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






                                   
 
                         [H.A.S.C. No. 114-56]

             UPDATE ON MILITARY SUICIDE PREVENTION PROGRAMS

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                            OCTOBER 8, 2015

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                                  ______

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                   SUBCOMMITTEE ON MILITARY PERSONNEL

                    JOSEPH J. HECK, Nevada, Chairman

WALTER B. JONES, North Carolina      SUSAN A. DAVIS, California
JOHN KLINE, Minnesota                ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado               NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice   JACKIE SPEIER, California
    Chair                            TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York          BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
               Jeanette James, Professional Staff Member
                Craig Greene, Professional Staff Member
                           Colin Bosse, Clerk
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                            C O N T E N T S

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                                                                   Page

              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Ranking 
  Member, Subcommittee on Military Personnel.....................     2
Heck, Hon. Joseph J., a Representative from Nevada, Chairman, 
  Subcommittee on Military Personnel.............................     1

                               WITNESSES

Burkhardt, RDML Ann M., USN, Director, 21st Century Sailor 
  Office, U.S. Navy..............................................    10
Ediger, Lt Gen Mark A., USAF, Surgeon General, U.S. Air Force....     6
Franklin, Dr. Keita, Director, Suicide Prevention Office, Office 
  of the Secretary of Defense....................................     3
McConville, LTG James C., USA, Deputy Chief of Staff, G1, U.S. 
  Army...........................................................     5
Whitman, MajGen Burke W., USMC, Director, Marine and Family 
  Programs, U.S. Marine Corps....................................     8

                                APPENDIX

Prepared Statements:

    Burkhardt, RDML Ann M........................................    78
    Ediger, Lt Gen Mark A........................................    55
    Franklin, Dr. Keita..........................................    38
    Heck, Hon. Joseph J..........................................    37
    McConville, LTG James C......................................    45
    Whitman, MajGen Burke W......................................    67

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Mr. MacArthur................................................    93

Questions Submitted by Members Post Hearing:

    Mr. Jones....................................................    97
    Ms. Tsongas..................................................   100
    
    
    
    
    
    
             UPDATE ON MILITARY SUICIDE PREVENTION PROGRAMS

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                         Washington, DC, Thursday, October 8, 2015.
    The subcommittee met, pursuant to call, at 2:00 p.m., in 
room 2212, Rayburn House Office Building, Hon. Joseph J. Heck 
(chairman of the subcommittee) presiding.

OPENING STATEMENT OF HON. JOSEPH J. HECK, A REPRESENTATIVE FROM 
      NEVADA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

    Dr. Heck. I will go ahead and call the hearing to order. I 
just want to give notice that votes are expected at sometime 
between 2:05 and 2:20. And so, when that happens, we will 
recess, go vote, and then come on back and finish.
    Good afternoon, everyone.
    Today, the subcommittee meets to hear testimony on the 
efforts by the Department of Defense [DOD] and the military 
services to prevent suicide by service members, family members, 
and civilian employees.
    I want to preface my statement by recognizing the 
tremendous work that both the Department of Defense and the 
service leadership have done to respond to the disturbing trend 
of suicide in our Armed Forces. As a military commander who has 
had to deal with suicide within the ranks, I know firsthand 
that this has not been an easy task, and I thank you all for 
your hard work.
    However, I do remain concerned that the recent Department 
of Defense inspector general assessment of the Department's 
suicide prevention program identified a lack of clear policy 
guidance and synchronization of organizations responsible for 
executing the program.
    I am also troubled that DOD has not completed the work 
necessary to beginning reporting more comprehensive and 
inclusive statistics on military-related suicides, as mandated 
by Congress last year.
    So I look forward to hearing from our witnesses how the 
Department is addressing these concerns.
    Suicide is a difficult topic to discuss. But last year, 442 
Active and Reserve service members took their own lives. Every 
one of them is a tragedy, every one of them has its own story, 
and every one of them demands that we not rest until we have 
taken action to change this extremely troubling statistic.
    We know that suicide is a multifaceted phenomenon that is 
not unique to the military. Unfortunately, in addition to the 
unique hardships of military service, our service members are 
subjected to the same pressures that plague the rest of 
society: troubled relationships, substance abuse, and financial 
difficulties.
    Each of the military services and the Department of Defense 
has adopted strategies to reduce suicide within our troops, so 
I would like to hear from our witnesses whether those 
strategies are working. I will tell you that I know that at 
least in the Army Reserve, we are at 47 suicides through 
September 30, 2015, which is more than we had in all of the 
last calendar year.
    How do you determine whether the programs incorporate the 
latest research and information on suicide prevention? I am 
also interested to know how Congress can further help and 
support your efforts.
    With that, I want to welcome our witnesses. I look forward 
to their testimony.
    And before I introduce the panel, let me offer the ranking 
member, the gentlelady from California, Mrs. Davis, an 
opportunity to make her opening remarks.
    [The prepared statement of Dr. Heck can be found in the 
Appendix on page 37.]

    STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
 CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mrs. Davis. Thank you, Mr. Chairman.
    And I appreciate all of you being with us today.
    I am very pleased that the subcommittee is continuing to 
work to help prevent suicides in the military.
    Since our last hearing, the Department of Defense and the 
services, with continued support from this committee and from 
the Congress, have worked hard to establish, to improve, and to 
enhance their suicide prevention programs with the goal, of 
course, of decreasing suicides in the military community and, I 
think we would all say, not only decreasing but someday looking 
towards a time when it is very rare.
    Sadly, even with these increased efforts, this issue 
continues to be a difficult one to grasp, and the number of 
suicides continues to grow.
    I am interested to hear from the Defense Suicide Prevention 
Office and certainly from each of the services on the changes 
that have been made to the programs over the past 2 years. What 
have we learned? What have we changed?
    In particular, I am interested in hearing more about the 
identification of potential indicators which may lead an 
individual to suicide, as well as the improvements which have 
been made to intervention programs providing help to those in 
need.
    In the past, we know that the services have struggled, we 
have all struggled, with how best to appeal to the friends and 
family of service members to encourage them to step forward 
before it is too late. I believe this is still a critical link 
to prevention. These are the people that are around the service 
member the most, and we must provide them the tools necessary 
to identify and to intervene when possible.
    I certainly welcome all of you, our witnesses, and look 
forward to hearing from you on what has been done, what is 
currently being done, and where we go from here.
    Thank you, Mr. Chairman.
    Dr. Heck. Thank you, Mrs. Davis.
    We are joined today by an outstanding panel, and, given the 
size of our panel and our desire to give each witness the 
opportunity to present his or her testimony and each member an 
opportunity to ask questions, I respectfully remind the 
witnesses to summarize, to the greatest extent possible, the 
high points of your written testimony in 5 minutes.
    I know most of you have been here before. The lighting 
system will be green. At 1 minute left, it will go yellow. And 
when your time is up, it is at red, and I would ask you at that 
point to please finish up quickly. I assure you that your 
written comments and statements will be made part of the 
hearing record.
    So let me welcome our panel. Dr. Franklin, Director of the 
Suicide Prevention Office, Office of the Secretary of Defense. 
Welcome. I know this is the first time in your position now 
before the committee. Welcome.
    Lieutenant General James McConville, Deputy Chief of Staff, 
G1, for the U.S. Army; Lieutenant General Mark Ediger, Surgeon 
General of the Air Force; Major General Burke Whitman, Director 
of Marine and Family Programs for the U.S. Marine Corps; and 
Rear Admiral Ann Burkhardt, Director of the 21st Century Sailor 
Office for the U.S. Navy.
    Dr. Franklin, the floor is yours.

 STATEMENT OF DR. KEITA FRANKLIN, DIRECTOR, SUICIDE PREVENTION 
           OFFICE, OFFICE OF THE SECRETARY OF DEFENSE

    Dr. Franklin. Chairman Heck, Ranking Member Davis, 
distinguished members of the subcommittee, thank you for the 
opportunity to appear before you today to discuss the current 
state of the Department's suicide prevention efforts.
    Suicide prevention is an issue near and dear to my heart. I 
am a daughter of a 22-year career Navy enlisted sailor, I 
married an Air Force officer, and I have spent the last 20 
years of my career working at various levels as a social worker 
with military families around the world. I have seen firsthand 
the trauma and devastating effects suicide has on families, 
friends, units, communities across the military.
    Previously, as a headquarters-level policy lead in the area 
of suicide prevention in the Marine Corps, I worked diligently 
with commanders, chaplains, medical, and nonmedical helping 
professionals to reduce the number of suicides in the Corps.
    During this experience, I realized three important things: 
First, suicide is absolutely preventable. Second, suicide is 
such a complex issue that the reduction of suicide across the 
services is possible only through active and at times intensive 
collaboration with a wide variety of stakeholders. And, third, 
the risk and protective factors are common across many of the 
challenges that service members face.
    When I train my staff as a licensed social worker, I always 
share how clients don't typically present to us with just one 
problem. They come to us and other helping professionals with a 
wide variety of problems, including financial, legal, 
relationship concerns. Some are contemplating suicide, and we 
have to know the signs and how to get them to help.
    Therefore, I stress that it is imperative that we approach 
the problems of our clients in an integrated, vice stovepipe, 
fashion, engaging across interdisciplinary approaches as 
needed.
    It is with this view and background that I eagerly accepted 
the job as the Director of the Defense Suicide Prevention 
Office [DSPO] in February 2015. When I accepted this 
challenging assignment, the Department had just adopted the 
2012 National Strategy for Suicide Prevention and was 
developing a defense strategy consistent with this national 
approach. This was encouraging, as these strategy documents are 
central to providing service delivery that is integrated in the 
fashion that I previously alluded to.
    Once on board, I conducted an internal assessment of the 
office responsibilities, mission, vision, functions. Parallel 
to that effort, I conducted a series of listening sessions with 
the services and other key stakeholders and partners, to 
include the Department of Veterans Affairs [VA].
    And my immediate takeaway was that, despite the adoption of 
this national strategy, the DOD suicide prevention paradigm and 
DSPO's functions were still largely organized around that 2010 
task force report. I realized the DOD strategic paradigm and 
DSPO's organizational structure had to shift in order to 
execute the office's responsibilities to support this new 
strategy and facilitate collaboration with so many 
stakeholders.
    With this understanding of necessary changes, my immediate 
actions were to order a closeout of the task force report 
recommendations, which is near completion; also, to adopt an 
underlying theory base drawn from the Institute of Medicine's 
Prevention Continuum; and to move the Department's strategy 
staffing forward, thanks to the constructive input from the 
services and the components; and to begin the development of a 
Department of Defense instruction that clearly spells out the 
policy, the responsibilities, the procedures; and, lastly, to 
develop an office approach and organizational structure that 
could more efficiently implement this new strategy.
    In my oversight responsibility, one of the main efforts of 
the office is to identify and leverage best practices across 
the services, thus ensuring rigorous science in all that we do.
    To best implement the Department's strategy, I have 
leveraged a public health framework in organizing DSPO along 
five lines of effort, including data and surveillance, 
assessment, advocacy, policy, outreach and education. While 
each of these are explained in detail in my written testimony, 
the data and surveillance efforts will be critically important 
to inform the other lines of effort.
    During the year 2013, according to our quarterly data 
reports, we know that across the Department, including Reserve 
and Guard Components, we, sadly, experienced 474 deaths to 
suicide. During 2014, we experienced 442 deaths to suicide. You 
will hear more about the trends associated with these tragic 
losses from my service counterparts today.
    In closing, I want to inform you that the Department has 
recently strengthened our longstanding relationship with the 
VA. We have already collaborated on awareness of the Military 
Crisis Line, as well as a database for advanced data and 
analytics across both departments, and, finally, an innovative 
campaign strategy, driven by the research, called ``The Power 
of 1'' that focuses on service members, families, civilians, 
offering one small gesture or one act of kindness for anyone at 
risk.
    Beyond the VA and the services, I recognize the Department 
will not prevent suicide alone. I continue to work diligently 
with the academic sector, with the private sector, with the 
National Action Alliance and key agencies, such as the American 
Association of Suicidology, to forge the necessary long-term 
relationships to prevent suicide.
    And I thank you so much for inviting me, and I look forward 
to your questions today.
    [The prepared statement of Dr. Franklin can be found in the 
Appendix on page 38.]
    Dr. Heck. Thank you.
    General McConville.

