[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
VETERAN SUICIDE PREVENTION: MAXIMIZING EFFECTIVENESS AND INCREASING
AWARENESS
=======================================================================
JOINT HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
and the
SUBCOMMITTEE ON HEALTH
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, SEPTEMBER 27, 2018
__________
Serial No. 115-79
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
35-833 WASHINGTON : 2019
COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
BRIAN MAST, Florida
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
NEAL DUNN, Florida, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
BILL FLORES, Texas Ranking Member
AMATA RADEWAGEN, American Samoa MARK TAKANO, California
CLAY HIGGINS, Louisiana ANN M. KUSTER, New Hampshire
JENNIFER GONZALEZ-COLON, Puerto BETO O'ROURKE, Texas
Rico LUIS CORREA, California
BRIAN MAST, Florida
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Thursday, September 27, 2018
Page
Veteran Suicide Prevention: Maximizing Effectiveness And
Increasing Awareness........................................... 1
OPENING STATEMENTS
Honorable David P. Roe, Chairman................................. 1
Honorable Tim Walz, Ranking Member............................... 2
WITNESSES
Gregory K. Brown Ph.D., Director, Center for the Prevention of
Suicide, Research Associate, Professor, Department of
Psychiatry, Perelman School of Medicine, University of
Pennsylvania................................................... 4
Prepared Statement........................................... 41
Michael C. Richardson, Vice President of Independent Services and
Mental Health, Wounded Warrior Project......................... 6
Lt Col James R. Lorraine USAF (Ret.), President and Chief
Executive Officer, America's Warrior Partnership............... 8
Prepared Statement........................................... 45
Bill Mulcahy, Co-Founder, Guard Your Buddy....................... 10
Prepared Statement........................................... 48
Keita Franklin LCSW, Ph.D., National Director, Suicide
Prevention, Office of Mental Health and Suicide Prevention,
Veterans Health Administration, U.S. Department of Veterans
Affairs........................................................ 12
Prepared Statement........................................... 51
Accompanied by:
Michael W. Fisher MSW, Chief Readjustment Counseling Officer,
Readjustment Counseling Service, Veterans Health
Administration, U.S. Department of Veterans Affairs
STATEMENTS FOR THE RECORD
American Veterans (AMVETS)....................................... 54
Disabled American Veterans (DAV)................................. 57
Barbara Stanley, Ph.D. Professor Of Medical Psychiatry At
Columbia University, and Director Of The Suicide Prevention
Training, Implementation And Evaluation Program At New York
State Psychiatric Institute.................................... 62
Iraq and Afghanistan Veterans of America (IAVA).................. 64
National Alliance on Mental Illness (NAMI)....................... 65
The American Legion (TAL)........................................ 68
TriWest Healthcare Alliance...................................... 79
Veterans Of Foreign Wars Of The United States (VFW).............. 82
Veterans and Military Families for Progress (VMFP)............... 86
Whistleblowers of America (WOA).................................. 88
Wounded Warrior Project (WWP).................................... 92
VETERAN SUICIDE PREVENTION: MAXIMIZING EFFECTIVENESS AND INCREASING
AWARENESS
----------
Thursday, September 27, 2018
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:30 a.m., in
Room 334, Cannon House Office Building, Hon. David P. Roe
presiding.
Present: Representatives Roe, Bilirakis, Coffman, Flores,
Radewagen, Bost, Poliquin, Dunn, Arrington, Bergman, Mast,
Walz, Takano, Brownley, Kuster, Rice, Correa, Lamb, Esty, and
Peters.
OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN
The Chairman. Good morning. The Committee will come to
order. Welcome and thank all of you all for joining us today
for the Full Committee hearing on Veteran Suicide Prevention.
Most of us have heard VA's staggering and heartbreaking
statistic that every day 20 veterans end their lives, 20. We
also know that over the past several years VA has invested
significant resources toward addressing that number, which
stubbornly has not changed. We know from VA's testimony that 14
of those 20 veterans have not sought medical care at a VA,
meaning that the 30 percent of the veterans who commit suicide
have been to a VA campus for an appointment. Significant
resources have been put forward as outreach as well.
These numbers leave me with a lot of questions, ones which
I hope we can find the answers to today. What did these
veterans, men and women who reached an appalling level of
crisis find lacking when they sought VA health care or what
prevented them from seeking mental health services from VA in
the first place? Sadly, it is too late to ask these veterans
themselves.
I hope to hear more about the various programs and
initiatives VA mentions in its testimony, such as those for
women and homeless veterans. I am also eager to hear about how
these programs and initiatives partner with communities and
organizations that also are working hard to be a part of the
solution.
I also want to know how these initiatives are truly
executed. It is nice to outline how a program should work, but
for every veteran who is not properly referred for treatment,
for every veteran who is not admitted due to a shortage of
staff or bed, or for every veteran who feels that they have
been ignored or dismissed, we run the risk of not only adding
another tragic number to the statistics, but the veteran is not
a number, the veteran is someone who has fallen through the
cracks regardless of the good intentions.
Today's conversation should primarily revolve around the
root cause of veteran suicide, identifying those at risk for
suicide, recognizing the unique barriers that certain veteran
populations face, and tying all of that to advancing and
innovative approaches at the promise of preventing suicide
among veterans.
I am eager to hear about the efficiency of recent
improvements to VA's eligibility rules for mental health care.
Under Trump Administration, VA will now expand mental health
services to all departing servicemembers for 12 months
following separation from the military, which as we know is
also the highest risk period for suicide among veterans.
And thanks to the works of this Committee, veterans with
other than honorable discharges may now seek mental health
services for conditions that possibly contributed to their
unfavorable separation status.
Have these changes made a difference? I hope that today's
hearing will shed light on this very challenging subject. We
have the expertise, we have the support of the President, we
can and must reduce suicide among veterans and there is no
excuse not to.
The Chairman. I will now yield to Ranking Member Walz for
any opening statement that he may have.
OPENING STATEMENT OF TIM WALZ, RANKING MEMBER
Mr. Walz. Well, good morning, everyone, and thank you, Mr.
Chairman, a special thank you for holding this important
hearing.
And I know the folks who are here testifying, the members
that are here, and those that are both in the room and
listening, this is the most important hearing happening on
Capitol Hill today, because the heartache that is here and the
things that we need to do are ongoing. And so for that I am
grateful.
The tragic epidemic of veteran suicide is one of the most
serious challenges facing our country. The VA Report on Veteran
Suicide detailed yesterday, the rate of suicide is increasing
amongst the younger veterans, and this is that ever-ongoing
process of reaching zero sum, that if we lose one veteran, it
is far too many. The need to work together, identify root
causes, and figure out a constructive, holistic way to turn the
tide on the veteran suicide epidemic.
I want to take a few minutes, and thank you, Mr. Chairman,
for indulging me on this, to tell the story of a young veteran
we tragically lost and, in the audience, became familiar with
in recent days because of the IG report that came out on this.
I share this story with permission. I was on with his mom,
Drinda, and his father, Greg, and his sister this morning, and
like so many who have lost this, they are trying to turn this
tragedy into something positive to tell the story.
On February 20th of this year, Justin Miller, a young, 33-
year-old Marine Corps reached out to the VA Crisis Line dealing
with thoughts of suicide. He explained that he had access to
firearms nearby and he feared for his life. He expressed a
sense of hopelessness, confusion, sorrow, regarding his
personal and professional life.
Justin reached out to VA for mental health care through the
Veterans Crisis Line. They recommended, correctly so, that
Justin visit the VA emergency department, which he did
immediately. Upon his visit to the emergency department, Justin
explained that his significant other of 2 years had asked him
to move out. Justin also explained that battling the symptoms
of PTSD, watching the erosion of his personal relationships and
the family, and financial stressors had been overwhelming to
him.
Unfortunately, when Justin arrived at the Minneapolis VA
Medical Center, the help he needed never materialized and VA
clinicians failed to utilize cutting-edge interventions that
the facility has at their disposal, one example being the
three-step REACH VET process, in which a clinician can assess a
veteran's risk of suicide. If a veteran is determined to be at
a high risk of suicide, the medical record is then flagged for
a suicide prevention coordinator, who will then ensure the
veteran receives an appropriate level of care, and has
knowledge of and access to other services throughout the VA
that may assist the veteran.
Those are things that previous hearings and we have put in
place that are best practices, and we will hear from I am sure
all of you, this could happen. In Justin's case, REACH was
never utilized, and so he was never given a high-risk
designation.
In the written testimony of Dr. Brown, an expert on the
development, implementation, and assessment of suicide
interventions, he commends the VA on its use of Safety Planning
Intervention, or SPI, the SPI six-step protocol in which a
clinician can empower a veteran to cope with suicidal thoughts
through the development of a post-discharge plan. When Justin
was discharged after 3 days, he did not have a discharge plan.
Clinicians weren't sure whether Justin had access to guns
or a surplus of medications that he could hurt himself with.
Clinicians failed to ensure that Justin had identified friends
and family who he could reach out to in the case he felt
suicidal again. The suicide prevention coordinator never
consulted with Justin, engaged with Justin's clinicians, of
flagged him.
Though Justin steps out of that hospital on that cold
winter day in February, away from the nurses, the doctors, and
the medications that could have assisted in stabilizing him, he
went to his car and tragically took his life. He was not found
until the next day.
Our hearts ache for his family and the friends of Justin
Miller. I cannot even begin to understand their pain. No loved
one should ever go through this. We may not know if what they
could have done at VA would have saved his life, but we
certainly as a Nation mourn his loss.
It is infuriating to me to know that the possibility was
there, though, that could have prevented this. It should
outrage all of us. The entire health care system failed at some
point on something so serious. We need to do better, and we
will. We can only do better if we do our jobs, the agency must
continue to serve veterans and we must continue to oversee the
agency.
Secretary Wilkie implying in his testimony yesterday before
the Senate that our constitutional right to oversight is a
burden on his ability to implement the VA MISSION Act signals a
very dangerous misunderstanding of the role of Congress; that
must be corrected immediately.
Our oversight is integral to ensuring that VA is accurately
and effectively carrying out policies and procedures that are
in place, including policies aimed to help prevent suicides.
Our ability to conduct oversight could literally be the
difference between life and death. This I cannot stress enough,
and it is why we are here today, to determine how we can better
prevent tragedies like the one that took place on that cold
winter day in Minneapolis last February.
Given this is my last term in Congress and sitting across
from Chairman Roe, I want to thank him and everyone on this
Committee for showing the true bipartisanship, probably
nonpartisanship, in serving our Nation's veterans. Veteran
suicide has been elevated to the top priority of this Committee
for years, both by Democrats and Republicans; there is no space
between us in saving the lives of heroes.
I am going to be gone, some of us in here will be gone,
eventually all of us will be gone from here, but this issue and
our charge must remain the same. That is why congressional
oversight is the absolute key, putting policies in place that
extend beyond individuals and making sure the oversight to
implement them is a priority.
I want to thank the Chairman and thank all of you for this
hearing. I look forward to our questioning.
The Chairman. Thank you, Mr. Walz.
We are joined on our first panel and only panel today by
Dr. Gregory Brown, Director of the Center for the Prevention of
Suicide at the Perelman School of Medicine at the University of
Pennsylvania. Welcome.
Mr. Michael Richardson, Vice President of Independent
Services and Mental Health, the Wounded Warrior Project.
Welcome.
Lieutenant Colonel James Lorraine, United States Air Force,
Retired, President and Chief Executive Officer of America's
Warrior Partnership.
Mr. Bill Mulcahy, Co-Founder of Guard Your Buddy. Welcome.
Dr. Keita Franklin, Ph.D., National Director of Suicide
Prevention for the Office of Mental Health and Suicide
Prevention for the United States Department of Veterans
Affairs. Dr. Franklin is accompanied by Mr. Michael Fisher, the
Chief Readjustment Counseling Officer for the Readjustment
Counseling Service at the United States Department of Veterans
Affairs.
Thank you all for being here today. I will now move to
witness testimony.
With such a big panel today, I respectfully ask that all of
our panelists keep their oral testimony at or under the 5-
minute time limit, as indicated by the timer on the microphones
in front of you. Your full written statements have been
included as part of the official hearing today.
And, Dr. Brown, we will start with you, you are recognized
for 5 minutes.
STATEMENT OF GREGORY K. BROWN
Dr. Brown. Good morning, Chairman Roe, Ranking Member Walz,
and Members of the Committee, thank you for giving me the
opportunity to appear before you on such a critically important
issue, veteran suicide prevention. I am honored to provide
testimony, as I have devoted my entire career to suicide
prevention, with a strong interest in preventing suicide among
veterans.
As I will discuss, there have been a number of
psychotherapy, evidence-based and brief interventions developed
and validated that are available for at-risk veterans to
prevent suicide. However, there remains some major challenges
in the dissemination and implementation of these strategies,
both in VHA and in the community. Today I will share some
thoughts on a couple of recommendations for improving suicide
prevention for our veterans.
I and my colleagues at the University of Pennsylvania
developed a 10-to-16-session psychotherapy intervention for
patients who recently attempted suicide called Cognitive
Therapy for Suicide Prevention. In a landmark study published
in the Journal of the American Medical Association, we found
that patients who received this intervention were 50 percent
less likely to re-attempt suicide during follow-up than those
that did not.
These findings were partially replicated by Dr. David Rudd
at the University of Memphis using a similar intervention for
Active duty Army soldiers called Brief Cognitive Behavioral
Therapy.
The dissemination and implementation of these interventions
in VHA have been limited; there are efforts underway, however,
to address this issue. For example, the Office of Mental Health
and Suicide Prevention launched a project to remotely deliver
this intervention via clinical video telehealth. This program
will increase access for high-risk veterans to evidence-based
suicide prevention services.
There also exists a strong need for scalable or brief
interventions that are used in acute care settings such as
emergency departments that often function as the primary or
sole point of contact for suicidal individuals in the health
care system.
To address this concern, Dr. Barbara Stanley of Columbia
University and I developed a 20-to-40-minute intervention
called the Safety Planning Intervention. This intervention was
designed to decrease the risk of suicide by providing at-risk
veterans with a written, personalized safety plan of coping
strategies and resources of support to be used in the event of
a suicidal crisis. This intervention also includes lethal means
counseling to reduce access to potential methods such as
firearms and lethal medications.
Since 2008, safety planning has been widely used in VHA. In
response to a recommendation from the Federal Blue Ribbon Panel
of Veteran Suicide in 2008, the VHA Office of Mental Health
Services called for the development and implementation of an
ED-based intervention for suicidal veterans. In this project,
safety planning was developed in the ED and follow-up telephone
calls were made until the veteran was engaged in care.
Recently, Dr. Stanley, myself, and others published the
results in JAMA Psychiatry. We found that safety planning, plus
follow-up care, was associated with 45 percent fewer safety
behaviors than usual care.
In another study, Dr. Craig Bryan of the University of Utah
found that crisis response planning, a brief intervention that
is similar to safety planning, was more effective than
contracting for safety for preventing suicide among high-risk
Active duty soldiers.
Since 2008, one of the most important lessons we have
learned about the implementation of safety planning is that
fidelity to the intervention involves more than simply
completing a piece of paper or completing a medical record
template. Rather, it involves taking a collaborative and
understanding approach for addressing painful experiences,
coupled with feasible and helpful suggestions that veterans can
do to manage a crisis.
Two published studies have explored the quality of safety
planning in VHA medical records. One study found that the
quality of safety plans was low and that higher safety plan
quality scores actually predicted a decreased likelihood of
future suicide behavior reports in VHA. The other study found
that safety plans in VHA were mostly complete and of a moderate
quality.
To improve the fidelity and quality of safety plans, the
Office of Mental Health and Suicide Prevention recently
developed a medical record template with detailed instructions
for safety planning, offered didactic training to use the
template, as well as a corresponding safety planning manual,
which I co-authored.
In closing, we have made considerable progress in
developing validated interventions to reduce suicide risk, but
there is important work to be done. This includes: (1) increase
the dissemination of proven interventions for individuals at
risk for suicide, such as CBT-SP (cognitive behavior therapy
for suicide prevention), with the goal of raising awareness
among providers and VHA and in the community, as well as the
veterans we serve; and, (2) systematically evaluate the
fidelity of implementing these evidenced-based interventions
and provide additional comprehensive training to improve the
quality, if needed.
Thank you for the opportunity to offer this testimony. I
welcome any questions from the Committee.
[The prepared statement of Gregory K. Brown appears in the
Appendix]
The Chairman. Thank you, Dr. Brown.
Mr. Richardson, you are recognized for 5 minutes.
STATEMENT OF MICHAEL C. RICHARDSON
Mr. Richardson. Chairman Roe, Ranking Member Walz, and
distinguished Members, thank you for the opportunity to testify
on how we together can work to increase the effectiveness and
the collective efforts to prevent veteran suicide.
I am Mike Richardson, I serve with the Wounded Warrior
Project, responsible for the mental health and brain health
programming. I am also a combat veteran and a military retiree,
as is my wife, Beth. I also commanded a Warrior Transition
Battalion in Europe. So I have seen firsthand the challenges of
combat and transition that our veterans and their families
face.
We just heard the data about the suicide rate among 18-to-
34-year-olds continues to increase. They now have the highest
rate of suicide across all generations at population. The
average age of the more than 120,000 warriors registered with
Wounded Warrior Project's free service and programs is 38. As
such, Wounded Warrior Project's largest program investment is
in mental and brain health.
We are transforming the way we approach mental health for
our veterans through our comprehensive and more holistic
approach, focused on resilience and psychological well-being.
We know mental health treatment works and it is our belief that
suicide prevention must move beyond the health care crisis
management model more towards an integrated, comprehensive,
public health approach, focused again on resilience and
prevention. We need a broader, multi-pronged approach to
prevention and treatment, a combination of clinical, non-
clinical, and peer-to-peer community-focused efforts.
Suicide prevention can't just be about saving someone's
life when they are in crisis, it must be about creating a life
that is worth living.
Wounded Warrior Project has a mental health continuum of
support that is comprised of a number of mental health
programs, both internal to Wounded Warrior Project and also
with our external partners where we serve and treat upwards of
10,000 veterans and family members a year. Although our
continuum is comprised of several programs, I would like to
highlight two, but please know our continuum provides warriors
and their families a path to increased resilience, thereby
lessening the likelihood of suicide.
The first program I would like to mention is our Warrior
Care Network, which is focused on warriors that present with
severe to moderate post-traumatic stress, anxiety, and
depression, as well as other mental health challenges. Wounded
Warrior Project partnered with four academic medical centers
from across the country, Massachusetts General Hospital, Emory
University, Rush University, and UCLA Health, who each
developed an innovative 2-or-3-week intensive outpatient
program that integrates evidence-based treatments with
wellness, nutrition, and family support and mindfulness as
well.
Since the launch in January of 2016, we have treated over a
thousand veterans in our intensive outpatient programs. On
average, the warriors are receiving more than 70 hours of
therapy in this 2-to-3-week period. We are seeing significant
clinical results.
Simply stated, on average warriors are starting treatment
at the severe level of post-traumatic stress and following
treatment they are now at the minimal level. The same holds
true for depression and we have over a 94-percent completion
rate for the treatment. These changes translate into increased
functioning and participation in life, again lessening the
likelihood of suicide.
I would like to specifically thank the VA for being an
integral part of our Warrior Care Network success in that we
have an MOU at the VA that allows for a VA teammate to work at
each one of our academic medical centers to help with medical
records, referrals, as well as education.
The other program I would like to highlight very quickly is
our Project Odyssey. Project Odyssey is a non-clinical, 90-day
program consisting of a multi-day, adventure-based mental
health workshop, with a lot of follow-up after that. Each
workshop includes psycho-educational activities, evidence-based
exercises focused on improving resilience. Each warrior cohort
learns how to process emotions in a productive way to build
resiliency, as opposed to employing avoidance techniques.
Over the course of the past several years, we have had over
10,000 participants in our Project Odyssey programs across the
country and, again, we are seeing statistically significant
increased levels of resilience. Again, these are just two of
our programs.
We strongly feel that peer-to-peer engagement in
communities is critical and, in addition to our own connection
programs, we partner with many other organizations, like
America's Warrior Partnership, Team Red, White, and Blue,
Mission Continues, Team Rubicon, and others, focusing on the
efforts, and as well as the Bush Institute's Warrior Wellness
Alliance, whose focus is on optimizing the efforts across the
veteran space to help foster the resilience of our veterans and
prevent suicide.
I would be remiss if I did not bring up the strong
connection between stigma and mental health care. Sadly, there
is still a deafening silence when it comes to suicide. We need
to demystify this topic through open dialogue like we are
having here today. We must loudly state that there is nothing
wrong with seeking help. We must make sure these incredible men
and women who serve our country know that seeking mental health
care does not equal weakness. Just the opposite, it takes
strength to step forward when you are having challenges with
mental health and seek that care.
And again I would like to thank you for having the
opportunity to testify.
The Chairman. Thank you, Mr. Richardson.
Colonel Lorraine, you are recognized.
STATEMENT OF LT. COL. JAMES R. LORRAINE
Lieutenant Colonel Lorraine. Chairman Roe, Ranking Walz,
and Members of the Committee, thank you for the opportunity to
provide testimony today on the crisis of veteran suicide.
Thank you for your leadership in holding this hearing and I
respectfully request my written statement be submitted for the
record.
Additionally, I am fortunate to follow my colleague at
Wounded Warrior Project, because without their vision and
financial support, the veterans in eight of our affiliate
communities and their families would not be served.
I am a veteran of nine combat deployments in conflicts and
locations from Desert Shield, Storm, Mogadishu, Somalia, Haiti,
Iraq, and Afghanistan. I have had brothers and sisters in arms
who have taken their own lives, leaving all who love them to
wonder why.
Last week, I talked to a close friend of mine and begged
him to promise me that he would get more assistance, and that
he would not take his life. For me in America's Warrior
Partnership, the prevention of suicide is not only necessary,
it is personal.
As the Veterans Affairs report indicates, the number of
veteran's death in suicide is unacceptable, with far too many
unknown and untreated by the Department. As a Nation, we can do
better.
In America's Warrior Partnership, our mission is to empower
communities to empower veterans. Our approach as accomplishing
this mission takes many forms, but it starts with getting to
know all veterans; not just those who are seeking assistance,
but all veterans, building a relationship ahead of a crisis, so
that they can reach out and seek you and get connected to
existing services.
Through this model, we have established a relationship with
more than 42,000 veterans in eight communities since 2014.
This year, the Department of Veterans Affairs released the
VA National Suicide Data Report. This study is impressive, this
report is impressive in the volume of the records, the big data
aggregation, and the national span that it analyzed, but it
didn't provide the granularity of the community impact, it
didn't provide the granularity of what the service experience
of the veterans was that contributed to the untimely death of a
servicemember, or how communities might be able to enact it. It
looks great about how the Nation has to respond, but it doesn't
talk to the community level.
As a Nation, we often speculate about the causal effects of
veteran suicide. We have not been able to differentiate the
attributes of veterans that might be in the life that might
take their life in Buffalo, New York, or Johnstown, Tennessee,
or Orange County, California. We believe that when it comes to
preventing veteran suicide, I believe when it comes to
preventing veteran suicide, we need to move from fishing for
those who are going to take their lives to hunting to those who
are going to take their lives, by a better understanding of the
characteristics of veterans at the local level, at the
community level.
In December 2017, we announced the launch of Operation Deep
Dive. It is the first-of-its-kind, four-year research study
that we are conducting in partnership with the University of
Alabama and through the visionary funding from Bristol Myers
Squibb Foundation. With our partners, we are examining the
context of community factors contributing to the potential
causes of suicide and early mortality.
This study is a community-based initiative with a national
scope, designed to be led by and for communities to ensure that
they gain direct and tangible benefits that are tailored to the
unique veterans. I have been absolutely amazed at how engaged
the local community, coroners, medical examiners, and community
leaders have been in getting involved in this project.
We are compiling the local data and aligning it with the
national databases. We are fortunate to have a great partner in
Keita Franklin in the Department of Veterans Affairs who have
really stepped forward and said we want to help. We are also
working the U.S. Census Bureau, the CDC, and civilian partners
using publicly available credit bureau data such as
organizations like TransUnion. And then we are applying
advanced analytics such as geo-spatial analysis to identify the
characteristics and gain a better understanding of what is a
veteran in a community who is going to take their life look
like in a specific community.
Through Operation Deep Drive, we will look at things such
as the community environments that impact the veterans, the
experience of all veterans across their service, and then into
the veterans and what happens in the community; the impact of
less-than-honorable discharges on the rate of suicide, and the
analysis of cases of self-harm, not just declared as suicide,
but self-harm that contribute to it.
We are currently in seven communities, many of them
represented here, and we will add another seven in the next
year.
When the four-year project is done, we hope to understand
the context and work closely with all of our benefits. One of
the issues that we are facing, and then I think all of us face
and I know VA faces, is understanding is having DoD provide us
with what does the data look like in terms of the service,
specificity of service-related data of those who took their
lives as veterans.
I want to thank the Committee for allowing me to testify
and I look forward to your questions.
Thank you.
[The prepared statement James R. Lorraine appears in the
Appendix]
The Chairman. Colonel Lorraine, thank you, sir.
Mr. Mulcahy, you are recognized.
STATEMENT OF BILL MULCAHY
Mr. Mulcahy. Chairman Roe, Ranking Member Walz, and
distinguished Members of the Subcommittee, thank you for the
opportunity to testify on the challenge of preventing suicide
among our veterans.
My comments today are informed by the cohort who is most at
risk. Behind me today is the Co-Founder of Guard Your Buddy,
Cindy Sheriff. I would ask her to stand just for a moment. She
is my buddy today in case I need her help.
In 2012, Guard Your Buddy was launched in the Tennessee
National Guard in response to General Max Haston's mission to
stop the suicides. A seasoned health care executive, Cindy
accepted this assignment, and drew upon our backgrounds and
professional colleagues to team with the Jason Foundation to
create a clinically sound solution to the General's request. We
are proud of Guard Your Buddy's impact in Tennessee, and we
appreciate the opportunity to share with you what we have
learned and hopefully expand Guard Your Buddy's capabilities to
all veterans.
Guard Your Buddy is strategically focused on two
priorities: suicide prevention and intervention. With Guard
Your Buddy's smartphone application, Guard Service members and
their families are directly connected to a master's level
clinician who can provide immediate intervention and support.
Professional help is literally a click away.
Guard Your Buddy is unlike other suicide prevention
programs that are accessed through an 800 number. It is
critical that individuals contemplating suicide have immediate
access to professionals who provide in-the-moment support.
Clinically, the window for successful interventions are during
that initial outreach. Once the crisis is resolved, Guard Your
Buddy clinicians will continue to assist with other resources
within the National Guard and their local communities.
Our clinicians become the personal advocates for the
servicemembers and/or their families by helping them get their
lives back on track.
We are wholly supportive of national crisis lines to
address a wide variety of concerns for millions of our
veterans. However, a suicide crisis requires a unique,
dedicated solution. It is unrealistic to expect a suicidal
person to have a crisis line number memorized or readily
available at that moment in need.
As the name suggests, Guard Your Buddy supports the
strategy of connecting someone, their buddy, or loved ones in
need with resources immediately. Since implementing Guard Your
Buddy with the Tennessee National Guard, suicides have been
reduced an average of 68 percent annually since 2012. As we
know, 2012 is recognized as the peak for active component
military suicides and Guard Your Buddy's baseline year for
program outcomes.
General Haston asked us to share with the Committee his
thoughts as follows. Since 2012, the Tennessee National Guard
believes that over 85 men and women of the Guard have been
talked off a ledge or possible prevented from hurting
themselves by using the Guard Your Buddy app technology. The
Guard Your Buddy program provides real help in real time.
When that master's level clinician answers the telephone,
you don't get forwarded to someone else and that makes a
difference.
The last 5 years is referred to as the new normal because
active component suicide rates remain stubbornly high and have
not receded to expected levels. That is not the Tennessee
National Guard experience. We reject this inevitably and hope
Guard Your Buddy's model will be considered as another tool
available to all of our veterans in time of need.
Imagine for a moment a Guard Your Veteran initiative with a
foundational community approach similar to Guard Your Buddy and
what we have heard today. The Guard Your Veteran strategy will
involve community-based groups, religious organizations,
Wounded Warriors, and existing veteran programs such as the
Readjustment Counseling Service. Guard Your Veteran will save
our veterans' lives using the proven Guard Your Buddy
prevention and innovation strategies with tactics adjusted for
demographic differences. Guard Your Veteran's goal will be to
reduce veteran by 34 percent within the first 36 months of
implementation.
Guard Your Veteran adjustments for veteran demographics
include the following. Leadership, convenient access,
educational outreach, and triage. Most importantly, branding.
We have to create a consensus around the country to address
this issue immediately.
Collaboration with veteran leadership organizations at all
levels to achieve the mission stop the suicides. The Guard Your
Veteran program design considerations would include the fact
that suicide rates for veterans are highest during the first 3
years out of the military; 70 percent of veterans who commit
suicide are not under VA care; suicide rates are 16 percent
higher for veterans who never went to Afghanistan or Iraq; and
approximately 65 percent of all veterans who committed suicide
were 50 or older.
Guard Your Veteran solutions will be multidimensional with
different sectors, young and old, working together every day.
Suicide prevention is everyone's job.
We appreciate the invitation to address this Committee and
the opportunity to share our experiences about Guard Your Buddy
and the Tennessee National Guard. We look forward to your
question and thank you for your time.
I would like to read to the Committee and everyone in the
room just an example of a letter that we got. ``This is not an
urgent matter. I just wanted to say thank you for helping me in
my time of need, as well as my brothers and sisters. You are
all very important, you are all a very important part of the
military community and I thank you for your service from the
bottom of my heart. P.S. your hard work saved four of my
buddies, including myself.''
[The prepared statement of Bill Mulcahy appears in the
Appendix]
The Chairman. Thank you.
Dr. Franklin, you are recognized.
STATEMENT OF KEITA FRANKLIN
Ms. Franklin. Good morning, Chairman Roe, Ranking Member
Walz, and Members of the Committee. I appreciate the
opportunity to discuss preventing veteran suicide.
I think you know that I am accompanied today by Michael
Fisher. He is our Chief Officer of the Readjustment Counseling
Service. He is also an Army National Guard veteran from OIF.
Please know that I accepted this position back in April of
this year. Like many in the room today, the military has always
been a significant part of my life. My father is a 20-year Navy
enlisted veteran and my husband is an Air Force veteran.
Prior to joining the VA, I did serve as the Director of the
DoD's suicide prevention program. My Ph.D. course work focused
on deployment in the heat of the war effort and trauma impact
on families, particularly marital relationships and parenting
of children. So, my background as a clinical social worker, I
have focused on child welfare, I have focused on programs in
the military sector around domestic violence, sexual assaults,
substance abuse, combat operational stress, before narrowing in
in the field of suicide prevention. I am also the proud mother
of two, Lexie and Trevor.
And we know and it was mentioned here already this morning
that suicide is a serious public health concern; it affects
communities across the country. Like all Americans, I have seen
firsthand the irreversible impacts on communities, on families,
on workplaces, in our Federal buildings across the Nation. I
can say without hesitation that suicide has had devastating and
long-lasting impacts.
I myself have learned from survivors of suicide that the
loss, the pain, the guilt, the emptiness, it never goes away.
So, despite this comprehensive a loss, the survivors have
tremendous courage. They share their stories with us, they
recommend solutions, and while they know they can't change the
past and bring their loved one back, they are here to help us
to change the future; they want to help us prevent this from
happening with anybody else.
They are the individual voices and stories that keep me
committed to this mission of eliminating suicide among our
Nation's veterans.
At VA, we ground our work in the truth that suicide is
preventable. Zero suicides is and must remain our ultimate
goal. So, with this in mind, I am prepared to talk to you today
also about the recently released IG report. I heard this
morning about Justin and, if his parents are in the room, know
that I am happy to talk to them and I would want nothing more
than to learn from their son's story, and to have them inform
our policies and the way forward.
You have likely heard the figure--and it was mentioned this
morning--about 20 veterans a day. It is a number that has
remained regrettably stable since 2008. And I want to break
this down, because it is important for how we understand the
way forward.
Within the 20 deaths per day, we know that six of the
individuals have received VHA health care in the last two years
leading up to their death, and we know that the other 14 have
not. Within these 14, the VA has also consistently reported on
servicemember deaths. So, it is about one a day when you run
the math by 365 days. So, we have also reported on deaths of
former servicemembers who don't meet the Federal definitions of
``veteran.'' So, I want to talk to you more. I am happy to
share more about that today.
So, when you hear this figure of 20 a day, I encourage you
to think about it as 20 current and former servicemembers'
deaths per day. And from our perspective, when it comes to
preventing suicide, we are committed to saving lives among all
those that have worn the uniform, so our approach must embrace
the full 20.
We are working, as you see today, with like-minded partners
across numerous sectors, a few here at this table this morning,
and including other partners across the national Federal space,
health care, the faith-based industries, community-based
organizations.
If we are going to be successful in the VA, we must prevent
suicide among all veterans, including those who do not and may
never seek VHA health care. This is an immense task, but one
that we fully accept and that we are fully equipped for. It
will require an expansion of our existing approach.
VA has long been a leader in suicide prevention and has
historically focused on providing crisis support for veterans
at imminent risk and helping them access mental health care. We
know that crisis support, and mental health care are vitally
important parts of the solution, but alone they are not enough.
We know that to end veteran suicide we must think about how
to support veterans well before there is a crisis. We need to
find new and innovative ways to deliver the support and care to
the entire 20 million-veteran population. This philosophy is at
the heart of our new public health approach, which is outlined
in detail in a recently published national strategy for
preventing veteran suicide, which was created to help guide the
Nation in preventing veteran suicide over the next decade. This
strategy is consistent with the U.S. national strategy, as well
as the Department of Defense strategies for suicide prevention,
so that we can ensure that our efforts align and are in concert
with the broader issue going on across the Nation.
VA recognizes the important role that we play in this work,
but we also recognize that we can't do it alone. This strategy
reflects VA's vision for a comprehensive approach that involves
many different sectors working together to achieve 14 shared
suicide prevention goals.
Our framework developed by the National Academy of Medicine
considers three levels of prevention. It focuses on making sure
we are providing services to all 20 million veterans, it calls
for us to dig in deep on those groups that we know are at
preexisting levels of risk, and then dig in even deeper for
those individuals that are at risk.
I also want you to know, the national network of over 300
Vet Centers and 80 mobile Vet Centers in over 950 community
access points under the leadership of my colleague here, Mike
Fisher, works alongside our 400 Suicide Prevention Coordinators
across the Nation, and I am just excited for you to hear more
about that work and dialogue.
But at the same time, I know that we have much work ahead
of us, Mr. Chairman. I have seen the public health approach in
action, I am confident that it can be successful. I appreciate
the Committee's continued support and encouragement as we
identify challenges and find new ways to care for veterans, and
my colleague and I are here, prepared to answer anything,
questions you may have.
[The prepared statement of Keita Franklin appears in the
Appendix]
The Chairman. Thank you, Dr. Franklin. And I am going to
before I turn my clock on, I am going to take a point of
privilege as the Chairman of the Committee.
And this will be our last Committee hearing before some
leave the Congress, and I want to just personally as the
Chairman of this Committee thank every Member of this
Committee. I look around, and I belong to other Committees, and
I don't see the participation has occurred in this Committee.
And I want to thank you here personally for passing 70 bills to
help our veterans out of this Committee onto the floor, over
into the Senate, 26 of which these bills are signed into law.
When we leave Congress, when all of us leave here, I think
you can leave with some pride with knowing that your time here
was well spent.
And I want to say one thing about my good friend Tim Walz
here, who is leaving Congress after many years of service and
he hopes to continue his public service in his state, and I
want to personally thank you, Tim, for the work you have done.
You have sat here at the end of the dais and you have sat at
the head of the dais, and I can tell you personally it has been
a privilege to serve with you.
