[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 
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unintentional errors or omissions. Such occurrences are inherent in the 
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                            C O N T E N T S

                              ----------                              

                      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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.

---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \1\ https://www.cdc.gov/vitalsigns/suicide/index.html
    \2\ https://www.va.gov/opa/pressrel/pressrelease.cfm?id=4074
---------------------------------------------------------------------------
    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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \4\ http://iava.org/blogs/rrrp-weekly-impact-report-september-14/
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \5\ https://www.va.gov/opa/publications/factsheets/April-2016-
Mental-Health-Fact-Sheet.pdf
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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

---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \6\ Ibid.

---------------------------------------------------------------------------
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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Their Communities. Center of Social Development. 2013.

    42. The Joint Chiefs of Staff. A Call to Continued Service. 2015. 
https://www.benefits. va.gov/GIBILL/docs/letters/Call%20to%20 
Continued%20Service%20Letter.pdf.

    43. Department of Veteran Affairs OIG. Health Care Inspection: 
Evaluation of the VHA Veterans Crisis Line. 2017.

    44. Department of Veteran Affairs OIG. Evaluation of Suicide 
Prevention Programs in VHA Facilities. 2017.

    45. Chinman, et al. ``Provision of peer specialist services in VA 
patient aligned care teams: protocol for testing a cluster randomized 
implementation trial.'' Implementation Science. 2017.

    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 
of the PTSD Psychopharmacology Working Group.'' Biological Psychiatry. 
82. (2017)

    51. Bush, et al. ``Suicides and suicide attempts in the U.S. 
military, 1998-2010.'' Suicide and Life-Threatening Behaviour. 43, 3. 
(2013).

    52. Hawkins, et al. ``Prevalence and Trends of Concurrent Opioid 
Analgesic and Benzodiazepine Use Among Veterans Affairs Patients with 
Post-traumatic Stress Disorder, 2003-2011.'' Pain Medicine. 16,10. 
(2015).

    53. Back, Waldrop, and Brady. ``Treatment challenges associated 
with comorbid substance use and posttraumatic stress disorder: 
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\.
---------------------------------------------------------------------------
    \3\ Suicide Data Report, 2012 Department of Veterans Affairs Mental 
Health Services Suicide Prevention Program
---------------------------------------------------------------------------
    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\.
---------------------------------------------------------------------------
    \4\ The Department of Defense (DoD) Task Force on the Prevention of 
Suicide by Members of the Armed Forces 2010
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \1\ A method of attempting suicide by acting aggressively and 
violently toward a police officer to get them to shoot.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \2\ Veterans Health Administration
    \3\ Mental Health/Substance Use Disorder

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    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.
---------------------------------------------------------------------------
    \4\ Zoroya, G. Experts worry that high military suicide rates are 
``new normal.'' USA Today. June 12, 2016
---------------------------------------------------------------------------
    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?
---------------------------------------------------------------------------
    \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
---------------------------------------------------------------------------
    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?
---------------------------------------------------------------------------
    \7\ Indefinite Deliverable/Indefinite Quantity
---------------------------------------------------------------------------
    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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