  STATEMENT OF LTG JAMES C. McCONVILLE, USA, DEPUTY CHIEF OF 
                      STAFF, G1, U.S. ARMY

    General McConville. Chairman Heck, Ranking Member Davis, 
and distinguished members of the committee, thank you for 
giving us the opportunity to speak before you on this very 
important topic.
    I am going to go ahead and highlight a couple of points 
from my testimony.
    When I was the commanding general of the 101st Airborne 
Division, a Gold Star mother who had lost one son in combat and 
one son to suicide came to the division and spoke to the 
spouses about suicides. And the one point that she wanted us to 
take away was that people don't commit suicide, they die of 
suicide.
    And when you think about that, people don't commit heart 
disease, they die of heart disease. There is no stigma attached 
to going to see a doctor for heart disease. There are also risk 
factors associated with heart disease, like high cholesterol, 
smoking, not exercising, and eating unhealthy food. And for our 
soldiers, identifying and managing these risks can help reduce 
the possibility of dying of heart disease.
    We think the same thing needs to be done with suicide. 
There are certain risk factors that we know, and we will talk a 
little bit about them, that put soldiers at high risk, and it 
is very important we identify these. And this is why I am a 
very big proponent of one of our best practices that we have 
put into the Army, which is embedded behavioral health at every 
single brigade level, so that when they identify the issues, 
they can get soldiers to the help they need.
    The Army had a reduction in suicides in 2014, and that was 
mainly due to the Reserve and the Guards. And, as the chairman 
said, this year we are about the same level for the Active but 
we have seen a rise in both our Guard and Reserve, and we are 
very concerned about that. And we are presently doing that 
analysis. But we are making progress in combating suicide, and 
it is really a multidisciplinary, holistic approach.
    You talked about getting to soldiers. To us, it is 
absolutely key that we get the soldier's family, their buddy, 
and the junior leaders involved in getting after suicides. We 
bring 100,000 soldiers into the Army every single year. They 
come from outside, and where we are going to identify the 
issues, it is the soldier's family members who will be the 
first ones to notice when they have behavioral health issues, 
alcohol and drug abuse issues, financial problems, relationship 
problems, all those risk factors for suicide.
    And the key leader is that squad leader, that junior leader 
who is down there with these new soldiers, who can help 
identify the risk factors and get these soldiers to the 
behavioral health at the appropriate level early on before they 
spiral out of control.
    We are training our total force, not just soldiers but also 
civilians and family members, and all the Army's components to 
get after not only suicide prevention but resilient skills that 
will make them strong in the face of adversity. We have 
increased our access to behavioral healthcare services.
    We are also fighting suicides through research. I know many 
of you are very familiar with the Army STARRS [Study to Assess 
Risk and Resilience in Servicemembers] program, and that is 
helping us get the best and brightest individuals after this 
problem. Historically, Army Medicine has found answers to some 
of the toughest medical problems, including yellow fever, 
malaria, and life-threatening infections. I am confident, 
working with these great partners, that they will do the same 
here.
    We have good policy, which we can improve. We have programs 
we can do better at. But, most importantly, we have exceptional 
leaders in the Army at all levels who are committed to taking 
care of our soldiers.
    My wife and I have three children serving in the Army. One 
just was commissioned as a social worker. And my wife expects, 
as all mothers do, for us to take care of those soldiers, their 
sons and daughters, who are serving their country during a time 
of war. And we will do that.
    I thank all of you for your continued support in sustaining 
a professional All-Volunteer Army, and I look forward to your 
questions.
    [The prepared statement of General McConville can be found 
in the Appendix on page 45.]
    Dr. Heck. Thank you.
    General Ediger.

STATEMENT OF LT GEN MARK A. EDIGER, USAF, SURGEON GENERAL, U.S. 
                           AIR FORCE

    General Ediger. Chairman Heck, Ranking Member Davis, and 
distinguished members of the committee, thank you for the 
opportunity to appear before you on behalf of the men and women 
of America's Air Force.
    The United States Air Force defends our Nation with a broad 
range of capabilities made possible by an incredible force of 
professional airmen, which include members of the Active 
Component, Air National Guard, Air Force Reserve, and civilians 
in government service.
    Secretary James, General Welsh, and leadership at every 
level of our Air Force are committed to the development of 
strong, resilient airmen and to coordinated, robust support as 
they confront problems inherent to life and mission. The Air 
Force strategy for suicide prevention focuses on resilience 
among airmen, coupled with a community-based public health 
approach to prevention and timely intervention with followup 
for those in distress.
    The Air Force leadership is very concerned about the 
increasing rate of suicides among airmen, a trend within the 
Active Force. Last year, 62 Active Duty airmen took their 
lives, a rate of 19 per 100,000. To date in 2015, that trend 
has persisted. Suicide rates in the Reserve Component and among 
government civilians have remained relatively static, but we 
are committed to prevention across the total force.
    The Air Force Suicide Prevention Program is an integrated 
network of policy, process, and education that focuses on 
fostering strong, resilient airmen, providing assistance 
through stressful circumstances and focused support for those 
in distress.
    In 2015, the Air Force changed its format for annual 
suicide prevention training to live, small-group discussions. 
Special vignettes and discussion guides have been developed for 
Active Duty and Reserve Component personnel, as well as DOD 
civilian employees, to address their different demographics and 
circumstances. This training emphasizes early intervention, 
risk factors, and warning signs to enable airmen to respond 
using the ``Ask, Care, Escort,'' or ACE, model.
    The Air Force has also fielded an annual refresher course 
for frontline supervisors in career fields with the highest 
incidence of suicide. In 2014, we updated the ``Airman's Guide 
to Assisting Personnel in Distress'' to help commanders and 
other leaders on effective intervention for an array of 
challenging problems. This year, we also released the ``Air 
Force Family Members' Guide to Suicide Prevention'' and trained 
over 200 family members as resilience training assistants.
    Since 2012, the Air Force has embedded mental health 
providers in operational units where performance demands and 
operational stress are concerns. Mental health providers have 
also been placed in all Air Force primary care clinics, 
allowing quick access for airmen and their families as well as 
reducing concerns about stigma. We are on schedule to complete 
our 25 percent increase in Active Duty mental health positions 
by 2016.
    We know the importance of effective identification and 
treatment and controlling the impact of PTSD [post-traumatic 
stress disorder] on airmen and families. To address this, we 
continue to screen airmen for PTSD symptoms via pre- and post-
deployment health assessments at various points through the 
deployment cycle. Effective treatment has enabled the majority 
of airmen diagnosed with PTSD to continue serving.
    In addition, in 2010, the Air Force established the 
Deployment Transition Center at Ramstein Air Base, Germany. 
This center offers a 4-day reintegration program for airmen 
returning from deployment that involved activities associated 
with post-traumatic stress.
    Our mental health providers are trained and current in 
evidence-based treatments. The Air Force is also committed to 
reducing suicides within the clinical setting by incorporating 
the latest research and innovative initiatives in our mental 
health clinics to better manage our highest-risk patients.
    Improvement rarely happens in a silo, so we are actively 
engaged with the Defense Suicide Prevention Office in helping 
to shape suicide prevention efforts across DOD through multiple 
committees and working groups.
    In April 2015, General Welsh initiated a comprehensive 
review of Air Force suicide prevention, to include an Air Force 
Suicide Prevention Summit, which occurred last month. Our aim 
is to verify factors underlying Air Force suicides, review the 
latest evidence regarding effective prevention, gain insight 
into the experience of other organizations, and refresh the Air 
Force strategy on identifying new actions to effectively 
prevent suicide. Recommendations from the review and summit are 
now being used to refresh the strategy and build action plans.
    The Air Force is committed at every level to develop and 
support total force airmen as resilient, mutually supportive 
professionals. We need every airman across the total force, 
including those in uniform and our government civilians. We 
will continue to work closely with our colleagues in the 
services, DOD, and other governmental agencies and in academia 
in this essential effort.
    Thank you for your attention to this important matter and 
your continued support.
    [The prepared statement of General Ediger can be found in 
the Appendix on page 55.]
    Dr. Heck. Okay, so that was the bell. My intention is to 
complete testimony, and then we will recess and come back for 
questions.
    So, General Whitman.

 STATEMENT OF MAJGEN BURKE W. WHITMAN, USMC, DIRECTOR, MARINE 
             AND FAMILY PROGRAMS, U.S. MARINE CORPS

    General Whitman. Thank you, Chairman Heck, Ranking Member 
Davis, and distinguished members. I am grateful for the 
opportunity on behalf of the United States Marine Corps to 
update you on our suicide prevention efforts.
    This is an institutional priority. It is also a personal 
priority for me. I had a friend, colleague, and fellow officer 
in the Marines who took his own life in 2012.
    Whenever a Marine chooses to end his or her own life, we 
are all devastated, and we ask ourselves, why? Is there 
something we could have done? Are there actions we can take to 
prevent the next suicide? And we believe the answer is ``yes.'' 
We can take some actions in three different areas. We can 
identify the risk earlier, we can intervene earlier, and we can 
provide robust, ongoing support.
    Together, the Department of Defense and the Marine Corps 
have developed programs to help us do just that, to identify 
early, intervene early, and provide robust support more 
effectively than we could in the past and with initiatives even 
in the last couple years since the most recent hearing here on 
this topic with you.
    The key to leveraging these programs is human engagement by 
leaders, by peers, and by families. Leaders at every level are 
trained, prepared, and engaged with our Marines. This includes 
each Marine's immediate leader, whose sacred responsibility is 
to know that Marine. Peers who already know each other are also 
trained to identify and intervene early. Marines are a close-
knit family. They tend to understand they have an inherent 
responsibility to look after each other. Equally important are 
family members, who may witness concerns before we do. Leaders, 
peers, and family members can leverage the programs and the 
training that your Department of Defense and Marine Corps 
developed as tools to help prevent the next suicide.
    Let me offer just a small sampling of some of the more 
recent program initiatives that help us identify early and 
intervene early and provide that support, and then I will tell 
you a brief recent story in which Marines leveraged those 
programs to save a life.
    Identifying a Marine at risk for suicide can be challenging 
because no single indicator can predict if someone is at risk. 
So we have taken a holistic approach to this, and we use all of 
our behavioral health skills to address the challenge.
    We know that Marines contemplating suicide often find 
themselves in a place of hopelessness, involving a mix of 
stress factors ranging from relationship problems to financial 
distress. So we train all our Marines to respond to stress in 
peers. To help identify the risk, family members and Marines 
are trained to help identify Marines and to seek help.
    To assess the risk, once we have identified some 
indication, we have introduced the evidence-based Columbia 
Suicide Severity Rating Scale across the entire Marine Corps, 
to include our behavioral health providers, chaplains, legal 
assistants, financial counselors, and others.
    To intervene early and provide that ongoing support, among 
the things we have done, we have added a community counseling 
program that enhances access to care by assisting Marines and 
families in navigating the many resources available for 
behavioral health issues. They can receive immediate support 
regardless of which door they have entered to get help.
    In addition, our Marine Intercept Program, MIP, interrupts 
the potential path to suicide by providing timely intervention 
and ongoing support, enhancing our ability to conduct ongoing 
risk assessment, evolve the safety plans for the at-risk 
Marine, and coordinate his or her care.
    These are but a few, and maybe we will have a chance to 
talk about some others.
    Let me quickly tell you about the story about one Marine 
from just a month ago. His trained leaders and peers had 
correctly identified him as being at risk for suicide due to 
several factors. Typically, we have 10 to 20 involved, and he 
was one of those.
    He entered the Marine Intercept Program, and the Marines 
continued to be watchful. One day, when he was not at his 
expected place of duty on time, his noncommissioned officer 
leader immediately launched a search in the right places 
because they knew him. They found him hanging from a rope, but 
they found him in time. He was still alive, so they revived 
him, they rushed him to the hospital, and that Marine is alive 
today. We are taking care of him. He is receiving support, but 
he is alive.
    So we have some successes; we are making some progress. 
But, Mr. Chairman, as you said, this is difficult work. We must 
remain vigilant. We must continue with the Department to 
analyze the data regarding suicides, seek effective new 
approaches based on evidence-based research and empirical 
tools, continuously enhance our training and resources that we 
make available to our leaders, Marines, and the families toward 
what works.
    I thank the subcommittee for supporting this work, and I 
will be happy to answer questions later. Thank you.
    [The prepared statement of General Whitman can be found in 
the Appendix on page 67.]
    Dr. Heck. Admiral Burkhardt.