And I just wanted to take that point of privilege and thank
this entire Committee for the work, the tremendous work that
you have done.
Mr. Walz. Thank you, Mr. Chairman.
The Chairman. Now you can turn my clock on.
[Applause.]
The Chairman. You know, I think this hearing is an
incredibly important hearing and what I look at, five experts
in the field of suicide prevention.
And I look back from 2004--and I spent over almost four
decades of seeing patients, and I look at the expertise that is
sitting in front of me and then I realize how fragmented our
mental health system is in this country.
If you are in an ER, if you work in emergency room in
Tennessee, Kentucky, I don't care, California, and you are
sitting there and you get a patient in extremis, you are
concerned about that patient committing suicide, you don't
really have anywhere to send him most places. You don't have
the resources and yet we have gone from spending $2.4 billion
in 2003 to I think $8 billion this year on mental health in the
VA, that is just in the public side. We just passed in this
last budget $8 billion for opioids, and we know that opioids
and addiction very much are mental health, that there is many
times the same issue, just using a different mechanism, whether
it is on the civilian side or the public side.
And what I want to do when we leave here today is, we want
to continue a roundtable discussion, which I find probably more
helpful than even the hearings that we have here, about how do
we coordinate all of this. If we are spending all this money
and effort, I mean, incredible programs that you all set up,
why is the rate still 20? Why is it still--we have not moved
the needle? That is so frustrating to me to realize that we are
either not getting the information out--and I want to start out
with Guard Your Buddy, with Mr. Mulcahy.
When General Haston came to me and he said, he mentioned
that I think in the first month, 6 weeks of his command, he had
four suicides the first 40 days. He said we have got to do
something. So the Tennessee Guard put this in. It reduced, it
looks like, the best they can calculate, based on data compared
to other Guards, they have reduced almost 70 percent. Why
aren't we doing that in every Guard, in every state, in every
Reserve unit in the United States? Why hasn't that been done?
Mr. Mulcahy. Can we take a vote on that right now?
[Laughter.]
The Chairman. I am just simply asking. It is not an
expensive program.
Mr. Mulcahy. No.
The Chairman. And that is the thing that impressed me was
it is functioning. I have been to Canandaigua, New York, and
been to the call center, and those folks are trying the best
they can. I have been there. And I asked them when I was there,
don't we need to study is what you are doing successful,
because if it is not, then we need to change and do something
different.
I am going to open it up to any of you. How can we better
coordinate all of these amazing--I mean, you all are amazing
people doing the work you are doing--how can we coordinate
that?
Dr. Brown, we can start with you, or Colonel Richardson or
whomever.
Dr. Brown. As I mentioned in my testimony, I think one of
the things that we can do is to assess the quality and whether
the programs actually work. I am a scientist. I am a
researcher, and we can use scientific methods to find out does
the intervention reduce suicide risk.--
The Chairman. It works, I agree.
Dr. Brown. We need to identify evidence-based interventions
to reduce suicide risk or prevent suicide, and then implement
it. And if it is successfully implemented, that is great, but
we need to monitor how well we implement these programs.
The quality of the implementation matters tremendously.
Just like any other medical procedure that you would do,
quality matters. And so I think, you know, we have to put in
some resources into measuring quality and then providing
additional training, you know, to improve quality.
Mr. Richardson. Sir, and again as I mentioned in my
remarks, it is going to take us all to do that, right? As you
mentioned, the roundtable synchronization of efforts across the
board. And there are some grassroots efforts of that happening
already. As I mentioned, working with America's Warrior
Partnership, working with the VA, working with the Travis
Manion Foundation, Elizabeth Dole Foundation, to really focus
on the mental health aspect of our warriors, as well as their
family members, because we can't forget about the family
members as well in this, because they are having their issues
as well.
And so having hearings like this is really the opportunity
to bring it to the forefront, to make sure it stays. It is not
just Suicide Prevention Month in September, it is Suicide
Prevention Month every day, every week, every month, all year
long, and we can never stop talking about it in trying to find
out which areas are working and leave the egos at the door and
come together, so we can better the environment for our
veterans and their families.
The Chairman. Well, I am going to cut myself off right now.
And I have been instructed by the Sergeant Major to not start
at the front, but to start with Mr. Peters at the end. So you
all have to wait here at the front.
[Laughter.]
Mr. Peters. Thanks very much, Mr. Chairman. I love these
days. We are going to miss Tim Walz for calling on me first,
but for a lot of reasons. You have been a tremendous Ranking
Member. And it has been a pleasure, by the way, to work on this
Committee, which is a model of bipartisanship.
And all of us here today are deeply concerned about the
gravity of veteran suicide. We are all troubled by the idea
that our servicemen and women might return home from battle,
survive battle, only to take their own lives because they are
tortured by something they experienced during their service.
Many of us have someone in mind as we tackle this tough
subject. I wanted to mention the Somers family who are here
right now. I know you have met them. Their son, Daniel, served
valiantly in Iraq, including multiple combat missions, that
caused severe post-traumatic stress and traumatic brain injury.
Caught in the back load of veterans' cases at the VA in
Phoenix, he didn't get the care that he deserved, that he had
earned, and tragically he committed suicide at 30 years old.
And as his mother said, if he not met so many obstacles, would
my son be alive today?
Dr. Howard and Jean Somers, they are now tireless advocates
for fixing and reforming the broken health care system at the
Department of Veterans Affairs. I think they would rather be
taking vacations and traveling places other than Washington,
D.C., but they are always here on the Hill and we are honored
to work with them, but it is tragic that it took a parent's
loss to draw this to our attention.
San Diego has the third largest population of veterans in
the country, about 235,000 who call our region home. And we now
know that veterans experiencing homelessness are at particular
risk for suicide. So veterans who haven't experienced
homelessness have a suicide rate of 35.8 per 100,000, but
suicide rates are 81 per 100,000 for veterans who have been
homeless in the last year, and that is more than twice as
likely.
So I wanted to put in my plug for making sure that we
understand that if we prevent homelessness, we can help prevent
many veteran suicides. We have to preserve and expand resources
to homeless vets, including HUD-VASH vouchers which provide
crucial support of housing. And I am relieved we were able to
stop the VA from thinking about taking that money away from
homelessness funding from the HUD-VASH program, which we did
last year.
I did also want to say, we want to make it not harder to
access care, we want to be actively working to reduce the
stigma, to increase the outreach.
So I had two questions, I think, Dr. Franklin, probably for
you. And it is how the VA uses data to intervene early and what
data comes through. In particular, what information are you
receiving from the DoD, the Department of Defense, about
exiting servicemembers in their transitioning screener? So how
would red flags be conveyed to you and what are the obstacles
for you getting that information?
Ms. Franklin. It is a very good question and thank you so
much for the opportunity to talk about this important topic in
terms of the intersection between DoD and VA.
Primarily, what we are getting in terms of data is heavily
reliance on medical data. So, the channels are cross-walked,
and we are getting clinical records and medical data. Where I
think there are areas for improvement are data points that
might not be as medically focused.
And so, things that we talk about if we were able to do
better in this space--it would be focused on more personnel
data. So, did they not deploy? Did they not get promoted when
they intended to? You can see how that can be a very quick risk
factor when they have perhaps fallen from glory within the
unit. Did they have an Article 15 while they were on Active
duty? Did they go through a rough divorce?
These types of personnel factors that are sometimes known
to the system because they are in a record and sometimes known
to the small unit leader, we could do a lot more, I think, in
the care for them while they are veterans if we had that good,
rich information.
Mr. Peters. I think it would be helpful going forward if
you identified what you needed from the Department of Defense,
and we could go check and see whether that information is
coming out as part of the screening.
Ms. Franklin. Yes, sir, very well.
Mr. Peters. The other thing I want to ask you about, there
was a recent report by KPBS in San Diego that said that only
115 veterans nationwide are enrolled in a suicide prevention
program targeted to vets with other-than-honorable discharges,
and of those 115, 25 went to San Diego VA.
I would like to know what the outreach for this program
looks like or how you would like to see it changed?
Ms. Franklin. Yes, this is another very good question and
top on our mind at the office as well--other-than-honorable.
You know, we've made great strides since this first got passed
and we started rolling out with this work, we made great
strides to put the word out. So, we brought all of our VSOs in
and we asked for their help to reach out to their millions of
veteran constituent groups, and fact sheets and Q&As, and we
did all of this good work. And some time has gone by, and now,
with the new omnibus coming out, we need to refresh it.
And one of the things that we are working on is bringing in
veterans themselves to really help us talk about how to market
that, so that we are using the right words and that we are
doing the outreach in the right way. So that family members in
particular we think are part of the equation, like they may not
recognize it, but a family member will help and help get them
in. I don't know if you guys--
Mr. Peters. My time is up, but if you could, you know, sort
of brief me in particular, but the Committee on what--
Ms. Franklin. Yes, sir--
Mr. Peters [continued]. --you are doing about that, we
would love to hear about it.
Ms. Franklin. --I would be pleased to.
Mr. Peters. Thank you. I yield back.
The Chairman. Chairman Bost, you are recognized.
Mr. Bost. Thank you, Mr. Chairman.
Dr. Franklin, first off, I want to say thank you for the
work that you do over here, over here. So I want to thank you
for the work you do and the work the others do.
But whenever Mr. Mulcahy gave his testimony about Guard
Your Buddy, in April he mentioned that the program emphasizes
the use of Master level clinicians. What are the requirements
for those that take those calls? What does the VA set as a
standard that their background should be?
Ms. Franklin. Thank you for the question. Are you talking
about our Veteran Crisis Line?
Mr. Bost. Yes.
Ms. Franklin. Okay. So traditionally the standards are--the
field has grown in this respect, so this is relatively new in
the last few years--the standards are a masters. So you go
through a standard graduate program and then you become
licensed. And so, that typically takes up to, depending on
whether you are in the field of social worker psychology,
between a year or two, where you work under somebody, and they
guide, and they sign off on your work. And then you take a test
and, upon completion of the test, then you are licensed and
then you can operate at the independent level.
Mr. Bost. Just so I am--I know that there were some
adjustments that needed to be made and recommendations that OIG
and GAO, how are you implementing the requests by them? Is
there some implementation being done there as well?
Ms. Franklin. Yes, sir. Yes, sir, the Veteran Crisis Line
has undergone great strides in many respects as a result of
working with this Committee and closed out all of their IG and
GAO recommendations. And they are in a good, healthy place as
an organization but continue to need to be oversighted and
monitored so that that stays in place.
Mr. Bost. Okay. My next question, I am going to stay with
you on this, in my district we have a number of organizations
that work with veterans with symptoms from PTSD, mental health
illnesses, and they work to reduce veteran suicide. One that I
am especially involved with and understand is something that is
called This Able Vet. Now, there has been like three college
studies done on the success of This Able Vet. It is a program
where they train them with a service dog, okay?
And it allows our veterans--because even in your testimony,
you highlighted that the veterans are resilient and they are,
and they have a strong sense of belonging to a unit, and what
this does is this--what this group did is it discovered that
and their research finds that when veterans leave service, you
know, as veterans we are taught to take charge, be in command,
boom, boom, boom, right? And this is in a case where, okay,
they give them a companion dog and, if something happens to the
dog, then they are upset or whatever. It gives them a purpose
to take care of that and hold that mission of the dog. So it is
different from that aspect.
So my question is, what groups like this are you working
with that have success rates, or do you do that? And where are
we reaching out, because, yes, the VA is trying desperately to
help with this, but there are other groups and organizations
that are trying to help to, and which ones are successful and
how do you check that and everything?
Ms. Franklin. It is such a good question. At the heart of
our model is partnerships, and so then when you drill down
within the partnership sort of framework, working with partners
around the service dog issue is absolutely part of the
solution.
You know, there will be people in the field, the
researchers or people like that will debate the merits of
service dog, caring, comfort dog, this, that, and the other. I
don't myself engage in that kind of debate. I think that if a
veteran tells us that something helps them, it helps them,
particularly if we know that it does no harm. Certainly, there
are studies underway, sort of testing that and that sort of
thing. But partners are partners, and we cannot do it alone,
and we need any and all type of partners. I particularly am
also interested in pursuing nontraditional partners.
So, we have in some cases worked with who we have worked
with for quite some time and we do have to turn our heads, I
think, to the left and right and find new partners that perhaps
we haven't worked with for quite some time. And they do undergo
a certain vetting process, particularly if we are going into a
formal agreement with them in the context of an MOA or an MOU;
it has to go through legal review and there are a number of
hoops, but that is all worth it when it comes to bringing them
on board arm-in-arm with us to save lives.
So I am not familiar with the one that you mentioned, but I
wrote it down, and my staff are here, and they are likely
already pulling it up.
Mr. Bost. I think you will be surprised on what they do do.
But thank you, thank you for being here today.
And with that, I yield back.
Ms. Franklin. Thank you.
The Chairman. Thank you.
Ms. Esty, you are recognized for 5 minutes. And I hope I
still get Christmas cards since I am going backwards here. It
is his fault.
[Laughter.]
Ms. Esty. Absolutely. And, again, I want to thank the
Chairman and Ranking Member. It has really been a pleasure and
an honor serving on this Committee, and in a very fractious
time in the Nation's political life, it has really been
gratifying to see the good work that we have been able to do
together. So I want to thank both of you and wish the Ranking
Member in particular safe travels as he returns to Minnesota,
in the district I grew up in.
We are all very concerned about these issues, and I think
frustrated and worried about the obstinance of those figures
staying where they are despite great effort. Everyone in this
room, those of you at this table, and allies around the
country. So we clearly need to do better and there are things
afoot that we don't understand yet.
So in that spirit, I think this is not about casting blame,
but continuing that search for greater effectiveness to support
each and every veteran and each and every family when people
return.
In thinking about these issues, I think it is also helpful
to look to other populations that could help us. The Israeli
Defense Force recently did a study looking at suicide rates
there and concluded the number one factor was access to
firearms. And in full disclosure, I represent the town of
Newtown. I have spent a great deal of time trying to figure out
what to do on these issues, and I have a very large veterans'
population in my district.
And looking at effective ways, recognizing in our country
we have the Second Amendment, which I am supportive of, but we
need to find--for men in particular it is a huge issue, 66
percent are using firearms and the access that veterans have to
firearms is pretty great. I have personal friends who have had
children, and this has been an issue in their families. We had
calls into our office and had to talk people down and get folks
there.
So this is for all of you. Mr. Mulcahy, I know on Guard
Your Buddy, there have been programs, Phoenix has tried a
program of, you know, give your gun to a buddy, trying things
outside maybe a formal legal process. So that's one thing I
would like you folks to address what your thoughts are, again
recognizing legally there may be some barriers, but we do know
that immediate access. I think having the app in a pocket has
got to be the sort of thing that we look at, because people
aren't going to remember the number. They may not actually be a
veteran by technical terms, we need to empower them.
And the final one, which we have talked about a lot about
on this Committee, is the importance of a warm handoff between
DoD and the VA, and in particular looking at a check-in maybe 6
months out. You know, we have the TAP program, we give people a
lot of information, and we know a lot of it gets at best thrown
into a drawer, because a veteran wants to go home and see their
family. And when those resources are really needed is later and
then they don't even know where that file is.
So if you could, anyone who would like to address the
firearms issue, creative approaches around that, continuing to
use things like apps, and what do you think the value would be
of having some kind of mandatory check back in 6 months out
maybe--or sometime within the first year, but maybe 6 months to
check in and see how things really are going, and people may be
open to and aware they need help at that point, or family
members may see.
Thank you.
Mr. Mulcahy. I think the data is pretty conclusive that
firearms are the primary vehicle, number one; number two, I
think the most recent data would indicate that suicide amongst
women has really become a big problem recently and firearms are
kind of central to that. That is a much larger discussion than
my pay grade for this discussion today, but I think it is
really clear that that is a problem.
What we focus on is--and let's just say firearms is the,
you know, vehicle of choice, if you will, the key is that we
have learned--and my background is in population health health
care, Cindy's background is in behavioral health care, so we
see this as a puzzle. And the way we came at this, I mentioned
that the cohort that is most at risk is the cohort that
actually helped us develop this program. We talked to those 20-
year-olds, 22-year-olds, 25-year-olds, General Haston brought
them in. We said help us understand what you see, because they
know people that have either committed suicide or who are in
trouble.
So from our perspective, the singular moment that we had to
focus on to make an impact on the numbers was in that moment
when that person is moving from ideation to, I am actually
going to do something about it. And what they do at that moment
is they typically reach out to somebody. It could be a flippant
comment, it is not necessarily a declaration of this is what I
am going to do, it is a signal. The problem across the country
is that we don't know what to do with that in that moment. And,
Dr. Brown, I don't know if that is your research, but that is
our experience, that if I were to tell you that, you know, you
would know what to do with that, but most people don't know
what to do with that at that moment in time. Over half of our
referrals to our call, if you will, comes from the buddy, not
from the person who is actually suicidal, it is a family
member.
And when you look at population health risk at large, risk
in population, the earliest sign of risk is psycho-social. So
all the things that Dr. Franklin was talking about that creates
that risk, that anxiety, that depression, that builds that
puzzle into a picture where somebody is going to do something.
What we focus on is that moment. There is a lot of good other
ideas around the table, around the country, but if you were to
say why do we think our program has worked well, and it has not
been successful, because General Haston asked us to stop the
suicide. You know, we had one quarter, you know, we were able
to do that. But the reason is recognizing that there is a brief
window to intervene and then, as General Haston said, talk them
off the ledge and then get them the help that they need.
Ms. Esty. Thank you. And I'm so sorry, that is over. But
thank you--
The Chairman. No, that's fine--
Ms. Esty [continued].--that was very illuminating.
The Chairman [continued].--that was a good discussion.
Dr. Dunn, you are recognized.
Mr. Dunn. Thank you very much, Mr. Chairman. I thank the
panel as well.
Please, I am going to start, if I may, with Dr. Brown. My
staff and I had the opportunity to visit Florida State
University recently and they are working, they are doing a lot
of research in veterans suicide, and they are using, at least
in one other experience, virtual reality and advanced
monitoring technology to study individuals as they deal with
stress, as they deal with situations, they put them in stress,
and then they design a response tailored to that individual so
that they develop resilience and a much more well-being sort of
focus on that.
Their problem is that they see no translation of their
research into clinical practice. How can we help these advances
of whatever type they are, wherever they come from, into
clinical practice in the evidence?
Dr. Brown. Yeah, I am a big advocate for using technology
to individualize suicide prevention strategies that may help.
We are just at the beginning stages, from a research
perspective, in understanding how, and if these interventions
work.
Mr. Dunn. What can we do to help here in Congress?
Dr. Brown. Excuse me?
Mr. Dunn. What can we do here to help here in Congress?
Mr. Brown. Well, we need to fund more research to develop
these programs. Once we develop the intervention, do they
actually work, and then if they work, how do we best implement
them.
Mr. Dunn. And my question is, how do we get it into the
clinics, right? Okay, so we have some research, we think it
works, we need to get that into the VA. Is there--I mean, who
do I call?
Dr. Brown. I will maybe defer to Dr. Franklin about that.
Ms. Franklin. We have a dissemination process and a
pipeline that goes that when studies and results come to bring
to bear and have positive results, that we look to generalize
them as quickly as possible across the VA. There are likely
areas for improvements--
Mr. Dunn. I want to work on that with you.
Ms. Franklin. Okay.
Mr. Dunn. We also have the VA Health Subcommittee. So we
are going to work on that together going forward, because I
think--
Ms. Franklin. Dissemination to practice, yes, sir.
Mr. Dunn. Yeah, I think that is something we can do better
with.
Now, Mr. Richardson, in recent years we have seen Active
duty suicide rates normalize, but it remains high for VA. And I
wondered, does this speak to how critical it is for our
veterans to continue to feel a sense of mission and connection
to a social network as they transition out of the service.
Mr. Richardson. Yes, sir, great question, and that is
absolutely critical. Again, doing 32 years myself, the sense of
purpose that entire time, from the time I was 17 and 32 years
later I retired, and I get that now with Wounded Warrior
Project. And not all of our veterans have that opportunity to
find that sense of purpose.
Where we find the real challenge is when they go back home,
back in the communities. It is not immediately right after, it
is as it manifests itself. And so that is where it takes us to
be involved in the communities--
Mr. Dunn. So I think you mentioned in your testimony one of
the groups that is helping veterans with that transition, the
Mission Continues. Did you--I think I heard you say that.
Mr. Richardson. Yes, sir, Mission Continues is one that we
partner with as well and, again, when there is disasters or,
you know, in communities helping build houses, et cetera--
Mr. Dunn. Team Rubicon, stuff like that?
Mr. Richardson [continued].--Team Rubicon with disasters,
exactly.
Mr. Dunn. So I think we do, I think we want to turn more
proactively. The conversation changes from suicide to
proactively communicating well-being and resiliency in our
veterans.
I wanted to ask a question, Mr. Mulcahy, if I can. There is
a concern among Active duty personnel that reporting mental
health issues or seeking help jeopardizes their career. And it
does, let's admit that. So, in effect, in the DoD end of the
spectrum now, so they are still on Active duty, we respond to
their call for help by bayoneting the wounded. What can we do
to address this in our Active duty population?
Mr. Mulcahy. That is a great question. Early on with Guard
Your Buddy, as we learned the protocols within the military,
there was a big question about confidentiality, and it was
clearly the largest obstacle that we were engaged with in
talking with the servicemembers about the program. And we
worked with General Haston and we, you know, created a way in
Tennessee where there was a level of confidentiality when
people reached out to Guard Your Buddy.
Mr. Dunn. You mean legally, you actually made--
Mr. Mulcahy. Yes.
Mr. Dunn [continued].--the medical records somehow so
confidential it did not invade their career?
Mr. Mulcahy. Yeah, we kept it confidential, and that made a
huge difference. We actually, another group, a group that we
partner with in Tennessee is the Jason Foundation, they have a
golf tournament every year, and at that golf tournament when
Cindy and I were there, people will come up to us and they will
say, you know, thank you for the program, we have to tell you,
it is working because it is confidential. They are concerned
about that type of information getting out, they are concerned
that it could impact their ability to advance.
There are a lot of concerns around that, that is a huge
stumbling block.
Mr. Dunn. I agree. Our time has run out, but thank you for
underscoring that. I am not really ready to take up golf yet,
but thank you.
I yield back, Mr. Chairman.
The Chairman. Thank you, Dr. Dunn.
Mr. Lamb, you are recognized.
Mr. Lamb. Thank you, Mr. Chairman.
Dr. Brown, first of all, I am a proud graduate of your
university. So thank you very much for your hard work on this.
You have made us really proud.
You talked about trying to replicate and prove the findings
of some of your research on cognitive therapy. It seems like
your research has mostly been on DoD populations and could you
explain a little bit about the limitations of that study or
maybe some of the challenges we would face going forward to
expand it to others?
Mr. Brown. Yes, actually my research for cognitive therapy
for suicide prevention was with non-veterans, non-DoD people,
but David Rudd did do a study with Active duty military--
Mr. Lamb. Correct.
Mr. Brown [continued].--soldiers at Fort Carson, and he
found that using a similar intervention was very effective in
reducing subsequent suicide behaviors, you know, in that
population than those who didn't receive the program. Now there
is a replication underway in the DoD just launching now to
replicate the studies, which is really important, because if we
have replicated studies, we can definitely say these programs
work, so we have got to get them out there. So replication is
crucial to raising awareness about interventions that we know
works and how to disseminate them.
Mr. Lamb. Thank you. I guess what I am getting at is the
challenge of replicating this within the veteran population,
knowing some of the unique circumstances of veterans' lives as
opposed to someone who is on Active duty within DoD right now.
Can you speak to the importance of data tracking and electronic
health records as they might relate to how we use the VA system
to learn more about this?
Dr. Brown. So I just got done--I haven't published the
results yet, but I just got done doing a study with suicidal
men in VA using the cognitive therapy intervention. It is
currently we are in the process of doing analyses. The VA is a
wonderful place to do this research, because they do
standardized assessments, they do follow-ups, it is easy to
engage providers in care and get referrals. So it is a really
beautiful place to do this type of research.
Mr. Lamb. Thank you.
Now, Dr. Franklin, have you been involved at all or met
with the EHR Modernization team within the VA?
Ms. Franklin. No, sir.
Mr. Lamb. Okay. Are you aware of what I am talking about?
There is an effort underway to basically modernize the
electronic health records--
Ms. Franklin. Oh, yes, I am absolutely aware. I have not
met with them personally, but I am absolutely aware of the
initiative, yes, sir.
Mr. Lamb. Okay. I would encourage you to do that and maybe
if you would like to meet at some point to go over that. I see
this as an important tool in the fight against veteran suicide
when it comes to data tracking.
Dr. Brown, you mentioned kind of the most successful model
has to do with doing the safety planning first, then having
follow-up phone calls, then having follow-up care, and it leads
to fewer behaviors. I would imagine that a well-functioning
electronic health records system is integral to that; would you
agree?
Mr. Brown. I totally agree. And the better that we can
identify suicide behaviors and note them in the medical record
reliably, that is going to help us evaluate whether these
programs are effective or not. So, absolutely.
Ms. Franklin. And this notion of, from an 18-year-old
soldier all the way through end of life, to be able to track
that in a consistent way, there is nothing but good going to
come from that.
Mr. Lamb. Exactly. Well, and I guess that is what I am
hoping is that, with your expertise, you can play a role in
making sure that the needs you would have as a professional in
this space are actually being baked into the EHRs that will be
used in DoD and the VA. I mean, we don't want to get to the end
of this product rollout and realize there are things that you
needed in there that--
Ms. Franklin. A piece or a part, yes, sir.
Mr. Lamb. Yeah. So I would encourage you to do that and
let's stay in touch--
Ms. Franklin. Will do.
Mr. Lamb [continued].--about that.
And with that, Mr. Chairman, I yield back. Thank you.
Mr. Dunn. [Presiding.] Thank you.
Next I recognize the gentleman from Florida, Mr. Brian
Mast.
Mr. Mast. Thank you, Chairman Dunn. And I note Chairman Roe
had to move on, but I think there were some pertinent comments
made by people on both sides that really recognize the
jurisdiction between both Veterans Affairs and Armed Services,
and I would just love to recommend or ask that it be considered
that we do have a joint hearing between Armed Services and
Veterans Affairs, because there should be a seamlessness that
exists between that Active duty, that Guard, that Reserve
service, and somebody moving into the veteran status, and I
think that that would be beneficial. I would love that that be
considered. So that is a request that I would like to make to
you.
I have got to pull up my phone a moment now, because it
timed out and I took some screen shots of some comments that
have been sent to me over time and I wanted to read some of
them, I am not going to disclose who they are.
``The hardest adjustment from being a soldier to now being
a civilian is realizing that you are all alone and you no
longer have battle buddies to lean on.'' That is one.
``I am just struggling with feeling worthless. I know I am
not, but when something does go wrong it is hard to fight those
thoughts. But I have got to retrain my brain and not let those
thoughts in my head just because something went wrong. I am not
worthless. I am a good person with a good heart. I am a child
of God and I trust He has a plan for me.
``I am a failure, I am a loser, and I am tired of kidding
myself that I can ever be more than that, more than what I was
and what I am now. I am tired of being a disappointment.
``I am not feeling down on myself at all, but honestly
dealing with mental health issues makes me feel like a wimp.
``I am not interested in''--I was referencing some specific
cares that exist out there, some very similar to what have been
discussed here today, and the response was, ``I am not
interested in that. I will leave that to somebody that's
actually worth something. Me, I'm a POS, and that's been proven
over and over again.''
And I have comments that continue more and more and more.
And I find as I deal with this year in, year out, that those
friends of mine that are struggling with suicide are constantly
struggling with what is their value. What is their worth in
this world? What is their worth to us as their friends, what is
their value to their family members? What is their value to
this world, to their employers?
I am not a medical doctor, and this isn't what I study as
my livelihood, but that is what I see across every message and
every phone call that I get from a family member or a veteran
or a mother that is worried about, you know, her son or her
daughter.
And so I have a question for all of you. Do you have
anything profound or something that I haven't thought about, or
the panel hasn't thought about to say how do we make sure that
our veterans know their value? Because that is what I see them
struggling with.
Lieutenant Colonel Lorraine. Congressman Mast, if I can, I
have listened to the comments and the questions and one common
thread amongst them, including yours, is the community-based.
You can't push purpose from Washington, D.C. down, it has got
to come from the community up.
The community has an enormous amount, all of your
constituents have an enormous amount of ability to reach out
and connect to veterans to bring them up. The fact that 21
million veterans are out there and that the VA, we know 9.7
million. And when you look at the other Veterans Service
Organizations that are great, you know, 140,000 veterans post-
9/11, but there are 5 million that served post-9/11.
I think the focus is that it has got to be from the
community up. How do you empower communities to reach out and
give veterans a purpose, give them opportunities to move
forward? I think it has got to start there through other
resources.
Mr. Fisher. Thank you for the question. I actually want to
talk a little bit about what vet centers do in that space and
that is first it starts with outreach. It is going out and
finding these kind of individuals. I look at my own experience.
I am here today because a vet center counselor wouldn't let me
shut my barracks room door on him until I came and talked to
him. All I wanted to do was say no and he helped me say yes.
And that is what our outreach workers are doing and in
partnership with communities, going out and creating those
connections. It is not about evidence-based modalities at that
time, it is about let's make a connection, a therapeutic
relationship. And then from there, once we are connected, how
can then we go on and provide whatever your goals are.
Now, one of the other things that we are doing within vet
centers is that ability to meet an individual while they are on
Active duty, be that force and start providing services to them
before they meet our eligibility to help them transition
through the veteran status into the next part of their life.
Mr. Mast. My time has expired, but thank you for your
comments.
Mr. Dunn. Thank you, Representative Mast.
The gentleman from California, Mr. Correa.
Mr. Correa. First of all, I wanted to say to Ranking Member
or Governor Walz, thank you very much for your friendship and
your guidance in this Committee. We are going to miss you. I
know you are going to do great things as governor, so I am not
going to say goodbye, but I look forward to continue working
with you.
I know Chairman Roe is not here right now, but I just
really thought his idea of a roundtable was excellent.
Personally, I served on the Veterans Affairs Committee in
California for almost a decade and right now I am feeling a lot
of frustration, because in terms of suicide, homelessness,
unemployment, opioids, cannabis, VA wait times, Choice Act,
education, mental health, stigma, we have been talking about
this forever. And as Chairman Roe said, we are all throwing
resources at these issues, but they are really uncoordinated.
The State of California, we are the home to the biggest
number of veterans in the country, we are doing a lot of these
things, yet I am not quite sure we are really coordinated with
the Feds. Of course, private sector, I do believe one of the
biggest issues when it comes to suicide is unemployment. A
veteran comes stateside, can't find a job, things start going
in a bad way. Maybe I am right, maybe I am wrong, but the point
is a lot of this research that has been going on and we still
have research that is going on, I would like that roundtable to
bring in the private sector, how can we give these veterans
jobs immediately.
And as I am thinking to myself, listening to all the great
research you are doing, thank you very much for what you do,
let's keep plugging at it.
We are talking about who is it that is prone to suicide and
I think--I close my eyes, I think about all the veterans in my
district, we have a lot of veterans in our district. It is like
we have time triggers, not quite sure if it is going to hit you
a year out or 10 years out or 15 years out. So we come back to
the assumption has to be made that you come back with some
serious invisible wounds and how are we preemptive in terms of
assuring that we find those factors that may lead you in that
direction.
Guard Your Buddy, I love the topic, I love the term,
because all of us as human beings need to have somebody to turn
to at all times in our lives, but especially I think veterans.
So my comment is, I will turn it into a question, what else
can we do to bring Chairman Roe's vision of a roundtable to
make sure we are addressing all these issues and not leaving
any of these factors out?
Ms. Franklin. I can go ahead and start on this. I think
this is a wonderful suggestion and I am going to share it with
Mr. Wilkie and Dr. Stone, our leadership, to talk about the VA
serving as the convening authority for something alongside and
with support from this Committee. So, it is a great idea.
And suicide is very complex, and I particularly appreciate
your idea around bringing private industry and public partners
and nonprofit partners to the table, and just leave no rock
unturned.
Mr. Correa. And of course let's not forget the states.
Ms. Franklin. Yes--
Mr. Correa. And I will say--
Ms. Franklin [continued].--yes, sir.
Mr. Correa. --I am glad you wanted to convene it around the
VA. I would like to convene it around this Committee, because
our job is oversight and making sure everybody is doing their
job.
Ms. Franklin. Please, and we will be in a support role.
Thank you. Yes, absolutely.
Mr. Correa. Thank you. Any other thoughts from the rest of
the panel?
Lieutenant Colonel Lorraine. I think, you know, when you
convene the roundtable, I think it is a great idea that
communities are represented, that there is a local perspective
of how to implement. I think suicide prevention amongst
veterans occurs at the--as I said, I think it occurs at the
community level. We have to understand more about it and then
aggregate it up, not aggregate it down.
Mr. Mulcahy. I think it needs a branding, frankly. What I
mean by that is, I think there are 1100 suicide prevention
programs that are funded by the government, all well-
intentioned, you know, but I think in this country people that
are not part of those 1100 programs and a lot of other people
think that their duty to address this issue is on a Sunday
afternoon--I happen to be a Giants fan, that is probably
sympathies from a lot of people, but--
Mr. Correa. You are excused.
Mr. Mulcahy. Yeah, you know, you go to a professional
football game or a college football game and they bring out
somebody, you know, usually at some point in time, some
individual that has lost a limb, you know, that has suffered
horrific experiences in war, and 80,000 people stand up, they
cheer that person, they say nice things about them or their
family, they go walking back into the tunnel and 80,000 people
cheer like crazy, and that is their duty for suicide. That is
how we look at it in this country.
And when I say a branding, I think we need to bring
everybody around the table and the roundtable is a great idea,
but it has to be a consciousness in this country that when
somebody hears something, like we say in airports, they say
something, we have to create those bridges so that when those
messages are sent by people out there that people know what to
do with it.
And we have a lot of ideas around that, but I think we have
to raise and elevate the issue that it is not just the 1100
programs or not just this Committee, it is everybody's issue
out there.
Mr. Correa. Thank you very much.
Mr. Chairman, I am out of time.
Mr. Dunn. Thank you.
Next, I would like to recognize the gentleman from
Colorado, Mr. Mike Coffman, for five minutes.
Mr. Coffman. Thank you, Mr. Chairman.
In 2015, in Colorado Springs, the State of Colorado, a
former Marine, combat veteran, Noah Harter, was suffering from
depression and had suicidal ideation, was diagnosed with that
from going and visiting a CBOC veterans' clinic in Colorado
Springs. He was given a fairly powerful antidepressant that I
think on the directions said that it required fairly close
monitoring. He was not scheduled for another visit. He
subsequently took his own life. And in looking into that
situation, it was very hard to get answers from the VA, because
they didn't want to admit that they had made a mistake. In
fact, it was a physician's assistant, not even a physician that
prescribed that particular, very powerful drug, psychotropic
drug, antidepressant drug.
And in looking to that situation and having other veterans
complain to me, it seems that VA is in a way part of the
problem by having a drug-centric modality of treatment where it
is a drug to sort of stabilize them, but then it is another
drug to help them go to bed at night, then it is another drug
to help them get up in the morning and, not too far along, they
are given a cocktail of drugs. That is very dangerous.
We even had a situation that came to the attention of this
Committee where a veteran moved, couldn't quite get his
prescriptions redone, was then going through fairly dramatic
withdrawal and took his own life there.
And so I have a concern to that. And, Dr. Franklin and Mr.
Fisher, maybe you could address my concern.
Ms. Franklin. Absolutely. We will start with Mr. Fisher?
Mr. Fisher. No, go ahead.
Ms. Franklin. Okay, I can go ahead and start.
When you review inside the VA, whether it is in the
literature or just inside our system, people who are on
psychotropic medication are absolutely at increased risk,
particularly as those medications, as they increase. And so,
for example, when they are on two and three of them at the same
time. And so, it is a great concern to us inside the VA.
