outpatient care, the 
inpatient mental health FTEs began to level off after 2009. Outpatient 
mental health FTEs began to lag behind the growth in patient numbers in 
2012, but as part of the President's 2012 Executive Order 13625, VA 
hired more than 1,600 new clinical providers by the June 30, 2013, 
target date.
    In the absence of any national benchmark related to mental health 
staffing, VA continues to refine our model that is intended to inform 
local facility decision-making about the number of staff necessary to 
meet local demand for mental health services.

Clay Hunt Implementation Accomplishments

    The Clay Hunt Suicide Prevention for American Veterans Act (Public 
Law 114-2) gives VA additional authority to advance suicide prevention 
efforts for Veterans within the Department and in partnership with the 
community. As of March, 2016, VA has taken steps to implement each of 
its requirements, including the Call to Action collaboration previously 
discussed. To conduct an independent evaluation of Mental Health and 
suicide prevention programs, VA has contracted with an independent 
third party, Enterprise Resource Performance, Inc. (ERPI). VA mental 
health program evaluation centers are collecting self-report outcome 
data from Veterans newly receiving mental health care. Funding has been 
provided to cover the programs included in the Clay Hunt evaluations. 
The Program Evaluation Centers will support ERPI's request for data to 
conduct the independent evaluation. The full report by ERPI is due to 
Congress in 2018, and the first VA interim report that provides 
descriptive data on specific mental health programs is due in September 
of 2016. The Office of Mental Health Operation (OMHO) is working with 
the independent 3rd party evaluator to ensure coordination for these 
reports.
    We are working towards the publication of a website that provides 
easily-accessible information about mental health services for 
Veterans. The current VA Facility Locator tool includes information 
regarding PTSD, Substance Use Disorder, and Vet Center programs and 
contact and resource information. This tool is currently accessible on 
several sites, including the VA homepage, VA Mental Health page, and 
the Make the Connection website. The vets.gov team has developed a 
prototype for a website to provide a facility locator that includes 
both services and facilities for Veterans. VA product team and mental 
health subject matter experts are reviewing the prototype with a 
planned launch of these enhancements on vets.gov in fall 2016 (Note: 
this capability is dependent on the existence and availability of 
required VA data. The VA team is currently working to determine if the 
necessary data will be available for this enhancement).
    To address critical VA health care workforce needs in the area of 
mental health, VA is establishing a pilot program for the repayment of 
educational loans (PREL) for certain psychiatrists seeking employment 
in VA. The program secures a service commitment to a VA health care 
facility from program participants who are either licensed or eligible 
for licensure to practice who are enrolled in their final year of a 
post-graduate physician residency program leading to either a specialty 
qualification in psychiatric medicine or a subspecialty qualification 
of psychiatry. In return, VA will pay up to $30,000 a year in 
qualifying student loan debt for each year of obligated service.
    VA has also developed a pilot program using community outreach and 
peer support to engage Veterans in care. Five Veterans Integrated 
Service Networks (VISNs), 6, 7, 16, 17, and 22, began implementing the 
pilot program, with support from the VISN 3 VA Mental Illness Research, 
Education Clinical Center to conduct the program evaluation component 
of this initiative.
    VA has also implemented an expanded period of eligibility for 
recent combat Veterans. This resulted in the new enrollment of about 
995 Veterans who discharged between January 1, 2009, and January 1, 
2011, and who did not enroll in the VA health care during their initial 
5 year period of eligibility.

Legislative Priorities

    VA is grateful for your continuing support of Veterans and 
appreciates your efforts to pass legislation enabling VA to provide 
Veterans with the high-quality care they have earned and deserve. As 
the Department focuses on ways to help provide access to health care 
across the country, we have identified a number of necessary 
legislative items that require action by Congress in order to best 
serve Veterans.
    Flexible budget authority would allow VA to avoid artificial 
restrictions that impede our delivery of care and benefits to Veterans. 
Currently, there are over 70 line items in VA's budget that dedicate 
funds to a specific purpose without adequate flexibility to provide the 
best service to Veterans. These include limitations within the same 
general areas, such as health care funds that cannot be spent on health 
care needs and funding that can be used for only one type of Care in 
the Community program, but not others. These restrictions limit the 
ability of VA to deliver Veterans with care and benefits based on 
demand, rather than specific funding lines.
    VA also requests your support for legislation that would allow VA 
to enter into agreements with providers on an individual basis in the 
community outside of Federal Acquisition Regulations, and includes 
explicit protections for procurement integrity, provider 
qualifications, price reasonableness and employment protections. Such 
legislation will ensure that VA is able to provide local care to 
Veterans in a timely and responsible manner. VA would support language 
that addresses concerns related to employment nondiscrimination and 
equal employment protections. We would have strong concerns with any 
legislative language, such as that currently being considered by this 
committee that rolls back employment protections. VA further requests 
your support for our efforts to recruit and retain the very best 
clinical professionals. These include, for example, flexibility for the 
Federal work period requirement, which is not consistent with private 
sector medicine, and special pay authority to help VA recruit and 
retain the best talent possible to lead our hospitals and health care 
networks.

Conclusion

    Mr. Chairman, VA is saddened by the crisis of suicide among 
Veterans, but committed to the work we have done in implementing and 
expanding upon the expectations of this Committee. We remain focused on 
providing the highest quality care our Veterans have earned and deserve 
and which our Nation trusts us to provide. Our work to effectively 
treat Veterans who desire or need mental health care continues to be a 
top priority. We emphasize that we in VA remain committed to preventing 
Veteran suicide, aware that prevention requires our system-wide support 
and intervention in preventing precursors of suicide \1\. We appreciate 
the support of Congress and look forward to responding to any questions 
you may have.
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