STATEMENT OF RDML ANN M. BURKHARDT, USN, DIRECTOR, 21ST CENTURY 
                    SAILOR OFFICE, U.S. NAVY

    Admiral Burkhardt. Chairman Heck, Ranking Member Davis, and 
distinguished members of the subcommittee, thank you for the 
opportunity to present you information on the Navy's suicide 
prevention programs.
    Every suicide is a tragedy, and a single life lost is 
definitely one too many. Sadly, in 2013, the Navy experienced a 
loss of 46 shipmates through suicide. Although this was a 
decrease of 20 suicide deaths from the previous year, in 2014 
we saw an increase in our suicide total, with 68 deaths. For 
2015 thus far, we have lost 44 shipmates to suicide.
    Suicide is complex, and, as such, it is difficult to draw 
conclusions from numbers alone. We continue to monitor the 
health of the force and investigate every suicide and suicide 
attempt. The Suicide Prevention Team examines each case for 
pertinent information that might inform our prevention program. 
Results from these reviews consistently reveal that demographic 
distribution of suicide largely mirrors the Navy demographics, 
and suicides typically occur when sailors are experiencing some 
combination of multiple recent stressors, including intimate 
relationship problems, loss, recent career transitions, 
disciplinary or legal issues, work problems, and financial 
strain.
    The 21st Century Sailor Office stood up shortly after the 
2013 hearing, facilitating an integrated approach to total 
sailor fitness and resilience. The office encompasses diverse 
elements that impact sailors' physical and psychological 
health.
    Promoting comprehensive wellness is one of our core 
strategies to proactively prevent destructive behaviors that 
can ultimately increase suicide risk. Our efforts are focused 
on education and awareness, prevention and intervention, sailor 
care, and crisis response.
    To that end, since 2013, we have launched several key 
initiatives. We have expanded our Operational Stress Control 
Mobile Training Teams, providing training to enable deckplate 
and senior leaders to better assess and mitigate stress in 
their units. In 2014, we mandated this training for all units 6 
months prior to their scheduled deployment.
    We have also assigned deployed resilience counselors to our 
aircraft carriers and large-deck amphibious assault ships, 
working alongside chaplains, behavorial psychologists, and 
medical professionals who proactively assist our sailors on a 
daily basis.
    We have also implemented several key evidence-based suicide 
prevention and intervention measures, including training on the 
use of the Columbia Suicide Severity Rating Scale and the 
Veterans Affairs Safety Plan to enhance risk assessment and 
intervention at the deck plate.
    We have also released guidance for commanders and health 
professionals to reduce access to commonly used lethal means of 
suicide through the voluntary storage of privately owned 
firearms.
    In 2014, we launched our ``Every Sailor, Every Day'' 
campaign to promote ongoing and active engagement, peer 
support, and bystander intervention so that no sailor feels 
alone. This campaign places strong emphasis on daily 
interaction to not only build trust and foster hope but enable 
that early recognition of warning signs and get sailors the 
help they need.
    During the 2015 Suicide Prevention Month, we introduced a 
new message to this campaign, ``1 Small ACT.'' This message 
encouraged simple actions to make a difference and perhaps save 
a life. It is based on the Navy's ``Ask, Care, Treat'' 
bystander intervention model and the Navy's supporting the DOD 
and Veterans Affairs ``Power of 1'' concept.
    We have also released an improved suicide prevention 
general military training which is interactive, scenario-based, 
and designed to generate dialogue about stress navigation, 
suicide prevention, intervention, and also crisis response.
    Suicide prevention is about taking care of people. Navy's 
commitment is to provide sailors and their families the tools 
they need to thrive during and beyond their Navy careers.
    Thank you, and I look forward to answering any questions 
you may have.
    [The prepared statement of Admiral Burkhardt can be found 
in the Appendix on page 78.]
    Dr. Heck. Again, I thank the panelists for keeping their 
testimony within 5 minutes. I think that is a record for 
everyone doing so.
    We will recess and return right after votes. I ask the 
members to return as quickly as possible.
    [Recess.]
    Dr. Heck. Okay. We will the reconvene the hearing.
    And, again, I thank the panelists for their testimony.
    We will now begin questions from the members of the 
committee. Reminding committee members that we will adhere to 
the 5-minute rule, and if there is time remaining after the 
first round, we will go with a second round of questions.
    So, Dr. Franklin, in your testimony, you talk about the 
rate of suicide among the Active and Reserve Components. And 
the question is, how does the DOD actually calculate the rate 
of suicide, and how do the current military suicide rates 
compare with the civilian rates?
    We hear a lot of emphasis, and rightfully so, on the number 
of suicides within the military, and perhaps it is because it 
is a much more closed, basically, society with a lot of 
oversight and opportunity to intervene. But do the rates within 
the military differ all that significantly from what we see in 
the general population?
    Dr. Franklin. Thank you so much for that question. I will 
go ahead and start with the latter part.
    Typically, I try to sway folks away from comparing the 
military rates to the civilian rates for a number of reasons, 
some of which you just mentioned. But the military as a whole, 
largely a healthy population, largely covered by health care. 
When you compare demographically across the civilian 
population, we are looking at folks that have no health care, 
perhaps they are homeless, unemployment rates. There are all 
sorts of factors that make the two populations drastically 
different.
    On the other hand, also, the military has additional 
stressors in some cases. I am actually looking at this a little 
bit further to see if I can find a demographically similar 
characteristic or population. What I want to make sure we don't 
do is just compare a CDC [Centers for Disease Control and 
Prevention] data set across gender and age and think that we 
have a one-for-one comparison with the military, because we 
don't.
    Dr. Heck. Right.
    Dr. Franklin. So that is a sticky wicket, but certainly I 
can understand why folks want to ask the question, looking at 
whether or not we should look at comparisons across the 
university sectors perhaps or other types of demographics like 
perhaps first responders and trying to dig deeper so that I can 
find a good comparison group.
    But the other question that you asked me was about the rate 
calculation. The rate calculation recently changed, and we are 
looking at the total force. We work within the Defense 
Suicide--I am sorry, the Defense Manpower Data Center to get 
the denominator. And then, from there, we will take the total 
number of suicides, and it is just a math equation where we 
will divide the two. And that is how we calculate the rate.
    Dr. Heck. So you say the rate recently changed. How was it 
calculated previously?
    Dr. Franklin. Before, we would separate it out. And so now 
we are looking at more of the total force.
    Dr. Heck. Okay. All right. Thank you.
    And, General McConville, I appreciated your analogy and the 
fact that you used the phrase ``die from suicide'' not ``commit 
suicide,'' and the analogy you made with heart disease. And you 
mentioned one of the issues that we find is the stigma 
associated with seeking behavioral health assistance and folks 
concerned that somehow if their chain of command learns about 
it, you know, it is going to impact their eval [evaluation], 
may impact their future promotions.
    So I would ask one of the panelists, what is being done 
within your service to try to remove the stigma of reaching out 
for help so that we can get ahead of this problem as opposed to 
being reactive?
    General McConville. Well, sir, thank you for that question, 
because, as a former commander, that is why we started to think 
about it in a different way. We have to change the culture of 
how we look at suicides, because it is just like heart disease.
    And so what I found very helpful and what, really, the Army 
as an institution is propagating is, if you have problems with 
mental health, it is the same thing as having some type of 
heart disease, and you need to go to the right doctor.
    So you identify those type of issues and, again, I talked 
to you about being a proponent for the embedded behavioral 
health. Having that as close to the point of need that we can 
get behavioral health is really very, very important. And the 
way that works in a division, that brigade combat team has a 
multidisciplinary team that actually sits there that does 
physical fitness with the unit that is there. So if a soldier 
starts to have problems, we can get them in early on.
    I use the analogy even with heart disease, if you wait and 
I am not a doctor, so, the doctors here, you know, don't--I 
make it up anyways. But, you know, if you wait till you are 95 
percent, you know, clogged and you go to the doctor, they may 
not be able to help you. But if you get them early on when you 
are starting to have high cholesterol and you are starting with 
these risk factors and you get them to see the doctor, they get 
you on the appropriate diet, they can get you to stop smoking, 
you can do those type things. We need to do the same thing with 
suicide if someone is starting to have a problem.
    And the ranking brought that up, about the family members 
is absolutely key. They are the ones that know. I have looked 
at a lot of suicides over the years, and people go, ``No one 
knew.'' Well, someone did know. And, usually, when you peel it 
back and you take a look at it, there was a buddy that knew or 
a family member knew. And if we got it early on, we could have 
got the help they needed, and we might have saved a life.
    Dr. Heck. All right. My time is about to expire, so I will 
come back on the second round and follow up.
    Mrs. Davis.
    Mrs. Davis. Thank you, Mr. Chairman.
    And I actually was going to ask all of you about perhaps 
one incident or story that you go back to, you know, every day 
when you come to work, thinking about either a success story or 
one that was tragic. And I think, you know, several of you 
mentioned that, but I guess I would wonder what that is.
    It is always helpful to have a family member at a hearing 
like this or someone who has sort of really been there. And I 
have a feeling that you have lived through that through the 
folks, but I wondered if you wanted to share that and what it 
has done in terms of your own drive to make sure that we are 
able to address this.
    General McConville. I will go ahead and start.
    I guess, you know, I have many examples, having commanded a 
very large organization in combat over the last couple years. 
But one of the things that we did at Fort Campbell is we used 
to do a Mother's Day brunch for all the Gold Star Mothers and 
family members the week before Mother's Day, and we invite all 
the Gold Star family members. And it was interesting who used 
to come as part of our survivors outreach. And we had people 
come that had lost their sons and daughters to suicide.
    And one man, in particular, came. And it is amazing, the 
pain that that father was going through, the fact that he had 
lost his son to suicide. And he came to Fort Campbell because 
there was a good program there. His son wasn't even in the 
division, but we had this great survivor outreach person, Suzy 
Yates, that took incredible care of these families, and he came 
to that brunch.
    And you could see the pain. And it is a very, very 
different pain, what parents go through with a suicide, than, 
you know, soldiers, I have lost soldiers in combat, I have lost 
soldiers to accidents, I have lost them--but that suicide, it 
has an--first of all, it is the end of the world for the 
parents. And it is a gaping hole to units when you see what 
happens when you have a suicide in the unit, because everybody 
wants to wonder what we could have done.
    Mrs. Davis. Uh-huh.
    General McConville. And so you can feel my passion about 
this stuff. And, you know, I have thought through this stuff, 
and it is getting after what we do to take care of soldiers. 
So, every day I wake up, we have a sacred obligation to take 
care of the sons and daughters that parents sent us, and the 
last thing we want to do is to have a son or daughter die of 
suicide. And that is a sacred obligation for us.
    Mrs. Davis. Uh-huh.
    General Ediger. The story I always think back to is, early 
in my career, when I was a squadron flight surgeon for a 
fighter squadron in the Air Force, we lost a lieutenant young 
fighter pilot to suicide, married, with a child on the way. And 
the thing that struck me about that was that it was really a 
somewhat impulsive act, in that case, in that he was confronted 
with an acute situation, a problem that was really, when you 
looked at it, completely solvable.
    And then I saw the rippling effect of that tragedy as it 
went out to the family, and a child that was born without a 
father. And that really struck me, that we really have a 
responsibility to help particularly our youngest members in the 
military arrive at a more functional approach to problems and 
how they approach problems, solve problems, and that we need to 
do a better job of connecting them with sources of help in 
terms of just their basic life skills so that their approach to 
problems like that don't turn into a tragedy.
    Mrs. Davis. Uh-huh.
    General Whitman. Mr. Chairman, you know, the Marine Corps 
tracks and studies every one of the suicides and attempts and 
ideations that we have. And we study them and pull from them 
what we can.
    Each of us, I am sure, has our own personal most 
devastating story. Mine would be the friend I lost in 2012. 
There is no question he was a very close friend.
    But we look at all these. We looked at them in 8-day 
reports. And the entire institution does. The assistant 
commandant of the Marine Corps gets those reports; we review 
them together. If someone has survived, if it is an attempt or 
an ideation, the commanders get involved through our Marine 
Intercept Program and evaluate what the problem is. We pull 
data out of that, as well.
    And then, finally, we have a regular institutional effort, 
an Executive Force Preservation Board that is led by our 
assistant commandant, that looks at all the cases in aggregate 
and tries to pull the lessons that we can from those to prevent 
the next one.
    Mrs. Davis. Uh-huh.
    Admiral Burkhardt. For me, I am passionate about people, 
and I strongly believe that every life is worth living. And it 
is really sad when I see the SITREPs [situation reports] that 
come in and I think about those lives that we have lost and the 
family members and the units impacted.
    And the Navy is committed to helping our young people and 
all our service men and women and their families understand how 
to better identify those risks and refer people to help and 
make sure that everyone has a chance to live life fully and 
really thrive in our environment.
    Mrs. Davis. Okay. Thank you.
    Dr. Heck. Ms. Tsongas.
    Ms. Tsongas. Thank you, Mr. Heck.
    Thank you all for being here. I can tell you that this is 
an issue that really strikes home with my constituents, as they 
read the alarming statistics and stories or if they have been 
personally impacted by a family member or friend who served in 
the military. So I appreciate all the work that each of the 
services has done and that the DOD has done, as well.
    But I really want to ask a question about, and you have all 
certainly given great testimony to the efforts that the 
services are doing, investing in. But I really want to address 
the issue of how you all are working together with each other 
and with the DOD.
    So, on September 30, 2015, the DOD Office of the Inspector 
General issued a report that states that, quote, ``DOD lacked a 
clearly defined governance structure and alignment of 
responsibilities for the Defense Suicide Prevention Program,'' 
unquote. And that report also states that the DOD, quote, ``did 
not standardize best practices across the Department, and the 
services did not take advantage of each other's knowledge and 