And I would offer that we get to a place where we are
looking at--noting the data on that. So how much are we
prescribing, over what period of time, and do we have goals
around that in such a way that it is not used as our main
effort when there could be other methods used, like talk
therapy, like community-based interventions, support structure?
So that it is used when it needs to be used, but it is not
necessarily the first and the go-to and/or only treatment
method. And when it is used, it absolutely needs to be used in
a safe and protected way where strong protocols are in place,
after-care models where they are monitored closely.
And so, it is tragic to me to hear about this Noah and
others that you mentioned in the State of Colorado, and we will
work on this and make sure that we are pulling the thread in a
better way, so that we have data to support medication rates
coming down over time, just as they have in other fields.
Mr. Coffman. Mr. Fisher?
Ms. Franklin. I don't know if you have something to add to
that, Mr. Fisher, or--
Mr. Fisher. The only thing I would add to that is exactly
what you said about talk therapy or what we do at vet centers,
and that is that ability to go out, create that individual
relationship, individualized treatment plan, and really set--
for us, readjustment is about setting a goal, helping that
individual create a support structure around that goal to
accomplish it, accomplish that goal and then identify another
one, and then just do it over and over and over again in
concert or collaboration with our medical center counterparts.
Mr. Coffman. Okay. Well, the Harter family has lost a son,
and so I would suggest that the VA take a look at that, and
instead of trying not to hold anybody accountable for failures,
to get down to the bottom of it and try to make best effort
away from a drug-centric treatment model.
Ms. Franklin. I agree with you, urgency and accountability,
yes, sir.
Mr. Coffman. Okay. Just a final point that one thing, these
other-than-honorable discharges was a terrible mistake for the
United States Army when we were drawing down from Iraq and
Afghanistan to take combat veterans that had trouble adjusting
from a combat environment to a peacetime environment and for
minor infractions discharging them with no access to VA care,
to include mental health care. And I was able to pass
legislation out of this Committee to mandate that the VA
provide mental health care to those with other-than-honorable
discharges.
And I can tell you as the Subcommittee Chairman for
Military Personnel in the House Armed Services Committee, I am
working not only to review those discharges, but to make sure
that our military never, ever, ever does that again in a draw-
down.
I yield back.
Mr. Dunn. Thank you.
Next, I would like to recognize the gentlewoman from New
Hampshire, Ms. Kuster, for 5 minutes.
Ms. Kuster. Thank you very much, Mr. Chairman. And I also
want to thank Mr. Coffman for that line of questioning and for
his bill that I have signed onto with Mr. O'Rourke on VA over-
prescribing practices as they are related to suicide.
I also want to thank Ranking Member Walz for his service
and leadership, and you have been a great mentor to us, and to
Representative Esty for serving on our Committee as well.
I just want to follow up on that over-medication and
contraindication. In particular, Dr. Franklin, The American
Legion has a statement for the record referring to the well-
known contraindication for opioids and that is benzodiazepines,
most often used to treat anxiety disorders that can be related
to military sexual trauma, PTSD. Could you just speak briefly
on the danger in combining benzodiazepines with opioids and
what steps are being taken to alert VA practitioners to caution
against that contraindication?
Ms. Franklin. Yes, absolutely, I will tell you what I know.
I am not a medical doctor, so I should start there, but I know
that when we look at our opioid, when we look at our
prescription rates, and we look just specifically at the
dangerousness of them, and since there has been an opioid
safety initiative put in place, we have reduced the
prescription of opioids by 45 percent. And so, I know also that
they are monitoring that very, very closely and training all
the providers in such a way that there is an increased level of
accountability and structure around all of that.
Specific questions that you asked that I felt are a little
bit more medically focused I would want to take back for the
record, if that is okay?
Ms. Kuster. That's fine. And actually what I was going to
ask for is some type of follow-up to this Committee on any
data. I am hoping that the improvements to the electronic
health record will help with tracking this, but that is an area
for concern that I wanted to be sure to have on the record in
this hearing.
The second area of concern that I have relates to military
sexual trauma and the under-accounting that has been going on,
the inappropriate denial of claims to the Veterans Benefit
Administration, and how this might relate to suicide both for
male and female veterans.
On August 21st, 2018, we had an OIG report detailing a
series of serious errors with VBA's adjudication of MST-related
PTSD claims, errors that led almost half of all MST claims to
be denied. And I think given that the entire country is riveted
on this issue of trauma from sexual assault and harassment
today, I would like to ask for your response.
This is a bipartisan letter, August 27, 2018, that I led
with my Republican colleague Jackie Walorski. If you could
please ask for a response from Secretary Robert Wilkie.
This is a very, very serious issue throughout our military,
and I cannot imagine a more dispiriting experience than to be
denied a claim, to be dishonorably discharged, to be dealing
with PTSD, anxiety, trauma related to an incident that happened
during their service to our country. And I just have to believe
that there are men and women taking their own lives every
single day because they have not been cared for by our country.
And if you could respond, I would be grateful.
Ms. Franklin. Yes, ma'am, I will absolutely take that back
to our VBA leadership for the benefits part of the question in
terms of running that to ground truth on what gives and why,
and if they need some education on the impact of trauma and
sexual assault and how that intersects with suicide.
Ms. Kuster. Well, and it is even worse, I don't mean to
interrupt you, but what is troubling about this is it
apparently has to do with retention of records and despite the
Secretary's best efforts to acknowledge these claims, when
there is not a record--that is what we are learning about,
there is not a record, there is not in the interest of a
survivor to bring this claim forward and create a record, and
yet the DoD destroys records one year following the date of the
victim's report of sexual assault. That is a very difficult
thing to do in the military, bring a claim of sexual assault,
and yet apparently those records are being destroyed.
And so my time is up, but if I could just ask you to take
back to Secretary Wilkie the bipartisan desire by Members of
Congress. And if I could just close by asking the chair for an
oversight hearing on this issue, because I think it is related
to the number of people taking their life in this country and
it is a tragedy.
Thank you.
Mr. Dunn. Thank you.
Next, I would like to recognize the gentleman from Texas,
Mr. Arrington.
Mr. Arrington. Thank you, Chairman Dunn.
And let me offer my well wishes to the Ranking Member. I
have enjoyed and have been honored to serve with you, and it is
abundantly clear to me and I think everybody who is on the
Committee or has participated in a hearing that you love our
veterans and you are passionate about service, and I am glad
you are seeking to continue that service for your state. So,
good luck, and thanks for letting me serve alongside of you on
this Committee.
I am obviously no expert and I know it is a very complex
issue, and I recognize that you all have thought about it a lot
more than I have and I appreciate all attempts to get at
solving the problem.
Three things come to mind as critical success factors--you
can dispute them and please do, I welcome that--early
identification and engagement of high-risk individuals,
coordination and continuity of care, and monitoring and
measuring outcomes.
Now, Dr. Franklin, I invite you to address the first two.
Where can we improve at early identification and engagement of
high-risk individuals. How early do we know people in the
military? Do we know from the front end? Do they screen people
coming into the military and know who is more susceptible, who
has a higher risk at the outset, at what point do we know that?
Do you have that information? Do you need it? Can we help you
get it?
Ms. Franklin. Thank you so much. It is a very good
question. And I have dialogued with military leaders about this
exact issue for years, all through the entire war effort, from
pre-9/11, all the way up where we have gotten into lots of
debate and discussion, on--are we pulling the thread right at
the recruit level? When they are in basic, are we asking the
right questions? Is there a different way to screen? Can we
give the A screener, which is like this adverse childhood
reaction screener, whether you have been through trauma when
you were seven and nine, and does that impact you in your teen
years? And there's a host of factors in that.
And at the end of the day, it seems, you know, they are not
screening for suicide risk per se, but they are screening for
mental health history. I should use caution speaking on behalf
of the DoD as well; it is not my area anymore. I know they do
extensive screening when they bring folks in, but that type of
information is necessary as we track veterans along their
journey.
Mr. Arrington. Do you have that information?
Ms. Franklin. Not before me today, no, sir.
Mr. Arrington. Okay. Do you know the correlation between
the DoD data on mental health, high-risk individuals, and those
who have committed suicide as veterans, and do we know that
there is any connection there?
Ms. Franklin. We are only in the early processes of sharing
that data, it has only just begun literally in my last 6 to 12
months.
Mr. Arrington. It seems like--
Ms. Franklin. It seems critically important--
Mr. Arrington [continued].--an imperative to me.
Ms. Franklin. --in part because one attempt is a predictor
of a future attempt, and what we see over time is, as somebody
who has had an attempt in their history, they are more likely
to end their life. And so, yes, absolutely.
Mr. Arrington. Dr. Brown, do we have good data? Are we
monitoring and measuring the various programs? I heard Mr.
Mulcahy mention 1100 government suicide programs throughout the
country. Do we know which ones are working, which ones work
well and why they work well, so we can--
Mr. Brown. I'm sorry, I didn't understand your question.
Mr. Arrington. Do we have good data on the strategies being
deployed today, the programs that are being implemented, which
ones are working, which ones aren't working, and then why are
they working, so we can double down. Do we have good data?
Mr. Brown. Yes.
Mr. Arrington. At least with the VA programs.
Mr. Brown. We have studies that have come out that have
supported the various programs that are being enacted in VA,
but I can tell you that the amount of resource we put into
research for suicide prevention programs is really small
compared to other problems. We need research to demonstrate
which interventions work and which ones don't.
Mr. Arrington. Well, the needle is not moving. We are
spending a lot of money, we have got a lot of programs, 1100,
and it is frustrating. And I don't know that we have good data,
that seems to be a theme in my tenure here. And I don't like
wasting money, I like solving problems, and I think the
taxpayer would say that and I think my colleagues would say
that.
So I feel like we have got to do something about
information, so we know what we are--again, what is working,
where we are getting traction and not.
To the community partners, what do you need from the VA
that they are not giving you, and to the VA, what do you need
from us legally where there are impediments to empower you to
get everything you need to solve this problem? I want the
partners to address what they need from you all and what you
need from us, and I am done.
I yield back, Mr. Chairman.
Mr. Dunn. Thank you.
I would now like to recognize the gentlewoman from
California, Representative Brownley.
Ms. Brownley. Thank you, Mr. Chairman. And I too want to
add my voice to others on the Committee to thank you, Ranking
Member Walz, for being truly a dedicated Member to this
Committee, an extraordinary leader on the Committee, and we are
certainly going to miss your expertise and your input on
virtually every issue that veterans experience. But we wish you
very, very well.
And I also wanted to thank all of the nonprofits that are
at the table today, because I think that I believe
wholeheartedly that there would be even more suicides if it
wasn't for your efforts and your partnership with the VA. So I
am very, very grateful to you all.
And, Dr. Franklin, I wanted to ask you, in your opening
comments you talked about, you know, out of the 20 a day of
veterans who commit suicide, you said six received VA
treatment, 14 did not. Do you have similar data on the men and
women in that universe of data? In other words, you know, do
you know--I know you know how many women commit suicide, but do
you know in terms of women who have reached out to the VA for
help and women who have not, who have committed suicide.
Ms. Franklin. Now, that is a very good question. I am not
sure we have sliced the data on help-seeking and non-help-
seeking.
I will tell you that we have improved our VHA as a whole;
we have increased our women accessing our health care three
times, by threefold. And so, from there, we can look at the
data. We know of the 20 a day, 19 of them are men and one is
female, one is a woman, and we can look at it from those that
are help-seeking and those that are not, certainly. It is a
very good question.
Ms. Brownley. Well, I do believe that the numbers of women
veterans committing suicide is becoming a much more significant
factor. And we certainly had a bill come out of this Committee,
my bill to look at that data, so that we can bifurcate
hopefully the data and come up with better practices in terms
of specifically treating women veterans.
But I do believe that it is an issue for women veterans
just to seek the help. And I think somebody made a comment
about we can't be fishing, but we have to be hunting, and I
think we have to be hunting in this case.
Dr. Roe in his opening comments asked the question, why are
we still having 20 veteran suicides a day and why haven't we
moved the needle. And I think part of that answer, quite
frankly, is this, and that is, in August the VA reported more
than 45,000 vacancies at the Department, more than 40,000
vacancies at VHA.
The Office of Inspector General determined that in fiscal
year 2018 the Veterans Health Administration's number one
shortage was psychiatrists, with psychologists as the fourth
largest shortage. And during our budget hearing last year, we
heard that the VA had 35,000 vacant mental health care
positions, including 300 psychiatrists, 700 psychologists, 250
nurses, and nearly 2,000 social workers. That is just, in my
opinion, unacceptable, and I think indeed it has to be part of
the problem.
And, Mr. Fisher, I wanted to ask you as well. In my
district in the Ventura County Vet Center--and I understand you
lead that effort within the VA--my vet center in my district is
suffering from ongoing staffing shortages. They just recently
lost an assistant office manager, they are scheduled to lose a
temporary readjustment counseling assistant in December, this
is combined with increasing veteran demand for local services.
And on top of that, the West L.A. VA is ending their long-term
PTSD support groups and transferring those veterans back to
Ventura County, a vet center that is having increasing demand,
is having shortages, professional shortages, and now saying we
are shutting this down in Los Angeles and now you need to go
back to your vet center for services.
I think this is a crucial issue and needs to be addressed,
and I guess I'm looking to you to see if you are committed to
trying to look at our situation in Ventura County and trying to
resolve it.
Mr. Fisher. Thank you, ma'am, and, yes, we are committed to
looking at that and resolving that situation.
Ms. Brownley. You are aware of it?
Mr. Fisher. I am. One of the projects that actually we
started on a national level is we moved all of readjustment
counseling service or vet centers to one HR office to increase
or speed up our time to hire. That transition was completed in
the beginning of the summer of this year.
So I would actually like to take this one back and I will
report back to you on the status of this particular vet center,
and when we can expect to have that staff on board to replace
the individuals that we lost.
Ms. Brownley. And as soon as you know that, will you reach
out to my office?
Mr. Fisher. Yes, ma'am.
Ms. Brownley. Thank you very much.
Mr. Fisher. Yes, ma'am.
Ms. Brownley. I yield back.
Mr. Dunn. Thank you.
I would like to make note, I cut short the answers to Mr.
Arrington's question before. If you would submit, if the panel
would submit those questions--rather those answers in writing
in the next 5 days, we would be grateful for that.
Now I would like to recognize the gentleman from Michigan,
General Jack Bergman.
Mr. Bergman. Thank you, Mr. Chairman.
And we have heard a lot of stories today, folks. Seventeen
years ago today, the 27th of September 2001, a Marine Corporal
who had served honorably for four years took his life. He was
my nephew. So it is real personal.
Now, having said that, those of us who have had the honor
to wear the cloth of our Nation know, number one, first and
foremost, it is our mission to win the fight, and, number two,
is to take care of everyone else after that. That is how it
works. And this is about taking care of others after they have
served, whether they deployed to combat or not, it doesn't make
any difference.
When we think about--and I am going to repeat a couple of
the data numbers that have been thrown out here--we have 1100
programs funded by the government. In 2005, we had $2.4 billion
committed to suicide prevention; in 2015, we had $6.9 billion
committed. So that is a big chunk of money and we are all in
kind of agreement here that we haven't been able to move the
needle, and that I know is frustrating for all of us.
So if we continue down the road, we are on without seeing
significant results, we need to really question is the road we
are on the right way. So that is why we have these hearings.
This group here on the Veterans' Affairs Committee is
absolutely the most bipartisan and singularly focused for the
outcomes of the veteran.
Now, Dr. Franklin, you have been in my office with your
colleagues, and we have had some very detailed and direct
discussions over a period of time about where we are and some
thoughts on where we need to go. What are we missing? Is there
anything that glaring, any point that we are missing here right
now that we need to refocus on?
Ms. Franklin. Thank you so much for the question.
When I think about this, because, as well, I am beyond
frustrated about the numbers and the data and the fact that we
are not seeing a difference, and having worked in this field as
long as I have, it does, it is frustrating, is not even the
right word for it. And I think--when I try to think about what
we are missing, I think about issues around dosage. And so,
bear with me, but this is what I mean by this.
We tend to do a lot of one thing at one time. So we will
invest in mental health and we will invest in crisis line work,
and we will just do it very well, full-throttle, if you will.
And preventing suicide, as you heard from the panel today,
takes broad public health approaches, probably a bundled
package of about 10 or 12 things at full throttle all the time.
So, it takes community efforts that you heard about today, it
takes crisis line work, it takes peer support that you heard.
And it takes them in a scientific way under the leadership of
the best, you know, scientists in the Nation, and the way that
they are evaluated, but in a way that it is not over reliance
on one and the absence of the other. So that is one thing.
And then the other is just when I think about it specific
to veterans, we need a whole-of-Nation approach to veteran
suicide. So, somebody brought up employment, I need all of the
employers--
Mr. Bergman. I have got a couple more questions here. So we
know we are not--because you and I talked. But the point is,
what I wanted to hear was your passion and I just heard your
passion for this, and that is one of the challenges we have in
a bureaucratic state where the energy behind and the sense of
urgency behind any task that is in front of us.
Dr. Franklin or Mr. Fisher, do you utilize the VA's
Chaplain Corps as part of your suicide prevention effort?
Mr. Fisher. Vet centers actually do collaborate with
chaplains, both in our outreach events and then also in our
referrals back and forth.
Mr. Bergman. Okay. Now also, Mr. Fisher, you know, to what
to attribute, you know, the vet center success. You have got a
28-percent increase, you know, in positive results. What has
happened and what do we need to do going forward to continue
for you to be an example?
By the way, I have traveled to many, you know, vet centers,
especially in my district, we have one in Escanaba, and they
are doing outstanding work because they are boots on the
ground.
Mr. Fisher. So I think the success is exactly what you just
said, sir, and that is we have amazing staff who--actually,
over 70 percent of our staff are veterans, so it is that
continuation of mission. Those that are not veterans, it is the
heart for the veteran. And that boots on the ground, meeting
the veteran/servicemember and family where they are, and then
creating that relationship and then begin to create that
individual plan to have them move forward.
Mr. Bergman. Thank you, Mr. Chairman, and I yield back.
Mr. Dunn. Thank you.
Mr. Bergman. Oh, Mr. Chairman, can I get just 30 seconds to
congratulate the Sergeant Major?
Mr. Dunn. You absolutely can.
Mr. Bergman. Because that was--but, you know, thank you,
Sergeant Major, for your service, because I know if there is
one thing you are passionate about, it is leading troops. So
thank you for your contribution to the community. And in a
Naval Officer format, I will say fair winds and following seas.
Mr. Walz. Thank you, General.
Mr. Dunn. So let me just before I recognize Mr. Takano from
California, I want to call everybody's attention to the irony
of this exchange. Sergeant Major Walz is the highest-ranking
noncommissioned officer ever to serve in Congress. Lieutenant
General Jack Bergman is the highest-ranking officer ever to
serve in the history of the country in Congress. So the
exchange between you two is wonderful and warms my heart.
Mr. Takano of California, you are recognized for 5 minutes.
Mr. Takano. If I might risk to punctuate it all with a
saying, a quaint saying that I have learned from the Sergeant
Major, which is to run it up the flagpole hard, and he has
often said that in our meetings. And I have come to admire his
leadership and I believe we have become very good friends.
And let me just also say on a personal basis, the Sergeant
Major brought the credibility of his military service and was
an important voice in the debate to overturn the ``Don't Ask,
Don't Tell'' policy. And that happened during his tenure here
and he was one of the salient voices on that, as well as on the
respect for marriage--you know, I thank you for your service,
sir.
Let us move on to the issue at hand. The VA-OIG report, you
know, we all know by now that the number that jumps out at us
is the increase in the suicide rate among younger veterans
during the year in 2015 and 2016. It was the highest rate of
any group, the other groups tended to remain stable.
For anyone on the panel, how does that number, what does it
imply for how we model our prevention and intervention
programs? Do we deliver information differently? The basket
of--Dr. Franklin, you mentioned a number of programs in
response to General Bergman, you know, your frustration that we
kind of emphasize one or the other, but what is it that we need
to--what does it imply we have to do now that we have seen this
data?
Lieutenant Colonel Lorraine. You know, I am going to go
back to--sir, I am going to go back to the community, and I
think what Representative Mast brought up, some of the things
that you see is that you have to build a trusting relationship
and it is about trust.
And so even with younger veterans, when I left the military
the biggest obstacle, I had in civilian life was trust, because
in the military you know who to trust. I think it is about
building peer networks, building friends that will use the
system to notify when there is--that you can turn to and say I
have got a problem, and you trust them to do that.
Mr. Richardson. Sir, if I could, just to add, going back to
being an old soldier, I think it starts, as Dr. Keita said,
right when you enter the service, having that discussion about
suicide prevention and mental health, and the importance of
that.
When we transition out of the military, there is a lot of
talk about resume writing and job-seeking, things along that,
but we don't do a lot within the mental health part of it
during the transition. But it really should start from basic
training all the way through their career, with a real emphasis
as they are getting ready to transition into the civilian
force.
Ms. Franklin. I think it is a very good question as well,
when we think about apps and the use of apps. The VA has made a
couple of apps to help deal with depression, and we have an app
called the Hope Box. I won't get into the specifics here, but
know that I think that does have relevance for your question
for this group, this cohort of 18-to-34-year-olds, as well the
role of social media. We are seeing servicemembers and veterans
put their risks online in a social media space and for
providers like myself, you begin to think, are we ready and
prepared to engage with people online when they are writing
their risks online, and do we have the right resources at the
ready for them in those environments?
Also, the last thing I would share is just thinking through
18-to-34-year-olds and the recency with which they leave the
DoD, and the potential need for gray space between the two when
it comes to this work. So, you know, it is not a hard and fast
line in the sand when they leave Active duty one day and they
are a veteran the next. And we have made great strides under
the Executive Order, recent Executive Order that was pushed out
in January to do something called Early and Consistent Contact.
And so, we are in the early stages of rolling this out, but
it basically has us reaching out to servicemembers when they
are still on the DoD rolls, perhaps 12 months before they
transition out, in an early and consistent way over time, and
then 12 months beyond. More recent looks at the data, we might
need to do that even further than the first 12 months beyond,
but this consistent engagement I think will help with that
population, but we are going to have to engage with them in
ways that they would like to be engaged. It might be text, it
might be a chat model, it might--so bringing them into the
solution I think will help. We don't know what we don't know
about these 18-year-olds and how they like to receive
information and that sort of thing.
Mr. Takano. So what you are telling me, we need to do a
little more work and find out what is the best way to engage
them.
All right. I yield back, sir.
Mr. Dunn. Thank you.
And at this point I would like to add my compliments to the
Ranking Member, Sergeant Major Tim Walz, you know, and to say
thank you to you not only for your service, but for your
leadership in this Committee and in our country. And I want to
recognize you now and yield the floor to you for any comments
that you may have, Sergeant Major.
Mr. Walz. Well, thank you all. I would like to know
publicly, should I die, I want all these people to give my
eulogy coming up and going, but I am grateful.
I am humbled and appreciative of the work this Committee
has done, but I am also very cognizant we have failed in areas.
There is much work to be done. But this Committee has been, I
think, a reflection of the best that Congress can offer.
These are not easy. Everybody says, well, it is easy in the
VA Committee, everybody agrees on that. This is the second-
largest agency with employees and costs, and ideological
differences on the care, but those things have not stopped us,
they have brought us closer together to find these. We have
been able to get out of the simplistic arguments of
privatization versus non-privatization and get to the delivery
of services for veterans in the most efficient, cost-effective
way, and that is what I am most proud of. There are heated
debates in here, but all towards that common goal.
And I think what comes out of this, there have been great
questions answered. The one thing we all know, especially as it
deals with mental health, we can't see veterans as a whole,
certainly veterans' mental health or health care in a vacuum.
These are broader societal issues that go at this.
And I think about this, when I came here in 2007, the
debate at that time was whether we should bury with honors a
veteran who died by suicide. We were still debating whether
that was an appropriate thing. Mental health parity had not yet
passed the Congress on how we paid for it. There was no
Veterans Crisis Line to even call, all of those things that
have happened.
So I say that not as an excuse for not having a fierce
sense of urgency, but to understand that a lot of this and on
this frontier of brain-based research, as Dr. Brown said, we
are on the beginning of this journey. There is a lot to be
done, but there is so much we can learn.
I also want to point out, when I told the story of Justin
Miller, it is not to point out a failing system at the
Minneapolis VA or the VA in general. I also have the privilege
of representing the Mayo Clinic in Rochester, Minnesota. And
the folks at the Mayo Clinic will tell you one of the most
outstanding medical, research, and delivery institutions in the
entire world is the Minneapolis VA. The practitioners that are
there, the employees that are there give everything. So when we
have a failure, it is a failure of the system and it reminds
us, trying to build in these redundancies, to make sure that if
we have those best practices, we are not missing them, or we
are having other eyes on that.
And I would say the thing that I have learned in this
journey, especially on the mental health piece, is of using the
science and using the best practices, bringing that down.
It comes back to what Mr. Peters says. My friends Howard
and Jean are sitting out there today, and they are my friends
because they lost their baby, they lost their son. And we would
have never crossed paths had not happened. I now add Drinda and
Greg Miller to that list of people that I have become
acquainted with, they are in my lives.
But what they taught me, and especially Howard and Jean and
Clay Hunt's family, is listen to the family, listen to the
people who are out there, include them. And I understand the
deep implications of HIPAA laws and privacy and all of that,
but these are the folks closest know, want to help and
integrate them, and that is what we were trying to do. And I
heard Mr. Mulcahy said it, I heard Colonel Lorraine say it, use
the institutions and use the support of the buddies and the
families that are closest to home. We have to figure out how to
get you to do that.
So there is much more to be done, the great questioning
here. I think, Mr. Lamb, I can't stress enough of this, when I
came here my mission was to align DoD and VA on electronic
health records, and I am not naive, that is going to be a
massive undertaking, but it possesses the great potential to
use technology and science to fix some of the things that are
there. But that human compassion piece of this, the willingness
to make functioning government be part of the solution rather
than holding us down.
This is the one place when we say, ``My dear friend from
Michigan,'' unlike the House floor where they are mostly lying
when they say that, it is true here, my dear friend, who I know
is committed. But that sense of mission, that sense of purpose,
that sense of listening to the experts, that sense of counting
on the broad array of the American public that wants to get
this right, is really hopeful. But, again, it just keeps coming
back to me, the absolute zero-sum nature of this is Daniel is
not here today because we didn't do or weren't able to fix
that. Justin is not here because of that; the General's nephew
is not here.
And so our commitment has to withstand folks will come and
go from these seats. What we need to know as a country and for
each of you, and I want to thank the panelists who are here
today of what you are adding to this, we can get this, we can
do this. It is what we know we need to do as a Nation.
So, thank you all. I want to thank my colleagues for the
privilege of a lifetime of serving on this Committee and
certainly, as a veteran myself, sleep very easily knowing that
you are in charge of this and making improvement.
So, thank you all.
Mr. Dunn. Thank you very much for that, Ranking Member.
That is a far more wonderful closing than I could manage, so I
am going to merely say we have 5 days to revise and extend
remarks, and add extraneous material.
And with that, this Committee is adjourned.
[Whereupon, at 12:53 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Gregory K. Brown
Director, Center for the Prevention of Suicide
Research Associate Professor, Department of Psychiatry
Perelman School of Medicine of the University of Pennsylvania
Research Psychologist, VISN 4 Mental Illness Research, Education and
Clinical Center
Corporal Michael J Crescenz VA Medical Center, Philadelphia,
Pennsylvania
Chairman Roe, Ranking Member Walz, and Members of the Committee,
thank you for the opportunity to offer testimony on Veteran suicide
prevention--maximizing effectiveness and increasing awareness. This is
an incredibly important issue, and I commend the Committee for its
leadership and convening this hearing. Over the past several years
there have been a number of efforts to develop evidence-based
treatments to mitigate suicide risk for Veterans at high risk for
suicide and we have made significant progress. However, there remains
some serious challenges in the dissemination and implementation of
these effective strategies.
A Public Health Approach for Reducing the Rate of Suicide Among
Veterans
The U.S. Department of Veterans Affairs (VA) has emphatically
acknowledged that suicide prevention is the VA's highest priority. The
National Strategy for Preventing Veteran Suicide for 2018-2028 provides
guidance in how the VA plans to address suicide prevention efforts for
Veterans. \1\ Suicide is a complex problem that reflects an interaction
among many different risk and protective factors at individual, family,
community, regional and national levels. Given that there is no single
cause for suicide, the VA has adopted a prevention framework that
involves using a combination of prevention strategies to lower rates of
suicide. Developed by the National Academy of Medicine, \2\ this
framework includes using universal strategies to reach all Veterans in
the U.S., selective strategies that are intended to reach subgroups of
Veterans who may be at some increased risk and indicated strategies
that are for a relatively few number of Veterans who are at high risk
for suicidal behavior, such as those Veterans who have attempted
suicide or who have experienced suicidal thoughts. The focus of my
testimony involves an update of a few of the indicated strategies for
Veterans at high risk for suicide.
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\1\ Office of Mental Health and Suicide Prevention. National
Strategy for Preventing Veteran Suicide: 2018-2028. Washington, DC:
U.S. Department of Veterans Affairs; 2018. Accessed September 24, 2018,
at www.mentalhealth.va.gov/suicide--prevention/docs/Office-of-Mental-
Health-and-Suicide-Prevention-National-Strategy-for-Preventing-
Veterans-Suicide.pdf.
\2\ Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for the Application of Prevention Technologies, Risk
and Protective Factors (2015). Accessed September 24, 2018, at
www.samhsa.gov/capt/practicing-effective-prevention/prevention-
behavioral-health/risk-protective-factors#universal-prevention-
interventions.
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A critical approach for reducing Veteran suicides, among high risk
Veterans, is to develop and test suicide prevention strategies, using
rigorous scientific methods, to see if they actually prevent suicide or
suicidal behavior. Once empirically validated prevention strategies
have been identified, then the next step is to disseminate and
implement these strategies to assure widespread adoption in the
Veterans Health Administration (VHA) as well as in community health
care settings who provide treatment to Veterans. These dissemination
and implementation strategies also need to be developed and tested,
again using rigorous scientific methods, to increase the likelihood
that these evidence-based prevention strategies are acceptable,
feasible, and most importantly, actually used by VA and community
health care providers in a way that maintains fidelity to the
interventions as designed, even if some adaptation is required.
Suicide as a Low Base Rate Event
The problem for the scientific community is that evaluating whether
newly developed prevention strategies are actually effective for
preventing suicide among high risk individuals often requires very
large sample sizes and multiple recruitment sites. Large samples are
necessary for ensuring that studies are adequately powered to detect
clinically meaningful treatment effects, including changes in suicide
rates. \3\ This low base rate is problematic for researchers because
obtaining adequate funding to support studies with enough statistical
power for determining whether interventions prevent death by suicide is
quite challenging due to the limited funding available. To address this
problem, researchers have adopted proxy measures of suicide for
evaluating the effectiveness of suicide prevention strategies, such as
the occurrence of nonfatal suicide attempts rather than actual
suicides, given that suicide attempts and other nonfatal suicide-
related behaviors are major risk factors for death by suicide.
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\3\ Institute of Medicine (US) Committee on Pathophysiology and
Prevention of Adolescent and Adult Suicide; Goldsmith SK, Pellmar TC,
Kleinman AM, et al., editors. Washington, DC: National Academies Press
(US); 2002.
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To improve the likelihood of accurately identifying and evaluating
Veterans who may be at high risk for suicide, the VHA Office of Mental
Health and Suicide Prevention has launched an initiative to develop and
implement a national, standardized process for suicide risk screening
and assessment, using high-quality, evidence-based measures and
practices. This protocol involves three stages: (1) conducting primary
screening for suicide risk using the suicide item from the Patient
Health Questionnaire \4\ --9, \5\ (2) conducting a secondary screen
using a screening version of the Columbia Suicide Severity Rating
\6\Scale \7\, and (3) conducting a VA comprehensive suicide risk
evaluation using a standardized medical record template. Using
standardized, evidence-based practices to screen for suicide risk will
not only help to link at risk patients to appropriate health care
services but will help with suicide prevention research. Support for
the implementation of this program is provided by Dr. Lisa Brenner and
colleagues of the VA Rocky Mountain MIRECC for Veteran Suicide
Prevention.
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\4\ Spitzer, RL, Williams, JBW, Kroenke, K et al. Patient Health
Questionnaire--9. Accessed September 24, 2018, at https://
www.phqscreeners.com/sites/g/files/g10049256/f/201412/PHQ-9--
English.pdf.
\5\ Simon GE, Rutter CM, Peterson D, et al. Do PHQ Depression
Questionnaires Completed During Outpatient Visits Predict Subsequent
Suicide Attempt or Suicide Death? Psychiatric Services (Washington,
DC). 2013;64(12):1195-1202. doi:10.1176/appi.ps.201200587.
\6\ Posner K, Brown GK, Stanely B, et al. The Columbia-Suicide
Severity Rating Scale, Screening Version. Accessed September 24, 2018,
at www.cssrs.columbia.edu.
\7\ Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide
Severity Rating Scale: Initial Validity and Internal Consistency
Findings From Three Multisite Studies With Adolescents and Adults. The
American Journal of Psychiatry. 2011;168(12):1266-1277. doi:10.1176/
appi.ajp.2011.10111704.
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Evidence-based Treatments to Prevent Suicidal Behavior
Our group at the University of Pennsylvania, developed a brief 10-
16 session psychotherapy intervention for patients who recently
attempted suicide, called Cognitive Therapy for Suicide Prevention (CT-
SP). In a landmark study, funded by the National Institute of Mental
Health and published in the Journal of the American Medical Association
(JAMA), we found that participants who were randomly assigned to the
cognitive therapy(CT-SP) group had a significantly lower suicide
attempt rate and were 50% less likely to reattempt suicide than
participants who were assigned to a usual care group. \8\ These
findings were partially replicated using a similar intervention, called
Brief Cognitive Behavior Therapy, that was developed by Drs. David Rudd
and Craig Bryan. In a randomized controlled trial, funded by the
Department of Defense, researchers found that active-duty Army Soldiers
who either had attempted suicide or experienced suicidal ideation and
who were assigned to a Brief Cognitive Behavior Therapy (BCBT)
condition were 60% less likely to make a suicide attempt during follow-
up than Soldiers who were assigned to a usual care condition. \9\
Efforts are underway to further replicate the findings of these studies
for supporting effectiveness of Cognitive Therapy for Suicide
Prevention and Brief Cognitive Behavior Therapy among Veterans and
Military Service Members, respectively. Replication of clinical
interventions helps to promote the adoption and implementation of these
treatments.
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\8\ Brown, GK, Ten Have, T, Henriques, GR, Xie, SX, Hollander, JE,
& Beck, AT. Cognitive therapy for the prevention of suicide attempts.
Journal of the American Medical Association. 2005; 294(5):563-570. doi:
10.1001/jama.294.5.563.
\9\ Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A.
L., Young-McCaughan, S., Mintz, J., ... & Wilkinson, E. Brief
cognitive-behavioral therapy effects on post-treatment suicide attempts
in a military sample: results of a randomized clinical trial with 2-
year follow-up. American Journal of Psychiatry. 2015; 172, 441-449.
doi: 10.1176/appi.ajp.2014.14070843.
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Although CT-SP has been recognized by the National Registry of
Evidence-based Programs and Practices, the dissemination and
implementation of cognitive behavior therapies for suicide prevention
(CBT-SP) in VA have been limited. However, a recent clinical
demonstration project, led by Dr. Mark Ilgen of the VA Ann Arbor
Healthcare System and supported by the Office of Mental Health and
Suicide Prevention, will train a group of therapists in CBT-SP at two
hub facilities, and remotely deliver this intervention via Clinical
Video Telehealth (CVT) to Veterans within two VISNs. This program will
increase access for high-risk Veterans to specialized, evidence-based,
suicide prevention services. Simultaneous evaluation of the
feasibility, acceptability, reach, and impact of this program will
provide key data to inform the potential implementation of a telehealth
delivery of CBT-SP across VHA. Additional dissemination and
implementation initiatives are sorely needed to ensure that Veterans at
risk for suicide have access to these evidence-based treatments.