experience,'' unquote.
    And I know that this is often not unique to suicide 
prevention. We hear that often in other contexts, as well, that 
you work within your own service and not always across 
services.
    So I would like first Dr. Franklin to address what changes 
are being made to address these issues. And, also, if each of 
you could comment upon how you share best practices and work 
across the services.
    So let's start with you, Dr. Franklin.
    Dr. Franklin. Sure. Certainly. Thank you so much for the 
question.
    Make no mistake, the DOD IG [Inspector General] absolutely 
cited a number of the things that you spoke about. The policy, 
the evidence-based practices, the research--all of it needs to 
be coordinated, and we absolutely needed a strategic approach.
    I will tell you, I think the Department was largely 
operating in a reactive mode early on in the suicide arena as a 
result of the Department of Defense task force. And so, by 
``reactive,'' I mean they were chasing down those task force 
recommendations, 76 of them, and they were trying to get 
current.
    Upon completion of that, like many programs, it was an 
opportunity to take a pause and look at the program and look at 
the national landscape in the area of suicide prevention and 
then determine our own strategy, moving away from task force 
recommendation mode to a science-based approach based on our 
current needs and the state of the program.
    So when I arrived in the office and I did a series of 
listening sessions with the services, we right away changed our 
practices. I couldn't be more pleased to tell you that the 
services meet on a quarterly basis. Their suicide prevention 
program managers are--we have had two of those meetings so far. 
They are 2-day meetings. They share a number of best practices. 
I could give you examples. And you heard in some of their 
testimony where some of them are implementing similar tools 
like the Columbia Suicide Severity Scale or the VA safety 
planning. They learned that from each other. And those are 
exciting opportunities, and I absolutely see that as the future 
of the office.
    I am a social scientist by trade, and I think that we need 
to leverage the research and we need to work together. And I am 
eager to see the future of this team when we can have more time 
and place to execute many of these evidence-based approaches.
    Ms. Tsongas. Can each of you give an example of where you 
learned a best practice from perhaps the DOD or from each 
other?
    General McConville. Well, I know there is coordination 
with--from where I sit, I know that we meet at the program 
manager level.
    What I am surprised to see as you listen to the testimony 
is how the concepts, especially when I look at my Marine 
colleague here, you know, we are pretty much moving towards 
getting after the problem the same way. We understand in 
combat-type units that these new soldiers coming in that are 
most susceptible, getting the leadership, getting the 
families--we have shared the STARRS studies that we have worked 
with that show, which we have all spent a lot of money on, what 
type of indicators. And as I listen to testimony, I see many of 
our colleagues using that same type information. And as we pass 
the information back and forth, for me, it kind of gives an 
idea that, hey, we are all getting after the same thing.
    I did an exchange with the Japanese, which is kind of 
interesting. We talked about sharing suicide information. Their 
concept is very similar to what we are trying to do. They have 
a one company, one floor concept. And it gets around to this 
whole relationship, which my Marine Corps colleague talked 
about, is how we make sure people are taking care of each other 
and identifying those risk factors so--I see the risk factors 
the same across each and every one of us.
    Thank you.
    Ms. Tsongas. General.
    General Ediger. A couple of examples I will add is, we are 
sharing the data from our research. And I know we have learned 
a lot from watching and studying the Army STARRS data in terms 
of resilience and the ability to measure that and predict 
certain outcomes.
    I mentioned our Suicide Prevention Summit in the Air Force 
that occurred 3 weeks ago. And Dr. Franklin was a prominent 
participant in that, but, also, the Marines were there and gave 
some excellent presentations in terms of their programs and 
actually, we are borrowing significantly from what the Marines 
are doing and what we are implementing now.
    Ms. Tsongas. I have run out of time, but thank you.
    Dr. Heck. Mr. MacArthur.
    Mr. MacArthur. Thank you, Mr. Chairman.
    I am sorry I missed your opening remarks. I was at another 
hearing. But I read the memo, the advance memo, and I just had 
a few things that maybe you have covered already, I don't know.
    First, there is nothing more tragic than young people--
often, these are the people we want to be the next greatest 
generation. And we see so much that they have to live for, and, 
obviously, sometimes they don't.
    You mentioned, Dr. Franklin, that it is a closed system, 
the military. I think that was your word, or maybe that was the 
chairman's words. But you suggested you can't really compare 
military suicide rates with civilian rates. I think the 
chairman called it a closed system, but same idea.
    So I am interested in comparisons within that system. And 
the years of numbers that I see here cover 4 years. And I just 
wondered, if you apply this new methodology of calculating the 
rate and I gathered it is currently done against total force. I 
am not sure what you looked at previously; you could tell me 
that.
    But if you applied this current methodology going back 10 
or 15 years--have you done that? And what does it show about 
the trending of suicide within the military? Is it going up? 
Down? Staying the same? Give me some sense of the magnitude of 
direction.
    Dr. Franklin. Sure. Certainly. Thank you so much for the 
question.
    I would need to get back to you on whether or not we took 
the current methodology and traced it back 10 or 15 years. The 
difference between the two methodologies are that one looks at 
the total force and the others sort of separate it out. But 
that is certainly something that we could do and get back to 
you.
    [The information referred to can be found in the Appendix 
on page 93.]
    Dr. Franklin. Overall, when I look at the numbers, I see a 
lot of fluctuation. There are times where you will see that it 
will spike, and you will try to study it and understand it. It 
is a 1-year spike or a 2-year spike. And then you will see 
where it has dipped slightly or it has gone up in a way that it 
is not statistically significant yet. And so it is just this 
up-and-down fluctuation over time.
    Either way, it is too many. We say one is too many and 
continue to study the data, not only in the context of the 
quantitative numbers, but, also, some of my colleagues today 
talked about the qualitative stories. Studying the full review 
of each and every one of these cases is critically important. 
They are not just a number. We must know the names, the faces, 
and the stories, the risks, the protective factors, what was 
behind each and every one of them.
    Mr. MacArthur. I would appreciate it if you could back get 
back to us. I think it could be helpful to look at trends over 
time, because perhaps there are some factors that are at play, 
with conflicts that they are in or different things, where you 
see elevated or depressed rates of suicide.
    Dr. Franklin. Yes, yes, certainly. Over time, we talk a lot 
about relationship issues being at the heart of a lot of this, 
but financial struggles, legal struggles, and also just this 
notion of, particularly within the military environment, sort 
of a falling from glory or no longer feeling a sense of 
belongingness with the unit or with the military. But, 
certainly, continuing to study those risk factors.
    And I would also turn it over to--my Army colleague may 
have more to say here about the identified trends specific to 
the Army.
    General McConville. Yes, sir. I could talk a little--and, 
again, I can't break down the numbers. I just have the 
statistics really for the Army as we look at different types of 
mortality, whether it is accidents, natural, suicide, or 
homicide.
    But, basically, what we see is, in the Army, compared to 
the civilian population, is in 2005 we were below the numbers. 
We were basically at a rate of about 13, and the U.S. was 
running about 18. And then, as we went from 2005 to 2012, it 
began to grow. And during that period of time, the Army 
actually crossed the civilian average. Now it has come back 
down to where we are a little higher, but, again, I am not a 
statistician, but they would say that is within the normal.
    So when we look at the death rate within the Army, what we 
find is, as far as accidents, it is much lower than our 
civilian counterparts. We talk about natural, much lower than 
our civilian counterparts. Suicides, a little higher, but, you 
know, again, the statisticians say that is about the same. It 
was statistically higher in 2012. And then, for homicides, it 
is much lower than the rate.
    So that is kind of how it breaks out. And I am not smart 
enough on the analysis of how they got all those numbers.
    Mr. MacArthur. I yield back.
    Dr. Heck. Mr. O'Rourke.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    I wanted to follow up on some questions asked by my 
colleagues Ms. Tsongas and Mr. MacArthur.
    One of the conclusions of the inspector general's report is 
that we don't have good or consistent measures for success. And 
so I would love to get your advice, Dr. Franklin, for this 
oversight committee on how we can best gauge the job that you 
are doing and that the different branches are doing in 
preventing suicide.
    Dr. Franklin. Thank you. Thank you so much for the 
question.
    And measuring suicide is difficult, but it is not 
impossible. And we absolutely owe you that, and we need to do 
that.
    When I arrived in the office, we started a refreshed effort 
in the context of our measures-of-effectiveness work. Early on, 
I think we were trying to bite off more than we could chew and 
attach measures of effectiveness to every single program out 
there. And now we have streamlined our approach, and we are 
looking at key indicators that we can collect from the 
chaplains, from the medical community, and then directly from 
the services that get after it.
    It is a much more streamlined, simple approach. We have 
developed a series of logic models to study the outcomes of the 
Suicide Prevention Program as a whole vice the individual parts 
and pieces that make it up. So I am certainly pleased to share 
those models with you.
    It is definitely an important issue. Measures of 
effectiveness should be part of everything we do, and we 
shouldn't think of it as an afterthought but, rather, part of 
the front end of programming.
    Mr. O'Rourke. One of the things that I think is cited as a 
success story in the IG report--and you mentioned it, I 
believe, in your opening testimony--is the data that you are 
collecting now, and you implied data across service and then as 
the service member transitions out and becomes a veteran.
    And you mentioned the analytics that you are doing, the 
advanced analytics that you are doing on that data. Can you 
give us an idea of what it is that you are measuring?
    And I appreciate the focus on ensuring that we are sharing 
best practices across service branches. How are we sharing with 
the VA and vice versa?
    Because I think all of us here are also very concerned with 
veteran suicides, as well. And so, you know, whether it is the 
risk factors that General McConville brought up earlier that 
are identifiable, I want to know if those are being shared with 
VA providers and clinicians and what kind of impact we are 
having there.
    Dr. Franklin. Yes. Yes. Two-part question.
    The first, I think you are getting after this Suicide Data 
Repository. This is a massive database, a data set that pulls 
together about 22 other data sets, drawn off of the CDC and the 
National Death Index data.
    It is a joint partnership between the Department of Defense 
and the VA. So we both put into it, and we can both pull out of 
it. And so far, we have developed a charter and had a series of 
meetings to discuss the art of the possible on the data and 
analytics, and it is very exciting. We do not have any results 
from it yet, but the framework is in place, and a number of 
discussions have been held, particularly in the context of 
predictive analytics.
    Mr. O'Rourke. Can you go deeper into that? And perhaps 
anyone else who is with you at the panel. Are you seeing 
correlations with combat, with specific kinds of combat, 
specific experiences within combat correlated to higher 
likelihood of suicide attempt?
    Dr. Franklin. Those are precisely the things that we are 
going to begin looking at. The database was just stood up. We 
have only recently put the business rules in place and put in a 
series of processes for folks to access the data, to begin to 
look at the research questions and going through proper IRB 
[Institutional Review Board] procedures and those sorts of 
things. So it is in its early stages, but there is quite a bit 
of excitement about the potential future of it.
    So far, what we have also done is discussed opening up to 
academic sector and letting folks know our research needs and 
our gaps so that folks can tap into the database and help us 
study these very issues.
    I wish I had more for you in the context of specifics on 
the analytics, and I hope to at another time, potentially even 
another hearing.
    Mr. O'Rourke. I look forward to that.
    And, General McConville, you mentioned identifying risk 
factors and then acting upon those. Any that I just mentioned 
right now, are those correlated? Are those risk factors that 
you are looking at, combat service, particular kinds of combat 
service?
    General McConville. We have.
    And the value of the massive STARRS study was it is really 
not as combat-related as some would think. And, you know, as we 
went through this, the folks that are most likely to commit or 
most likely to die of suicide are those that have zero or one 
deployments. It is not the multiple deployers, which we were 
kind of--you know, that is counterintuitive to what a lot of us 
thought. And that was, again, you know, a very--and we are 
continuing to look at that. It doesn't mean that one deployment 
does not affect you, but it does get back to those that may 
have some type of behavior health issues going into the 
military. That is very, very important.
    And as we move to a complex behavior module, it is more 
than one effect. The fact that someone goes through a divorce 
does not mean they are going to die of suicide. The fact that 
someone has a drinking problem does not mean--all those. But it 
is getting those compact factors coming together and then 
understanding how they affect--because they affect all very 
differently.
    The thing we are trying to get to is really trying to 
measure resilience. And it is not like on the positive side. 
You know, when we bring soldiers in, resilience or grit is 
something we are trying to define in our screening process. So 
if when someone comes in--we know what a resilient person is. 
We have always focused on physically fit, but we are also 
focusing on mentally fit, and we are also focusing on 
character. Because those are the attributes that we are trying 
to bring into the service.
    And then, once we get them in, is to give them the type 
training they need when they are brand-new soldiers in initial 
training and during that first period of time. Because what we 
see is, if we look at suicide attempts and what our studies 
have shown us, actually, it is female soldiers that are most 
likely, first-term soldiers, to attempt suicide. Brand-new 
soldiers--male soldiers are most likely to die of suicide 
during their first term.
    So that first term is very, very important, the first 
couple years when a soldier comes in, because we really haven't 
fully brought them into the culture of the military. And this 
goes for a lot of things, with sexual harassment, sexual 
assault. All those things tend to happen at a higher percentage 
in that 1- or 2-, first-year soldier. And that is why we are 
really focusing on this ``Not in My Squad'' campaign that we 
are going after.
    Mr. O'Rourke. Thank you for your answers. I am going to 
have to yield back to the chairman.
    I appreciate the indulgence.
    Dr. Heck. Mr. Coffman.
    Mr. Coffman. Thank you, Mr. Chairman.
    One, first of all, I want to commend the Army, and I don't 
know if the other services are doing it too, in terms of 
recruiting and now trying to develop methodologies to determine 
who is more resilient than others, who is more likely to fall 
victim to the stressors of training, of combat training, of 
deployment, of all the things in the military. And so I think 
that is very important, if we could mitigate problems through 
the intake process in terms of who comes in.
    One thing I wanted to ask all of you is that, what is 
different, if I look at my service in the first Gulf war and my 
service in the Iraq war later on, in 2005-2006 in Iraq, that in 
the first Gulf war, you were just checked out. It was probably 
the last war where there wasn't the Internet, where you just--
you know, it was snail mail. You checked out. You went there, 
you came back. You didn't have communications with your family 
until post-conflict, then occasionally on a land line, on a 
phone.
    But in the Iraq war, where you have--and Afghanistan too--
where you have forward operating base and you have soldiers, 
Marines, and sometimes airmen and sailors going outside the 
wire, coming back in, getting in real-time with their families, 
being told, you know, we are having these problems and these 
problems. And so, all of a sudden, they have the compounding 
effect of being concerned about what is going on at home in 
real-time and being deployed in a combat zone.
    How much are those stressors factors in suicide rates? And 
the fact that we have fewer deployed troops today, does that 
bring it down? Although we have a lot of deployed troops, just 
not in a combat zone, but all over the world.
    Who can comment on that?
    General McConville. Sir, I can comment on it.
    Really, I think you bring up a great point. And as I look 
and try to put this in perspective with the strategy that we 
have, is, you know, when we were going to the Gulf war and we 
were doing that before, there was no contact. Now, the soldier 
is sitting there, he or she is Skyping with their significant 
other. And, I mean, I could give you some horror stories of 
some of the things that happened while people are Skyping and 
things that have been said.
    So that creates a tremendous amount of stress on our 
soldiers. Because we look at some of the factors, we are 
saying, okay, so relationships is a problem, financial is a 
problem. Well, they have a direct access to that soldier to do 
that. So that is a significant concern as we go forward.
    And, again, that is why we want to build the resilience, 
both in the soldiers but also the families. And one thing that 
we really haven't talked about is our resilience training for 
families. And right now we are training master resilience 
trainers. Spouses have taken that on. They are more ecstatic, 
and they are excited about that. That is making a difference, 
so much so that we are standing up a program for our teens too, 
because they want it. And, again, anyone that has, as you know, 
had military kids traveling around, and with the stress of the 
military--very, very important for our folks.
    Mr. Coffman. Good.
    General Ediger. This is one of the prime factors that led 
us to start training family members as resilience training 
assistants. Because the connectivity back home, while 
comforting in many cases, it can also share the stress from 
what is happening in the operational environment. And so we 
recognize the importance of having Key Spouse programs and 
actually incorporating resilience training into the Key Spouse 
program, which led us to do that.
    I think in terms of the members who are actually deployed, 
we have actually found that our suicide rates among airmen 
during the time they are deployed are far lower. And we think 
that is because of the sense of responsibility to their fellow 
airmen, and they are part of a team, and they understand that 
they have a responsibility to be there for their team. And so, 
during the actual deployment, we have found that the rates of 
suicide attempts are far lower.
    General Whitman. Three parts of your question, I think.
    Is there a link to combat and deployment? We have not found 
any in the Marine Corps, similar to the Army experience and the 
Air Force experience. It is a factor, but it is one of many. 
And, typically, suicide is related to 10 to 20 of those, in any 
given case. Sometimes it is, but it more often than not in the 
past year, it wasn't, deployment or combat.
    We are looking at screening very hard. Part of our Marine 
Corps Recruiting Command effort, a very deliberate effort to 
look at what screening would be the most effective up front 
before a Marine comes in. And we use a Marine total fitness 
model to look at body, mind, and spirit, and social.
    And, finally, we are also training families through a new 
Conquering Stress with Strength program that we initiated this 
past year. It is fairly new, but it has been well received. And 
we expect to expand that across the Marine Corps.
    Admiral Burkhardt. The Navy has similar results, where we 
have not found that deployments has been significantly related 
to death by suicide.
    Mr. Coffman. Okay.
    Thank you, Mr. Chairman. I yield back.
    Dr. Heck. Mr. Walz.
    Mr. Walz. Thank you, Chairman and Ranking Member.
    I want to thank each of you for the work you have done. It 
is gratifying to me to see the commitment is here. And I know, 
going out and talking to folks over the years and having worn 
the uniform within the last 10 years, this is not a box to 
check, obviously, for the services. This is a commitment that 
is deeply engrained in the culture. And for that, I am 
incredibly grateful.
    It is a very difficult task to take on. It is one we 
understand we have a moral responsibility to, but it is a 
readiness responsibility, as we all know. This is a force 
multiplier, keeping people healthy.
    And I think the resiliency training--I would make the case 
that, once again, you are probably outstripping the private 
sector. And this issue of mental health parity is still a 
troubling thing, a stigma in the private sector. We have worked 
very hard to get insurance to pay for it, in some cases, until 
very recently.
    So I understand the challenges. And I also think you know, 
all of us here, that it is amazing to me, and people want to 
fix this badly, and they want a fairly easy fix. And I remember 
we worked really hard in the VA earlier this year when we 
passed the Clay Hunt bill. And I was gratified to see that 
happen. But I said, if you needed a stark reminder of this, in 
my hometown of Mankato, Minnesota, the day we passed it, the 
next day on the paper, the top half of the paper said, ``Clay 
Hunt Bill Passes Congress.'' The bottom half of the front page 
was a young man walked into the Minnesota State University, 
Mankato, library and died by suicide, gunshot wound, on that 
very same day.
    And so it reminds me that this is a deep dive. We are in it 
for the long haul. There are many factors. The research is 
catching up or starting to. And I am grateful for where you are 
going.
    And I think that leads, to me, I am not going to ask in 
detail. This is just my hunch on this. I think the spirit that 
I have seen this be taken on is real, it is happening. And so 
when I see the IG was talking about unsynchronized, I think 
that is pretty much a condemnation of our entire mental health 
system, if you will. And so I am not sure if there is any 
question to ask there, if you agree with where they are at or 
if there is something we can do. I read that and am--and 
perhaps we should be more concerned, but it strikes me as 
perhaps this is deeper. I don't know.
    Maybe starting with you, Dr. Franklin. And, also, I am 
grateful for your office proactively reaching out soon after 
you were in your job and working with us. Because we are 
unsynchronized with the VA, if you will, and you are working to 
try and make that happen.
    Dr. Franklin. Yes. Thank you so much. Good question.
    And the unique part of this challenge at the DOD level is 
putting the standards in place, making sure we have the best 
research and opportunities for the services to work together. 
And the Department really serves in a facilitator role, in some 
regards, bringing some synergy to the table so that the 
services learn from one another.
    But, at the same time, I couldn't agree with you more, in 
the context of the services needing to have service-unique and 
-specific programming where relevant, provided that it meets 
the standard and that it is the best and the best that we know 
from the science.
    So honoring the service uniqueness. Having worked as a 
social worker for the Army and the Air Force and at the 
headquarters level for the Marine Corps, I can tell you that 
they are quite similar but also quite different, as you 
probably well know.
    Mr. Walz. Yeah. And I hear it listening to folks talk. And 
I think that is important. So I think, you know, it is 
important for us to publicly address that. I appreciate the IG 
pointing this out, but I think there is more to this than what 
the report said.
    So the next thing is part of that and I heard each of you 
say this, and, General McConville, you mentioned this, this 
peer-to-peer piece or whatever. We did best practices on Clay 
Hunt and showed there is a lot of success there. We are kind of 
looking outside the governmental things, different 
organizations, one I am partial to, Ride for Recovery, and some 
of these, of how do we use these with evidence-based programs 
that are making a difference? How do we synchronize across 
these? Because they have their own issues inside the world of 
the Army, the Marines, and so forth.
    And I don't know if any of you want to tackle that or maybe 
this is to you again, Dr. Franklin of, how do we use those 
external resources?
    Dr. Franklin. External resources, in some sense, even from 
the VA and also from just, sort of----
    Mr. Walz. Yeah.
    Dr. Franklin [continuing]. What I say, outside-the-gates 
resources. Certainly, we have come up with a number of good 
ideas by looking at best practices with other population 
groups. Whether we study police officers or firefighters, there 
are evidence-based practices that can be applied right inside 
the DOD.
    And part of that is hearing about them, learning about 
them. I have taken a number of briefs myself on these 
practices, trying to stay current. At our quarterly council 
meeting, we bring in experts from outside industry. Most 
recently, the American Association of Suicidology came in and 
briefed. The Coast Guard has come in and briefed a number of 
best practices.
    And then, from there, the relationships are in place for 
folks to gain more information and further discovery and 
determine how that particular practice might fit within their 
service.
    Mr. Walz. Well, I am glad to hear that. Because I think 
what I hope you need to know is in the VA, we talked about 
this--this is all of our issues, all Americans.
    Dr. Franklin. Yes.
    Mr. Walz. We need to pull in every resource. And you are 
doing all you can, but if there are things we can do, we need 
to make that as available as possible.
    So thank you, Chairman.
    Dr. Heck. Thank you.
    Dr. Franklin, let me ask this. And I know you are new into 
the position, and I appreciate you with your office call that 
you had a few weeks back. We talked a little bit about metrics 
and the effectiveness and measures.
    But the question I have for you specifically now is: Last 
year, Congress required DOD to develop a policy to collect data 
on suicide attempts involving members of the Armed Forces and 
deaths of military family members that are reported as 
suicides. It is my understanding that the policy is still being 
developed. So when can we expect to see that policy?
    Dr. Franklin. You are absolutely right; the policy is in 
progress, and it should be done by now. I agree with you. And 
if folks on the panel are frustrated, as am I. We need to move 
this policy along sooner rather than later. It is an important 
policy, and looking at the family member data piece intuitively 
makes sense. It is the right thing to do.
    I wish I could give you an exact date, but just know that 
it is one of the top priorities on my list right now, and I am 
working it hard, as is our entire P&R [Personnel and Readiness] 
leadership team.
    Dr. Heck. Can you ballpark it, maybe not an exact date?
    Dr. Franklin. I would say February 2016. And my leg 
[legislative] affairs person behind me is probably not 
appreciating me giving that date, but I am trying to get it 
done sooner----
    Dr. Heck. All right.
    Dr. Franklin [continuing]. Sooner rather than later. And, 
definitely, like I say, I couldn't agree with you more.
    The good news about this policy is that all the services 
have met; they have agreed upon a standardized approach. 
Actually, the Army led that group. I couldn't have been more 
pleased with them for that.
    And so, methodologically, the process has been staffed and 
looked at and studied. And I feel confident that when you get 
the data there will be an increased level of fidelity, in part 
because of the length of time that it has taken to put the plan 
together. But, again, it needs to move.
    Dr. Heck. Great. I appreciate you making that a priority.
    You know, all of you talked about the importance of the 
first-line leader, the squad leader, and being the person to 
identify at the lowest possible level somebody who may be at 
risk. And I certainly agree.
    And I know it is very hard to prove the negative, to prove 
the thing that didn't happen, but how are you measuring whether 
or not the programs you have that are training the frontline 
leaders are actually effective in decreasing suicide attempts?
    I can tell you that, again, in personal experience, I had a 
squad leader, had been through all the training, the ACE [Ask, 
Care, Escort] training, it was actually a master resilience 
trainer--and was out with one of his squad members on a Friday 
night. Two hours later, after he dropped that squad member off, 
the squad member died of suicide.
    And so the question is, how do we know that the programs 
that we have are actually effective in giving the tools 
necessary to those first-line leaders?
    And I am going to start with Admiral Burkhardt, because we 
have been starting this way, and you have been awfully quiet. 
So we will start this way and go in reverse order.
    Admiral Burkhardt. Yes. Thank you, sir.
    I think one of the things we have noticed with our 
bystander intervention is helping sailors know that it is 
``Every Sailor, Every Day'' and that they have responsibility 
to step up and step in. And that has resonated with that peer-
to-peer training and the dialogue and the methodology that we 
have been rolling out, our training and our awareness. The 
sailors are engaged, and they want to make a difference.
    I think the struggle is connecting the dots. So a lot of 
different--whether it is a family member or the unit or one of 
the programs that the member has been engaging, like financial 
counseling or if they have been going through administrative or 
legal separation processing or transitions from duty stations, 
is that we have a way to make sure that there are warm handoffs 
between programs and also that we are keeping in touch with 
that sailor to recognize the change.
    Where I have seen a lot of difference between the suicide 
ideations and--that the sailors are sharing with their 
shipmates, and the shipmates are bringing it to attention and 
referring the sailor to the proper resource. And I see that 
quite often in the reports I receive, that it is happening, 
whether that referral is to a shipmate or to the chain of 
command or it is a family member that is bringing it to the 
attention of the chain of command or the chaplain.
    And the chaplain--we are really focused on a strategy to 
make the confidentiality apply to the service member and making 
a concentrated effort to say that also applies to the family 
member. And it can make a difference where the family member 
may have a perceived or real perception that if they bring 
something forward to the Navy that they could be hurting the 
member's career.
    Dr. Heck. Thank you.
    Admiral Burkhardt. Yes, sir.
    Dr. Heck. General Whitman.
    General Whitman. Yes, sir. It is hard to prove a negative, 
of course, but we, too, track each individual story. I 
mentioned one in my opening report. And we do have a number of 