The Need for Scalable Interventions to Prevent Suicide
Although psychotherapy approaches, such as CT-SP, are effective for
lowering risk, a limitation of these interventions is that they require
multiple sessions and cannot be easily used in acute care settings
where patients may be briefly evaluated and then referred for
additional care. Emergency departments (EDs), for example, frequently
function as the primary or sole point of contact with the health care
system for suicidal individuals. This contact often occurs either
immediately following a suicide attempt or when suicidal thoughts
escalate and the individual feels in danger of acting on these
thoughts. Moreover, the risk of suicide is very high following contact
with acute psychiatric services, and persistent challenges exist for
providing continuity of care after discharge. To address this concern,
Dr. Barbara Stanley of Columbia University and I, co-developed a 20 to
40 minute intervention, called the Safety Planning Intervention (SPI).
\10\ Although safety planning was a commonly-used strategy in cognitive
behavioral therapies, we thought it would a useful strategy if it could
be found to be effective as a stand-alone intervention.
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\10\ Stanley, B & Brown, GK. Safety Planning Intervention: A brief
intervention to mitigate suicide risk. Cognitive and Behavioral
Practice. 2012; 19: 256-264.
What is the Safety Planning Intervention (SPI) and how does it work to
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prevent suicidal behavior?
The SPI is a brief clinical intervention that we designed to
decrease future risk of suicide by providing suicidal individuals with
a written, personalized safety plan to be used in the event of a
suicidal crisis. The SPI uses evidence-based strategies to reduce
suicidal behavior by providing prioritized coping strategies to
successfully cope with a suicidal crisis. The SPI also includes lethal
means counseling to reduce access to potential suicide methods such as
firearms and lethal medications.
The Safety Planning Intervention consists of six key steps:
1. Identify personalized warning signs for an impending suicide
crisis;
2. Determine internal coping strategies that distract from suicidal
thoughts and urges such as listening to uplifting music or watching a
comedy show;
3. Identify individuals who are able help patients to distract from
suicidal thoughts, without necessarily disclosing suicidal thinking, as
well as social settings that provide the opportunity for interaction;
4. Identify individuals, typically close friends or family members,
who can provide help during a suicidal crisis;
5. List mental health professionals and urgent care services to
contact during as suicidal crisis including the National Suicide
Prevention Lifeline;
6. Lethal means counseling for making the environment safer.
In 2008, the SPI was adapted for Veterans and has been widely used
in VHA for patients deemed to be at high risk for suicide. \11\ Safety
planning was identified as a recommended practice by the VA/DoD
clinical practice guidelines for suicide prevention. \12\
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\11\ Stanley, B & Brown, GK. (with Karlin, B, Kemp, JE, VonBergen,
HA). Safety plan treatment manual to reduce suicide risk. Washington,
DC: U.S. Department of Veterans Affairs. Accessed on September 24,
2018, at https://www.mentalhealth.va.gov/docs/va--safety--planning--
manual.pdf.
\12\ VA/DoD clinical practice guideline for assessment and
management of patients at risk for suicide. Washington, DC: U.S.
Department of Veterans Affairs and Department of Defense. Accessed on
September 24, 2018, at www.healthquality.va.gov/guidelines/MH/srb/
VADoDCP--suiciderisk--full.pdf.
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In response to a priority recommendation from a federal Blue Ribbon
Panel on Veteran Suicide in 2008, the Office of Mental Health and
Suicide Prevention (formally, the Office of Mental Health Services)
called for the development and implementation of an ED-based
intervention for suicidal Veterans. \13\ The rationale for such an
approach was based on the recognition that ED providers may prefer to
hospitalize Veterans because of limited availability and feasibility of
interventions that can be provided in the ED. Hospitalizing patients at
risk for suicide may be problematic for a variety of reasons such as
disrupting the person's life. The overall vision of this VA initiative
was to augment emergency mental health service delivery to (1) enhance
identification of Veterans at risk for suicide in VA hospital EDs, (2)
provide a brief intervention to reduce risk, and (3) ensure that
Veterans receive appropriate and timely follow-up care. This clinical
intervention included the SPI and it was paired with follow-up contact
for suicidal Veterans, resulting in an intervention we called SPI+.
Follow-up contact consisted of telephone contacts after patients were
discharged from an emergency department (ED). Calls were made by our
trained project staff, social workers and psychologists, and were
initiated within 72 hours of discharge from the ED. Calls were
continued on a weekly basis until Veterans had attended at least one
outpatient behavioral health appointment or until they no longer wished
to be contacted.
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\13\ Knox KL, Stanley B, Currier GW, Brenner L, Ghahramanlou-
Holloway M, Brown G. An Emergency Department-Based Brief Intervention
for Veterans at Risk for Suicide (SAFE VET). American Journal of Public
Health. 2012;102(Suppl 1):S33-S37. doi:10.2105/AJPH.2011.300501.
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The follow-up telephone contacts generally included three
components:
1. Brief risk assessment and mood check;
2. Review and revision of the safety plan from the SPI, if needed;
3. Facilitation of treatment engagement.
The results from this clinical demonstration project were recently
published in a high-impact journal, JAMA Psychiatry. \14\ The study
used a cohort comparison design with 6 months follow-up at 9 VHA
hospital EDs (5 intervention sites and 4 control sites). SPI+ was
administered to a total of 1,186 Veterans who presented to the
intervention EDs for a suicide-related concern, but for whom inpatient
hospitalization was not clinically indicated. Veterans in the SPI+
condition were less likely to engage in suicidal behavior than those
receiving usual care during the 6-month follow-up period. The SPI+ was
associated with 45% fewer suicidal behaviors, approximately halving the
odds of suicidal behavior over a 6-month period. Intervention patients
had more than double the odds of attending at least 1 outpatient mental
health visit following ED discharge than control patients.
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\14\ Stanley B, Brown GK, Brenner LA, et al. Comparison of the
Safety Planning Intervention With Follow-up vs Usual Care of Suicidal
Patients Treated in the Emergency Department. JAMA Psychiatry.
2018;75(9):894-900. doi:10.1001/jamapsychiatry.2018.1776.
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In a randomized controlled trial, funded by the Department of
Defense, Dr. Craig Bryan and his colleagues found that Crisis Response
Planning, a brief intervention that is similar to SPI, was more
effective than contracting for safety for preventing suicide attempts,
resolving suicidal ideation, and reducing inpatient hospitalization
among high risk active-duty Soldiers. \15\ Contracting for safety
typically involves asking patients to promise the clinician that they
will not kill themselves.
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\15\ Bryan, CJ, Mintz, J, Clemans, TA, Leeson, B, Burch, TS,
Williams, SR, ... & Rudd, MD. Effect of crisis response planning vs.
contracts for safety on suicide risk in US Army soldiers: a randomized
clinical trial. Journal of Affective Disorders. 2017;212, 64-72. doi:
10.1016/j.jad.2017.01.028.
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Additional clinical trials, funded by the National Institute of
Mental Health, are currently underway to examine the effectiveness of
SPI+ in the year following jail release and to examine the
implementation of the SPI in community outpatient settings in New York
State, as well as in community ED settings across the county. We are
also evaluating the efficacy of SPI in acute care hospital settings,
funded by the American Foundation for Suicide Prevention, and we are
evaluating the effectiveness of an adapted version of SPI for Veterans
using an outpatient group format, funded by the VA. Finally, a
randomized controlled trial of SPI, funded by the Department of
Defense, is being conducted with Military servicemembers who were
hospitalized for a suicide related event.
Quality Matters!
One of the most important lessons we have learned about
implementation of the SPI in the VA since 2008 is that fidelity to the
intervention involves more than simply completing a piece of paper, the
safety plan form, but involves taking a collaborative and understanding
approach to addressing painful experiences reported by Veterans. A 2015
study explored the implementation fidelity of safety planning in a
regional VHA hospital. \16\ A comprehensive chart review was conducted
for patients who were flagged as high risk. Safety plans were mostly
complete and of moderate quality, although variability existed. Despite
the general mention of safety plans in the medical record, a
significant proportion of the patient charts had no explicit evidence
of ongoing review or utilization of the safety plan in treatment. An
additional study of safety plans in VA medical records found that the
quality of safety plans was low. \17\ Higher safety plan quality scores
predicted a decreased likelihood of future suicide behavior reports.
Higher scores on Step 3 of the safety plan form (people and places that
serve as distractions) predicted a decreased likelihood of future
suicide behavior reports.
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\16\ Gamarra JM, Luciano MT, Gradus JL, Stirman SW. Assessing
variability and implementation fidelity of suicide prevention safety
planning in a regional VA Healthcare System. Crisis. 2015;36(6):433-
439. doi:10.1027/0227-5910/a000345.
\17\ Green, J. D., Kearns, J. C., Rosen, R. C., Keane, T. M., &
Marx, B. P. Evaluating the effectiveness of safety plans in military
veterans: Do safety plans tailored to veteran characteristics decrease
risk?. Behavior Therapy. 2017. doi: 10.1016/j.beth.2017.11.005.
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The discovery of low quality safety plans highlights the need for
additional training in the administration of the SPI. To improve
fidelity and quality of safety plans, the VHA Office of Mental Health
and Suicide Prevention recently developed a comprehensive medical
record template with detailed instructions for SPI as well as a
corresponding, comprehensive SPI manual. Additional training efforts to
assess and improve the quality of safety plans are planned for VHA
mental health providers. Simply providing additional, noninteractive
training materials for SPI is not likely to be sufficient for improving
the quality of the intervention, however. Additional professional
training for clinical staff of SPI may be implemented, using a blended
learning model, that involves (1) interactive, web-based didactic
training that includes demonstration videos, (2) experiential exercises
that include individualized feedback from expert trainers, and (3) an
evaluation of safety planning administration using standardized rating
measures.
Recommendations for Improving Suicide Prevention Efforts for Veterans
1. Adopt and fully support the VA National Strategy for Preventing
Veteran Suicide;
2. Increase funding of research to develop and evaluate suicide
prevention practices in VHA and community settings;
3. Develop novel suicide prevention strategies, such as apps or
web-based formats, that are feasible and acceptable to patients and
staff;
4. Disseminate and implement evidence-based interventions to reduce
suicide risk in VHA, including cognitive behavior therapies for suicide
prevention;
5. Evaluate the quality of evidence-based, suicide prevention
practices that have been implemented for Veterans at risk for suicide;
6. Provide training programs for clinical staff to improve the
administration of evidence-based practices to reduce suicide risk;
incentivize and support staff in using these practices;
7. Evaluate the effectiveness of dissemination efforts of evidence-
based suicide prevention practices for Veterans at risk for suicide.
Thank you for the opportunity to offer this testimony. I welcome
any questions from the Committee.
Prepared Statement of Lt Col James Lorraine, USAF (retired)
Testimony on Preventing Suicide Among Veterans:
Chairman Roe, Ranking Member Walz, and Members of the Committee:
Thank you for the opportunity to provide testimony today on the
critical issue of preventing suicide among our nation's military
veterans. The Department Of Veterans Affairs reported earlier this year
that, on average, 20 veterans die by suicide every day, 6 of whom are
nominally under Veteran Health Administration care and 14 who are not.
This is a major public health concern that affects every community in
the country, and it is one that my team at America's Warrior
Partnership is actively combatting on a daily basis.
My name is Jim Lorraine, and I served as an Air Force Officer and
Flight Nurse for 22 years. I was the founding director of the United
States Special Operations Command Care Coalition; a Department of
Defense wounded warrior advocacy organization that has been recognized
as the gold standard in supporting wounded, ill or injured warriors
along with their families. I also served as Special Assistant for
Warrior and Family Support to the Chairman, Joint Chiefs of Staff,
where I helped to transform the Chairman's ``Sea of Goodwill'' concept
into a strategy.
I currently serve as the president and CEO of America's Warrior
Partnership, a national nonprofit organization where our mission is to
empower communities to empower veterans and their families. Our
approach to accomplishing this mission takes many forms, but it starts
with connecting community organizations with local veterans to
understand their unique needs and situations. After gaining this
knowledge, we connect local veteran-serving organizations with the
appropriate resources, services, and partners to support each veteran.
Our ultimate goal is to create a better quality of life for all
veterans.
The foundation of our work is our Community Integration model, a
framework for organizations to conduct proactive outreach to veterans
and holistically serve all of their needs. Through this model, we have
established relationships with more than 42,000 veterans since February
2014 in eight affiliate communities located across the country.
We are here today to discuss suicide among veterans, and I would
like to share the work our team is doing to study this issue. I hope
these insights will help guide this Committee's decisions towards
developing and supporting the most effective community based outreach
and prevention programs possible.
I am a veteran of nine combat deployments dating back to 1991 in
conflicts and locations such as Desert Storm, Somalia, Haiti, Iraq, and
Afghanistan. I've had brothers and sisters-in-arms who've taken their
own lives, leaving all who loved them to speculate why. Just last week,
I talked to a close friend and begged him to promise me he would get
more assistance and not take his life. I've had a hero of mine leave me
a note explaining that he could not take the constant head pain caused
by his numerous blast injuries and asked that I forgive him for
quitting. For me and America's Warrior Partnership, the prevention of
suicide is not only necessary, it is personal.
The Department of Veterans Affairs released the ``VA National
Suicide Data Report 2005-2015'' this past July. It was a comprehensive
work that reported a vast improvement from previous studies in 2012,
which estimated there were 22 veteran suicides per day, and 2014, which
estimated there were 20 veteran suicides per day. The 2018 study is
impressive in the volume of records, big data aggregation, and national
span that it analyzed, but there was little granularity for communities
to use in their efforts to prevent veteran suicide-in terms of
veteran's service experience, their lives following service separation,
their communities' attributes, or how communities might have engaged
them during the years, months, or days before their death.
As a nation, we often speculate about the causal factors of veteran
suicide. We speculate about the lack of access to treatment, the impact
of head injury, the influence of pre-existing medical and behavioral
conditions, the role of hereditary traits, access to lethal means, loss
of purpose contributing to post-service transitional stress, and how
financial or relationship strain could lead to a veteran taking their
own life. A veteran who takes their life could be impacted by all, some
or none of these factors. To further complicate matters, we have not
been able to differentiate the characteristics of a veteran who might
take their life in Buffalo, New York, as compared to Johnson City,
Tennessee, or Orange County, California. We may never know exactly why
a person finally dies from suicide, or how to interrupt them during the
final moments just before death. However, energized communities can
develop partnerships dedicated to engaging distressed veterans and
their families at a time when, together, we can help to change the
trajectory of their lives, such that they never become suicidal and
accept help at times of increasing distress.
In December 2017, America's Warrior Partnership announced the
launch of Operation Deep Dive, a four-year research study that we are
conducting in partnership with University of Alabama researchers
through visionary funding from the Bristol-Myers Squibb Foundation. The
study is examining the factors and potential causes involved in
suicides and early mortality due to self-harm among veterans. Our
ultimate goal is to identify the risk factors that lead to suicide in
veteran communities as well as guide the development of programs to
reduce self-harm among veterans. Or as I like to say, to move from
fishing for veterans who are going to take their life, to using
predictive factors to hunt for veterans who are going to take their
life.
Operation Deep Dive is the first study of its kind in many ways. It
is a community-based initiative with a national scope, designed to be
led by and for local communities to ensure they gain direct and
tangible benefits that are tailored to the unique veterans in their
area. Representatives from America's Warrior Partnership and University
of Alabama researchers are leading the study nationally, while local
teams are coordinating the study at the community level. Currently,
organizations from the following areas are participating in the study:
Orange County, California
The Panhandle Region of Florida
Atlanta, Georgia
Minneapolis/St. Paul, Minnesota
Buffalo, New York
Greenville, South Carolina
Charleston, South Carolina
We are expanding the study to seven more communities within the
next few months.
Operation Deep Dive is researching factors that have never before
been evaluated. These include:
The impact of community environments on veterans, which
is an area that has typically been generalized in previous studies;
The experience of all veterans across the spectrum of
service, gender, and lifespan, which is an unprecedented level of
detail for a study of this magnitude;
The impact of dishonorable or less-than-honorable
discharges on veterans who died by suicide, which has not before been
quantified to this level;
The use of geospatial analysis to provide greater
granularity of the characteristics of a veteran who may take their
life; and finally,
An analysis of cases of self-harm in addition to suicide,
which will provide a comprehensive understanding of behavior that can
potentially prove fatal within veteran communities.
The project will be completed in four years. Phase 1 of the study,
which is currently in progress, will take a year to complete. Our
community-based teams have recruited enthusiastic local medical
examiners, coroners, veteran-serving organizations, civic leaders and
veterans, and military families to participate in Community Advisory
Boards. These boards are shaping, reviewing and helping to direct the
research within their respective areas. Researchers have also begun to
conduct a five-year retrospective analysis of suicides and suspected
suicides among veterans within each community. These cases will be geo-
mapped to determine different geo-cultural contexts and locations that
may affect the likelihood of suicide.
Once these actions are complete at the end of the first year, Phase
2 will begin. Researchers from The University of Alabama will compile
all data collected at the community level and conduct a ``sociocultural
autopsy'' to identify the specific individual, organizational and
community factors that lead to suicide or self-harm among veterans.
Researchers will also conduct in-depth, qualitative matched interviews
with veterans at higher risk for suicide. The objective is to determine
the role of community organizations in engaging those who have served
and preventing negative outcomes that lead to suicide and self-harm.
To complement these qualitative interviews, we will conduct a
quantitative, multi-database statistical analysis that links Operation
Deep Dive data with records from a wide range of national sources.
These include the Department of Defense, the Department of Veterans
Affairs Suicide Data Repository, the U.S. Census Bureau, the Centers
for Disease Control and Prevention, and civilian partners using
publically available credit bureau information from companies such as
TransUnion and geospatial analysis from Radiant Solutions. All of this
will ensure the research team is positioned to access as much data as
possible on the potential community and social factors that were
identified during the first phase of the project.
When this four-year project is complete, we expect to have
actionable insights into what risk factors, both individual and
community are important markers in characterizing risk, as well as
understand how to systemically and systematically engage veterans.
However, Operation Deep Dive is only the beginning. The project's
findings will help guide the development of more effective outreach
programs, and we hope it will spur additional studies to identify those
critical elements that will empower communities to help veterans live
and thrive long after their service is complete.
Thankfully, there is already movement in the right direction. The
administration is preparing a strategic multi-department Executive
Order to synchronize prevention efforts from communities up to the
national level. Additionally, as you know, efforts have been underway
in both chambers through hearings such as today's session that are
contributing to impactful legislation enabling the Department of
Veterans Affairs, the Department of Defense, and the Department of
Labor to establish a program to award grants for the provision of
community integration solutions and suicide prevention services.
We enjoy a collaborative relationship with the Department of
Veterans Affairs and are finalizing a data-sharing agreement critical
to the success of Operation Deep Dive. Additionally, we have engaged
with the Department of Defense for a similar data-sharing agreement
that would bring understanding of service waivers, service experience
and the impact of characterization of discharge to our research. We
believe it is virtually impossible to study the suicide of former
service-members without the active participation of the Department of
Defense. Collectively, we need to create a data set that follows the
veteran from Department of Defense recruitment through the Department
of Veterans Affairs service. Lastly, the financial support from the
federal level to all studies of veteran suicide, combined with the
insights provided by community-based projects to holistically
understand the needs of all veterans and suicide studies such as
Operation Deep Dive, would signal a hopeful future for veterans in
need.
In the end, our team at America's Warrior Partnership remains
dedicated to empowering communities to help veterans achieve a higher
quality of life. Much of the work we have accomplished to date would
not have been possible without the cooperation of the Department Of
Veterans Affairs and other veteran-serving organizations across the
country. Continued collaboration and sharing of insights will be
essential as we strive to understand the context that individual,
community, and societal factors play in veteran suicide. Thank you
again for the opportunity to testify on this critical issue.
Prepared Statement of Cindy Sheriff and Bill Mulcahy
Chairman Roe, Ranking Member Waltz and distinguished Members of the
House Committee on Veterans Affairs , thank you for the opportunity to
testify on the challenge of preventing suicide among our veterans.
Before I begin, I would ask Cindy Sheriff, co-founder of GYB LLC (Guard
Your Buddy) to stand and be recognized. She will be my ``buddy'' today
and called upon if needed to back me up.
In 2012 Guard Your Buddy (GYB) was launched in the TNNG in response
to AG Max Haston's mission to ``stop the suicides.'' As seasoned health
care executives, Cindy and I accepted this assignment and drew upon our
backgrounds and professional colleagues to team with The Jason
Foundation to create a clinically sound solution to the General's
request. We are proud of GYB's impact in Tennessee, and we appreciate
the opportunity to share with you what we've learned and, hopefully,
expand GYB's capabilities to all Veterans.
We know twenty suicides a day between active servicemembers and our
Veterans is twenty too much. GYB is a cost-effective, proven solution
that we can scale nationally for active components and the Veteran
population. Opportunities exist for GYB to partner with VA health care
system Vet centers (Readjustment Counseling Service), Wounded Warriors,
like-minded organizations, community resources and many other
organizations to disseminate GYB's best-practices model to save lives
and help those who have put their lives on the line for us.
We believe GYB can reduce Veteran suicide by 34% over the next
three years and is strategically focused on two priorities: suicide
prevention and intervention. With GYB's smartphone application, Guard
servicemembers and their families are directly connected to a Master's-
level clinician who can provide immediate intervention and support.
Professional help is a click away.
GYB is unlike other suicide-prevention programs that are accessed
through an 800 number. It's critical that individuals contemplating
suicide have immediate access to professionals who provide ``in the
moment support''. Clinically, the ``window'' for successful
interventions are during the initial outreach. Once the crisis is
resolved, GYB clinicians will continue to assist with other resources
within the NG or their local community.
Our clinicians become the personal advocate for the servicemember
or their families by helping them get their lives back on track.
We are wholly supportive of national crisis lines to address a wide
variety of concerns for millions of our Veterans. However, a suicide
crisis requires a unique dedicated solution. It is unrealistic to
expect a suicidal person to have a crisis line number memorized or
readily available. Long call queues, call backs, or having a phone
answered in a moment of crisis by anyone other than a Master's Level
Clinician is not the GYB model. To fight suicide, we need to bring our
best educated and trained staff to serve our esteemed servicemembers
and their families.
As the name suggests, GYB supports the strategy of connecting
someone, their buddy, or loved ones in need with resources immediately.
Since implementing GYB the TNNG suicides have been reduced an average
of 68% annually since 2012. 2012 is recognized as ``peak'' for active
component military suicides and GYB's base-line year for program
outcomes. AG Haston asked us to share with the Committee his thoughts
as follows:
``Since 2012, the TNNG believes, that over 85 men and
women of the TNNG have been talked off a ledge or possibly prevented
from hurting themselves by using the GYB app.''
``The GYB program provides real help in real time.''
``When that Masters level clinician answers the
telephone, you don't get forwarded to someone else.and that makes a
difference. Getting put on hold or getting transferred to a number
that's not answered is not the answer.''
The last five years is referred to as the ``new normal'' because
active component suicide rates remain ``stubbornly'' high and have not
receded to expected levels. That is not the TNNG experience, we reject
this premise and hope GYB's model will be considered as another
``tool'' available to all of our Veterans in time of need.
Imagine a ``Guard Your Veterans'' (GYV) initiative with a
foundational communal approach similar to GYB. The GYV strategy will
involve community-based groups, religious organizations, Wounded
Warriors and existing Veteran programs such as the Readjustment
Counseling Service.
GYV will save our Veterans lives using the proven GYB prevention
and intervention strategies with tactics adjusted for demographic
differences. GYV's goal will be to reduce Veteran suicides by 34%
within the first 36 months of implementation. ``Guard Your Veteran''
adjustments for Veteran demographics, include:
Leadership: collaboration with trusted Veterans leaders
and organizations
Convenient Access: All calls must receive ``in-the-
moment'' support. Eliminate the clutter. Technology must facilitate
connectivity, not frustrate callers seeking help.
Education Outreach: Most of our calls come from concerned
``buddies'' or loved ones. Suicidal individuals will often tell someone
about their distress. The problem is people don't know what to do with
that information at that critical moment. GYV will change that.
Triage: beyond immediate assessment/support, refer to
appropriate VA resource professionals, programs, and facilities to
ensure optimal engagement and follow-up.
A national Branding strategy to support collaboration with Veteran
leadership organizations at all levels to achieve the mission--stop the
suicides--is important. ``Guard Your Veteran'' Program design
considerations:
Suicide rates for Veterans are highest during the first
three years out of the military
70% of Veterans who commit suicide are not under VA care
Suicide rates are 16% higher for Veterans who never went
to Afghanistan or Iraq
Approximately 65% of all Veterans who committed suicide
were 50 or older
GYV's solution will be multi-sectoral including, young and old,
working together. Servicemember and Veteran suicide prevention is
everyone's job and a national imperative. GYB hopes to be part of that
strategy and an integral part of the solution.
We appreciate the invitation to address this Committee and the
opportunity to share our experiences with GYB in the TNNG. We look
forward to your questions and thank you for your time.
Respectfully,
Cindy Sheriff and Bill Mulcahy, GYB Co-founders.
If time allows, I would like to share the following letter received
from a servicemember that will give the Committee a feel for GYB's
effectiveness in the TNNG.
An email we recently received (redacted).
From: XXXXXXXXXX
Date: December 12, 2017 at 7:23:06 PM CST
To:
Subject: Thank you
This is not an urgent matter. I just wanted to say thank you for
helping me in my time of need as well as my brothers and sisters. You
all are a very important part of the military community and I thank you
for you service from the bottom of my heart.
Sincerely, XXXXXXXXXXXXX
P.S.--Your hard worked saved four of my buddies including myself.
What is Guard Your Buddy?
In 2012 ``Guard Your Buddy (GYB) was launched in Tennessee as a
program designed and developed from TNNG General Max Haston's mission
to ``stop the suicides''. The GYB initiative has two goals:
Prevent suicide among members of the Tennessee National
Guard
Promote psychological fitness and resiliency by providing
members of the Guard-and their loved ones-the confidential support,
education, advocacy and resources needed to eliminate this ``silent''
epidemic before it can continue to do harm
What makes Guard Your Buddy unique?
Singular focus on stopping suicide, focus both on
prevention and intervention
Leverage technology: Smart Phone App to help a Guard-
member, ``buddy'' and family
Masters level clinicians are two clicks away
Clinical intervention and resources for both Guard-
members contemplating suicide and their battle buddy/family
What are the Guard Your Buddy outcomes in Tennessee 2012 through 2017?
The annual suicide rate in TNNG dropped an average of 68% year over
year
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
What impact could a ``Guard Your Veterans'' (GYV) initiative have?Su
icide is a public health issue and population health challenge. Similar
to GYB, GYV's foundation will be a communal approach. We anticipate
that GYV's strategy will involve public-private partnerships, religious
organizations, Wounded Warriors, community-based groups and existing
Veteran programs such as the Readjustment Counseling Service.
GYV will save Veterans lives using the same GYB strategy of
prevention and intervention, with tactics adjusted for demographic
differences. GYV's goal will be to reduce Veteran suicides by 34%
within the first 36 months of implementation. Preliminary
considerations for GYV program design include:
Suicide rates for Veterans are highest during the first
three years out of the military
70% of Veterans who commit suicide are not under VA care
Suicide rates are 16% higher for Veterans who never went
to Afghanistan or Iraq
Approximately 65% of all Veterans who committed suicide
were 50 or older
Suicide prevention is everyone's job.
[email protected]
www.guardyourbuddy.com
[email protected]
Prepared Statement of Keita Franklin
Good morning, Chairman Roe, Ranking Member Walz, and Members of the
Committee. I appreciate the opportunity to discuss preventing suicide
among Veterans. I am accompanied today by Mike Fisher, Chief Officer,
Readjustment Counseling Service (RCS).
Introduction
Suicide is a serious public health concern that affects communities
nationwide. Nationally, suicide rates are rising for Veterans and non-
Veterans alike, and after adjusting for differences in age, both male
and female Veterans have an elevated rate for suicide across nearly all
ages groups compared to their civilian counterparts. Veterans as a
group tend to possess unique characteristics and experiences related to
their military service (such as transition-related challenges or
posttraumatic stress disorder (PTSD)) that may increase their suicide
risk; however, they also tend to possess protective factors, such as
resilience or a strong sense of belonging to a unit, that may minimize
this risk. Our nation's Veterans are strong, capable, valuable members
of society, and it is imperative that we eliminate Veteran suicide.
Suicide prevention is a top priority for the Department of Veterans
Affairs (VA). According to recent data published by the VA Suicide
Prevention Program, an average of twenty (20) Veterans, active-duty
Service members and non-activated Guard or Reserve members die by
suicide each day. Of those twenty (20), fourteen (14) have not been in
our care. That is why we are implementing broad, community-based
prevention strategies, driven by data, to connect Veterans outside our
system with care and support. In June, VA published a comprehensive
national Veteran suicide prevention strategy that encompasses a broad
range of bundled prevention activities to support the Veterans who
receive care in the VA health care system as well as those who do not
come to us for care.
Since 2010, the Veterans Health Administration (VHA) has worked to
reach all Veterans through a national suicide prevention media outreach
campaign, which raises awareness about suicide prevention, the Veterans
Crisis Line, and services available through VA. Established by VHA in
2007, the Veterans Crisis Line provides confidential support to
Veterans in crisis. Veterans, as well as their family and friends, can
call, send a text message, or chat online to speak with a caring,
qualified responder, regardless of VHA eligibility or enrollment. VA is
committed to providing free and confidential crisis support to Veterans
24 hours a day, 7 days a week, 365 days a year. In addition, we as a
nation must do more to support Veterans before they reach a crisis
point in the first place.
VA Is Advancing a National Public Health Approach to Suicide Prevention
In order to be effective, suicide prevention efforts must be
comprehensive and encompass a wide variety of initiatives. To cite one
successful effort, the U.S. Air Force significantly lowered suicide
rates among its Service members over a 16-year period by taking a
broad, bundled approach that relied on community-based outreach. As VA
advances a public health approach to preventing Veteran suicide, we are
using data and the best evidence available to design and promote
prevention strategies across many sectors.
As not all Veterans have the same risk for suicide, VA has relied
on a framework developed by the National Academy of Medicine (formerly
the Institute of Medicine) in designing our prevention strategies. This
framework, which is also employed by the Defense Suicide Prevention
Office, considers three levels of prevention strategies:
Universal strategies aim to reach all Veterans in the
U.S. An example of a universal strategy is VHA's ongoing suicide
prevention media outreach campaign.
Selective strategies are intended for some Veterans who
fall into subgroups that may be at increased risk. An example of a
selective strategy is our collaborative work with the Department of
Defense and the Department of Homeland Security to support Service
members transitioning out of the service with suicide prevention and
mental health services.
Indicated strategies are designed for the comparatively
few individual Veterans identified as being at high risk for suicidal
behaviors. An example of an indicated strategy is referring Veterans in
crisis to the Veterans Crisis Line or providing a Veteran survivor of a
suicide attempt or loss with enhanced support and expedited access to
care.
This framework and other guiding principles are outlined in the
recently published National Strategy for Preventing Veteran Suicide.
The strategy is intended to serve as a framework for identifying
priorities, organizing efforts, and contributing to a national focus on
Veteran suicide prevention and is organized around four strategic
directions:
1. Healthy and Empowered Veterans, Families, and Communities
2. Clinical and Community Preventive Services
3. Treatment, Recovery, and Support Services
4. Surveillance, Research, and Evaluation
Further, the Suicide Prevention Program has developed an evaluation
framework for tracking and measuring both short- and long-term outcomes
of suicide prevention activities related to the goals described in the
National Strategy for Preventing Veteran Suicide.
VA recognizes that our experience, expertise, and leadership make
us well-positioned to lead the charge on suicide prevention. However,
VA alone cannot end Veteran suicide. We are working with like-minded
partners across numerous sectors--including health care, faith-based,
and community organizations--to advance our public health approach. To
date, the Suicide Prevention Program has established 21 formal
partnership agreements with organizations in health care, research,
government, and beyond to expand the network of support and care for
Veterans. In addition, we have dozens of informal partnerships with
Veterans Service Organizations, nonprofits, employers, and technology
companies, among others.
One resource that many of our external partners and internal teams
have found valuable is our S.A.V.E. (Signs of suicidal thinking, Asking
the question, Validating the Veteran's experience, Encouraging
treatment and expediting help) suicide prevention course, which was
developed through a partnership with the education nonprofit PsychArmor
Institute and educates people on how to support a Veteran in crisis.
Since May 1, 2018, the S.A.V.E. course has been viewed 9,140 times on
PsychArmor.org and social media and is one of PsychArmor's five most-
viewed courses. This is just one example of our efforts to equip
partners and networks across the country with the skills they need to
support Veterans.
VA has also partnered with the Substance Abuse and Mental Health
Services Administration (SAMHSA) to implement the public health
approach at the local level. The Mayor's Challenge is a program that
empowers city leaders to work together in preventing suicide among
local Veterans.
As of today, seven cities nationwide have established coalitions to
prevent Veteran suicide, and we are planning to expand the program to
20 more.
Suicide Prevention Is VA's Top Priority
As the largest integrated health care system in the United States,
VHA's role in preventing Veteran suicide is imperative, and we are
continuing to develop and implement innovative suicide prevention
approaches and resources. While continuing to expand our crisis
intervention services, we are also expanding our treatment and
prevention efforts to address issues that arise well before a suicidal
crisis:
VA has expanded the Veterans Crisis Line to three call
centers. Since its launch in 2007, the Veterans Crisis Line has
answered more than 3.5 million calls and initiated the dispatch of
emergency services to callers in crisis nearly 100,000 times. The
anonymous online chat service, added in 2009, has engaged in more than
413,000 chat conversations. In November 2011, the Veterans Crisis Line
introduced a text messaging service to provide another way for Veterans
to connect with confidential, round-the-clock support and since then
has responded to nearly 98,000 texts.
Through innovative screening and assessment programs such
as REACH VET (Recovery Engagement and Coordination for Health--Veterans
Enhanced Treatment), VA identifies Veterans who may be at risk for
suicide and who may benefit from enhanced care, which can include
follow-ups for missed appointments, safety planning, and care plans.
VA works continuously to expand suicide prevention
initiatives by:
Bolstering mental health services for women
Broadening telehealth services
Providing free mobile apps to help Veterans and their
families
Improving access to care by providing mental health
screening and treatment services through Vet Centers and readjustment
counselors
Using telephone coaching to assist families of Veterans
VA's Community Outreach and Mental Health Access
Every day, more than 400 Suicide Prevention Coordinators (SPC) and
their teams--located at every VA medical center--connect Veterans with
care and educate the community about suicide prevention programs and
resources:
In fiscal 2017, 100 percent of VA's facilities conducted
monthly outreach events, for a total of over 14,000 events that reached
more than 400,000 people.
VA facilities have reported 14,511 outreach events in
fiscal year (FY) 2018 to date.
The estimated total attendees for year-to-date outreach
events is more than 1.46 million.
VA has undertaken efforts to improve Veterans' access to VHA's
high-quality mental health care; these efforts are proving effective:
From 2005 to 2015, the number of male and female Veterans
who had recently used VHA services increased by nearly 20 percent and
55 percent, respectively.
From 2012 to 2017, the number of unique Veterans
receiving mental health care from VHA has risen 20 percent and the
number of outpatient mental health visits delivered by VHA has risen 24
percent.
According to the National Academies of Science,
Engineering, and Medicine's 2018 ``Evaluation of the Department of
Veterans Affairs Mental Health Services,'' VA provides mental health
care of comparable or superior quality to care in the private sector
and elsewhere in the public sector. This report--the result of a
Congressionally mandated assessment of access to and quality of VA
health care services for Veterans of the wars in Afghanistan and Iraq--
indicated that Veterans who use VA services reported positive aspects
of and experiences with VA mental health services. These aspects of
care include the availability of needed services, the privacy and
confidentiality of medical records, the ease of using VA mental health
care, the mental health care staff's skill and expertise, and the
staff's courtesy and respect toward patients.