those, where we can at least see that, in that case, at that 
moment, we saved a life.
    We have a more robust now training, annual training program 
for our Marines called Marine Awareness and Prevention 
Integrated Training. Every Marine goes through this every year, 
and it includes elements of identifying risk factors, 
triggering events, warning signs, protective factors. I have 
tested this when I have gone to visit units, and Marines can 
read back to me what they have learned.
    So, again, anecdotally, I think it is making a difference. 
They know. And you can trace back that training to some of 
these individual cases for peers and for the direct leaders 
with those Marines.
    Dr. Heck. Great. Thank you. My time has expired.
    Ms. Speier.
    Ms. Speier. Mr. Chairman, thank you. And thank you for 
holding this very important hearing.
    And thank all of you for being here.
    I have been rattling around in my head the New York Times 
Magazine story just a few weeks ago. I mean, I just can't get 
the pictures of some of those tragic stories out of my mind. 
And I hope all of you, I see the Rear Admiral is nodding her 
head; she has read it. I don't know if all of you have read it. 
If you have it, I really commend you to read it. Because while 
it talks about the suicide rates among veterans, it raises a 
lot of questions.
    And one of the earlier questions by one of my colleagues 
was about whether we are tracking combat versus stateside and 
the like. And I get the impression that you don't see any 
difference in terms of the suicide rate between those that 
actually serve in active combat and those who are not in a 
combat setting. They raise that question in that article.
    And I don't know, I guess the question is, do you track 
that?
    Dr. Franklin. Absolutely. This is tracked through the 
DODSER [Department of Defense Suicide Event Report], Suicide 
Event Reporting, tool. It is tracked whether the----
    Ms. Speier. And you see no difference, basically.
    Dr. Franklin. There was recently an article published in 
the New England Journal of Medicine. The title of the article 
is something to the effect of ``Deployment is not a singular 
risk factor when it comes to suicide.''
    The issue is you often have to unpack that variable of 
deployment. Not only have they deployed, how many times? What 
was the length of their deployment? What was their level of 
combat exposure while they were on that deployment? And what 
was their preexisting trauma perhaps that they have experienced 
before they even went into the war zone? So it starts to get 
complicated very quickly. Also, what protective factors did 
they have in place if they had had preexisting trauma or not?
    So I struggle when we try to narrow it down to just two 
simple variables: deployment, suicide. It is really not that 
simple. The issue around suicide that a lot of the folks on the 
panel----
    Ms. Speier. So, excuse me a minute, Doctor.
    Dr. Franklin. Yes.
    Ms. Speier. I have limited time.
    Dr. Franklin. Yes.
    Ms. Speier. So do we think that possibly multiple 
deployments may have an impact on the higher incidence of 
suicide? You don't know that either?
    Dr. Franklin. It is not what the data is telling us.
    Ms. Speier. Okay. I----
    Dr. Franklin. No, ma'am.
    Ms. Speier. That is fine. Okay.
    Let me ask this question. In that same article, there was a 
reference to one vet who went to seek help, spoke to a 
counselor, and the counselor said to him, ``You have to think 
about this as a breakup, like a breakup with a woman, and you 
have to think of it in those terms and move on with your 
life.'' And I thought to myself, we have serious problems if we 
have healthcare professionals providing services to persons 
with mental health issues talking to them in those kinds of 
terms.
    So it raises the question, what are the qualifications of 
those who are counseling persons that have mental health issues 
who are Active Duty military?
    General Ediger. I can speak to that.
    So, across all three services, we have common standards in 
terms of the credentials that are required in order to gain----
    Ms. Speier. And they are?
    General Ediger [continuing]. Privileges.
    Well, for licensed clinical social workers, there is a 
licensure in one of the States of the Union. And they must be 
certified as a licensed clinical social worker.
    As far as psychologists, we privilege them at the Ph.D. 
level, for our clinical psychologists across the three 
services.
    And, of course, psychiatrists, residency-trained in a 
program approved by the ACGME [Accredited Council for Graduate 
Medical Education], which is the----
    Ms. Speier. Right.
    General Ediger [continuing]. Organization in the U.S. that 
does that.
    Ms. Speier. So a clinic social worker could, in fact, be 
counseling someone who is suicidal.
    General Ediger. Yes. Yes. And they are trained to do that.
    Ms. Speier. Okay.
    So have we, kind of, reviewed the qualifications of those 
who provide those services and see success versus non-success? 
I mean, maybe that is not something we can do, but it certainly 
would be interesting to see if there is a certain level of 
educational attainment and experience that is most effective in 
assisting someone who has suicidal tendencies.
    General Ediger. And so, in the Military Health System, we 
have a scope of practice that is specifically defined for each 
individual provider and that is tailored to their certification 
and their specialty. And so each commander of each medical unit 
specifically privileges the provider to provide certain 
elements of mental health care.
    And so a licensed clinical social worker knows full well 
what privileges they hold and what services they are qualified 
and cleared to perform. And then, if they recognize that a 
patient needs care that goes beyond their scope of practice, 
then they refer them to a higher level of care, to a clinical 
psychologist or a psychiatrist as the case may be, or perhaps 
refer them for residential or inpatient care.
    And so this is all monitored through a quality assurance 
process that is defined in a DOD instruction.
    Ms. Speier. Mr. Chairman, could I have one more question?
    Dr. Heck. We are going around for a second round, so 
hopefully we will get to you.
    Mrs. Davis.
    Mrs. Davis. Go ahead.
    Dr. Heck. Okay. Mrs. Davis will yield.
    Ms. Speier. Thank you. I thank you for yielding.
    I have one question, one comment.
    The use of psychotropic drugs with persons that have 
suicidal tendencies I am sure is used a great deal. Have you 
tracked those who have committed suicide as to whether or not 
they have taken their lives with drugs or by use of firearms?
    And what has that told you? What have you learned from 
that?
    General Ediger. We do.
    In regards to firearms, at the DOD level, we actually have 
statistics, and that is the most frequent means of committing 
suicide among service members across all three services. And 
that is true of males nationally in the U.S., as well.
    In regards to mental health care, we do actually track, and 
we know which of the patients, which of the service members 
that commit suicide were under mental health care within 90 
days, in our case, of the time they committed suicide. Each of 
those cases is individually reviewed.
    And we have a lot of service members that receive mental 
health care month to month. I know in the Air Force we have 
230,000 mental health visits a year across it. And, of course, 
the rate at which those mental health patients commit suicide 
is well below, you know, .01 percent.
    But everyone that does commit suicide who was under some 
kind of mental health care, both Army, Navy, and Air Force, is 
reviewed to determine if there is something we can learn from 
that.
    And I can tell you, in many cases, those patients had 
encounters with mental health, but, actually, even though at 
every visit we have a standard that we require a suicidal risk 
assessment, in many cases those patients never expressed an 
intent or a desire to commit suicide during their mental health 
visit.
    Ms. Speier. I thank the gentlelady for yielding, and I 
yield back.
    Mrs. Davis. Thank you.
    You all talked about the resilience and trying to build 
that in with families. And I have some dear friends, and it is 
kind of an amazing case that has been followed by a lot of 
people because their son had enough going for him to write a 
very extensive suicide note. And one of the issues for them was 
whether or not there would have been the ability for someone to 
contact them that their son was having such difficulty.
    We have many safeguards in terms of confidentiality, and I 
respect all of those. But are there some tools, in working with 
this and I was trying to go through, as well, with the IG's 
report. I didn't see them making any specific recommendations. 
Obviously, we are concerned about confidentiality on a number 
of different levels. But families want to be there for their 
loved one, and often they have no idea.
    Are there some ways that you are seeing that that can 
perhaps be someone would have the ability to sign off on 
permission? And I would see this even as early as the 
recruitment phase, that while you are educating families and 
parents and the service member--I don't know. How do we do 
that? Because I think we would prevent more problems if 
families had the knowledge.
    Dr. Franklin. Yes. And thank you, Rep. Davis, for sending 
that family to me. I had a wonderful afternoon with them, and I 
really appreciated the opportunity that you provided in terms 
of hooking us up. And I appreciated the special time that I had 
with them to hear their unique story.
    And I could see their story transferrable across multiple 
other stories, and so I was thankful that they highlighted it 
and brought it forward, because I think that could be a 
practice. And I gave them my commitment to look into that 
further, this notion of a listserv or perhaps some education 
and outreach to parents of young service members that would 
educate the parents on just military life in general.
    Being a part of this culture for my entire life, there are 
some things we take for granted about the culture that we know 
because we have always known them. And that family and many 
others like them could greatly benefit just from some education 
and some awareness in a way that doesn't impact the 
confidentiality that you mention.
    Thank you so much.
    Mrs. Davis. Thank you.
    Dr. Heck. Mr. MacArthur.
    Mr. MacArthur. I recognize your primary focus is on 
prevention, as it should be, and I respect you for that. I have 
a question for General McConville, and it has more to do with 
the impact of these suicides on others and its effect on 
military readiness.
    And you noted earlier that there is a higher suicide rate 
among those with fewer deployments, which is surprising, I 
guess, to me. And you suggested the possibility, maybe even the 
likelihood, that this is related to preexisting conditions when 
people enter service.
    And I wondered, are your findings making their way to the 
recruitment process? Things likes resiliency, are you looking 
at indicators and putting that into recruitment? Or is it too 
unformed yet, the conclusions, for that to have happened?
    General McConville. Thank you for the question, sir.
    Where we are right now is this notion of measuring 
resiliency, because we want to prevent suicides, but what we 
really want to do is we want to build these incredibly high-
quality soldiers that can go out on the battlefield and do the 
things that we need to do for the country.
    So what we use, we have the Army Research Institute that 
works for us. It is social scientists; that is what they do for 
a living. And what we are trying to do is take terms like 
``resilience'' and say, okay, how do you actually test someone?
    We have tests that we do right now when soldiers come in. 
They take, other than the standard-type test, we call it TAPAS 
[Tailored Adaptive Personality Assessment System], where we try 
to get an idea of how sound they are. But we are trying to 
refine that science.
    Mr. MacArthur. But does that imply, because I am inferring 
that you have concluded that lack of resilience is a possible 
precondition, something that predisposes somebody to taking 
their own life.
    General McConville. Well, what we have found, at least from 
the Army perspective, is, we were doing what I would call a lot 
of diving catches and my Marine colleague talked about that, is 
how we, all of a sudden, had a soldier in serious and we 
basically saved his life. We have lots of stories, Marines, all 
of us have.
    So that is one part of it. But what you want to do is kind 
of move away from that. What we are trying to do is move the 
whole force, really, away from what the red area. I call the 
diving catch the red area. We move to a yellow area, where we 
start to manage and identify these transitions or these high-
risk factors that we are training our solders to do.
    And we move them even further, where they are really in a 
resilience phase, where we build soldiers who can handle 
stress, who can handle adversity. If they have behavioral-
health-type issues, they are getting that early on, just like 
if you had knee injuries or physical-type injuries.
    Mr. MacArthur. Yeah. And my question is take your knee 
injury. There is a certain degree of physical incapacity that 
would render someone unfit for military duty.
    General McConville. Right.
    Mr. MacArthur. Are you taking some of these findings 
regarding resilience and other things that I think you are 
suggesting may be precursors or things that cause somebody to 
be more tending towards that, are they coming into the 
recruitment process? Are you looking at resiliency or 
brittleness, maybe the opposite, in personality testing to see 
whether someone raises a red flag at the recruitment?
    Or is it, again, too unfounded yet and would actually be 
discriminatory? I am trying to get a sense of whether you have 
closed the loop on the recruitment side.
    General McConville. Yeah. What we are trying to do is we 
are trying to find that sweet spot. Because we don't want for 
folks that have sought treatment, to say, ``Hey, you can't 
serve.'' You know, we are trying to find--I mean, just like 
some of the types of injury. We want to give everyone the 
opportunity to serve that can meet the standards and is 
mentally fit enough to do that. So we don't want to have an 
arbitrary, if you have had some type of behavioral health 
counseling, if you saw a high school counselor.
    So the challenge we have right now and I have asked my, I 
am not a scientist. I am a helicopter pilot by trade. But what 
we are trying to do is get the science to help us do that, 
where it is a fair-type assessment where we can screen and look 
at that.
    Part of the STARRS study was to try to find that. We are 
not there yet in science. And we would like to get there 
because we think that would be helpful for everyone involved, 
if we could screen to a level where we identify--like we could 
do with a lot of the physical-type injuries.
    Mr. MacArthur. I would just add, in my few remaining 
seconds, I am not faulting you for that. I think it could be a 
slippery slope, but I am interested in, as we come to 
conclusive findings, where they make their way into our 
practices in the military. I think that would be helpful.
    I yield back.
    Dr. Heck. Mr. O'Rourke.
    Mr. O'Rourke. Mr. Chairman, I just want to thank those who 
testified today.
    I learned a lot at today's hearing. And some of the facts 
that you gave us were counterintuitive to my assumptions about 
where we should be looking and where we see risk.
    But I do think, Dr. Franklin, that we do need to see the 
analysis that you talked about, and we do need to better 
understand the measures for success and hold ourselves and you 
accountable for that going forward.
    And I am very interested in understanding how we apply what 
we learned here or within the Department of Defense to taking 
care of veterans who may be at higher risk for death by 
suicide.
    So thank you all for what you are doing.
    Thank you, Mr. Chairman.
    Dr. Heck. Mr. Walz.
    Mr. Walz. I am good.
    Dr. Heck. Ms. Speier? Okay.
    Again, I thank you all very much for being here today and 
offering your testimony. We all stand ready to assist you in 
whatever way possible as we try to erase this scourge of 
suicide within our military.
    This hearing is adjourned.
    [Whereupon, at 4:00 p.m., the subcommittee was adjourned.]