The quality of VA mental health care is generally as good
or better than care delivered by private plans, and VHA outperformed
private plans on seven of nine quality measures, according to a RAND
study from 2011.
VA Readjustment Counseling Service (RCS)
RCS provides services through the 300 Vet Centers, 80 Mobile Vet
Centers (MVC), 18 Vet Center Out-Stations, over 990 Community Access
Points and the Vet Center Call Center (877-WAR-VETS). The Vet Center
model of service is designed to decrease barriers associated with
receiving care including providing services during non-traditional
hours or in communities distant from existing ``brick and mortar'' Vet
Center facilities. Over 70 percent of Vet Center staff are Veterans,
and the majority have served in combat zones.
RCS is aggressively focused on preventing Veteran suicide through
partnership with other VHA programs, expanded access to Vet Center
services, and innovation. In FY 2017, RCS increased the number of
successful suicide interventions by 28 percent over the previous two
FYs.
In 2017 RCS and the VHA Office of Mental Health and Suicide
Prevention began collaborating to increase coordination between the
Program Offices to address Veteran suicide. Since beginning this
collaboration quality improvements include:
Increased collaboration through regularly scheduled
interaction with local Vet Center staff and SPCs to provide
consultation, support, and joint care coordination to high-risk
Veterans.
Increased bi-lateral connection to services for high-risk
Veterans.
Increased training to local Vet Centers by SPCs. In
addition, RCS held 29 mandatory face-to-face trainings for clinicians,
outreach specialists, and office managers between May and September
2018. Each training had a focus on Suicide Prevention Strategies and
Best Practices. Participants discussed warning factors, various suicide
risk assessments, safety planning, VA's REACH VET Program, and other
available resources and trainings.
RCS has consistently increased access and delivered services to
more Veterans, Service members, and families each year. In expanding
access over the last two FYs:
The number of unique Veterans, Service members, and
families provided these services increased by 31 percent. Vet Center
visits for Veterans, Service members, and families increased by 18
percent.
Visits during non-traditional hours (before 8:00 AM, or
after 4:30 PM), and on weekends and holidays increased by 41 percent.
Community Access Points where services are available on a
regularly scheduled basis, depending on the demand in communities
located away from the brick and mortar Vet Centers increased by 76
percent.
Visits provided specifically to Service members increased
by 12 percent.
In addition to providing quality readjustment counseling, RCS staff
focus on early intervention through targeted outreach designed to
create face-to-face connections with the sole purpose of providing
access to services.
Over the last two FYs, the number of distinct outreach
events Vet Centers hosted or participated in increased by 28 percent.
RCS is coordinating with the National Guard Bureau and
State Adjutant Generals to leverage Vet Center clinical and outreach
staff and 80 MVCs to provide outreach, direct counseling, and referral
to National Guard and Reserve Units during drill weekends to combat the
rising suicide rate. This includes connection to other available
services when National Guard and Reserve members are not eligible for
other VA services.
VA is always looking for new and innovative suicide prevention
strategies. Some examples of these strategies taking place at Vet
Centers across the nation include:
Provision of suicide prevention training to community
stakeholders such as police, fire departments, and schools. First
responders typically encounter more Veteran suicidal ideation and
Veterans in crisis than other community stakeholders.
Vet Centers have been working directly with the Suicide
Prevention Resource Center in obtaining Suicide Alertness for Everyone
(SafeTALK) training. SafeTALK is a training program that teaches
participants (Veterans and non-clinical staff) to recognize and engage
persons who might be having thoughts of suicide and to connect them
with their local Vet Center. As a result of the training, several
Veterans have entered into care due to interventions implemented by
this first set of participants.
Conclusion
VA's goal is to prevent suicide among all Veterans, including those
who do not--and may never--seek care from our health system. To do
that, we are using a public health approach to suicide prevention,
finding new and innovative ways to deliver support and care to all
Veterans where they live and thrive. We are committed to advancing our
outreach, prevention, and treatment efforts to further restore the
trust of our Veterans and continue to improve access to care and
support inside and outside VA. Our objective is to give our nation's
Veterans the top-quality care they have earned and deserve. Mr.
Chairman, we appreciate this Committee's continued support and
encouragement as we identify challenges and find new ways to care for
Veterans. This concludes my testimony. My colleague and I are prepared
to respond to any questions you may have.
Prepared Statement of American Veterans (AMVETS)
Statement for the Record of Sherman Gillums Jr.
Chief Advocacy Officer
American Veterans
Legislative Hearing on Veteran Suicide Prevention: Maximizing
Effectiveness and Increasing Awareness
Chairman Roe, Ranking Member Walz, and members of the Committee, on
behalf of the men and women of American Veterans (AMVETS), thank you
for allowing us this platform to address a serious problem in our
country, veteran suicide, that has reached crisis proportions and now
requires redoubled efforts in order to effectively confront it.
Past and recent Department of Veterans Affairs (VA) studies that
explored the question of which veterans committed suicide, how they did
it, and the number who chose this path only tell part of the story. The
latest VA report provided an examination of more than 55 million
records of veterans who served in the United States military from 1979
to 2015. The report is based on veteran suicide data that essentially
echoes the findings of past research: approximately 20 veterans are
choosing self-inflicted death over life in our country, each and every
day, a trend that is going in the wrong direction despite collective
efforts to curb veteran suicide. The question that persists is why.
Why are veterans, according to the data, 2.1 times more likely to
die by suicide than non-veterans? Why has the suicide rate risen
fastest among Post-9/11 veterans ages 18-24? Why do veterans over age
55 and those who served during peacetime still experience the overall
highest numbers of suicide? These questions have remained unanswered
throughout study after study, and it is imperative that any new
research going forward gets to the heart of why so many of our nation's
veterans die by suicide.
A key aspect of the recently released VA report is that it compares
differences in suicide mortality between veterans who access VA health
care to those who have not recently used VHA services. The report
showed that, in 2016, veterans who had recently used VHA services had
higher rates of suicide than veterans who did not. Conditions, such as
mental health challenges, drug addiction, chronic pain and severely
disabling conditions were associated with an increased risk for
suicide. What efforts are being undertaken to reach these veterans and
explore whether their contact with a VA hospital has a causal
connection to suicide? The research data and their conclusions are only
as good as the actions that have been taken in light of new
information.
We also question the timelessness of the data used in the recently
released VA report. AMVETS is concerned that we are nearing the end of
2018 and trying to develop current and relevant solutions by parsing
data from over two years ago. The lag in being able to study recent
data makes it difficult to be as proactive as stakeholders could be.
Despite the less-than-optimal information related to veteran suicide,
we will continue to work diligently and tirelessly to reverse the
troubling trend that negatively affects all generations of veterans.
However, steps must be taken to improve the relevance of national data
on veteran suicide by using timelier collection and examination
protocols, which may require tighter coordination with local and state-
level authorities that are responsible for aggregating and reporting
death-by-suicide data.
Accountability continues to concern AMVETS when veteran suicides
occur. In August 2016, a 76-year-old shot himself in the parking lot of
the Northport Veterans Affairs Medical Center in New York. In March
2018, a 62-year-old veteran shot himself in the John Cochran VA Medical
Center waiting room in St. Louis. In June 2018, a 58-year-old Air Force
veteran died after he set himself on fire near the Georgia State
Capitol in Atlanta to protest the VA system.
While these isolated examples of veteran suicide on VA property and
in protest of VA itself do not conclusively prove the existence of
systemic problems across the agency, one cannot ignore the fact that
these ``statement'' suicides are frequently disassociated from policies
and/or actions on the part of VA clinical staff that played some role
in these veterans' fateful narratives.
Another case in point, a recently released VA Office of Inspector
General (OIG) report entitled, Review of Mental Health Care Provided
Prior to a Veteran's Death by Suicide Minneapolis VA Health Care
System. In this instance, the systems in place to address a veteran in
crisis were not implemented. The Iraq War veteran in question was
referred to inpatient care after he called the Veterans Crisis Line
while in the midst of a suicidal crisis. He stayed in inpatient care
for three days, and then he shot himself in the parking lot of the VA
less than 24 hours after being discharged.
The OIG team determined that inpatient mental health staff failed
to include the patient's outpatient treatment team in discharge
planning; failed to identify an outpatient prescriber and schedule an
outpatient medication management follow-up appointment; failed to
adequately document assessment of firearms access and educate the
patient on limiting access to firearms; and failed to document the
patient's declination to engage family in treatment planning and
discharge planning. Despite these failures, the inspectors arrived at
the fruitless conclusion that ``the OIG team was unable to determine
that any one, or some combination, was a causal factor in the patient's
death.''
Whether the actions on the part of VA personnel directly
contributed to the veteran's suicide may never be known beyond a
reasonable doubt. But that's not the evidentiary standard in this case.
Was it possible that, but for those breakdowns in the system, the
veteran may not have committed suicide? Why is more benefit of the
doubt given to the institution that failed the veteran than the veteran
who had turned to the system for help? The VA suicide report revealed
that many younger veterans--specifically those of the Post-9/11 era--
are slipping through the cracks despite the myriad efforts being made
to address mental health care access and barriers to seamless
transition after service. But if the system is not forced to correct
itself through stronger accountability measures then nothing will
change, and more lives will be lost.
We cannot speak of veteran suicide, and the tragic case at the
Minneapolis VA, without mentioning Army Sgt. John Toombs, an
Afghanistan veteran, who was wrongfully expelled from a regimented VA
Residential Treatment Center after he arrived to the program later than
his designated time to take his medications. He wanted to get back in
the program, but was rejected, after which he hanged himself later that
night. Besides telling his family he loved them, his last words on a
video found on his phone were: ``When I asked for help, they opened up
a Pandora's box inside of me and just kicked me out the door.that's how
they treat veterans 'round here.''
There is currently a bill in the Senate, which passed the House,
that seeks to honor his memory,
H.R. 2634, To designate the Mental Health Residential
Rehabilitation Treatment Facility Expansion of the Department of
Veterans Affairs Alvin C. York Medical Center in Murfreesboro,
Tennessee, as the ``Sergeant John Toombs Residential Rehabilitation
Treatment Facility,'' which AMVETS wholeheartedly supports. AMVETS
thanks the House of Representatives for passing this bill, which now
sits with the Senate for consideration.
When the day comes that the treatment facility is named in his
honor, it will serve as a powerful reminder that those who work in the
mental health profession must take every measure possible to help and
respect those who seek treatment.
Notwithstanding our criticisms, AMVETS does commend the VA for
taking steps to improve its services and programs that target veteran
suicide. In 2017, VA announced a Recovery Engagement and Coordination
for Health--Veterans Enhanced Treatment (REACH VET) Initiative. REACH
VET analyzes existing data from veterans' health records to identify
those at a statistically elevated risk for suicide, hospitalization,
illness or other adverse outcomes. This allows the VA to provide
preemptive care and support for veterans, in some cases before a
veteran even has suicidal thoughts.
Once a veteran is identified, his or her VA mental health or
primary care provider reaches out to check on the veteran's well-being,
and review conditions and treatment plans to determine if enhanced care
is needed. It is clear this did not happen in the Minneapolis or
Murfreesboro cases. That said, AMVETS does more than point out failures
and breakdowns in the system. Earlier this year, AMVETS initiated a
HEAL Program to ensure that veterans receive the health care they need,
both physical and mental health services, so they may live longer,
healthier lives. The AMVETS HEAL Program is staffed by a team of
clinical experts with experience in eliminating the barriers veterans
often face in accessing health care.
HEAL, stands for health care, evaluation, advocacy, legislation,
and encompasses all necessary steps the team will take to intervene
directly on behalf of veterans, servicemembers, families, and
caregivers to reduce veteran suicide, unemployment, homelessness, and
hopelessness as it relates to mental and physical wellness. Since the
Program's inception, we have been able to garner firsthand knowledge of
specific issues that veterans are trying to manage through our town
hall meetings, and through conversations with those that call the
AMVETS HEAL help line at 1-833- VET-HEAL. Many of the issues we have
addressed involved problems with timely access to mental health care,
and proper management and monitoring of psychiatric symptoms once they
begin treatment.
AMVETS has also partnered with the VA recently so that we could not
only offer our recommendations for improvement, but also play an active
role in implementing our recommendations. At our annual National
Convention in August 2018, AMVETS and the Department of Veterans
Affairs signed a Memorandum of Agreement (MOA) in furtherance of our
mutual ongoing efforts to eliminate risk factors that contribute to
veteran suicide and establish programs and practices that offer at-risk
veterans the interventions necessary to avert potential suicide.
The agreement enhances cooperation between the AMVETS HEAL Program
and the VA, through the VHA Office of Suicide Prevention. Together,
AMVETS and the VA will work to identify and eliminate the barriers
veterans face in accessing health care, enroll more at-risk veterans
into the VA health care system, and provide training for those who work
with veterans so that intervention begins once red flags are
identified. The agreement also outlines terms under which the VA can
refer veterans for services to the HEAL Program and vice versa.
VA Secretary Robert Wilkie noted at the MOA signing that suicide
prevention remains VA's top clinical priority, and that it requires a
focused, national approach to engage with all veterans whether or not
they receive care in the VA. AMVETS could not agree more, and we are
also encouraged by the January 2018 executive order signed by President
Donald Trump that directed the VA, Department of Defense, and
Department of Homeland Security to integrate efforts to provide
seamless access to mental health care and suicide prevention resources
for veterans who have recently separated from military service.
While there is much more work to be done, we are encouraged by the
VA's willingness to partner with stakeholders in order to extend its
reach to veterans who may be suffering silently in crisis. Preempting
the crisis through immediate intervention, holistic assessment, and
sustained support is key to giving at-risk veterans hope whenever they
face problems such as mental issues related to post traumatic stress
and/or traumatic brain injury, unemployment, homelessness, substance
abuse, or other severe adjustment issues after service.
Americans should recognize that this problem is not just a VA
problem. It is a problem for our entire country with very real and
serious implications for the future of our military. We consider it a
national emergency that requires immediate action. A better part of the
last decade has been spent on efforts to improve the transitioning
process for our veterans, but clearly it is failing in too many cases,
and veterans are dying unnecessarily.
In order to address veteran suicide more effectively, Congress and
the Department of Veterans Affairs must invest in research methods that
produce timelier results, increase accountability among mental health
providers employed at VA when the system fails, and conduct improved,
targeted outreach to at-risk veteran populations through partnerships
with organizations that have active and effective initiatives, such as
the AMVETS HEAL Program, that are designed to intervene and avert
crises that typically lead to suicide. No veteran should die by suicide
in a country where saying ``thank you for your service'' is as common
as saying ``hello'' and ``goodbye,'' if such gratitude is sincere.
Chairman Roe, Ranking Member Walz, and members of the Committee, on
behalf of the men and women of AMVETS and the nearly 20 million
veterans in the United States whose interests are served by our
mission, we thank you for the opportunity to contribute to this
important discussion. AMVETS looks forward to working with this
Committee and the Department of Veterans Affairs to take every step
necessary to end this crisis.
Prepared Statement of Disabled American Veterans (DAV)
STATEMENT OF
SHURHONDA Y. LOVE
DAV ASSISTANT NATIONAL LEGISLATIVE DIRECTOR
On behalf of DAV (Disabled American Veterans) and our more than one
million members, all of whom are wartime injured or ill veterans, thank
you for inviting DAV to submit testimony for the record for today's
hearing to discuss the findings of the Department of Veterans Affairs
(VA) most recent suicide data. We appreciate the Committee's attention
to this critical topic.
Suicide prevention is not ``just'' a VA and Department of Defense
(DoD) problem because it affects everyone and every community.
According to VA's most recent report on suicide, its numbers within the
military and veteran community have remained relatively static in spite
of all of the new programs, services and community partnerships put
together to reduce it or stop it altogether. For this reason, we must
take a look beyond the data, to examine what VA is doing to prevent
suicide, the efficacy of its suicide prevention programs, what it is
doing to reduce or eliminate suicide, and its suicide prevention
efforts in its partnerships within the community and other Federal
agencies.
One way VA is attempting to lower the rates of suicide is its
social media campaigns to increase awareness and the provision of tools
for veterans, their families, and those working with veterans. One of
these campaigns between VA and DoD is the ``Be There'' campaign. ``Be
There,'' in summary, means feeling comfortable to address someone you
think may be in distress, knowing what to do and who to call, and being
there to hear the needs of that person. We know that suicidal behavior
is often related to the consequences of problems like failed
relationships, combat exposure, illegal substance use, terminal
disease, poor physical health, low or no income, job stress, physical
or sexual trauma, and legal or housing stress. ``Be There'' and other
awareness and prevention campaigns could be the first steps in lowering
the rates of suicide, by arming more individuals with the knowledge and
confidence to speak up and recognize when they, a loved one or someone
they know is struggling.
A simple way we can all make a difference within our communities is
by asking the question, ``Are you ok; are you thinking of harming
yourself?'' ``Be there'' to listen for the response, and if necessary,
to keep them safe. In acknowledgment of suicide prevention month, DAV
recently provided S.A.V.E. training at our Service and Legislative
Headquarters in Washington, D.C. Personnel having received the training
have been provided with resources to aid them in feeling comfortable
enough to address a fellow staff member, veteran, friend or neighbor
who they perceive may be experiencing distress. Through the support of
the VA's Office of Suicide Prevention, staff members who participated
in the training received items with the VA Crisis Line number, 1-800-
273-8255, along with other relevant information to aid a person in
crisis. This line connects persons in need to first responders trained
to deploy lifesaving conversation skills or actions, who know what to
do, and have access to life saving interventions such as activating EMS
or the police, and stabilization methods to follow up with additional
screening and/or treatment as needed.
VA's Suicide Report
VA's study found that the general trends in veteran suicide have
remained relatively consistent at about 20.6 veteran suicides per day,
and about 6 of the 20 were recent users of VHA services. DAV recently
released a new report, Women Veterans: The Journey Ahead. This report
highlights research data to indicate the importance of looking more
closely at subpopulations of veterans such as women. While women
veterans are at lower risk of suicide than their male peers, VA's
recent study indicated that women veterans are two times more likely to
commit suicide than women who have never served. In contrast, male
veterans have 1.3 times increased risk of suicide. Women veterans' rate
of suicide is also increasing much faster than their male peers.
As we examine the findings of VA's most recent report on veterans'
suicide, the efficacy of its current suicide prevention programs,
community involvement, and the identification of veterans shown to be
at highest risk, we must also evaluate how these programs and services
meet the needs of women veterans. Women veterans represent a small
portion of veterans; however, they continue to be the fastest growing
cohort, not only in the Veterans Health Administration (VHA), but also
in the Active duty and Reserve components of the military.
Women veterans continue to die from suicide each year at twice the
rate of women that have not served. However, there is a difference in
the method these two cohorts choose when committing suicide. Women who
have not served tend to use less lethal means of self-directed
violence, such as suffocation or poisoning. Women veterans have a
higher tendency to use firearms, resulting in higher rates of fatality.
In addition, while male veterans' use of firearms was relatively
stable, women veterans' use increased from 34.3 to 39.9 between 2005
and 2015.
VA Approach a Public Health Model
VA has adopted a public health model for addressing veterans'
suicide, which is impressively outlined in its recently released
National Strategy for Preventing Veteran Suicide 2018-2028. This model
relies upon using a population-focused approach; focusing on primary
prevention; using science to inform policy; and multidisciplinary
collaborations that develop solutions for diverse populations. VA's
plans include bolstering health and empowerment in veterans and their
families; taking steps to prevent veterans from committing suicide,
including reducing access to firearms for those veterans at the
greatest risk; treating those at risk of suicide; and creating systems
of surveillance, research and evaluation to support preventive efforts.
With this understanding, VA has partnered with the American
Foundation for Suicide Prevention (AFSP). AFSP is a community effort
led through state chapters to reach the approximately 10.2 million
(only 6 million use VA health care) out of 19.9 million veterans that
do not use VA benefits or services. The AFSP places an emphasis on
teaching providers about identifying those at risk, determining their
level of risk, and appropriate actions to take for individuals at risk
of suicide, gun safety, and post-vention (interventions for survivors
following a death by suicide), and is one of the five initiatives
identified by VA to combat veteran suicide from within the community.
VA continues to fine tune its REACH-VET (Recovery Engagement and
Coordination for Health-Veterans Enhanced Treatment) program, which
uses predictive analytics to assist its providers in identifying and
intervening in patients identified as being at high risk of suicide.
DAV believes this is a state of the art program rivaling or even
besting programs in large-scale private sector health maintenance
organizations. DAV endorses the recommendation within our new report on
Women Veterans that in updating its Clinical Practice Guidelines for
Assessment and Management of Patients at Risk for Suicide with DoD, the
guidelines work group should assess the scientific basis and publish
recommendations on gender-based differences in risk, protective factors
and treatment efficacy for suicide prevention. Gender-focused risk
factors such as lack of social support or a history of sexual abuse may
factor into VA's predictive analytics. In addition, the growing use of
firearms in self-directed violence seen in women signals the need to
provide firearm safety training to all at-risk veterans.
Initiatives to combat veteran suicide from within the community
include the Mayor's Challenge, which features partnerships between VA,
Health and Human Services Substance Abuse and Mental Health Services
Administration (SAMHSA), and the Mayors of eight cities in its initial
phase. The goal of the Mayor's Challenge is to reduce suicides among
servicemembers, veterans and their families using a public health
approach to suicide prevention including building awareness of problems
and knowing where to get help.
Suicide prevention effort has also been extended to some college
campuses where veterans are taking classes. The Veterans Integration to
Academic Leadership (VITAL) program provides mental health services to
student veterans on college campuses. In 2017, VITAL programs served
124 college and university campuses, and assisted 2,012 new student
veterans on those campuses. Although suicide rates are generally higher
for veterans using VHA, veterans not using VHA have higher risks of
suicide relative to non-veteran peers. Unfortunately, these veterans
are also harder to reach. For this reason, DAV is pleased to see
emphasis on partnerships within the community to combat suicide.
Military Sexual Trauma
High rates of military sexual trauma (MST) among women may also
factor into reasons some women veterans are at high risk for suicide.
Among VHA users, 20 percent of women compared to 1 percent of men
report military sexual trauma. In fiscal year (FY) 2017, DoD reports
having received a 9.7 percent increase in the reporting of sexual
assaults. DAV's Women Veterans report recommends that DoD work with
other federal agencies and outside experts to evaluate and disseminate
effective approaches to creating gender equity within a male-dominated
workplace. Additionally, DoD should take an aggressive stand against
sexual harassment and assault in the military by holding commanders
accountable for creating a positive culture of inclusion and respect
and sponsoring women's empowerment.
The effects of MST are often felt many years after service women
and men have left the military. Once servicemembers transition into
their communities, DoD, VA and community providers must work together
to be sure all veterans receive the care they deserve.
Exceptional care must continue in the veteran's pursuit of benefits
related to MST. In August 2018, the Office of Inspector General (OIG)
issued a report (17-05248-241) that found that nearly half of denied
MST-related claims from reviewed cases were not properly processed in
accordance with Veterans Benefits Administration (VBA) policy, possibly
resulting in the denial of benefits to these survivors of military
sexual trauma. MST-related claims can be complicated, difficult to
develop and often appear to lack the necessary evidence to warrant a
grant of service connection. DAV supports recommendations made by the
OIG for VA to revert back to ensuring its Veterans Service
Representatives and Rating Veterans Service Representatives that are
processing MST-related claims, have up to date, issue-specific training
on MST. Furthermore, all denied MST claims during the period of the OIG
report are reviewed and assessed for accuracy.
VA provides MST-related care to survivors free of charge, and
regardless if service connection has been established through VA's
disability compensation process. Veterans having experienced MST should
be referred to VA to receive treatment and related services.
Need for Gender Specific and Sensitive Care
Women veterans also need patient care environments that they
perceive as safe, private and inviting. They need knowledgeable gender-
specific care providers who understand their issues and the health and
mental health conditions in addition to their gender-specific needs.
Women providers should be available to women veterans who request them,
along with peer specialists who have similar experiences who can help
them navigate services. DAV believes that VA provides comprehensive
services and a whole health model approach that is best for women
veterans. VA's wraparound services, military competencies, integrated
system and holistic approach to care make it superior to care in the
private sector.
Assessing the Effectiveness of VA Mental Health Programs and Ability to
Identify At-risk Veterans.
A critical step in ensuring VA's ability to deliver the high
quality mental health care that veterans have not only earned through
their service, but also deserve, is highly dependent on having
appropriate resources including personnel and capital assets to meet
the demand for this specialized care. OIG released a report (17-00936-
385) in September of 2017, that ranks the shortage of psychologists as
third out of the top five occupations with the largest staffing
shortages over the last four years. In the OIG's more comprehensive
report (18-01693-196), released in June of 2018, the most frequently
cited shortages were in the Medical Officer and Nurse occupations; a
lack of qualified applicants, non-competitive salaries, and high staff
turnover were cited as the most common reasons for the shortage. VA
must have adequate resources to allow it to not only compete with
salaries within the private sector, but also attract qualified
candidates. With mental health conditions being cited as the third most
frequently diagnosed category of conditions at VA for male and female
patients, it is imperative that mental health providers be adequately
staffed at VA facilities.
In response to these OIG reports, VA has implemented the Mental
Health Hiring Initiative, and committed to hiring more than 1,000 more
psychiatrists, psychologists and other mental health professionals. DAV
Resolution 129 adopted at our most recent National Convention calls for
a simple-to-administer alternative VHA personnel system, in law and
regulation, which governs all VHA employees, applies best practices
from the private sector to human capital management, and supports pay
and benefits that are competitive with the private sector. We
acknowledge VA's efforts and responses to the shortage of critical
personnel in mental health, and we encourage the Department to continue
its efforts in establishing innovative ways to not only attract, but
retain qualified mental health professionals.
One way VA has leveraged its mental health capabilities, and
increased veteran access to mental health care is through its
``Anywhere to Anywhere Telehealth'' initiative. As part of a federal
health care system, VA providers are able to treat patients across the
country unrestrained by state-specific telehealth laws and licensing.
Leveraging telecommunication technology to provide mental health care
to remote veterans greatly enhances veterans' access to care.
Telehealth has been implemented in over 900 sites of care with high
rates of satisfaction from providers and patients electing its usage.
More than 450,000 veterans receiving care at VA have used home and
clinical video telehealth. According to VA, mental health services that
have been provided to veterans via clinical video telehealth
(TeleMental Health) have reduced acute psychiatric VA bed days of care
by 39 percent. VA also reported a 32 percent decrease in hospital
admissions while boasting a 92 percent approval rate by veterans.
DAV Resolution No. 293, adopted at our most recent National
Convention calls for program improvements, data collection and
reporting on suicide rates among servicemembers and veterans; improved
outreach through general media for stigma reduction and suicide
prevention; sufficient staffing to meet demand for mental health
services; and enhanced resources for VA mental health programs,
including Vet Centers, to achieve readjustment of new war veterans and
continued effective mental health care for all enrolled veterans
needing such services.
VA's REACH-VET program was piloted in October of 2016, and was
fully implemented in April of 2017. This program was designed to
identify veterans in need of care, and provide care as early as
possible by using predictive analytics to flag charts of veterans who
may be at risk for suicide. Once a veteran has been identified, his or
her VA mental health or primary care provider reaches out to check on
the veteran's well-being, and reviews their condition(s) and treatment
plans to determine if enhanced care is needed. By identifying at-risk
veterans early, it allows VA to provide treatment before a crisis can
occur, and decreases the likelihood of more serious conditions
developing later. In May of 2017, VA reported that all VHA medical
centers are working with those veterans at the highest risk; 0.1
percent of the veteran population, which includes about 6,400 veterans,
roughly 46 per facility. Over time, the focus will expand to include
those at a more moderate risk for suicide.
DAV views the REACH-VET program as a valuable tool for VA mental
health providers in identifying veterans who are most at risk for
suicide and connecting with them. It is important to ensure that once
the connection is established, and the needs have been assessed, that
there is a clear path for the veteran to receive the care that they
need in a timely, efficient way. It is important that every opportunity
is taken to eliminate barriers to this care and that these veterans
receive the care that they have earned, and need. These veterans should
continue to have their needs assessed until they no longer meet the
criteria placing them in the highest risk for suicide.
Expanding Access to Veterans with Discharges Characterized as Other
Than Honorable
According to the Government Accounting Office (GAO) report 17-260,
more than 57,000 veterans that had been separated from service due to
misconduct during fiscal years 2011 through 2015, had been diagnosed
within two years prior to separation with post-traumatic stress
disorder (PTSD), traumatic brain injury (TBI), or certain other
conditions that could be associated with misconduct. Because their
service had been characterized as other than honorable, these veterans
lacked access to VA health care for many years. In January of 2018, the
VA Secretary concurred that this problem should be remedied and
authorized emergency mental health care for veterans with other-than
honorable discharges. This should allow VA to intervene with a new sub-
group of veterans who may be at high risk of suicide.
Inter-agency Initiatives
In January 2018, the President signed Executive Order 13822,
``Supporting Our Veterans During Their Transition From Uniformed
Service to Civilian Life,'' directing the DoD, VA, and Homeland
Security to develop a plan to ensure that all new veterans receive
mental health care for at least one year following their separation
from service. In implementation, the first goal of these three
organizations is to facilitate seamless access to mental health
treatment for transitioning servicemembers. Goal two is to provide
access to suicide prevention resources to transitioning servicemembers
and veterans through collaborative communication, and outreach efforts
to veterans service organizations (VSO), and other stakeholders. The
final goal is to leverage interagency partnerships to educate those who
have recently transitioned about eligibility for VA mental health care
services.
Several key initiatives have resulted from this interagency
partnership. The Concierge for Care is a health care enrollment
initiative that connects with former servicemembers shortly after they
separate from the service. The Military Once Source, provides tools to
help plan for deployments, educational and employment resources, and
resilience tools to include medical counseling and other consultations
in military life. The ``Be There'' peer support call and outreach
center, helps provide access to a number of tools including help with
relationships, family and financial counseling. Whole Health groups is
an initiative that focuses the overall health of the veteran, desired
health goals, and collaboration between the provider and veteran in
making a plan around the veteran's desired goals. This may also include
a connection to the community in the fulfillment of those goals. Whole
Health groups have been established at all VA medical centers, which
will help identify areas of life that are affecting veterans' lives,
through communication between the veteran and his or her health care
team to set goals, build a plan around those goals, and connect with
the community. These interventions may be an important way of
addressing newly separating veterans within a year of discharge, who
are known to be at high risk of suicide.
Readjustment Counseling Service-VA Vet Centers
VA Readjustment Counseling Service (RCS) is home to VA Vet Centers.
Vet Centers are one of VA's most popular and widely used programs.
Qualifications to utilize these centers include veterans having served
in any combat theater of hostility, those having experienced MST, those
having served as a member of an unmanned aerial vehicle crew that
provided direct support to operations in a combat zone or area of
hostility, and for family members of veterans and servicemembers who
require counseling for military-related issues such as bereavement
counseling for families having experienced an Active duty death.
According to RCS, Vet Center staff participated in over 40,000 outreach
events during FY 2016.
Currently, there are a total of 300 ``brick and mortar'' Vet
Centers located in every state, the District of Columbia, American
Samoa, Guam and Puerto Rico. RCS staff members also deliver
readjustment counseling services in other areas away from these
traditional facilities through the use of its Vet Center Community
Access Points (CAPS) and Mobile Vet Centers. CAPS are places where
clinicians are able to provide readjustment counseling from other
locations in accordance with the needs of that community. In FY 2016,
RCS operated more than 740 CAPS which was reported to be a 25 percent
increase from the previous fiscal year. Mobile Vet Centers allow RCS
staff to deploy within the community to different locations to offer
readjustment counseling where veterans are. Events such as gatherings
hosted by VSOs or other stakeholders allow additional opportunities to
reach veterans that may not receive care from VA for one reason or
another, and provide them with the counseling services they need. RCS
maintains a fleet of 80 Mobile Vet Centers that are designed to extend
RCS staff ability to provide readjustment counseling to more locations
within the community to qualifying veterans.
One of the least well-known services that RCS provides within the
community is emergency response. In the aftermath of shootings, floods
and other disasters, the Vet Center staff frequently partners with Red
Cross to provide clinical support in the affected communities. Most
recently, Vet Center staff participated in responses to the West
Virginia flooding, and the Dallas and Orlando shootings. According to
RCS, more than 500 veterans and 60 family members were provided
services at these sites, and through a leveraged partnership with Red
Cross, provided referral and services to over 3,500 citizens of
affected areas.
Peer Support
Peer Specialists in VA are generally veterans in recovery from a
mental health or co-occurring condition(s) who have been trained and
certified to help others with similar conditions. These veterans may be
actively engaged in their own recovery and may volunteer or be hired to
provide peer support to other veterans who are engaged in mental health
treatment.
Peer specialists draw upon their own recovery experience to inform
their support of veterans. The shared experience of military service
tends to foster trust between the Peer Specialist and the veteran with
whom they are working. Roles of the peer specialist are varied and
include facilitating groups, role modeling, providing outreach and
support, teaching coping skills, case management and acting as liaison
between the veteran and mental health team.
VA peer support groups have also been seen as invaluable tools in
helping veterans cope with symptoms of PTSD, depression, and other
mental health related issues. Veteran peer support groups are an
opportunity for interaction with people who share similar life
experiences. This is especially important for women veterans, whose
small numbers within each care facility may make it harder to find
other women with whom to relate. While trained volunteers are a
valuable resource, employing Peer Specialists often requires higher
levels of commitment and engagement with veterans, care teams, in
addition to accountability for the roles and responsibilities of the
position that may exceed what can be expected of a volunteer. DAV
supports Peer Specialists; however, we recommend that VA define
specific outcome measures for the Women Veterans Peer Specialist
program, including if they successfully connect veterans to mental
health services, whether those services include evidence-based
therapies, and whether participants had greater adherence to treatment
and were more satisfied with their care. VA should continue to evaluate
a variety of models to meet needs expressed by women veterans,
including the integration of peer counselors in women veterans'
comprehensive primary care teams.
In closing, DAV believes that VA and DoD have made important
strides in understanding and addressing the issue of suicide among
America's veterans. Unfortunately, the unchanged rates of suicide among
veterans-and even increases in certain subpopulations such as women and
younger veterans-make clear there is more work to be done. Within VHA
programs, sufficient resources-staff, space and funding-are essential
to ensure all veterans have access and are evaluated and treated within
a reasonable timeframe. Veterans in crisis must be assessed
immediately. VHA must continue to address staffing issues and other
barriers to care such as transportation and child care that affect some
veterans' ability to access care. VA and DoD must also ensure that
programs are appropriately tailored for women veterans whose needs may
be somewhat different than their male peers. VA and DoD must ensure its
community partners are trained and effectively assisting in suicide
prevention efforts and understand the special risk factors for veterans
and when they should be referred to VA for help. Finally, VA must also
continue its efforts to increase Americans' awareness of this crisis
among veterans so we can all help to end it.
We appreciate the opportunity to provide this statement for the
record. We ask the Committee to consider our views and statements as it
addresses the issue of suicide prevention in the veteran population. I
am pleased to address any questions from the Chairman of other Members
of the Committee.
Prepared Statement of Dr. Barbara Stanley Ph.D.
PROFESSOR OF MEDICAL PSYCHIATRY AT COLUMBIA UNIVERSITY
AND
DIRECTOR OF THE SUICIDE PREVENTION TRAINING, IMPLEMENTATION AND
EVALUATION PROGRAM ATNEW YORK STATE PSYCHIATRIC INSTITUTE
WITH RESPECT TO
"Veteran Suicide Prevention: Maximizing Effectiveness and Increasing
Awareness"
Chairman Roe, Ranking Member Walz and members of the Committee,
thank you for the opportunity to provide remarks on the critical issue
of how to address the suicide epidemic among our veterans, including
effective treatments and increasing awareness.