      
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                            A P P E N D I X

                            October 8, 2015

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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                            October 8, 2015

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     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 
    
      
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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                            October 8, 2015

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            RESPONSE TO QUESTION SUBMITTED BY MR. MacARTHUR

    Dr. Franklin. Prior to our implementation of the current rate 
methodology in March of 2014, we used a method that was based on duty 
status. The previous method did not distinguish the Active Component 
from the Reserve Component, represented the number of Reserve and 
National Guard Service members in the force at 11% of the Active Duty 
population, and combined fiscal and calendar year data. The current 
methodology provides leadership with a clearer distinction between 
Active and Reserve Components, and we are able to determine that the 
Reserve Component appears to be tracking at a higher rate than the 
Active Component.
    We have applied the current rate calculation methodology to our 
data going back 11 years (2003-2013) for the Active Component, and 4 
years (2010-2013) for the Reserve Component. Once we applied the new 
method to the past years for the Active Component, we did learn that 
the new Active Component rates followed yearly trends similar to the 
previous methodology which was based on duty status. We do not have the 
data needed to calculate the rate retroactively prior to 2010 for the 
Reserve Component.
    Applying the new method and examining the Active Component data 
from the Armed Forces Medical Examiner (2003-2013), the suicide rate 
increased from 2003 (10.8 per 100,000) until it peaked in 2012 (22.7 
per 100,000). In 2013, the Active Component suicide rate declined to 
18.7 per 100,000. We have not yet published a 2014 rate.
    Applying the new rate calculation method and examining the data 
from the Reserve Component, there was an initial decrease from 23.5 per 
100,000 in 2010 to 21.8 per 100,000 in 2011. Since 2011, the rate 
steadily increased to 26.4 per 100,000 in 2013. In the current 
methodology, Reserve Component rate includes members of the National 
Guard and Reserve regardless of their duty status.   [See page 17.]

?

      
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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                            October 8, 2015

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                    QUESTIONS SUBMITTED BY MR. JONES