The hearing's aim, to examine the findings of the Department of
Veterans Affairs' (VA's) most recent suicide data reports as well as
the efficacy of ongoing efforts to prevent suicide among veterans
receiving care in the VA health care system, is of critical importance.
An additional goal, identifying actions needed to lower the rates of
suicide among at-risk veterans, is within reach.
Suicide is one of the ten leading causes of death in the United
States and, unfortunately, has increased by nearly 30% in the past 15
years. This increase stands in stark contrast to most other western
countries where the suicide rate has either declined or remained the
same. Furthermore, while suicide deaths have risen, other leading
causes of death in the United States have mostly declined in this same
time frame.
Among suicide victims, Veteran suicide remains a persistent
problem. Veterans die by suicide at a significantly higher rate than
the non-Veteran population with Veteran suicide 2.1 times higher than
non-Veteran adults with about 2/3 of suicide deaths in Veterans by
firearms.) This is dramatically higher than the overall firearm suicide
rate in this country that stands at about 50%.
Despite the seriousness and complexity of the problem, simple
actions can be taken that can help reduce suicide in the Veteran
population that already have established effectiveness. While there are
many strategies can and should be employed to address suicide in
Veterans, this statement focuses on low burden intervention strategies
with established effectiveness. Much has been done to identify those
Veterans within the VA at greatest risk of dying by suicide. However,
outreach to Veterans in the community who are not within the VA system
can be increased by identifying those at risk using simple assessment
tools like the Columbia Suicide Severity Rating Scale (C-SSRS), an
assessment tool that is widely used within the VA.
Furthermore, once identified, Veterans need help to deal with their
suicidal feelings to avoid acting of them. But the transition from
identification of risk to asking for help is a challenge for Veterans.
The majority of Veterans are male with females comprising only about
10% of the Veteran population. In general, males are much less likely
to seek help than females particularly for emotional problems. Efforts
made to encourage them to seek help should include care models that are
consistent with a military approach that includes systematic problem
solving, implementation of predetermined action plans and teamwork.
These models are more likely to be acceptable and employed.
One such approach is the use of the Safety Planning Intervention.
This intervention coupled with follow-up phone calls, called SAFE VET,
has been found to reduce suicidal behavior almost in half in Veterans
at risk for suicide. My colleague, Dr. Gregory Brown from the
University of Pennsylvania, and I developed this simple, easy to use
intervention that is consistent with a military approach to problem
solving and includes identification of simple strategies to use in a
crisis, people who can provide support and acceptable ways to reduce
access to lethal means that the Veterans would use to kill themselves.
As one Veteran who used this intervention reported when asked about
the usefulness of safety planning reported, "How has the safety plan
helped me? It has saved my life more than once." This Veteran's
reaction has been echoed by many others who have used safety planning.
While this intervention is used in the VA, the quality of its delivery
is variable and needs to be improved. Furthermore, while we have
established effectiveness of the safety planning intervention with
phone follow-up for at risk Veterans discharged from the emergency
room, large scale implementation in the VA with adequate resources for
training to ensure high quality health care delivery has not been done.
Additionally, outreach efforts to implement safety planning with at
risk Veterans who not in VA care are negligible. Finally, simple
interventions can be readily translated into electronic modes of
delivery in the form of apps with or without assistance of health care
professionals. For example, a safety planning app could easily be
developed, tested and disseminated to all Veterans whether or not they
received health care within the VA. This app could be paired with
additional suicide prevention apps such as insomnia apps, problem
solving apps and depression apps.
Recommendations:
1.Systematic implementation of the SAFE VET intervention which
includes the Safety Planning and telephone follow up in Emergency
Departments, Behavioral Health and Substance Use Disorder Programs
throughout the VA.
2.Couple training and dissemination of safety planning with efforts
to screen for at risk Veterans who are not being treated in VA
settings.
3.Develop and disseminate suicide prevention apps that include
safety planning that are available to all Veterans whether or not they
are receiving VA health care.
Prepared Statement of Iraq and Afghanistan Veterans of America (IAVA)
Statement of Stephanie Mullen
Research Director
Chairman Roe, Ranking Member Walz and Members of the Committee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA) and
our more than 425,000 members worldwide, thank you for the opportunity
to share our views, data, and experiences on the matter of suicide
prevention among veterans.
Suicide prevention is an incredibly important part of our work; it
is why it is at the top of our Bix Six Priorities for 2018 which are
the Campaign to Combat Suicide, Defend Education Benefits, Support and
Recognition of Women Veterans, Advocate for Government Reform, Support
for Injuries from Burn Pits and Toxic Exposures, and Support for
Veteran Cannabis Utilization.
Suicide rates over the past 10 years have been rising at a shocking
rate; in 2016, the Center for Disease Control reports that 45,000
Americans died by suicide. \1\ And while suicide is an American
problem, it is severely impacting the veteran population in particular.
According to the most recent Department of Veterans Affairs data,
twenty veterans and servicemembers die by suicide every day. Women
veterans are two and a half times more likely to die by suicide than
their civilian counterparts. And veterans aged 18 to 34, the Post-9/11
generation, had the highest rate of suicide. \2\
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\1\ https://www.cdc.gov/vitalsigns/suicide/index.html
\2\ https://www.va.gov/opa/pressrel/pressrelease.cfm?id=4074
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We've been watching this trendline for years. In our latest Member
Survey, 58 percent of IAVA members reported knowing a Post-9/11 veteran
who died by suicide; 65 percent know a Post-9/11 veteran who has
attempted suicide. In 2014, these numbers were 40 percent and 47
percent respectively. \3\ Our members intimately know the devastation
of this act. And despite recent efforts around suicide prevention, an
increasing number of our members have a personal connection to suicide.
---------------------------------------------------------------------------
\3\ iava.org/survey
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Perhaps no one knows this better than our own IAVA team, many of
whom have been personally affected by veteran suicide. Patrice
Sullivan, IAVA's Senior Veteran Transition Manager within the Rapid
Response Referral Program, knows first hand of the impact a veteran
suicide can have on a community. Her story, in her own words, is below:
On March 13th, 2005, my best friend, my person, my Marine, my Thomas,
died by suicide.
Thomas always knew he wanted to join the Marine Corps, and in June
2000, a week before our high school graduation, he was off to bootcamp.
Thomas was stationed in Okinawa, Japan during the attacks on 9/11, and
I remember him assuring me that everything was going to be ok. There
was no fear in his voice, just genuine love and honor. Being a Marine
gave him a level of confidence and self-worth I had never seen in him
before, a feeling of true purpose.
I can honestly say I didn't see any of the signs, but that doesn't
mean they weren't there. I can say that because I didn't know anything
about suicide. Surviving a loved one's suicide is the most unimaginable
hell. In that one moment, your world is forever changed and nothing
makes sense. You grieve. You cry, scream, but you survive. Some days I
wonder how I've made it through these last 13 years, and I am always
brought back to my first step towards finding hope.
For me, that first step was finding a group of people that could
relate. I found a local support group for suicide survivors on the
American Foundation for Suicide Prevention (AFSP) Web site. It
eventually became my ``safe place'' and I truly believe it saved my
life.
Today, Patrice works on the front lines to combat suicide through
our Rapid Response Referral Program (RRRP). The RRRP team connects
veterans and their families to the support and services they need.
Whether it's navigating the VA or confronting significant challenges
like unemployment, homelessness, legal, financial or mental health
injuries, the RRRP team connects clients to the quality resources they
need. As of September 14, 2018, the RRRP team has handled 8,895 cases
and this year alone, the RRRP team has connected 24 clients to the
Veteran Crisis Line at a critical moment in that client's life. \4\
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\4\ http://iava.org/blogs/rrrp-weekly-impact-report-september-14/
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Suicide is a multidimensional problem that demands a range of
solutions. In 2014, IAVA launched the Campaign to Combat Suicide. This
was a result of our members continually identifying mental health and
suicide as the number one issue facing post-9/11 veterans in our annual
membership survey. This campaign centers around the principle that
timely access to high quality mental health care is critical in the
fight to combat veteran suicides.
The signing of the Clay Hunt SAV Act into law was an important
first step to addressing this. We thank you for your support of this
legislation, and the VA for its commitment to fully implement this law.
Over the past three years, 995 combat veterans have enrolled in VA
health care thanks to the eligibility expansion under this legislation.
Community partnerships and outreach have grown tremendously at VA, and
a one-stop shop for mental health resources, called the VA Resource
Locator, provides mental health resources for those searching for care.
More recently, designated funding for the Clay Hunt provisions
supported the law's implementation, and we appreciate Congress' support
for this additional funding that will improve mental health services
for the 1.6 million veterans who receive specialize mental health care
at the VA. \5\ We look forward to the final evaluation of mental health
and suicide prevention programs called for under the Clay Hunt SAV Act,
expected in December of this year.
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\5\ https://www.va.gov/opa/publications/factsheets/April-2016-
Mental-Health-Fact-Sheet.pdf
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The Clay Hunt SAV Act was a critical piece of legislation to target
mental health and suicide prevention, and bring attention to the
growing need for resources in this area. Since then, we've seen a
number of advancements and many pieces of legislation passed addressing
the issue. Since 2015, within the VA, the Veterans Crisis Line has
expanded, community partnerships have expanded, VA has opened up
emergency mental health care to those with Other Than Honorable
discharges, and started using predictive analytics to reach out to
veterans who show risk factors for suicide.
More recently, IAVA was pleased to work with the VA and other
stakeholders on the plan put forth in conjunction with the Executive
Order (E.O.), Supporting Our Veterans During Their Transition from
Uniformed Service to Civilian Life. This plan involves a comprehensive
and community based approach to suicide prevention, paired with
targeted mechanisms for at-risk populations. As this plan is
implemented, we look forward to being part of this continuing process
with VA, Department of Defense, Department of Homeland Security, and
Members of Congress.
We have come so far since the signing of the Clay Hunt SAV Act in
2015, but there is still much work to be done. Continuing to expand
access to mental health care, easing transition stressors for
servicemembers and their families, ensuring access to suicide
prevention tools and programs, creating community based solutions, and
ensuring high quality and timely data analysis are all essential in
moving the needle on this issue.
Of note, ensuring adequate staffing of VA mental health care
clinicians is imperative to address the issues of mental health and
suicide prevention. Programs such as the loan repayment program for
psychiatrists under the Clay Hunt SAV Act incentivize mental health
professionals to seek a career at VA. We call on Congress to continue
its vigilant oversight of the Clay Hunt SAV Act, ensuring the loan
repayment program and other provisions are fully implemented in
addition to ensuring these provisions are fully funded. We ask that
Congress continue to work with IAVA, other Veteran Service
Organizations, and the VA to fill the critical mental health vacancies
at VA.
We look forward to continuing to work with you on this critical
issue. Thank you for allowing IAVA to share our views.
Prepared Statement of the National Alliance on Mental Illness (NAMI)
Submitted by:
Emily Blair
Senior Manager, Military, Veterans & Legislative Affairs
Chairman Roe, Ranking Member Walz, and members of the Committee,
thank you for affording NAMI, the National Alliance on Mental Illness,
the opportunity to submit a statement for the record (SFR) on this
important hearing examining the most recent Veterans Affairs (VA) data
reports on Veteran suicides. This statement also seeks to cover NAMI's
view of the ongoing efforts to address the crisis of suicide among
Veterans at VA-including the predictive analytics modeling tool REACH-
VET and readjustment counseling-as well as highlighting areas in which
there could be improvement.
NAMI is the nation's largest grassroots mental health organization,
dedicated to building better lives for the millions of Americans
affected by mental illness. Our organization advocates for the
promotion of innovation and research, improving care, and supportive
recovery services for all Americans living with mental health
conditions. NAMI envisions a world where all affected by mental illness
experience resiliency, recovery, and wellness.
NAMI Supports Congressional Efforts to Bolster VA Mental Health
Initiatives
NAMI appreciates that VA continues to designate suicide prevention
as the Department's top clinical priority, the efforts made to
implement suicide prevention programs and the larger focus on providing
increased access to high-quality mental health care. Accordingly, NAMI
applauds Congress for your continuous work on this important issue.
This Congress has made important contributions to this endeavor,
including the substantial investments made in mental health research,
expanding mental health care access at the Veterans Health
Administration (VHA), the passage of the VA MISSION Act, and assuring
Veterans with other-than-honorable (OTH) discharges can access mental
health care at VA-as included in the FY 2018 omnibus. NAMI believes
that all these efforts working together will aid in moving the needle
towards the reduction of Veteran suicides in America-though we all know
more work must be done to realize the goal of an America that no longer
loses its Veterans to suicide.
Fully Funding the VA MISSION Act
NAMI was pleased to see an additional $1.25 billion included in the
FY 2019 Military Construction and Veterans Affairs division of the
Minibus I appropriations package that was recently passed by Congress
and signed by the President. \1\ While it does fall short of the $1.6
billion necessary to fully fund and implement the new Veterans Choice
Fund as passed in the VA MISSION Act for FY 2019, it represents an
initial good-faith investment by Congress to support the new and
improved Veterans health care program.
---------------------------------------------------------------------------
\1\ Energy and Water, Legislative Branch, and Military Construction
and Veterans Affairs Appropriations Act, 2019, H.R.5895, 115th Cong.
(2018).
---------------------------------------------------------------------------
While we understand and appreciate that Congress must be good
stewards of U.S. taxpayer dollars, NAMI remains deeply concerned about
the willingness of Congressional Appropriators to fully fund the
remaining $18.2 billion-over FY 2020 and FY 2021-to cover the costs
associated with the program. Since the current domestic discretionary
budget cap for FY 2019, and the anticipated caps for FY 2020 and FY
2021, did not consider the increased costs associated with the VA
MISSION Act, NAMI strongly encourages Congress to appropriate this
additional discretionary funding to meet the new requirements, without
triggering sequestration.
VA National Suicide Data Report, 2005-2015
When VA released the National Suicide Data Report for 2005-2015 at
the end of June 2018, NAMI remained deeply disappointed and concerned
that among ``general trends in Veteran suicide, previously reported
through 2014, remained consistent through 2015.'' \2\ While we
understand substantial efforts are being made to target this serious
issue within VA, through identifying Veterans at risk earlier,
readjustment counseling services offered at Vet Centers, and providing
increased access to care-it's clear that much more must be done since
the numbers remain the same. It is also understood that full-scale
implementation across an organization as large and diverse as VA takes
substantial time, and sometimes years to determine if efforts yield to
positive outcomes.
---------------------------------------------------------------------------
\2\ (2018, June). VA National Suicide Data Report, 2005-2015.
Office of Mental Health and Suicide Prevention, U.S. Department of
Veterans Affairs. Retrieved August 2018, from https://
www.mentalhealth.va.gov/docs/data-sheets/OMHSP--National--Suicide--
Data--Report--2005-2015--06-14-18--508-compliant.pdf
---------------------------------------------------------------------------
NAMI appreciates the further stratification of the data in the 2015
report to include the specific numbers of suicides among Active-Duty
Service Members, National Guardsmen or Reservists, and Veterans each
day. This small distinction in how the data is presented can aid in
informing how we better identify and provide outreach to individuals
who may be currently experiencing suicidal ideation.
However, as an organization uniquely aware of the toll one single
suicide takes on a family and oftentimes an entire community, we
encourage this Committee, Congress and VA to consider the following
actions in order to reach our shared goal of the reduction-and eventual
goal of zero-suicides among American Veterans.
REACH-VET & Predictive Modeling Analytics
While the Recovery Engagement and Coordination for Health--Veterans
Enhanced Treatment (REACH-VET) predictive model has shown early promise
for identifying Veterans who could be at-risk for suicide at a much
earlier stage, more must be done in the interim to identify and engage
Veterans at more immediate risk for suicide. Data analytics and
predictive models to determine suicidality can be very effective when
utilized properly.
NAMI continues to be interested in the diagnosis piece of the
predictive model and concerned that certain mental health diagnoses
including post-traumatic stress disorder (PTSD), anxiety, bipolar
disorder II, and incidences of traumatic brain injury (TBI) are not
included. NAMI recommends that this Committee work closely with VA to
determine why these mental health diagnoses were excluded from the
REACH-VET suicide prevention predictive model. Additionally, NAMI
recommends this Committee ask VA for written reports or briefings when
components of the model is adjusted. Using data analytics and mining
data from VA health records of Veterans who died by suicide to
determine certain trends for risk is a powerful tool that when
implemented correctly and precisely, can have very positive outcomes.
As such, we also encourage the Committee to ensure VA is utilizing the
best possible data analytics for REACH-VET.
Furthermore, recognizing the correlation between Veterans
prescribed opioids and the high rate of suicides among Veterans, NAMI
would encourage consideration of more collaboration between REACH-VET
and the Stratification Tool for Opioid Risk Mitigation (STORM), a web-
based dashboard that prioritizes review of Veterans receiving opioids
based on their risk, who are receiving care through the Veterans Health
Administration (VHA). \3\
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\3\ Minegishi, T., Garrido, M. M., Pizer, S. D., & Frakt, A. B.
(2018). Effectiveness of policy and risk targeting for opioid-related
risk mitigation: a randomised programme evaluation with stepped-wedge
design. BMJ Open, 8(6), e020097. http://doi.org/10.1136/bmjopen-2017-
020097
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Vet Centers
NAMI is increasingly pleased with the services provided by Vet
Centers, and we refer eligible Veterans to seek care at Vet Centers on
a regular basis because of the continuous positive experience Veterans
report receiving. A trend that NAMI and our state organizations often
see worth reporting is that many Veterans and family members are
unfortunately unaware of the existence of Vet Centers and the
incredible services they provide. Therefore, NAMI recommends that the
Committee work more with VA, Vet Centers and stakeholder organizations
to more widely-disseminate information about Vet Centers.
Rural Veterans
When reviewing the State data breakdown of the 2015 National
Suicide Data Report, NAMI remains deeply concerned about the mental
health of rural Veterans, and their access to high-quality care.
Observing the top 10 rural states by population in the U.S., the
suicide rate among Veterans ranges between 40.3% (40 per 100,000) to
52.3% (52 per 100,000). \4\ In many rural areas and states, there are
very few mental health professionals for hundreds of miles. As such,
NAMI applauds the Committee's work and the passage of the VA MISSION
Act which will, once implemented, greatly improve the care rural
Veterans are able to obtain.
---------------------------------------------------------------------------
\4\ (2018, June). VA National Suicide Data Report, 2015 State Data
Sheets. Office of Mental Health and Suicide Prevention, U.S. Department
of Veterans Affairs. Retrieved August 2018, from https://
www.mentalhealth.va.gov/docs/data-sheets/OMHSP--National--Suicide--
Data--Report--2005-2015--06-14-18--508-compliant.pdf
---------------------------------------------------------------------------
Accordingly, NAMI believes that the provisions specifically
removing barriers for VA health care professionals to practice
telemedicine and treat Veterans across state lines, strengthening peer
supportive networks for Veterans living in rural areas, and the
authorization of access to walk-in community clinics for enrolled
Veterans-will all be positive steps in the right direction for
adequately addressing both the urgent and long-term mental health care
needs of rural Veterans.
Improving Diagnostics through research on Psychiatric Biomarkers
As an organization that promotes innovation to accelerate research
and advance treatment for mental health conditions, NAMI remains very
supportive of the research and development of psychiatric biomarkers
for brain health conditions, and we encourage this Committee and
Congress to make the necessary investments in research to begin to
accomplish this goal.
Currently, the only tools available to diagnose a mental health
condition are survey-based. This results in a large amount of
misdiagnosis of conditions, and therefore lack of timely and
appropriate treatment. NAMI continues to advocate for VA to work in
coordination with the Department of Defense (DoD) to develop and carry
out a longitudinal research study which will identify biomarkers or
non-survey diagnostic tools, which will enable clinicians to make a
more precise diagnosis. This will result in earlier identification of
conditions, which will lead to better treatment outcomes for Veterans
and servicemembers living with mental health and brain health
conditions-to include TBI. Earlier identification and treatment for
these conditions is essential, and we believe a necessary component to
reducing suicides among Veterans.
Utilizing Evidence-based Treatments
As an organization, NAMI is proud that our advocacy North Star is
always based upon the latest scientific research, and that we continue
to be proponents of utilizing evidence-based treatments and
interventions for individuals with mental health conditions. Therefore,
NAMI strongly encourages the Committee to work with VA to ensure mental
health professionals within the walls of VA and community providers
enrolled in the Choice Program, delivering care to Veterans are trained
in and administering the latest evidence-based treatments for those at-
risk of suicide or experiencing suicidal ideation.
Two evidence-based treatments specifically designed to address to
unique needs of an individual who is struggling with suicidal ideation
or has a prior suicide attempt is Cognitive Behavioral Therapy for
Suicide Prevention (CBT-SP) and Dialectical Behavior Therapy (DBT).
CBT-SP is based upon the principles of cognitive behavioral therapy
(CBT) and can be used with adults and adolescents. This treatment
includes cognitive restructuring strategies, such as identifying and
evaluating automatic thoughts from cognitive therapy; emotion
regulation strategies, such as action urges and choices, mindfulness,
and distress tolerance skills; as well as other CBT strategies, such as
behavioral activation and problem-solving strategies. \5\
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\5\ Zero Suicide Model Toolkit: Treat Suicidal Thoughts and
Behaviors Directly: Evidence-Based Interventions for Suicide Risk.
Retrieved September 2018, from https://zerosuicide.sprc.org/toolkit/
treat/interventions-suicide-risk
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Dialectical Behavior Therapy (DBT) has four components, and
numerous research studies including multiple randomized control trials,
have shown DBT to be effective in reducing suicidal behavior and other
mental health conditions. \6\
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\6\ Ibid.
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Conclusion
NAMI is grateful to Secretary Wilkie, Congress and this Committee
for the continued focus on ending Veteran suicide and improving the
lives and care of America's Veterans. We wish to express our gratitude
to the Committee for the invitation to submit a statement for the
record on this important topic.
It is a devastating tragedy that our nation continues to lose an
average of 20 Veterans each day to suicide. This is an issue of
personal importance to myself, the organization I represent and all
NAMI members across the country. We continue to commit our organization
to working shoulder-to-shoulder with Congress, VA, the Department of
Defense, and our advocacy partners to achieve our shared goal of the
reduction, and eventual elimination, of suicide among Veterans in
America.
Prepared Statement of The American Legion (TAL)
Chairman Roe, Ranking Member Walz and distinguished members of the
Committee, on behalf of National Commander Brett Reistad and our nearly
2 million members, we thank you for the opportunity to share the views
of The American Legion regarding Veteran Suicide Prevention.
Introduction
Suicide prevention is a top priority of The American Legion.
Deeply concerned about the number of military veterans who take
their own lives at rates higher than that of the general population,
the nation's largest organization of wartime veterans established a
Suicide Prevention Program under the supervision of its TBI/PTSD
standing Committee, which reports to the national Veterans Affairs &
Rehabilitation Commission.
The TBI/PTSD Committee reviews methods, programs and strategies
that can be used to treat traumatic brain injuries (TBI) and post-
traumatic stress disorder (PTSD). In order to reduce veteran suicide,
this Committee seeks to influence legislation and operational policies
that can improve treatment and reduce suicide among veterans,
regardless of their service eras.
This white paper report examines recent trends in veteran suicide
and their potential causes and recommends steps to address this public
health crisis.
Summary
``I hate war as only a soldier who has lived it can, only as one
who has seen its brutality, its futility, its stupidity.''
- Dwight D. Eisenhower
Since 2001, the U.S. military has been actively engaged in combat
operations on multiple continents in the Global War on Terror. More
than 3 million Americans have served in Iraq or Afghanistan through the
first 17 years of the war. Traumatic brain injury (TBI) and post-
traumatic stress disorder (PTSD) have become known as the ``signature
wounds'' of the war, and in recent years, countless studies, articles
and reports have documented an inordinately high suicide rate among
those who have come home from the war, those of previous war eras and
among active-duty personnel.
The American Legion is deeply concerned by the high suicide rate
among servicemembers and veterans, which has increased substantially
since 2001.(1) The suicide rate among 18-24-year-old male Iraq and
Afghanistan veterans is particularly troubling, having risen nearly
fivefold to an all-time high of 124 per 100,000, 10 times the national
average. A spike has also occurred in the suicide rate of 18-29-year-
old female veterans, doubling from 5.7 per 100,000 to 11 per
100,000.(2) These increases are startling when compared to rates of
other demographics of veterans, whose suicide rates have stayed
constant during the same time period.
In order to combat this crisis, The American Legion believes it is
imperative to determine the causes of the increase in the suicide rate
among these youngest of veterans.
With no current end date to the Global War on Terror in sight, the
Post-9/11 cohort will continue to grow, as will the number of veterans
who require psychological care. The Department of Veterans Affairs
projects a Post-9/11 veteran population of just under 3.7 million by
2020.(3) As our nation deals with the effects of nearly two decades of
conflict, the need for mental health services to care for U.S. military
veterans is certain to increase in the years to come.(4)
It is difficult to determine if the suicide rate among veterans is
higher now than it was after previous wars, mainly due to the quality
of data previously collected. In the past, bias and stigma against
mental injury prevented accurate data collection, research and
treatment. After World War II, those suffering from PTSD symptoms were
often labeled as malingerers, neurotics, having moral turpitude, or as
latent homosexuals.(5) Accurate numbers may also have been hard to
determine after previous wars due to classifications of suicide as
deaths by motor vehicle accident, poisoning, drowning or as other
accidents.
High suicide rates among veterans are not a recent phenomenon. In
1922, The American Legion declared the ``worst casualties of World War
are just appearing'' as high rates of veteran suicide were gaining
national notice four years after the armistice that ended World War
I.(6) In 1921, The Washington Herald reported that the state of New
York lost more than 400 Great War veterans to suicide in that year
alone.(7) Similarly high rates of suicide emerged after the Second
World War, the Korean War and the Vietnam War.(8)
Historically, the peacetime suicide rate among American military
personnel has been much lower than the civilian rate. Experts have
explained this phenomenon by invoking the ``healthy soldier effect''
which suggests that sound emotional, psychological and physical fitness
are necessary for an individual to serve in the military. This healthy
baseline is then complemented by the sociocultural protective factors
of gainful employment, stable housing, additional education and good
leadership.(9) Supporting this premise is the fact that the suicide
rate in the U.S. Army remained stable from 1977 to 2003 before jumping
80 percent in 2004. In 2008, the suicide rate among Active duty
military personnel exceeded that of the civilian population for the
first time in history.(10) This sharp increase corresponded with the
beginning of the Global War on Terror, the longest war in American
history.
Suicidal behavior is complex. There is no single cause. Multiple
factors instead feed into four primary causes discussed in this report:
Post-traumatic stress disorder
Traumatic brain injury
Loss of a sense of purpose
Loss of a sense of belonging
This report concludes with steps The American Legion recommends to
help prevent veteran suicide and reduce a rate of self-inflicted death
that in recent years has risen to a crisis level.
Causes
Post-traumatic Stress Disorder
PTSD, which was first accepted as a recognized diagnosis by the
American Psychiatric As-sociation in 1980, has become a household term
since the terrorist attacks of Sept. 11, 2001. The condition, however,
is as old as warfare itself.
PTSD symptoms among those who have conducted or witnessed the
trauma of battle are addressed in some of the earliest literature.
Reactions to trauma, for example, are described in The Epic of
Gilgamesh, The Odyssey, The Old Testament and Shakespeare's Henry IV.
Among the symptoms recorded in these earliest accounts are reoccurring
nightmares, anxiety, loss of interest and feeling of hopelessness in
reaction to traumatic events.(11)
Suicidal behavior is multi-factorial, and the exact cause of the
high veteran suicide rate remains a matter of considerable debate.
However, what cannot be disputed is the truth that combat is an
extremely stressful and traumatic experience. Exposure to combat can
result in significant psychological injury, which when left untreated
can have a long-term effect on a veteran's health, well-being, family
and society.
Since the Vietnam War, clinicians have noted that suicidal behavior
is a frequent manifestation of PTSD. Multiple studies have clearly
established that combat veterans have higher rates of PTSD when
compared to veterans who have not seen combat.(12) The greater the
exposure to combat the more likely the veteran's mental health will be
negatively affected.(13) In addition, veterans who have sustained
Military Sexual Trauma (MST) are at a higher risk for developing PTSD;
studies have documented that sexual trauma is a risk factor for
suicide.(14)
In 2008, the RAND Corp. reported that at least 20 percent of Iraq
and Afghanistan veterans have PTSD and/or depression.(15) The current
rate of PTSD is consistent with that of veterans from the Vietnam War
and previous conflicts.(16)
The increased rate of veteran suicide since 2001 is often
associated with an increase in PTSD due to combat exposure. A 2017
study of U.S. Army Infantry units, Special Forces personnel and combat
medics revealed that suicide risk varies by military occupation
specialty and combat experience. Troops in combat arms occupations had
significantly higher rates of PTSD and higher rates of suicide.(17) The
connection between PTSD and suicide may be explained by the symptoms of
PTSD experienced. PTSD is correlated to mood alterations including
anxiety, depression, irritability, insomnia and survivor's guilt. These
symptoms and changes in mood have all been shown to be considerably
related to suicide attempts.(18)
In addition to the symptoms, PTSD is also often accompanied by
secondary effects, such as strained intimate relationships after
deployment.(19) Research on combat veterans and their families has
shown that veterans with PTSD are more likely to have severe
relationship problems and higher divorce rates when compared to their
peers without PTSD.
An anonymous and confidential study in 2009 showed that a
relationship exists between PTSD in combat veterans and higher rates of
substance abuse.(20) Substance abuse and relationship problems can
subsequently lead to legal and financial problems, all of which can
place a veteran at risk for suicidal ideation and behavior.
In order to better understand how PTSD is connected to suicidality,
it is important to first understand the effects of PTSD on the human
brain. PTSD should not be considered a mental illness but rather a
psychological injury that alters the way an individual's brain
functions. Traumatic and extremely stressful events are often
associated with drastic changes in the human brain.
Research has shown that individuals with PTSD experience a
hyperactive amygdala as well as volume reduction and decreased
functioning in the hippocampus and prefrontal cortex. This is a
troublesome combination because the amygdala produces conditioned fear
and stress responses to stimuli. The prefrontal cortex keeps the
amygdala's responses in check. A failure of the prefrontal cortex to
control the amygdala would cause a reduction in an individual's ability
to self-regulate responses to mental and emotional stimuli.(21) The
inability of the brain to function normally in its critical roles may
place a veteran with PTSD at higher risk of suicide.
Traumatic Brain Injury
TBI is the most common injury suffered by servicemembers in the
current conflicts in Iraq, Afghanistan and across the globe. According
to DoD, at least 370,688 servicemembers were medically diagnosed with
TBI between 2000 and 2017.(22)
The detonation of improvised explosive devices and indirect fire
account for over 60 percent of U.S. battle casualties.(23) Shock waves
from blasts can cause severe injury to the human brain. Due to modern
armored vehicles, protective body armor and improvements in battlefield
care, servicemembers are surviving attacks that in previous conflicts
would have proven fatal. The ratio of being wounded to killed in the
war in Afghanistan is 7.4 in to 1, compared to 1.7 to 1 during the
Second World War and 2.6 to 1 during the Vietnam War.(24) Saved lives
of military personnel often means more return home with brain injuries.
In a 2008 study, military personnel with TBI were significantly
more likely to report physical and mental health problems than those
with other injuries.(25) This is because chronic neurodegeneration is
often the consequence of traumatic brain injury. Symptoms of TBI may
include memory and concentration issues, irritability and depression.
Many also experience apathy, anger, disinhibition and a lower tolerance
for frustration.
In 2009, a study of active-duty soldiers concluded that TBI
contributes to an increased risk for suicide.(26) Distressingly, each
additional TBI increases the risk. In 2011, research showed that among
Veterans Health Administration users, veterans with TBI were nearly
twice as likely to die from suicide as veterans without a TBI
diagnosis.(27) Veterans with TBI are more likely to suffer from
concentration issues and depression which place them at risk for
suicide.
Sense of Belonging
In the late 19th century, Emile Durkheim, often referred to as a
founder of the field of sociology, wrote one of the first analyses on
suicide. Durkheim believed that one of the main causes was lost sense
of belonging to society. Durkheim also noted that the transition to
modern urban industrialized society had negatively impacted how
individuals connected to their communities. Durkheim concluded that
high levels of isolation and decreased social integration can lead to
suicidal behavior.(28)
During the First World War, psychiatrists noted that ``shell-
shocked'' soldiers treated near the frontlines with the support of
their comrades had a high likelihood of recovery and mental health
improvements. Soldiers who were evacuated away from their units and
placed in hospitals often developed chronic symptoms and were
eventually discharged from the military.(29) This indicates that a
sense of belonging to a group or society contributes to a higher level
of psychological well-being.
Today's veterans rejoin a civilian society which is largely
disconnected from the current Global War on Terror and military service
in general. Fewer Americans than in the past have direct family or
social ties to the Armed Forces. War bond drives and the need for
American workers to rush into factories to create munitions, planes,
ships or tanks for the war effort are a thing of the past, which had
previously connected U.S. society with the war effort. A smaller
percentage of Americans serve in the military today than at any other
time since the period between World Wars I and II.(30)
In a 2011 Pew Research Center study, 84 percent of Post-9/11
veterans said that the public does not understand the problems faced by
those in the military or their families.(31)
Average Americans may view veterans as ``damaged heroes'' often
portrayed in media as objects in need of charity and pity rather than
as potential leaders, co-workers, peers and friends.(32) Research has
shown that the current average American's perception of veterans is
largely formed by how veterans, servicemembers and the military are
portrayed in the media. Veterans are often portrayed as troubled
individuals who struggle to readjust to civilian life due to mental
health and substance abuse issues.
In a recent online survey, participants were asked to describe the
way Post- 9/11 veterans are most often depicted in the media. Among the
top responses were: PTSD, homeless, troubled, unemployed, injured,
suffering, victims, and unstable. Forty-one percent of those surveyed
stated that the way veterans are portrayed in the media is generally
accurate.(33)
Stereotypes can affect how a veteran re-integrates into society.
Research has shown that negative perceptions cause adverse outcomes in
an individual's performance, motivation and self-esteem.(34) Public
perceptions of veterans in need of charity and pity do not promote
recovery from a psychological injury like PTSD but may actually act as
a self-fulfilling prophecy. In order to facilitate recovery,
individuals need social support and understanding. The kind of society
that veterans return to can influence how quickly they recover from
psychological injuries. The key piece is intimate connections and
meaningful trusting relationships with others in society.
Israel has extremely low PTSD rates among its veteran population. A
2016 study in Israel surveyed veterans of combat operations in major
wars from 1948 until 1982. The surveys showed that the probability of
PTSD among those who had combat experience was less than 1 percent.(35)
The low PTSD rates might be attributed to Israel's cohesive society, in
which everyone shares a commonality of service and military experience.
When Israeli veterans return home, they receive social support from
family and loved ones who have served and understand the difficulties
of transition, which may be a contributing factor to the low rates of
PTSD.
Many veterans also face alienation when they enter academia. In a
2011 study conducted by the University of Nevada Reno, over half of
student veterans stated that they do not fit in on campus, and almost
one-third said they feel unfairly judged by their peers.(36)
When servicemembers transition from the military into civilian
life, they undergo multiple personality and social identity changes.
Losing camaraderie and belongingness to a unit can strip individuals of
their social support; many veterans refer to their former military
units as family. The loss of trusting relationships and a social
support system can reduce the way a veteran manages intimate
relationship stressors, financial instability and may lead to substance
abuse or legal issues.