    Mr. Jones. What is the Department of Defense and the services doing 
to determine what information sharing would be most helpful to help 
prevent suicides?
    Dr. Franklin. The Department of Defense has two governance 
structures to guide suicide prevention efforts and share best 
practices. The first is the Suicide Prevention Risk and Reduction 
Committee (SPARRC) which meets on a quarterly basis. The SPARRC serves 
as a collaborative forum of subject matter experts to facilitate the 
flow of information between the Defense Suicide Prevention Office 
(DPSO), Military Departments, and other stakeholders for the exchange 
of best practices and lessons learned. It also advises the Director, 
DSPO on suicide prevention issues; identifies policy and program 
changes required to improve suicide-related programs; submits 
recommendations to the Director, DSPO for approval; and facilitates and 
implements action items approved by the Suicide Prevention General 
Officer Steering Committee (SPGOSC). The SPARRC also facilitates 
collaboration between federal organizations such as the Department of 
Veterans Affairs, Department of Health and Human Services, including 
the Substance Abuse and Mental Health Administration, Centers for 
Disease Control and Prevention, and National Institute of Mental 
Health.
    The second governance is the SPGOSC which serves as an advisory 
body to the Under Secretary of Defense for Personnel and Readiness 
(USD(P&R)). The SPGOSC facilitates the review, assessment, integration, 
standardization, implementation, and resourcing of suicide prevention 
policies and programs. It also addresses present, emerging, and future 
suicide prevention needs, and evidence-based practices for military and 
civilian personnel that have DOD-wide applicability and provide 
recommendations to the USD(P&R) via the DSPO.
    DSPO most recently attended last month's Air Force summit on 
suicide prevention to share evidence-based best practices to help 
inform the Air Force's suicide prevention, intervention and postvention 
efforts. The Army, Navy, and Marine Corps also had representatives at 
the Summit to share best practices. It is through on-going engagement 
with the Services and other stakeholders that we will continue to share 
best practices to guide the Department's suicide prevention efforts.
    Mr. Jones. As I understand it, military members and veterans all 
access the same call center when they call in to a DOD/VA suicide 
prevention hotline. The person providing the immediate counseling must 
have as much information as possible to help prevent a suicide and get 
the military member or veteran the help they need. All information is 
vital to include medications, number of deployments, martial status, 
children, etc, anything that will help the counselor connect with the 
caller. Is this type of information readily available to the counselor 
and if not why not?
    Dr. Franklin. Veterans/Military Crisis Line (VCL/MCL) staff has 
read-only access to callers' relevant information that aids in thorough 
suicide assessment and dispatch of emergency services, if needed. Staff 
can view the Department of Veterans Affairs (VA) medical records for 
registered Veterans and Guard or Reserve members; staff use Joint 
Legacy Viewer (JLV) to view the Department of Defense's medical records 
for Active Duty Service members and Guard or Reserve members who are 
not registered with VA. Except in an emergency for which VCL/MCL staff 
must dispatch emergency response, staff ask for a caller's permission 
to access medical record information, and will respect the caller's 
request for privacy and not access records if denied permission. There 
are no other limitations on information VCL/MCL staff can legally ask 
callers. Information that is particularly relevant to the VCL/MCL 
mission and routinely reviewed via access of records during calls 
includes:
      Past suicide attempts, recent assessments of suicidality 
and safety plan for suicide prevention
      Past and current lists of medications and the conditions 
for which they were prescribed
      Branch of service, dates of service, and combat status
      Demographic information including address, age, social 
security number, and race
          The Social Security Number (SSN) is a primary field used 
        to search within both VA medical records and Joint Legacy 
        Viewer (JLV) in order to identify the correct patient record. 
        Both systems can be searched using only the last 4 of the SSN 
        and, if multiple results are returned, the name or other 
        demographic information can be used to confirm the correct 
        record is viewed
      Next of kin information
      Recent medical or mental health care and upcoming 
appointments
    Mr. Jones. What is the Department of Defense and the services doing 
to determine what information sharing would be most helpful to help 
prevent suicides?
    General McConville. Suicide prevention efforts between the Military 
Services are now more integrated compared to recent years as a result 
of the collaborative approach under the Defense Suicide Prevention 
Office (DSPO). The DSPO established the Suicide Prevention Risk 
Reduction Council (SPARRC) for the purpose of collaboration, 
communication, and documentation of suicide prevention best practices 
across the Department. The DSPO General Officer Steering Committee was 
also established with participation across the Department to provide 
oversight and guidance for governance and execution of the Defense 
Strategy for Suicide Prevention.
    To further our collaboration and information sharing efforts across 
the four Services, the Army established a Service Suicide Prevention 
Program Manager (SPPM). SPPM conducts a monthly teleconference to 
review ways to bolster our holistic prevention efforts across multiple 
prevention portfolios. We frequently review and share policy guidance, 
data sharing, tools, and training curriculum, and have worked closely 
on intervening techniques with the Navy and Resilience Training with 
the Air Force. From the Medical perspective, the Army Director of 
Psychological Health conducts a weekly meeting with participation 
across all Services to discuss potential Office of the Secretary of 
Defense, Mental Health policy changes.
    Mr. Jones. As I understand it, military members and veterans all 
access the same call center when they call in to a DOD/VA suicide 
prevention hotline. The person providing the immediate counseling must 
have as much information as possible to help prevent a suicide and get 
the military member or veteran the help they need. All information is 
vital to include medications, number of deployments, martial status, 
children, etc, anything that will help the counselor connect with the 
caller. Is this type of information readily available to the counselor 
and if not why not?
    General McConville. Yes, the Veterans/Military Crisis Line (VCL/
MCL) staffs have access to each caller's relevant information to aid in 
thorough suicide assessment and dispatch of emergency services, if 
needed. Data sources available include the Department of Veterans 
Affairs (VA) medical records for registered Veterans and use Joint 
Legacy Viewer (JLV) to view the Department of Defense's medical records 
for Active Duty Service Members. Except in an emergency, for which VCL/
MCL staff must dispatch emergency response, staff must ask for each 
caller's permission to access medical record information, and must 
respect callers request for privacy and not access records if denied 
permission. Typical access of records during calls includes: Past 
suicide attempts, recent assessments of suicidality and safety plan for 
suicide prevention, Past and current lists of medications and the 
conditions for which they were prescribed, Branch of service, dates of 
service, and combat status, Demographic information including address, 
age, social security number, and race, Next of kin information, and 
Recent medical or mental health care and upcoming appointments.
    Mr. Jones. What is the Department of Defense and the services doing 
to determine what information sharing would be most helpful to help 
prevent suicides?
    General Ediger. Suicide prevention efforts within the Services have 
become increasingly integrated and standardized in recent years under 
the guidance and support of the Defense Suicide Prevention Office 
(DSPO). The DOD Suicide Event Report (DODSER) tool is the standard 
mechanism for the Services to report suicides and suicide attempts of 
Service members. The DODSER contains approximately 150 data fields that 
can be further analyzed at the Service and DSPO levels. Service Suicide 
Prevention Program Managers hold a monthly teleconference to coordinate 
their efforts and share information. Also, the Quarterly Suicide 
Prevention and Risk Reduction Council meetings provide opportunities 
for the Services to meet together with DSPO and a quarterly Tri-Service 
Suicide Prevention General Officer Steering Committee ensures senior 
leader engagement and interservice coordination. In September 2015, AF 
Suicide Prevention Summit brought the military Services and DSPO 
together to participate in forging recommendations to enhance suicide 
prevention efforts in the AF. Attendees included a wide cross-section 
of AF leaders and key stakeholders and brought them together with 
esteemed experts from agencies such as National Institute of Mental 
Health and Centers for Disease Control and Prevention, as well as 
academia. This positive shift in terms of the climate of collaboration 
has promoted alignment between the U.S. national strategy for Suicide 
Prevention, the DOD strategy and the individual Service strategies. The 
current status of information sharing represents a significant 
improvement in recent years and further integration and standardization 
of data collection, reporting and analysis are progressing 
consistently. From the clinical; while military healthcare providers 
have limitations in what they can share based on regulations such as 
HIPAA, they are required to inform commanders if there is a concern of 
harm to self or others, potential harm to the mission or duty 
impairment. Commanders and supervisors are encouraged to share 
information if they are concerned about a member. Medical information 
is shared and available in real time to all medical personnel across 
the military services through the AHLTA system, which is also available 
in the deployed setting and linked with VA data systems to facilitate 
Service member transitions. The AF has initiated systematic 
multidisciplinary reviews of suicides, while DSPO is working on 
developing an analytic framework for reviewing suicides to further 
capitalize on the opportunity to capture and share such information 
across Services and DOD. This data will be a critical next step in 
advancing our understanding of suicides in the military and informing 
our next wave of prevention and intervention efforts.
    Mr. Jones. As I understand it, military members and veterans all 
access the same call center when they call in to a DOD/VA suicide 
prevention hotline. The person providing the immediate counseling must 
have as much information as possible to help prevent a suicide and get 
the military member or veteran the help they need. All information is 
vital to include medications, number of deployments, martial status, 
children, etc, anything that will help the counselor connect with the 
caller. Is this type of information readily available to the counselor 
and if not why not?
    General Ediger. Hotlines such as the DOD/VA Crisis Line follow a 
crisis response model that minimizes stigma and promotes autonomy for 
the user providing 24/7 access and allowing them to share only the 
information they are comfortable with. Callers may opt to use the 
service in lieu of traditional counseling or medical care and having 
control over disclosure of their medical and personal information may 
be crucial to allowing them to establish rapport. Crisis line 
counselors have access to the CAPRI system which contains medical 
information for those enrolled in the VA system, but must obtain the 
caller's consent and personal information before accessing the system. 
DOD/VA Crisis Line counselor can connect the member to counseling or 
medical care through a local crisis coordinator in their geographic 
region. These local coordinators can refer to military, VA or civilian 
resources for support, information or counseling and can alert command 
or civilian authorities for an emergency response if warranted. Each of 
the military services has medical liaisons to the Crisis Line to ensure 
seamless support and a rapid exchange of information to facilitate 
appropriate medical or mental health care referrals. By occupying a 
unique niche outside of established medical and mental health services 
the Crisis Line provides an additional option for veterans and Service 
members in distress.
    Mr. Jones. What is the Department of Defense and the services doing 
to determine what information sharing would be most helpful to help 
prevent suicides?
    General Whitman. The Marine Corps continues to address information 
sharing as a key element of preventing suicide, including what 
information is most helpful. We currently have several ongoing 
initiatives highlighting the importance of the availability of 
information. For example, we participate in quarterly Suicide 
Prevention and Risk Reduction and General Officer Steering Committee 
meetings in collaboration with the Department of Defense Suicide 
Prevention Office (DSPO) and sister services in an effort to determine 
best practices to prevent suicide. The Marine Corps recently completed 
an initiative to improve Commanders access to health information by 
training Commanders and behavioral health providers on confidentiality 
rules and effective coordination of care.
    Mr. Jones. As I understand it, military members and veterans all 
access the same call center when they call in to a DOD/VA suicide 
prevention hotline. The person providing the immediate counseling must 
have as much information as possible to help prevent a suicide and get 
the military member or veteran the help they need. All information is 
vital to include medications, number of deployments, martial status, 
children, etc, anything that will help the counselor connect with the 
caller. Is this type of information readily available to the counselor 
and if not why not?
    General Whitman. For specific information on the DOD/VA suicide 
prevention hotline, we defer to DSPO and VA. In general terms, when a 
call center responder speaks with a service member or veteran in 
crisis, s/he gathers information directly from the caller to 
appropriately respond to the crisis. This may include the caller's 
geographic location, service status, suicide-related intent, 
environmental safety, access to lethal means, and any active medical 
emergencies impacting the crisis. If the service member or veteran has 
contacted the call center previously, that information is also 
available. Ultimately, a call center responder's ability to connect 
with a service member or veteran calling in crisis is fostered more by 
appropriate training and the ability to quickly build rapport.
    Mr. Jones. What is the Department of Defense and the services doing 
to determine what information sharing would be most helpful to help 
prevent suicides?
    Admiral Burkhardt. Navy meets regularly with the other Services, in 
multiple venues that occur at various levels, from action officer to 
flag officer, to collaboratively identify and share best practices for 
suicide prevention across the Department of Defense (DOD). 
Additionally, the Armed Services collaborate with the Defense Suicide 
Prevention Office (DSPO), which collects evidenced-based best practices 
from the Services and civilian entities, and disseminates them 
throughout DOD.
    Mr. Jones. As I understand it, military members and veterans all 
access the same call center when they call in to a DOD/VA suicide 
prevention hotline. The person providing the immediate counseling must 
have as much information as possible to help prevent a suicide and get 
the military member or veteran the help they need. All information is 
vital to include medications, number of deployments, martial status, 
children, etc, anything that will help the counselor connect with the 
caller. Is this type of information readily available to the counselor 
and if not why not?
    Admiral Burkhardt. The suicide prevention hotline is a Department 
of Veterans Affairs initiative in collaboration with the National 
Suicide Prevention Lifeline. The hotline operates 24 hours a day, seven 
days a week, and is staffed by trained mental health professionals 
prepared to deal with immediate crisis. As with all mental health 
professionals, VA hotline mental health professionals must rely on 
information provided by the person seeking their services. Callers must 
have the option of remaining anonymous, if they so choose, or they can 
disclose their identities to allow the staff to access VA medical 
records real-time during the call.
                                 ______
                                 
                   QUESTIONS SUBMITTED BY MS. TSONGAS
    Ms. Tsongas. What actions has DOD leadership taken to respond to 
the Inspection General on the observations and recommendations from the 
November 14, 2014, DOD Suicide Prevention Assessment? When do you 
expect DOD will have a response to all the findings and 
recommendations?
    Dr. Franklin. The Department agreed to implement the 
recommendations and is working to modify policy for the Department of 
Defense Suicide Event Report submission process. The Under Secretary of 
Defense for Personnel and Readiness published a memorandum to the DOD 
components which provided interim guidance in support of the 
recommendations contained in the report. At this time, many of the 
recommendations from the DOD Suicide Prevention Assessment have been 
addressed.
    In addition, the Defense Suicide Prevention Office is working 
diligently with the Services to incorporate the recommendations into an 
upcoming Department of Defense Instruction (DODI), which is currently 
in development. We estimate completion of this DODI in 2016.
    Ms. Tsongas. What steps has leadership taken to allow medical 
record sharing with the VA's Military Crisis Line and service member's 
health records? Especially since the IG identified a substantial and 
specific danger to public health and safety with regards to the DOD 
appropriately transmitting relevant service records to the VA.
    Dr. Franklin. This recommendation is complete. The Veterans Crisis 
Line/Military Crisis Line staff received access to the Joint Legacy 
Viewer on July 31, 2015, to access Department of Defense medical 
records, and this capability has resulted in more timely access to 
crisis intervention services.
    Ms. Tsongas. Where is the DOD with the milestones they established 
with regards to the recommendations from the (DODIG-2015-016) report? 
Was DOD able to meet any of their established milestones? If milestones 
were missed has OSD established new milestones?
    Dr. Franklin. The Department has achieved a number of milestones 
with regard to the observations and recommendations from the DODIG-
2015-016 report.
    Refinement to the under/technical assistance has been completed, 
after a complete help text overhaul of the DODSER survey deployed in 
2015.
    After action reviews are an ongoing process that began in 2015 with 
the task of engaging in weekly After Action Reviews with actual DODSER 
users. The findings of these reviews have been presented quarterly to 
the Defense Suicide Prevention Office and the Service Suicide 
Prevention Program Managers.
    Quality Assurance reviews are an ongoing process involving monthly 
data quality reviews of submitted DODSERs where ``missing'' or 
``unknown'' responses are selected. Frequently occurring errors or 
missed data will be discussed with the Services' DODSER Program 
Managers so that findings from the Quality Assurance Review can be 
incorporated into feedback and guidance to their DODSER form 
completers. Items that are commonly ``unknown'' will be compared 
against the feedback from the After Action Reviews in Recommendation 
3.c. to identify questions that are likely to cause confusion or that 
are difficult to answer.
    The DODSER has been modified and the software development aspect of 
these recommendations has been completed and is currently being 
reviewed by an internal quality assurance team for overall 
compatibility with the system. This review will be completed in 
November 2015, at which point the software changes will be ready for 
deployment. We anticipate deploying these changes alongside the other 
Annual Changes on January 1, 2016, in compliance with the IG deadline.
    With regards to trend data, official action related to this is 
pending the development of policy, per the IG recommendations, because 
of Protected Health Information/Personally Identifiable Information 
privacy concerns regarding the provision of raw, identified DODSER data 
to Installation Commanders. However, the DODSER software and web-
interface already contain an automated reporting tool through which 
users can specify variables of interest and create a customized, de-
identified data report containing counts and percentages. Additionally, 
if installations need identified data, there are processes that exist 
within the Defense Health Agency system to get approvals for sharing 
identified data.
    Ms. Tsongas. The November 14, 2014, DOD IG report identified 
shortcomings in the DOD Suicide Event Report (DODSER). How do the DOD, 
DSPO, and all services plan to fix these problems before implementation 
of a new policy that includes the Guard and Reserves?
    Dr. Franklin. The Department has made significant progress on 
efforts to address shortcomings identified in the November 2014 DOD IG 
Report, to be completed by the IG deadline of January 1, 2016.
    The DODSER has been modified to allow for ``No Known History of 
XXX'' responses and to require an explanation for ``don't know/data 
unavailable.'' The software development aspect of these recommendations 
has been completed and is being reviewed by a quality assurance team 
for overall Information Technology compatibility with the system. This 
change will be deployed alongside the other, Service Requested, Annual 
Changes set for January 1, 2016.
    The refinement of the user/technical assistance has been completed. 
The completely revised help text was deployed on January 1, 2015, and 
has been available to users since that date.
    The Department is conducting ongoing, weekly after action reviews 
with DODSER users as well as monthly Data Quality Reviews on 10% of a 
given month's submitted reports. Frequently occurring errors or missed 
data are discussed with the Services' DODSER Program Managers so that 
findings from the Quality Assurance Review can be incorporated into 
feedback and guidance to their DODSER form completers. Items that are 
commonly ``unknown'' will be compared against the feedback from the 
After Action Reviews in Recommendation 3.c. to identify questions that 
are likely to cause confusion or that are difficult to answer.
    Official action related to software updates to allow unit and 
installation trend reports is pending the development of policy because 
of Protected Health Information/Personally Identifiable Information 
privacy concerns regarding the provision of raw, identified DODSER data 
to Installation Commanders. However, the DODSER software and web-
interface already contain an automated reporting tool through which 
users can specify variables of interest and create a customized, de-
identified report containing counts and percentages. Additionally, if 
installations need identified data, there are processes that exist 
within the Defense Health Agency system to get approvals for sharing 
identified data.

                                  [all]