The severity of PTSD cannot be explained by merely looking at the
source or causal event alone.(37) How PTSD manifests itself in an
individual is also impacted by social support systems in place that a
veteran can depend on. Veterans can be affected differently by similar
traumatic experiences. The conditions may vary depending on their level
of social support and solidarity in the society they return to. A close
cohesive and understanding society enhances recovery and can help to
reduce the symptoms of PTSD and help prevent suicide. Israel has
extremely low PTSD rates among its veteran population. A 2016 study in
Israel surveyed veterans of combat operations in major wars from 1948
until 1982. The surveys showed that the probability of PTSD among those
who had combat experience was less than 1 percent.(35) The low PTSD
rates might be attributed to Israel's cohesive society, in which
everyone shares a commonality of service and military experience. When
Israeli veterans return home, they receive social support from family
and loved ones who have served and understand the difficulties of
transition, which may be a contributing factor to the low rates of
PTSD.
Many veterans also face alienation when they enter academia. In a
2011 study conducted by the University of Nevada Reno, over half of
student veterans stated that they do not fit in on campus, and almost
one-third said they feel unfairly judged by their peers.(36)
When servicemembers transition from the military into civilian
life, they undergo multiple personality and social identity changes.
Losing camaraderie and belongingness to a unit can strip individuals of
their social support; many veterans refer to their former military
units as family. The loss of trusting relationships and a social
support system can reduce the way a veteran manages intimate
relationship stressors, financial instability and may lead to substance
abuse or legal issues.
The severity of PTSD cannot be explained by merely looking at the
source or causal event alone.(37) How PTSD manifests itself in an
individual is also impacted by social support systems in place that a
veteran can depend on. Veterans can be affected differently by similar
traumatic experiences. The conditions may vary depending on their level
of social support and solidarity in the society they return to. A close
cohesive and understanding society enhances recovery and can help to
reduce the symptoms of PTSD and help prevent suicide.
Sense of Purpose
Many servicemembers find purpose and meaning during their time in
the military. Serving our nation in uniform, whether here at home or in
combat operations overseas, can be personally rewarding in numerous
ways. Servicemembers often report that having a mission, working as a
team, and completing daily tasks to be fulfilling. The military
provides individuals the opportunity to contribute to something larger
than themselves, to learn new skills and to grow.
The loss of the psychological benefits from their military
obligations can lead some veterans to struggle with despair as they
transition into civilian life. For many veterans, service is core to
their identity and the way they define purpose in their lives. In a
2009 study, 92 percent of veterans surveyed stated that serving their
community was important to them.(38) Data from the same survey shows
that volunteering in communities can help veterans transition smoothly
into civilian life. Fifty-five percent of veterans who volunteer
regularly said their transition was going well, compared to 46 percent
of non-volunteering veterans.
A significant relationship exists between an individual's sense of
purpose in life and his or her psychological well-being and levels of
self-efficacy. The ability to maintain an understanding of one's
purpose for existence has shown to be an important factor to protect
individuals from suicidal ideation. Having a sense of purpose increases
feelings of being able to deal with difficult life events, helps fight
symptoms of depression, and contributes significantly to lower suicidal
behavior and thoughts.(39) A renewed sense of purpose can also help
mediate the effects of moral injury, guilt and cognitive dissonance
felt after losing faith in what some Post-9/11 veterans have deemed to
be a futile war.(40)
Post-9/11 veterans have stood out in the veteran community for
their desire to continue to serve and give back, not only to local
communities but across the globe. Veterans of Iraq and Afghanistan are
finding ways to apply the skills they learned in the military in giving
back to their communities in ways not seen before. Team Rubicon and The
Mission Continues, non-profit organizations founded by Post-9/11
veterans, are challenging veterans to volunteer in disaster response,
social services or youth programs. Research on The Mission Continues
participants has shown dramatic increases in self-worth, strengthened
relationships and enriched family life.(41)
In addition to volunteering on civic projects, Post-9/11 veterans
are running for public office in record numbers. Until 2011, the number
of veterans in Congress decreased every year since the end of the
Vietnam War. The number of veterans running for public office
significantly increased in 2016, and more veterans of the current wars
entered races for public office in 2018. Veterans show through many
avenues that they are a population that desires to continue to provide
meaningful service to our nation.
In February 2015, the Joint Chiefs of Staff wrote a letter
addressed to all of those who have served in the military since Sept.
11, 2001. In their letter, the Joint Chiefs challenged veterans to
begin serving in their communities as soon as they take their uniforms
off.(42) The Joint Chiefs astutely recognized that veterans need a
sense of purpose to live fulfilling lives.
The American public should follow the Joint Chiefs guidance and
encourage veterans to regain their lost sense of purpose through public
service, volunteering, rewarding careers, learning new skills or
crafts, or advocating for issues important to them, just to name a few
options.
Risk factors for veteran suicide
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
ConclusionProgress by the Department of Veteran Affairs
The Department of Veterans Affairs (VA) has taken great strides to
reduce veteran suicide. Of particular note, VA has expanded the
Veterans Crisis Line (VCL), which responds to 500,000 phone calls every
year as well as thousands of electronic chats and text messages. Since
its launch in 2007, through September 2016, VCL staff dispatched
emergency services to callers in crisis over 66,000 times.(43)
VA has hired hundreds of Suicide Prevention Coordinators (SPCs),
mental health professionals that specialize in suicide prevention. SPCs
are based in VA medical centers and local community-based outpatient
clinics all over the country. Over 80 percent of the SPCs are
conducting five outreach activities per month for at-risk veterans.(44)
These events provide opportunities for VA to connect to veterans who
may have fallen through the cracks and are not currently seeking VA
health care.
In 2017, VA implemented REACH VET, a predictive analytics mechanism
that utilizes existing data from VHA records to identify veterans who
may be at risk for suicide. REACH VET measures variables such as age,
gender, prescription medications, missed appointments, emergency room
visits, and other variables to determine risk and notify primary care
providers. By utilizing data and predictive analytics, VA is reaching
more veterans who may have slipped through the system.
VA has made concerted efforts to destigmatize mental illness
through its ``Be There'' campaign. This initiative seeks to teach
community leaders, colleagues, friends and family members of veterans
how they can make differences in a veteran's life. The campaign seeks
to increase social cohesion by educating the American public.
In 2017, VHA had more than 1,100 veterans working as peer
specialists, veterans with formal training who lead support groups,
conduct outreach, case manage and help other veterans navigate the
services available to them. A 2017 study showed that veterans who
worked alongside peer specialists benefited and had increased levels of
``patient activation'' or buy-in. Veterans also showed increased levels
of knowledge, self-efficacy and beliefs in managing their personal
health.(45)
VA has implemented numerous successful initiatives and programs.
However, as an average of 20 veterans a day continue to take their own
lives, according to the June 2018 analysis, much more must be done, and
VA must continue to strive to provide patient-centered care and improve
the patient experience through adequately staffed and properly funded
programs and services.
A June 2018 analysis by VA showed that veteran suicide has
increased at a faster rate for those who have not recently used VA care
and services available to them than for those who have used those
services.
The American Legion's Concerns
Hiring Process
Despite VA's most recent hiring initiative, many hospitals and
clinics are struggling with severe staffing shortages which can be
attributed to the tedious hiring process, a high employee turnover rate
and a significantly reduced recruitment, retention and relocation
budget. The shortage of employees can lead to overworked staff, poor
patient experiences and lower quality of care. Exemplary patient
experience is vital to keeping veterans in the VA care network, which
studies have shown significantly decreases risk of suicide.
According to a 2018 evaluation by the National Academies of
Science, Engineering and Medicine, the Department of Veteran Affairs
has ``difficulty recruiting, problems with retention, and lengthy
hiring procedures that contribute to high vacancy rates throughout the
system, and these vacancy rates can be a barrier to service.''(46)
This is further supported by reports of veteran experience at VA.
When veterans were surveyed, 54 percent stated that the process of
getting mental health care was burdensome, and 49 percent stated that
it was not easy to schedule an appointment. Seventy-seven percent of
veterans said that improving customer service was an important change
needed at VA.(47)
After applying for employment at VA through USAJOBS.gov, qualified
medical professionals can wait multiple months to begin work or even
receive notice. Many applicants report a tedious, confusing and
bureaucratic application process. While waiting to hear back from VA,
many potential candidates seek employment elsewhere.
VA also struggles with a high employee turnover rate. In 2016, GAO
found that Veterans Health Administration personnel losses in key
clinical occupations increased to 7,700 annually. These positions
include physicians, registered nurses and psychologists.
Dissatisfaction with certain aspects of work, dissatisfaction with
senior management, burnout and lack of benefits were reported as top
reasons for resigning. In addition, 50 percent of employees reported
that one or more benefits, such as tuition reimbursement, would have
encouraged them to stay with VHA.(48)
In order to discover and resolve the root cause of the current
resignation rates, The American Legion recommends that Congress fund a
nationwide VA climate survey of mental health professionals. The
American Legion also urges Congress to pass legislation to improve VA's
tedious hiring process and increase VA's recruitment, retention and
relocation budget. These measures will allow VA to retain quality
mental health providers, incentivize exemplary performance, and
increase employee morale.
Dangerous Drugs
Starting in the late 1970s, benzodiazepines, commonly known as
``benzos'' became one of the most prescribed psychotropic drugs in the
United States. Benzodiazepines are a class of psycho-active drugs that
were initially well-favored due to their immediate effect on anxiety,
insomnia and agitation. Xanax, Valium and Klonopin are a few well-known
benzodiazepines. Beginning in the late 1980s, multiple studies revealed
that benzodiazepines had severe negative side-effects, and high
potential for abuse and dependency. VA researchers published reports
that cited studies highlighting the risks of benzodiazepines well
before the Global War on Terror began in 2001.(49) However, despite
knowledge regarding these dangers, VA medical providers have continued
to prescribe benzodiazepines to veterans.
In 2010, VA Clinical Practice Guidelines for the Treatment of PTSD
cautioned providers against the use of benzodiazepines, citing growing
evidence of negative side effects, including an increase of PTSD
symptoms, risk of suicidal thoughts and of accidental overdose. Despite
the severe risks, over 25 percent of veterans newly diagnosed with PTSD
are still being prescribed harmful and potentially deadly amounts of
medications.(50) According to a 2013 study, 43 percent of
servicemembers who attempted suicide between 2008 and 2010 had taken
psychotropic medications.(51) The link between certain dangerous
prescription medications and veteran suicide should be recognized, and
steps should be taken to reduce unnecessary prescriptions.
Additionally, benzodiazepines can be extremely harmful to veterans
who are already prescribed opiates for pain therapy. Sixteen percent of
veterans with PTSD are prescribed a morphine-equivalent dose of opioids
concurrently with a benzodiazepine.(52) The concurrent use of these two
medications is extremely dangerous and puts individuals at increased
risk for overdose. Combining these medications can lead to depressed
breathing, affect heart rhythm, increase sedation and lead to
accidental death. Despite this known risk, VA dispenses benzodiazepines
and opiates concurrently to thousands of veterans every year. Multiple
studies have shown that benzodiazepines have no health benefit in
treating PTSD and that there is extreme concern for overdose among
veterans who misuse alcohol while on them. This is especially
worrisome, considering that nearly 50 percent of veterans with PTSD
also struggle with comorbid substance abuse.(53)
Once initiated, it can be very difficult for veterans to stop or
taper off from benzodiazepines. In many cases, providers prescribe
medications they know are likely harmful to a veteran who is unwitting
to the potential negative side effects. The American Legion recommends
that written, informed consent becomes a requirement before a veteran
is prescribed benzodiazepines.(54) In addition, providers should
clearly document their clinical rationale on why they believe the
potential benefits outweigh the severe known risks and have supervisors
agree and sign off on the decision.
To minimize the dangers of benzodiazepine misuse, The American
Legion recommends that mechanisms be put in place to track and monitor
possible toxic prescription combinations that veterans receive.(55) An
automatic flagging system would alert providers, their supervisors, and
pharmacists of potential fatal prescription drug combinations. It is
also important for state-level prescription drug monitoring program
databases to share data. This can help cut down on doctor shopping and
the unknowing prescription of dangerous drug combinations. This is
especially important considering the potential impacts for many
veterans seeking treatment through the Veterans Choice and Community
Care programs.
Services to Veterans with Other Than Honorable Discharges
Despite reforms intended to halt administrative separations of
veterans suffering from service-related conditions, over 62 percent of
servicemembers separated for misconduct between 2011 and 2015 had also
been diagnosed with PTSD or TBI.(56) Depending on the circumstances,
veterans with ``bad paper'' discharges may not be eligible for a broad
array of VA health care and benefits, including mental health services
that may be critical for veterans with PTSD or suicidal behavior. This
is troublesome because evidence collected by VA continues to indicate
that there are decreased rates of suicide among veterans receiving VA
health care, as opposed to veterans who do not.
The American Legion strongly urges VA to provide mental health care
to any veteran who was deployed in a theater of combat operations or an
area at a time during which hostilities occurred, or any veteran who
participated in or experienced such combat operations or hostilities,
including controlling an unmanned aerial vehicle from a location other
than such theater or area.(57)
Gatekeeper Training
In response to the high suicide rate, it is now time to ensure that
the necessary stakeholders are given training so they may use their
knowledge and skills to identify and refer veterans with suicidal
ideation to care. It is imperative that suicide prevention training is
provided to community leaders, military officers, NCOs, combat medics,
chaplains, human resources staff and office managers. VA and DoD
suicide-prevention training programs such as SAVE or ASIST can provide
those who may be able to intervene the tools they need to save lives.
Complementary and Alternative Therapy
Lack of access to alternative treatments may cause an increase in
patient care program dropouts and a rise in prescription drug use. The
American Legion commends VA for establishing its integrative health and
wellness pilot program. Many veterans have reported great success with
veteran-centric treatments such as acupuncture, yoga, meditation,
martial arts and other forms of complementary and alternative
therapies. It is our responsibility to our nation's veterans to expand
this successful program and ensure all those in need have access.
The American Legion believes all health-care possibilities should
be explored and considered, based on individual veteran needs, to find
the appropriate treatments, therapies and cures for veterans suffering
from TBI and PTSD. These treatments should be accessible to all
veterans; if alternative treatments and therapies are deemed to be
effective they need to be made available and integrated into veterans'
current models of care. The American Legion requests that Congress
provide VA the necessary funding to make complementary and alternative
therapies part of its health-care treatment plan for veterans suffering
from injuries such as TBI, PTSD and other mental health conditions.(58)
Volunteerism
Many veterans return home and miss the sense of purpose and
belonging that they felt from military service. The American Legion is
among the nation's leaders in providing volunteer service and believes
that the nation depends on veterans to continue to engage in their
civic duty. The American Legion recommends and supports any government
efforts to create incentives to encourage volunteerism.(59)
The American Legion's Commitment
Chairman Roe, Ranking Member Walz, and distinguished members of
this Committee, The American Legion thanks this Committee for holding
this important hearing and for the opportunity to explain the views of
the nearly 2 million members of this organization. The American Legion
remains deeply concerned by the high suicide rate among servicemembers
and veterans and is committed to finding a way to help end this crisis.
To ensure that all veterans are being properly cared for at Departments
of Defense and Veterans Affairs medical facilities, The American Legion
has established a Suicide Prevention Program and aligned it under the
TBI/PTSD Committee. This Committee is currently reviewing methods,
programs and strategies that can be used to reduce veteran suicide.
That work will help guide American Legion policy and recommendations.
For additional information regarding this testimony, please contact
Larry Lohmann Esq., Senior Legislative Associate of The American
Legion's Legislative Division at (202) 861-2700 or [email protected]
Supporting American Legion Resolutions
No. 19: Homeland Security and the Opioid Epidemic. Aug. 22- 24,
2017, National Con-vention, calling for increased federal surveillance
and targeted local law-enforcement and public health intervention to
curb opioid abuse.
No. 23: Department of Veterans Affairs Provide Mental Health
Services for Veterans with Other than Honorable and General Discharges.
May 10-11, 2017, National Executive Committee, calling for access to VA
mental health care for qualified veterans who receive Other Than
Honorable or General discharges and for qualified veterans deployed in
combat
No. 2: Suicide Prevention Program. May 9-10, 2018, National
Executive Committee, establishing an American Legion Suicide Prevention
Program and aligning it with the national TBI/PTSD Committee
No. 28: Volunteerism. Oct. 14-15, 1981, National Executive
Committee, encouraging and providing government incentives to increase
volunteerism in the United States
No. 160: Complementary and Alternative Medicine. Aug. 30-Sept. 1,
2016, National Convention, calling for legislation to improve VA and
DoD pain-management policies and acclerate government research into CAM
treatment options for veterans
No. 165: Traumatic Brain Injury and Post Traumatic Stress Disorder
Programs. Aug. 30-Sept. 1, 2016, National Convention, calling for
comprehensive joint DoD-VA TBI-PTSD program in one office that provides
oversight and funding for alternative treatment programs. enhanced
research into effectiveness treatment programs
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2. Ibid.
3. National Center for Veterans Analysis and Statistics. Profile of
Post-9/11 Veterans: 2015. 2017.
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5. Brill and Beebe. A follow Up Study of War Neuroses. VA Medical
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6. The New York Times, Veterans' Suicides Average Two a Day. June
2, 1922.
7. The Washington Herald. Federal Neglect Causes Suicides of 400
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8. Postservice mortality among Vietnam veterans. Journal of the
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31. Ibid.
32. Strengthening Perceptions of America's Post-9/11 Veterans
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https://www.benefits. va.gov/GIBILL/docs/letters/Call%20to%20
Continued%20Service%20Letter.pdf.
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44. Department of Veteran Affairs OIG. Evaluation of Suicide
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patient aligned care teams: protocol for testing a cluster randomized
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46. National Academies of Sciences, Engineering, and Medicine.
Evaluation of the Department of Veterans Affairs Mental Health
Services. Washington, DC. The National Academies Press. 2018.
47. Ibid.
48. Veterans Health Administration: Actions Needed to Better
Recruit and Retain Clinical and Administrative Staff. United States
Government Accountability Office. 2017.
49. Kosten, et al. ``Benzodiazepine use in posttraumatic stress
disorder among veterans with substance abuse.'' Journal of Nervous and
Mental Disease.188, 7. (2000).
50. Krystal, et al. ``It Is Time to Address the Crisis in the
Pharmacotherapy of Posttraumatic stress Disorder: A Consensus Statement
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82. (2017)
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military, 1998-2010.'' Suicide and Life-Threatening Behaviour. 43, 3.
(2013).
52. Hawkins, et al. ``Prevalence and Trends of Concurrent Opioid
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53. Back, Waldrop, and Brady. ``Treatment challenges associated
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Clinicians' perspectives.'' American Journal of Addiction. 18. (2009).
54. Resolution No. 165: Traumatic Brain Injury and Post Traumatic
Stress Disorder Programs. The American Legion. 2016.
55. Ibid.
56. DoD HEALTH: Actions Needed to Ensure Post Traumatic Stress
Disorder and Traumatic Brain Injury Are Considered in Misconduct
Separations. United States Government Accountability Office. 2017.
57. Resolution No. 23: Department of Veterans Affairs Provide
Mental Health Services for Vet-erans with Other than Honorable and
General Discharges. The American Legion. 2017.
58. Resolution No. 160: Complementary and Alternative Medicine. The
American Legion. 2016.
59. Resolution No. 28: Volunteerism. The American Legion. 1981.
Prepared Statement of TriWest Healthcare Alliance
Written Testimony
Mr. David J. McIntyre, Jr.
President and CEO of TriWest Healthcare Alliance
Introduction
Chairman Roe, Ranking Member Walz and Members of the Committee, I
deeply respect you for holding this hearing on the critically important
issue of preventing Veterans' suicides. As long as there is even one
Veteran suicide in any community anywhere in our country, we should not
rest. We should treat the loss of even one Veteran to suicide as a
national tragedy and the loss of 20 Veterans a day as a national
crisis.
This topic is very personal to us at TriWest Healthcare Alliance;
we have several employees who have lost family members to suicide,
including some on our leadership team. Helping Veterans in crisis is
the most privileged, sacred work we do. For us, it is not a business,
but a mission. A mission to find and serve those in need, to ensure
they have access to the right service with the right provider.
Veteran suicide is a heart-breaking issue, a complex issue that
defies simple solutions. If the solutions were simple, Congress and the
Department of Veterans Affairs (VA) already would have implemented
those solutions. VA and the Department of Defense (DoD) deserve credit
for having invested untold efforts and resources into solving the
suicide crisis, but the crisis continues because each case can be
different from every other.
While we might not ever be able to prevent every suicide, it should
nevertheless be our goal. Striving for it should be our mission,
together.
I wish I could offer you today a guaranteed solution to this
crisis, but no one can do that. What I am grateful and humbled to have
the privilege to do is to share with you some of the lessons learned by
TriWest as we have worked for 22 years in partnership with DoD and VA
to reduce suicides by those who wear or have worn our nation's uniform.
If sharing our experiences with you can help save the life of even one
Veteran, I will forever be grateful to you for holding this important
hearing.
Mr. Chairman, I will share with you some background on TriWest
Healthcare Alliance for one and only one purpose today: to help you
understand the nature of our work and the lessons learned regarding
suicide prevention.
If I could summarize the most important lessons learned from
TriWest's many years of workingin support of VA's and DoD's suicide
prevention efforts, it would be these:
1. First, when a Veteran or Service member is at the cliff's edge,
it is critical that there is a clear, simple and quick way for them to
reach out for help.
2. Second, it is crucial that a Veteran on the verge of committing
suicide can talk to a peer who can relate to their service and
situation. The insight of an Army General might explain this when he
once said, ``Before the soldiers care about what I say to them, they
have to know I care about them.'' In short, the Veteran needs empathy
from a fellow comrade, not sympathy from a well-intentioned civilian.
3. Third, the most effective way to prevent Veteran suicide is to
intervene with accessible, timely and quality mental health care
services long before the Veteran is seriously considering suicide. No
health care system in our nation is better equipped to provide that
expert care than our VA health care system. Its expertise in dealing
with Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury
(TBI), military sexual trauma and warrelated combat wounds is second to
none. However, until the day when VA has enough mental health care
providers within its system to handle all mental health care patients'
needs on a timely basis, VA community care must be used, expanded and
improved to prevent the tragedy of Veteran suicide.
Ensuring our nation's Veterans have access to the full range of
timely, high-quality mental health services they have earned and
deserve must be our collective mission. Meeting our Veterans' ever-
growing demand for mental health services is an urgent, life-saving
priority. We owe it to those who have sacrificed so much for us to
provide them with the best care humanly possible.
We should strive to not only prevent tragedy from striking, but
also afford our Veterans an opportunity to live a healthy, full life.
History
Twenty-two years ago, TriWest Healthcare Alliance was formed by a
group of non-profit health plans and university hospital systems. For
the leadership team of TriWest and our 3,000 employees, most of whom
are Veterans or family members of Veterans, what we do is more than a
job; it is an honor to which we are steadfastly and passionately
committed. Our first 18 years were spent helping DoD stand-up and
operate the TRICARE program in a 21-state area.
Today, as you know, TriWest serves as a partner to VA,
administering Patient-Centered Community Care (PC3) and the Veterans
Choice Program in our geographic area of responsibility, which includes
28 states and three U.S. territories. Through these programs, TriWest
serves as a relief valve to VA when it is unable to provide needed care
to Veterans within a VA facility. TriWest now has over 210,000
community health care providers in our network, and we have helped over
1.2 million Veterans receive more than 9.2 million total medical
appointments since the start of the programs we administer on behalf of
VA.
While VA initially was reluctant to use PC3 and the Veterans Choice
Program for mental health services out of concern that community
providers were not familiar with, or fully qualified to address, the
mental health challenges of Veterans, today every VA Medical Center in
our area of responsibility is sending us authorizations for mental
health services. Our network of 22,500 behavioral health providers now
has delivered over 119,000 behavioral health care appointments to
Veterans in their community when they cannot be seen by VA.
Of particular focus to TriWest over the past 22 years has been
serving the mental health needs of our nation's Veterans, Active duty
Service members and their families. During our 18-year engagement with
TRICARE, we learned a great deal and built an extensive mental health
network around military bases in the 21 states we served. We continue
to leverage much of that network today in support of the Veterans
Choice Program and every VA Medical Center in our region.
Key Mental Health Initiatives
Through our 22 years of operation, we have developed substantial
experience in providing quality, accessible mental health care services
and administering suicide prevention programs.
We offer the following initiatives for your consideration as VA and
Congress continue their work together to improve mental health care
services and to prevent suicides for at-risk servicemembers and
Veterans.
1. Expand peer-to-peer support programs. In 2010, the U.S. Marine
Corps asked TriWest for help in designing a pilot to increase access to
mental health support for Marine Corps personnel returning from
deployment(s). We were privileged to help create the ``DSTRESS Line''
pilot providing 24/7/365, Marine-to-Marine Peer-to-Peer Call Center
access to stress/suicide prevention support, staffed by Veteran
Marines, Fleet Marine Force Navy Corpsmen who were previously attached
to the Marine Corps, Marine spouses and family members, and licensed
behavioral health counselors trained in Marine Corps culture. Under the
program, we provided phone, chat and videoconference capability for
non-medical, short-term, solution-focused counseling and briefings for
circumstances amenable to brief intervention, including but not limited
to stress and anger management, grief and loss, the deployment cycle,
parent-child relationships, couples' communication, marital issues,
relationships, and relocations based on the needs of the community
being served.
The Marine Corps leadership believes the program has been hugely
successful as an efficient, effective and innovative peer support
program for Marines to access mental health support by talking with a
fellow Marine they can trust. TriWest provides the staffing resources
for these critical programs aimed at serving the U.S. Marine Corps.
The highly-effective service saved the lives of many. We are proud
to share that no military member who sought support through the DSTRESS
line was lost to suicide. On average, there are over 6,000 total
program interactions each year through calls, chats, and Skype. We
believe there are some valuable best practices learned in this program
that could serve VA well as it continues to expand and enhance
behavioral health services for Veterans.
Due to the success of the DSTRESS line, DoD's Defense Suicide
Prevention Office (DSPO) chose TriWest to construct and implement a 24/
7, global peer-to-peer support suicide prevention program to serve all
military Service members, National Guard and Reservists, and their
families through telephone, chat, text and email. Launched in October
2016, the BeThere Peer Support Call and Outreach Center was designed to
recognize the risks of suicide within the military community and
provide solutions for breaking through barriers when it comes to
seeking help. This program, staffed by Veterans of all the Service
branches and military spouses, builds on the success of the DSTRESS
program providing confidential support from peers who understand
military life. Calls to the peer assistance line have increased
steadily since the program launched, with an average of 250 to 300
interactions per week.
2. Expand mental health training for community providers serving
Veterans. With a desire to expand access to needed behavioral health
services to give VA the critical services it needs, TriWest is moving
beyond simply appointing to our substantial mental health network of
22,500 providers. We have invested in and are training our community
mental health providers in evidenced-based therapies that are known to
be maximally effective in meeting the needs of Veterans. In 2016,
TriWest partnered with PsychArmor Institute, in collaboration with VA,
to help prepare community primary care and behavioral health providers
to most effectively serve Veterans who have so valiantly served our
country. Together, we created a school--a suite of free online courses
taught by nationally-recognized experts--to educate community health
care providers on military culture and the unique experiences and
challenges Veterans face.
Known today as ``Veteran Ready'' (formerly known as ``Operation
Treat a Veteran''), this collaboration between TriWest, VA, the Center
for Deployment Psychology, and PsychArmor Institute offers evidence-
based training to all community-based network providers in the 28-state
TriWest Healthcare Alliance regions of care. Training covers two broad
topics: Military Lifestyle and Culture; and Evidence-based
Psychotherapy. The three learning paths have four levels of training.
Each level of completion corresponds to a level of patient acuity. With
the completion of each level, TriWest will refer Veterans who require
primary or specialty care, or the treatment of PTSD with either
Cognitive Processing or Prolonged Exposure Therapy. And, the Veteran
Ready digital certificate and badge can be earned by providers who
understand the value of military and Veteran cultural awareness in
their practices.
3. Expand community-based tele-mental health care services serving
Veterans. TriWest has designed and deployed a tele-behavioral health
platform to connect community behavioral health providers with Veterans
in need of counseling, who desire the use of this tested modality of
care delivery. The initial rollout of this initiative was in Phoenix,
San Diego and South Texas, and now we are expanding these services
across all the regions we serve. Our telehealth initiative broadens and
strengthens VA's current telehealth footprint aiding Choice Program
Veterans for medication management and psychotherapy. Under this
prototype, we now have approximately 1,500 unique Veterans appointed to
tele-mental health services.
Telehealth increases access to care by increasing size and reach of
each provider because it provides greater flexibility on timing and
location, which lowers travel time and expenses for Veterans. TriWest
continues to focus on expanding the network by assessing locations with
high necessity and high returns, where we are collaborating with mental
health leaders to educate providers and conduct outreach. As long as
there is a shortage of mental health care providers in many parts of
our country, tele-mental health can truly be a life saver for Veterans
who would otherwise not receive timely mental health care services.
4. Expand community mental health options for urgent care. To
ensure that those who are presenting themselves in VA Medical Center
Emergency Rooms, where there is a lack of inpatient mental health beds
to meet the needs of Veterans, VA and TriWest designed and deployed a
pilot program in Wichita, Kansas, that would enable us to place the
Veteran in an inpatient bed with one of our nearby behavioral health
network providers rather than letting him or her wander out the front
door without receiving potentially life-saving services. This pilot
builds on a successful, similar one we conducted in Phoenix. We have
developed the prototype, and VA is using this valuable tool in Kansas
today.
5. Increase VA and DoD collaboration to create a seamless
transition for Veterans.
There is not one simple way to achieve success, and it will take a
concerted joint effort of many to do so. That is why we highly
encourage VA and DoD to streamline their efforts, as they are doing on
Electronic Health Records (EHR), to create a seamless transition for
Service members becoming Veterans. During our work with TRICARE we
learned Service members often become disconnected once their physical
wounds are healed. That is why VA and DoD absolutely need to
collaborate to solidify continuity during the transition to ensure no
Veteran is left behind. We are glad the Administration is spearheading
efforts to consolidate suicide prevention initiatives by uniting
multiple departments and leaders in this space. The Executive Order
will provide a strong framework to create a public-private partnership
from the community to federal level that will help bring resources and
expertise forward to help combat and lower the number of Veterans
committing suicide.
Conclusion
Mr. Chairman, I salute you and this Committee for placing a high
priority on the critical issue of preventing Veterans' suicide. Our
Veterans risk their lives to protect American values and society, so
when their lives are at risk here at home, it is our moral obligation
to protect them.
They have had our back, so now we should have theirs. Collectively,
we must seize the opportunity to enhance access and make the health
care delivery model more efficient and effective. I believe doing so
will necessitate leveraging the best of both the public and private
sectors. No private health care system in the country has more
expertise than VA in addressing the mental health care issues that put
Veterans' lives at risk. The work ahead should not be to replace the VA
system, but to learn from it and to supplement that VA care in the
community, when necessary.
We look forward to doing our part to support VA Secretary Robert
Wilkie and his team in many areas going forward, including in the
critical space of supporting VA in delivering on the mental health care
need.
As TriWest has done for 22 years, we stand ready today to do
whatever it takes to work with Congress and VA to help protect the
lives of our nation's heroes. Together, we can succeed and we must
succeed in this mission, because our Veterans and their families
deserve no less.
Prepared Statement of Veterans Of Foreign Wars Of The United States
(VFW)
STATEMENT OF
KAYDA KELEHER, ASSOCIATE DIRECTOR
NATIONAL LEGISLATIVE SERVICE
Chairman Roe, Ranking Member Walz, and members of the Committee, on
behalf of the women and men of the Veterans of Foreign Wars of the
United States (VFW) and its Auxiliary, thank you for the opportunity to
provide our remarks on veteran suicide prevention.
After examining more than 55 million records of individuals who
served in the United States military from 1979 to 2015, VA released its
most recent publication of veteran suicide data during summer 2018.
This data mostly remained consistent from previous research.
This most recent data showcases that while veterans are 2.1 times
more likely to die by suicide than non-veterans, that rate is highest
for post-9/11 veterans ages 18-24. Yet, veterans over age 55 and those
who served during peacetime experience the overall highest numbers of
suicide.
Veteran suicide is an issue that plagues the veteran community.
There is no justifiable reason for suicide to be in the top 10 reasons
Americans die, let for veterans to be overrepresented in this daunting
statistic--in 2015, veterans made up less than 10 percent of the
American population, yet 16.5 percent of all American suicides. Without
changing, an average of 20 veterans will continue to die by suicide
every day.
In order to address veteran suicide, Congress and the Department of
Veterans Affairs (VA) must invest in more research, increase mental
health providers employed at VA, and conduct better outreach to pre-9/
11 veterans, women and LGBT veterans. There is also more work that can
be done to improve the Veteran Crisis Line (VCL).
Research
Data provided by VA, with thanks to interagency cooperation, is
critical in the hope of eradicating veteran suicide. A third of
veterans, or six of the daily average, who die by suicide were active
VA users. Research indicates that veterans who do not use VA for their
health care are at an increased risk of suicide. Which comes as no
surprise to the VFW, as our members have continuously told Congress
they prefer VA health care.
Veterans service organizations, VA, and Congress must know more
about the two-thirds of veterans who do not use VA and die by suicide.
The VFW urges VA to analyze the demographics, illnesses, socioeconomic
status, and military discharges of those 14. There are questions that
need to be answered in order to properly address this epidemic. Did
those 14 use private sector care? Were they eligible to use VA? Were
they among the many who were discharged without due process for
untreated or undiagnosed mental health disorders related to sexual
trauma or combat? Were they discharged for unjust and undiagnosed
personality disorders due to transgenderism or during the era of
``Don't Ask, Don't Tell?'' If veteran suicide is going to be honestly
combatted, we must know more about the 14 veterans who die each day
without using VA.
As technology continues to improve, VA must continue funding new
ways to reach those in need of mental health care. Over time, VA has
offered computer and phone applications, such as PTSD Coach, for
veterans to conveniently open in their time of need. Yet apps are not
the avenue of prevention or intervention all veterans prefer. More must
be conducted to find reliable statistics regarding what platforms of
technology veterans prefer for all eras and age groups. Those
technologies should also be analyzed by VA researchers to further
understand key phrases and actions taken by those experiencing mental
health crises and/or suicidal ideations. While most people know there
are signs of possible suicide, such as an individual beginning to give
their belongings away, linguistic psychologists in academia have found
there are words used at increased frequency when individuals are
experiencing suicidal ideations and mental health crises. These words
are not the ``cliche'' words currently taught to Americans. The VFW
urges VA to conduct linguistic psychology research, or to partner with
schools, such as Massachusetts Institute of Technology, already doing
so.
With the number of VA opioid prescriptions continuing to decrease,
and the increased number of providers receiving training on effective
psychotherapies specific to post-traumatic stress disorder (PTSD) and
military sexual trauma (MST) patients, the VFW believes VA has made
great strides in treating this population. Yet, it still has more work
to do.
The VFW's members believe medical cannabis must be researched to
determine if it can be a non-pharmaceutical alternative. Conducting
such research would not only provide better education for VA clinicians
to remain informed and providing the highest quality of care, but it
would also provide sound empirical data regarding the medicinal value
of cannabinoids. Varying academic and state-funded studies have found
preliminary results showcasing that medical cannabis may be helpful for
veterans struggling with PTSD or MST, which are closely associated with
increased risk of suicide. The VFW strongly urges Congress to pass H.R.
5520.
Throughout the years, research on mental health issues associated
with combat or sexual trauma, such as PTSD and traumatic brain injury
(TBI), has allowed providers and researchers to understand and diagnose
mental health disorders in ways never before possible. This has been
advanced by extensive genomic research conducted by VA for varying risk
factors such as the SKA2 gene and RNA deficiencies. The VFW also urges
VA to complete recruitment of the Post-Deployment Afghanistan/Iraq
Trauma Related Inventory Traits study, which will provide a pool of
20,000 veterans of Iraq and Afghanistan to identify possible genetic
variations that may influence risk of PTSD and TBI.
Increase Access
The entire nation is experiencing a critical shortage of mental
health providers. In addition to this deficiency, applications to work
at VA have significantly dropped since the 2014 crisis in Phoenix. The
Office of Inspector General determined that in fiscal year 2018, the
Veterans Health Administration's number one shortage was psychiatrists,
with psychologists as the fourth largest shortage. Congress must
provide VA with the assets necessary to increase hiring and retention
of mental health care providers, and to assure they are appropriately
included in graduate medical education improvements passed in the
MISSION Act. The VFW also urges Congress and VA to establish and
monitor quality assurance metrics to hold non-VA community care
providers accountable to.
Mental health providers within VA have continued to receive
extensive training in areas such as prolonged exposure and cognitive
processing therapy, which are the most effective and empirically proven
therapies to treat PTSD. Medication treatments are also offered and,
thanks to the VFW-supported Jason Simcakoski Memorial and Promise Act,
medications are being more closely monitored. Through VA's Opioid
Safety Initiative, opioids are being prescribed on a less frequent
basis for mental health conditions and are better monitored for
negative consequences such as addiction.
The VFW has long advocated for the expansion of VA's peer support
specialists program, and thanks Congress for passing H.R. 4635. VA peer
support specialists are healthy and recovered individuals with mental
health or co-occurring conditions who are trained and certified by VA
standards to help other veterans with similar conditions and/or life
situations. Veterans who obtain assistance from peer support
specialists continuously sing their high praises. Peer-to-peer programs
are also critically important for minorities, LGBT and woman--or any
group within the veteran community which makes up a smaller population
and can at times feel ostracized or as though nobody within their
community understands them. This is instrumental in helping veterans
avoid loneliness, which can lead to suicidality.
The VFW urges Congress to make sure VA has the resources required
to continue expanding this effective, low-cost form of assistance. To
ensure VA is offering a holistic approach in effectively addressing
PTSD, VA must have the ability to provide peer specialists outside of
traditional behavioral health clinics. Veterans overcoming
homelessness, seeking employment, or in mental health crisis would
benefit from these services. For these reasons the VFW calls upon
Congress to pass H.R. 2452, and to further expand this program to other
specific populations.
Aside from veterans receiving support from fellow veterans who have
recovered from similar health conditions and experiencing the bond and
trust veterans share, peer support specialists also greatly assist in
destigmatizing mental health conditions such as PTSD. For a veteran to
become a peer support specialist, they must have actively gone through
treatment, and be living a relatively healthy lifestyle. This allows
veterans who may be struggling to see that their condition is
treatable, manageable, and not something that has to negatively impact
or control their lives.
Outreach to Women, Minorities, and Older Veterans
Outreach works. In August 2017, an entertainer named Logic
performed a song on live television about suffering from suicidal
ideation and mental health crisis, but then eventually getting help and
recovering. The song was titled ``1-800-273-8255"--the National Suicide
Prevention Lifeline. In the days following the performance, the
National Suicide Prevention Lifeline saw a 50 percent increase in
callers. This is just one example showing that VA must conduct more
strategic outreach.
Short of producing music, the VFW has partnered with VA and other
non-government organizations for our Mental Wellness Campaign.
Beginning in fall 2016, this outreach campaign was launched to raise
awareness, foster community engagement, improve research and provide
intervention for those affected by invisible injuries and emotional
stress. Over the last two years more than 200 VFW posts and 13,000
volunteers have successfully reached 25,000 people through our annual
Mental Wellness Campaign Event. This event consists of the VFW, VA, and
other partners conducting community service, spending time with
veterans, their families, and people in the community educating.
Participants learn the five signs of emotional suffering--personality
change, agitation, being withdrawn, poor self-care and hopelessness. VA
also provides information about programs and opportunities for
assistance from VA and local community partners.
In today's society, it seems as though many people assume veterans
at the highest risk of suicide are men who were in combat roles and
served during the post-9/11 era. That is where society is wrong.
Veterans with the highest number of suicide are males over the age of
50, and women veterans who do not use VA.
Studies also show survivors of sexual trauma are among the highest
for increased risk of suicide. With nearly a third of women who serve
experiencing some degree of sexual assault in the military, and LGBT
veterans being overrepresented in that as well, care for survivors of
sexual trauma must remain a priority.
The rate of female veteran suicide since 2001 has increased by
nearly 100 percent for women who do not use VA. Currently, women
veterans are twice as likely to die by suicide as non-veteran women.
While tracking of LGBT suicide data is not currently done by VA, there
is data showcasing that LGBT veterans experience depression and
suicidal ideations at twice the rate of heterosexual veterans. These
numbers are atrocious and completely unacceptable.
The VFW urges Congress and VA to continue expanding telemental
health programs. These programs are often invaluable in decreasing risk
of suicide for sexual trauma survivors--who are overrepresented within
the female and LGBT populations--wanting to use group therapy for
mental health linked to sexual violence. In VA facilities where there
may not be enough women or other individuals comfortable participating
in group therapy, telemental health provides an alternative.
Better outreach must also be conducted to veterans who served prior
to 9/11. Veterans who are age 50 or older make up approximately 65
percent of the total population of veteran suicides. More must be done
to reach this population. Post-9/11 veterans are more likely to enroll
in VA and VA has really excelled at providing access and conducting
outreach to this population. Now it is time to expand these outreach
initiatives and increase their access.
Joint Action Plan
VA is the largest integrated health care system in the United
States. The number of veterans using this system to seek treatment for
mental health care has also continued to increase as more veterans who
served in Iraq and Afghanistan leave the military. This is part of the
cost of war. Congress and VA must ensure those seeking treatment are
provided timely access to VA care.
This year, at the request of the current administration, VA, the
Department of Defense (DoD), and the Department of Homeland Security
began implementing the Joint Action Plan to improve mental health care
access for servicemembers transitioning out of the military for their
first year out of uniform. This plan was set in place with the hope of
annually reducing veteran suicides for a population at increased risk.
The plan focuses on universal access to mental health care for all
veterans during their first year as civilians. Additional framework was
also built for more support of veterans identified to be higher risk.
This way of identifying varies from algorithms already set in place at
VA to identify veterans using VA health services who are among the
highest risk of suicide. The overall goals, which are still being
implemented, include better assurance that all servicemembers leaving
DoD know how to access VA, and streamlining access to their first year
of mental health care.
There are also provisions in the plan that calls for increasing
partnerships between VA and private sector providers. The VFW agrees
that sometimes there is a need for care to be supplemented within the
community, but also firmly believes that these non-VA providers must be
held to a high standard of care. Current reports show the care provided
by non-VA providers is of lower quality, and that these providers
prescribe veterans opioids at an alarmingly higher rate than VA. When a
veteran does require community care, empirically proven forms of
therapy must be done, medical and pharmaceutical records must be shared
with VA, and the non-VA providers must meet or exceed the same standard
as VA. This is particularly true for mental health, as VA's suicide
data shows that non-VA users are more likely to die by suicide.
Veterans who have deployed to a combat zone, but do not have a
service connected disability, still earned the benefit of having access
to VA for up to five years after leaving the military. The VFW supports
all veterans having access to mental health care at VA for their first
year out of service, but watches steadily to assure other veterans who
may be older or combat hardened do not suddenly have to overcome new
found access standards. For this reason, the VFW asks for proper
congressional oversight of the Joint Action Plan and for VA to provide
more transparency during this time of implementation.
Veterans Crisis Line
In 2007, VA established the Veterans Crisis Line (VCL). The hotline
was established to provide 24/7 suicide prevention and crisis
intervention to veterans, servicemembers, and their families. The VCL
provides crisis intervention services to veterans in urgent need, and
helps them on their path toward improving their mental wellness. The
VCL plays a critical role in VA's initiative of suicide prevention and
ongoing efforts to decrease veteran suicide. The VCL has answered
millions of calls and text messages. It has also initiated the dispatch
of emergency services nearly 100,000 times. Since opening its doors in
2007, VCL has expanded to three locations--Canadaigua, N.Y., Atlanta,
and Topeka, Kan.
If a veteran currently calls a VA Medical Center or most Community
Based Outpatient Clinics the veteran will receive the option to dial
the number seven for an automatic transfer to the VCL. This technology
has been successful, but the expansion is another example of VA
struggling to keep up with modernized technology due to lack of funding
and prioritization. The VFW believes all VA facilities, including Vet
Centers, must have this capability sooner rather than later.
The VFW is pleased with other technology modernizations the VCL has
made throughout 2018. This summer, Apple and Android smartphones
developed the capability for Siri and Google Assistant to connect
individuals to the VCL through voice command. Now a veteran can just
say, ``Call the Veteran Crisis Line'' and be connected even if the
number is not saved to their contact list. There will also be a three
number dial-in, similar to 911, which will connect dialers with the
VCL. Current estimates anticipate this new technology will launch in
early 2019.
Prepared Statement of Veterans and Military Families for Progress
(VMFP)
Statement of
Thomas E. Bandzul, Esq.
I thank Chairman Phil Roe, Ranking Member Tim Waltz, and members of
the Committee for allowing Veterans and Military Families (VMFP) to
submit this Statement for the Record on Veteran Suicide Prevention:
Maximizing Effectiveness and Increasing.
VMFP has a long history on trying to promote suicide prevention
because this issue has had a direct impact on members of our
organization, including me. We have worked closely over the years with
other Veteran Service Organizations (VSOs) and promoted legislation to
increase suicide prevention awareness in all the communities we serve.
The suicide crisis has been going on for years, with little
improvement. For example, a research article by Michael de Yoanna
published in 2005 factually stated ``78,000 Veterans and troops were
lost to suicide'' \1\. In following this trend in successive years, it
was found that more veterans were dying from suicide than from combat.
In 2007, CBS News devoted a long segment to challenges facing Veterans
and families. This was followed up by the PBS News Hour in 2008.
---------------------------------------------------------------------------
\1\ VA National Suicide Data Report--2006
---------------------------------------------------------------------------
https://www.cbsnews.com/news/the-veteran-suicide-epidemic/
http://www.pbs.org/newshour/extra/daily-videos/military-sees-rise-
in-troop-suicides/
As an advisor to past Executive Director Paul Sullivan at Veterans
for Common Sense (VCS), VMFP and VCS worked hand in hand with others in
the Veterans community to expound on the need for more resources to
help prevent suicides. In 2007, VCS filed a lawsuit specifically to
increase awareness and raise the issues of this tragic and
heartbreaking scourge plaguing Veterans and the Department of Veterans
Affairs (VA).
The reason VCS took their action was the dramatic increase in the
number of Veteran suicides, the long wait times for Veterans to see a
health care professional, and the ever-increasing delays in processing
valid disability claims. Evidence produced by VCS at trial included
dozens of audits and investigations by the General Accountability
Office and VA's Office Inspector General regarding long waits, improper
appointment documentation (later called ``secret wait lists'' by CNN in
2014), and worse.
An article by Jeff Hargarten published by the Center for Public
integrity, found that ``Nearly one in five suicides nationally is a
veteran; 49,000 took own lives between 2005 and 2011'' and supported
the finding in the VCS law suit \2\. Together with many of the other
VSOs and the help of Congress, this travesty was deemed an ``Epidemic''
within the Veterans communities.
---------------------------------------------------------------------------
\2\ VCS v Erick Shinseki--644 F.3d 845 (9th Cir. 2011).
---------------------------------------------------------------------------
Every year since that time, steps have been taken by VA and the VSO
communities to help promote awareness and institute legislation aimed
at stemming this problem and ending suicides among Veterans. However,
as the grim numbers have shown, the ``epidemic'' remains despite a 2007
law requiring the Department of Veterans Affairs to increase its
suicide prevention efforts. In response to the Joshua Omvig Veteran
Suicide Prevention Act (Public Law No: 110-110)--named for an Iraq War
Veteran who committed suicide in 2005--VA's efforts include educating
the public about suicide risk factors, providing additional mental
health resources for veterans and tracking veteran suicides in each
state. The VA's mental health care staff and budget have grown by
nearly 40 percent over the last six years and more veterans are seeking
mental health treatment.
Since the VCS lawsuit in July 2007, the Veterans Crisis Line opened
in August 2007 and experienced a steady increase in the number of
calls, texts, and chat session visits from former soldiers and active
military persons struggling with suicidal thoughts. The first year,
9,379 calls went to the crisis line. Over a period of more than 10
years, VA has answered more than three million calls. Even more
impressive, VA's dedicated professional staff have dispatched emergency
responders nearly 78,000 times in our view, saving the lives of the
Veterans in crisis. One alternative that should be mentioned as a
possibility is that VA's response to the VCS lawsuit has mitigated what
may very have been a far worse suicide epidemic. VMFP expresses our
thanks to VA staff saving Veterans' lives every day.
https://www.blogs.va.gov/VAntage/44327/veterans-crisis-line-
answered-three-million-calls/ VA \3\.
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\3\ Suicide Data Report, 2012 Department of Veterans Affairs Mental
Health Services Suicide Prevention Program
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In 2009, the Secretary of Defense established a Task Force ``to
examine matters relating to prevention of suicide by members of the
Armed Forces'' and in 2010, the published report was the results of the
two-year study of suicides in the military with a 12-point
recommendation program to help identify people at risk of committing
suicide and prevent future issues. While this was not a panacea, it was
a great help \4\.
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\4\ The Department of Defense (DoD) Task Force on the Prevention of
Suicide by Members of the Armed Forces 2010
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The recommended programs were not implemented by all branches of
the military but the two that did, the US Marine Corp. and the US Navy,
showed dramatic results in lowing the number of suicides, suicide
attempts and suicide threats. At the same time, these two departments
significantly increased awareness programs, budgets for mental health
professionals and cooperation from the highest level of command within
their respective units. (The Commandant of the Marine Corp made a video
on suicide prevention. This was distributed to all levels of all
installations and was mandatory viewing by all Marines).
In each of the following years, this issue gets worse or at least,
no better. The connection between military service and the Veteran
community is tightly integrated and interwoven into this problem. The
logical connection between military service and Veterans is so apparent
that the need to examine the patterns between the two, most believe,
would reveal significant details. This has not yet been fully developed
by previous separate studies within VA and the Department of Defense
(DoD).
VMFP submits this statement because we are deeply concerned about
recent data gathered by VA that indicates the suicide problem remains.
Our nation remains at war. Casualties return home every day, and the
public has moved on.
The ``elephant in the room'' has often been the Veteran's tie to
hopelessness and despair. One of the major driving forces deserving the
attention of Congress and VA is the frustration a Veteran develops
after filing a claim for disability benefits. VA still improperly
denies claims, forcing Veterans into years of complex appeals before a
valid claim is granted. VMFP asks this Committee to request that VA
produce a report to Congress with counts, for the past five years of
the number of Veterans who died waiting for a claim. Veterans have a
right to know how many claims were resolved by death due to suicide or
suspected suicide, for claims pending at every Regional Office, the
Board of Veterans' Appeals, and the Court of Appeals for Veterans
Claims. The five year look-back is important because VMFP understands
there are more than 450,000 VA disability claim appeals now pending. We
ask, how many are those for mental health? And how long have they been
pending?
To VA's credit, based on the advocacy of this Congress and VSOs,
new science-based regulations for posttraumatic stress disorder were
promulgated in 2010. VA's new rules brought benefits to hundreds of
thousands of Veterans with PTSD while also reducing VA's error rate.
https://www.nytimes.com/2010/07/13/us/13vets.html
Finally, we raise one last issue for your consideration: cultural
competency training about Veterans, including suicide prevention. An
issue seldom seen as a possible preventive measure is a level of
improved training for first responders and clergy. In many instances,
the first point of contact with a person in a crisis is either the
police, a fireman, a paramedic, a nurse, or a member of the clergy.
Other than referrals to VA's crisis line, there appears to be no
unified training program used across states adaptable to the needs of
meeting a Veteran contemplating suicide. This means Veteran suicide is
not a Veteran / military / VA challenge. Rather, with our nation
continuously at war and deployed in scores of nations, reducing and
preventing Veteran suicide is a national problem that needs the
attention of all of Americans. Thus, we call for more cultural
competency training for first responders, clergy, plus state and local
governments to identify and refer Veterans for care.
It is VMFP's sincere hope that the integration between VA, DoD,
VSOs, and the public will take place in the near future to combat this
epidemic. Until this becomes the active mission of every person, I
believe there may be some improvements, yet the problem will remain
VMFP fully appreciates all the efforts and concern of Congress. Our
hope is, collectively, we can gather enough resources to put an end to
this forever.
If you have any questions, or if VMFP can be of further assistance,
please contact us.
Prepared Statement of Whistleblowers of America (WOA)
Jacqueline Garrick, LCSW-C
Chairman Dunn and Ranking Member Brownley:
``Never think there was ever anything more that you could have
done.''
I've read that line a hundred times looking for some hidden clue
that would tell me if it were true or not. One of my Vietnam veterans
had died by suicide and left me a note. He had been a combat Marine
suffering from Posttraumatic Stress Disorder (PTSD) and I was his
assigned social worker. The survivor guilt over the men lost in the war
and the nightmares filled with gunfire ate away his spirit. Any sparkle
of kindness or hope he felt would flash across his face as quick as
lighting. He was alienated from family and friends, so his treatment
team was all he felt he had. He saw vodka as a refuge that let his mind
drift back to those buddies on that battlefield. It eventually also
took his body in 1989. The Vietnam War had ended 15 years before, but
its body count was still rising.
For the better part of the next 30 years that statement would
continue to puzzle me. Not because I think I failed him personally, but
because I think that our health care professions and organizations
failed him. I have dedicated my career to combat trauma recovery and
resilience. I did my first (peer reviewed) clinical presentation on
Suicide and Vietnam Veterans in 1990 at a Society for Traumatic Stress
Studies conference. At the time, suicide was the 10th leading cause of
death in America taking about 38,000 lives. For Vietnam veterans, it
was the second leading cause of death behind accidents. The tools for
assessing military combat trauma and PTSD were burgeoning with limited
attention on addressing suicidal thoughts and behaviors. The best
practice was a ``no suicide contract.''
After the Gulf War, Clinical Pathways for PTSD treatment were being
developed, and VA reported an increase in Gulf War Veterans who were
dying by suicide. This was still a time when being in the military was
a protective factor against suicide and the rates were significantly
lower for the Active duty. However, I remember sitting in a meeting at
VA Central Office while Dr. Han Kang noted that female veterans had
died by homicide with greater frequency. When I questioned those
suicide and homicide rates, I was told that it reflected lifestyle
choices and maladaptive behaviors on the part of those veterans. VA was
blaming deceased victims. VA refused to fund further studies to see if
these female homicides were like ``copicides. \1\ `` When I looked at
the VA 2017 suicide data that showed an increase in women veterans who
have died by suicide, I was left wondering if a generation later, women
have moved from choosing dangerous relationships to their own firearm
proficiency. I guess we will never know because, as with much of the VA
data, it does not inform research or intervention priorities.
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\1\ A method of attempting suicide by acting aggressively and
violently toward a police officer to get them to shoot.
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The June 2018 VA National Suicide Data Report; 2005-2015 is
extremely confusing and contradictory to previous data reports released
by VA in several ways. The report itself while describing methodologic
enhancements says, ``These were applied for all years to support
comparisons over time.'' But then it says, ``These updates may limit
direct comparisons of current results with previously reported
findings.'' How did VA make enhancements that limit trend analysis? The
report then adds in military suicide data that it has never reported
upon before. Did the Department of Defense (DoD) coordinate on this
data release and where is their explanation of those numbers? Are these
numbers duplicated in the DoD Suicide Event Report (DoDSER)? Are the
agencies now double counting or over-inflating suicide mortality? The
report notes that in some cases, the VA was unable to confirm Title 38
status, but given the advent of the Suicide Data Repository that
matches to the DoD manpower data, how is this possible? Congress should
ask DoD to comment on these military deaths being reported by the VA.
Regarding opioids, Figure 31 seems to be erroneous in its reporting of
Opioid Use Disorder as it appears to have flatlined at 0 for the last
decade, which contradicts Figure 32. VA should be asked to explain or
correct these data points given the deadliness of opioids in this
country today. However, the most concerning statistic in this report is
the notation that ``Veterans who use VHA \2\ services had a higher rate
of suicide death than non VHA Veterans, overall Veterans and non-
Veterans. Veteran VHA patients with a MH/SUD \3\ diagnosis who accessed
mental health treatment services had higher rates of suicide than other
Veteran VHA patients.'' In its 2016 report, VA said, ``VHA users has a
decreased suicide rate with a mental health diagnosis. Overall VHA user
rate decreased in suicide. In the 2014 report, VA said, ``VHA reported
decreases in suicide rates, including mental health.'' This reverse
trend should be alarming. For several years, VA touted its successes in
treating suicidal veteran. If this was in fact not true or mental
health care had degraded so much so that veterans who use VHA are more
likely to die by suicide, a true overhaul and immediate accountability
is demanded. VA MUST be able to align suicide data to program
effectiveness and the congressional funding allocated. Furthermore,
this data is not the result of psychological autopsies, which would
provide much more in-depth analysis of each veteran who has taken his/
her own life, especially if they were enrolled in VHA.
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\2\ Veterans Health Administration
\3\ Mental Health/Substance Use Disorder
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Decades ago, the Institute of Medicine (now the National Academy of
Medicine) developed a ``protractor'' framework for a continuum of
health care. It is a simplistic model because it is easy to see where
you should be as a clinician or an organization. It helps shape an
understanding of mission and priorities so that the data can be used to
inform funding decisions. Think of it more like a fan that opens and
closes at the necessary points. I used it to inform a strategic plan,
when the DoD asked me to lead the effort in establishing the Defense
Suicide Prevention Office (DSPO) in 2011 and by 2014 we were seeing an
eking downward in some of the mortality numbers. But 2 years later,
when Pentagon experts classified military suicide as the ``new normal''
\4\ because there was no clear pattern to the data that explained the
increases in suicides, I was horrified because that simply was not
true.
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\4\ Zoroya, G. Experts worry that high military suicide rates are
``new normal.'' USA Today. June 12, 2016
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Today, the VA just as the Secretary of Defense needs ``universal''
suicide prevention policies and curriculums to standardize the
messaging and training, but without over-using one tool, like the
Columbia Suicide Severity Rating Scale as a panacea. It needs
``selective'' interventions that takes data points and creates
opportunities for engagement, such as peer support. I once incorporated
predictive analytics to assess wellness within the armed forces, so we
could hone in on Service members with ``indicative'' accumulating risk
factors and a velocity of change. I was glad to see VA embrace this
approach even after it was abruptly cancelled by DoD soon after I left
DSPO, wasting an invested $4 million in development and losing hundreds
of nodes of wellness data on over 2 million active and reserve
components. However, if VA could map wellness risks, it could use a
peer support model to conduct well-being checks, which the Henry Ford
Healthcare System was showing great success implementing. They had
reduced their patient suicide rate to zero by providing caring
contacts. It meant not waiting for someone to engage in help-seeking
behavior but re-lensed the organization's focus onto its help-offering
behavior. Encouraging help-seeking behavior and stigma reduction
campaigns were getting to be too trite with little effectiveness.
But, there is the rub. Senior leaders like awareness campaigns and
spend millions of dollars on them. They make a big splash in the media.
It is measurable in how many outputs--``views'' or ``hits'' Web sites
or social media pages get but does not generate outcomes. Leaders get
to report to Congress on their success. Yet, suicide has been the 10th
leading cause of death in America for 30 years. Research published by
several sources including Stanford University, University of Michigan,
and in a specific study on suicide published by the University of
Southern California (USC) found that, ``.suicides could be prevented if
persons with mental illness were provided care. Instead of doing that,
the mental health industry's main tool in reducing suicide takes the
form of public service announcements, brochures, hotlines, and speeches
targeted to the general population. .. But those charged with
overseeing the funds, refuse to measure rates of suicide to see if the
funds are having an impact. Instead they measure tangential issues like
``attitudes'' and number of presentations made. The money is wasted.''
\5\ese campaigns do not work because they cannot change behavior and
sometimes the unintended consequence is that they normalize the
suicidal behavior they are trying to abate--a phenomenon known as
suicide contagion. Yet, VA has spent over $100 million on a ``Digital
Strategies'' contract to contractors affiliated with a former Assistant
Secretary for Public Affairs. Each year, the VA's Office of Suicide
Prevention rebrands the Veterans Crisis Line Campaign with a new
onslaught of slogans--this year's theme is ``Be There''. In years past,
the slogan has been ``It's Your Call'', ``The Power of One'', and ``It
Matters''. Each year millions of dollars are spent on new posters,
magnets, brochures, coaster, and other giveaways. The Make the
Connection campaign warehouses 736 videos \6\ that are posted on
Facebook and other social media platforms. These videos, albeit
emotionally impactful, are only so until the viewer scrolls to the next
posting. And upon searching the video ``likes'' and ``shares'' there
are an inordinate number of VA employees and contractors in the mix--
giving an inflated sense of impact within the veteran community.
Comments are usually encouraging but are nebulous. Does VA really need
to spend millions of dollars producing 700 videos while there is a
shortage of clinicians?
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\5\ Jaffe, J.D. (2014) Preventing suicide in all of the wrong ways.
Center for Health Journalism. USC Annenberg. https://
www.centerforhealthjournalism.org /2014/09/09/ preventing-suicide-all-
wrong-ways
\6\ https://maketheconnection.net/stories-of-connection
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Furthermore, the most recent IDIQ \7\ contract vehicle created by
VA; Veteran Enterprise Contracting for Transformation and Operational
Readiness (VECTOR) will spend $25 Billion on 68 companies over the next
10 years. Billions of dollars will be spent on more management
initiatives, that include deliverables like trade shows, conferences,
advertising/marketing, public relations, outreach, video and film
production, surveys and other management tools. It is unknown how VA
will assure task order compliance and quality assurance oversight for
68 companies over the next 10 years to mitigate any waste, fraud, and
abuse. It is also unknown if any of the billions spent on VECTOR will
in fact demonstrate an ability to save a single life. Although the
advantage of an IDIQ is it allows flexibility to get things done in a
timely manner, it does not require enunciated statements of work with
performance metrics that can track outcomes. Congress should hold
annual hearings on VECTOR to know what outcomes VA is getting for the
billions it will be spending on non-patient care activities. Will there
be a report?
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\7\ Indefinite Deliverable/Indefinite Quantity
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None of this facilitates treatment outcomes as described by the
above-mentioned USC study in the same way that money spent on hiring
mental health providers, upgrades to the Veterans Crisis Line,
increasing peer support counselors and suicide prevention coordinators
or conducting root cause analyses and psychological autopsies when a
veteran has died by suicide could do. While billions of dollars are
being divert from actual patient care, Whistleblowers of America (WoA)
hears from providers all over the country on how those funding
shortfalls have obstructed their ability to provide actual suicide
prevention and intervention to veterans.
Staffing shortages exist throughout the VA system, including the
Readjustment Counseling Services (RCS). While Vet Centers served a
total of 287,095 Veterans, Service members, and Military Families in
FY2017 and provided 1,960,900 no-cost visits for readjustment
counseling, military sexual trauma counseling, and bereavement
counseling services, it has done so at great compromise to quality
care. Vet Centers are under a mandate to see 30 patients a week and
meet other performance metrics, while still attending staff meetings,
documenting chart notes, writing claims support letters or referrals,
and providing case management services or face an adverse personnel
action. One Vet Center counselor documented over 33 anonymous RCS
employee quotes that categorized their work environment as,
``ruthlessly fixated on productivity; not optimal for patient care;
focus has changed from clinical care to cumbersome bureaucratic record
keeping; unethical practices; coming in on my days off to catch up on
documentation; sleepless; harassing; retaliatory; vindictive; or
traumatizing. Counselors reported impacts to their own emotional and
physical wellbeing and low morale because of the stress and many
respondents were leaving or retiring so as not to burn out and make
judgment errors. However, most compelling were those who reported on
the numbers of veterans who stopped coming to the Vet Center because of
the ``impersonal environment.'' A veteran shared his protest letter to
his Vet Center with WoA.
Other examples of observations shared with WoA:
A VA doctor recently bemoaned that she spends more time looking at
her computer screen than at patients while in sessions, so she can
answer all of the alerts. She believes that loss of eye contact and
ability to read body language impairs her ability to focus on the
veteran's mental status because her back is to the veteran most of the
time.
At one VA Medical Center, a suicide prevention coordinator reported
that they do not have time to complete suicide assessments or write
prevention plans with every veteran who potentially needs one because
of the case load and its complexity. She had 35 patients at one time.
Administrators directed to note patients as ``moderate risk'' for
suicide so as not to raise red flags in the system. When a veteran died
by suicide on VA property, her supervisor refused to conduct a root
cause analysis because that would be too time consuming. While on
another ward across the country, a nurse reported that she is often
left alone at night on a ward with seriously mentally ill patients and
recovering addicts, if one of the patients attempts suicide, he/she
must be sent to the Emergency Room, which requires the enlistment of
another patient to push a wheelchair since she cannot leave the ward
unattended and no other staff is available to arrive urgently. She has
Narcan on the ward, but not the key to the cabinet to get it.
Community Based Outpatient Clinics (CBOCs) are just as challenged.
One social worker reported that patients are not properly diagnosed,
and some are in danger of not being properly followed up on. Another
counselor commented that even when we have access to the Choice
Program, the VA doctor still has to write the referral, it needs
administrative approval, and then the contractor has to process the
request and contact the veteran to schedule an appointment. By the time
that happens months later, the veteran could be dead.
A father lamented that his son went to the VA hospital to get help,
but he was turned away because there was no available bed. He was given
an appointment for several weeks away. He went back to the ER and sat
all night without being seen. In the morning, he killed himself in the
parking lot. The father, also a veteran, felt enormous guilt for having
sent his son to the VA and was now feeling suicidal himself. This
highlights how family member suicide and survivors have little
visibility in the VA system since their needs are mostly met in the
private sector, which impairs a holistic approach to suicide prevention
within the VA community and ignores a primary risk factor for a family
history of suicide.
Additionally, it has come to the attention of WoA that the DSPO
designated $5.5 Million from its DoD line item in its 2016 President's
Budget for ``Veterans Suicide Prevention.'' However, there is no audit
trail for this money. What DoD or VA actually did and who spent the
money is unclear. It is never mentioned again. However, no one yet at
DoD has been able to explain why it needed VA to execute its funds or
for what purpose. Was there a shortfall in the VA suicide prevention
budget? Did Congress not provide VA enough funding?
WoA recognizes that suicide prevention is the new cottage industry.
With government money flowing, there is no shortage of contractors,
nonprofits, or private enterprises looking for those dollars. All too
often appropriated dollars for quality of life programs, such as those
set aside for suicide prevention are awarded by government officials
for contracts and jobs to their friends and family. This practice is so
commonplace, it's dubbed ``the friends and family plan'' by many
throughout the system. If a program manager or contracting officer does
not ``go along to get along'' then the retaliation can be severe as too
many who have contacted WoA have come to learn. WoA has heard from
hundreds of VA whistleblowers that exposing medical errors, patient
care mismanagement, waste, fraud, and/or abuse of funds or authority,
or any other type of wrongdoing becomes an involved, complicated,
expensive, and life altering process. This Committee has passed
legislation in honor of Dr. Chris Kirkpatrick, a Tomah VA Medical
Center psychologist who died by suicide after suffering retaliation in
the wake of his reporting suspected overmedication of the hospital's
mental health clinic's patients. So, you know that reporting wrongdoing
is ``career suicide'' for those who place their patient's care above
their own livelihood. These employees are the powerless in the face of
institutional wrongdoing, incompetence, or bureaucratic policy when
veterans' lives are at stake, but you are not. This Congress can do
more to save veterans and their families from suicide and reducing
program costs by exerting greater oversight and accountability over the
funds appropriated to VA and the alignment of intervention programs to
the data. There is more we can do.
Thank you for considering this statement.
Prepared Statement of Wounded Warrior Project (WWP)
Wounded Warrior Project Mental Health Continuum of Support
Wounded Warrior Project's (WWP) comprehensive approach to mental
health care is focused on improving the levels of resilience and
psychological well-being of warriors and their families. The Mental
Health Continuum of Support is comprised of a series of programs, both
internal to WWP and in collaboration with external partners and
resources, intended to assist warriors and their families along their
journey to recovery. The Mental Health Continuum of Support provides
diverse programming and services in order to better meet their needs.
All programs are at no cost to the warrior or their families.
The programs within the continuum are designed to complement one
another to foster momentum in the healing process. Through the
implementation of the Connor Davidson Resiliency and the VR12 Rand
Quality of Life scales, WWP measures outcomes of services and provides
the most effective programming based on the needs of warriors and their
families.
Inpatient Care
Inpatient care is the highest level of care offered on the
continuum and is intended to meet the most urgent needs of warriors by
providing immediate stabilization. Inpatient services are reserved for
those who are actively suicidal, had recent suicide attempts, require
drug or alcohol detox, or other similarly acute needs. WWP contracts
with a number of vetted skilled facilities across the country. These
warriors have usually exhausted all other resources for care and are in
severe psychological distress.
Warrior Care Network
Warrior Care Network (WCN) is a collaborative program between WWP
and four Academic Medical Centers (AMC)--Emory University,
Massachusetts General Hospital, Rush University, and UCLA. Each AMC
provides a 2-3 week long post-traumatic stress (PTS) centric intensive
outpatient program (IOP) as well as regional outpatient (OP) services.
The IOP is structured around a cohort model with clinicians who
specialize in the care of veterans. WCN is designed for warriors who
are not in acute levels of psychological distress but still have
significant impairment due to PTS and/or other mental health
conditions.
Project Odyssey
Project Odyssey (PO) is a 90 day program which includes a multi-day
event led by WWP teammates specially trained in adventure based
counseling and experiential learning. The strong mental health
component fully integrated into PO is what separates it from other
adventure based programs.here are male only, female only, and couples
POs at multiple sites across the country designed around a cohort model
leveraging the peer to peer support. During the event portion,
participants are challenged through a variety of activities such as
rock climbing, kayaking, high ropes courses, and the like, while
continuously engaged in psycho-education.O not only improves mental and
emotional well-being, but provides additional tools to help with PTSD,
combat stress, and other invisible wounds of war.articipants engaged
with PO are further along in their recovery journey and relatively
stable but are still in need of mental health support. Following the PO
event, participants are engaged by WWP teammates, either telephonically
or via the web, for 90 days to strengthen the skills learned during the
PO, set growth goals, and receive support on goal achievement.
WWP Talk
WWP Talk is an internal program where WWP teammates, specially
trained in active listening, reach out telephonically to warriors,
family members and/or caregivers on a routinely scheduled weekly basis
for 6-9 months. Participants are provided an empathic ear without fear
of judgment and are provided assistance in establishing and achieving
SMART goals. WWP Talk is often used simultaneously while participants
are engaged in other programs and services throughout the Mental Health
Continuum of Support.
Outpatient therapy
Traditional outpatient therapy is a resource available to warriors
and families throughout the continuum. WWP engages with an external
partner to provide individual, family, or couples therapy delivered by
a military culturally competent therapist in the participant's local
community. WWP refers warriors and family members to various external
partners who have created a national network of therapists. WWP funds
12 sessions with the possibility to extend those sessions if clinically
appropriate.
Independence Program
The Independence Program is a long-term support program available
to warriors living with a moderate to severe traumatic brain injury,
spinal cord injury, or other neurological condition that impacts
independence. WWP has a partnership with specialized neurological case
management teams at Neuro Community Care and Neuro Rehab Management to
provide individualized services. These teams focus on increasing access
to community services, empowering warriors to achieve goals of living a
more independent life, and continuing rehabilitation through
alternative therapies.
Living the Logo
Living the Logo is WWP's ultimate goal for all warriors--the WWP
logo is much more than a trademark, it is a symbol of empowerment.
Living the Logo refers to a warrior that was once being carried who has
become empowered through the healing and recovery process and can now
carry another warrior along their journey of recovery. As resiliency
and psychological well-being reach the highest levels in the continuum,
warriors become community ambassadors and engage as peer mentors and
leaders.
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