[Senate Hearing 115-336]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-336

          #BETHERE: WHAT MORE CAN BE DONE TO PREVENT SUICIDE?

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

                                 HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 27, 2017

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman

Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Richard Blumenthal, Connecticut
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia

                  Thomas G. Bowman, Staff Director \1\
                  Robert J. Henke, Staff Director \2\
                Tony McClain, Democratic Staff Director

                      Majority Professional Staff
                            Amanda Meredith
                             Gretchan Blum
                            Leslie Campbell
                            Maureen O'Neill
                               Adam Reece
                             David Shearman
                            Jillian Workman

                      Minority Professional Staff
                            Dahlia Melendrez
                            Cassandra Byerly
                                Jon Coen
                              Steve Colley
                               Simon Coon
                           Michelle Dominguez
                             Eric Gardener
                               Carla Lott
                              Jorge Rueda


\1\ Thomas G. Bowman served as Committee majority Staff Director 
through September 5, 2017, after being confirmed as Deputy Secretary of 
Veterans Affairs on August 3, 2017.
\2\ Robert J. Henke became the Committee majority Staff Director on 
September 6, 2017.
                            C O N T E N T S

                              ----------                              

                           September 27, 2017
                                
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......    39
Boozman, Hon. John, U.S. Senator from Arkansas...................    28
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    30
Heller, Hon. Dean, U.S. Senator from Nevada......................    32
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    34
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    37
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    43
Moran, Hon. Jerry, U.S. Senator from Kansas......................    57
Murray, Hon. Patty, U.S. Senator from Washington.................    59
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    64

                               WITNESSES

Daigh, John D., Jr., M.D., CPA, Assistant Inspector General for 
  Healthcare Inspections, Office of Inspector General, U.S. 
  Department of Veterans Affairs.................................     2
    Prepared statement...........................................     3
    Response to posthearing questions submitted by Hon. Mazie K. 
      Hirono.....................................................    75
Bryan, Craig, Psy.D., ABPP, Executive Director, National Center 
  for Veterans Studies, University of Utah.......................     9
    Prepared statement...........................................    11
    Response to posthearing questions submitted by Hon. Mazie K. 
      Hirono.....................................................    76
Kuntz, Matthew, Executive Director, National Alliance on Mental 
  Illness for Montana............................................    16
    Prepared statement...........................................    18
    Response to posthearing questions submitted by Hon. Mazie K. 
      Hirono.....................................................    77
Shulkin, Hon. David J., M.D., Secretary, U.S. Department of 
  Veterans Affairs; accompanied by David Carroll, Ph.D., 
  Executive Director, Office of Mental Health and Suicide 
  Prevention.....................................................    47
    Prepared statement...........................................    49
    Response to request arising during the hearing by:
      Hon. Jon Tester............................................    78
      Hon. Bill Cassidy..........................................    89
      Hon. Joe Manchin III.......................................    89

                                APPENDIX

Falke, Ken, Chairman, Boulder Crest & EOD Warrior Foundation; 
  prepared statement.............................................    89
Keleher, Kayda, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States; prepared 
  statement......................................................    92
Lloyd, Paul, State Adjutant, Department of New Hampshire, 
  Veterans of Foreign Wars of the United States; letter..........    96
Smoker, Kenny, Jr., Director, Fort Peck Tribes Health Promotion/
  Disease Prevention, Fort Peck Indian Reservation, Poplar, 
  Montana; prepared statement....................................    97
Somers SCVA; prepared statement..................................    99
    Attachment 1: Daniel Somers fairwell letter..................   110
    Attachment 2: TRIBE white paper..............................   113
    Attachment 3: Support Network................................   132

 
          #BETHERE: WHAT MORE CAN BE DONE TO PREVENT SUICIDE?

                              ----------                              


                     WEDNESDAY, SEPTEMBER 27, 2017

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room 418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Moran, Boozman, Heller, Cassidy, 
Rounds, Tillis, Sullivan, Tester, Murray, Brown, Blumenthal, 
and Manchin.

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

    Chairman Isakson. Let me call this hearing of Veterans' 
Affairs Committee to order. I thank all of you for coming 
today, especially our witnesses. We have a number of Members 
who are on the way, but in the interest of your time, we are 
going to go ahead and get started.
    Today's hearing is about the issue of suicide. As many 
people in the room know, this month in America is National 
Suicide Prevention Month across the country. Suicide is a 
terrible, terrible, terrible loss, a wasteful loss of life, a 
preventable loss of life.
    I think Jon will remember when we first came in as a 
Committee 3 years ago, our first bill that was passed was the 
Clay Hunt Suicide Prevention bill. It passed this Committee 
unanimously and the Senate 99-0. We will ask the Secretary and 
the other members from the VA who are here today to give us any 
report they might have on the progress on the implementation 
that is done in terms of the Clay Hunt Act. It is a very 
important Act.
    In August 2014, I held a hearing at Georgia State 
University as a Member of this Committee. It was a field 
hearing on the issue of suicide. The reason I did was because 
in that years and the months leading up to August 2014, the 
Georgia principal VA hospital on Clairmont Road in Decatur had 
three suicides, two on campus, some of it from mishandling 
available tools for suicide like pharmaceuticals and things of 
that nature, others for a lack of awareness, and many for a 
lack of capacity. That was the real thing that concerned me. So 
we began working in the Clairmont VA hospital in Atlanta to 
improve VA's response to suicide and to mental health issues.
    Suicide is a disease, and it is preventable, and there are 
many things that we can do. To set the example, our staff 
director, Bob Henke, did a great job of seeing to it that every 
member of the staff, majority and minority, has been through 
the SAVE training for suicide prevention.
    SAVE stands for signs of suicide thinking should be 
recognized; ask the most important question of all, ``Are you 
thinking about committing suicide?,'' which is a tough thing to 
address but the key question to ask; validate the veteran's 
experience; and encourage treatment and expedited getting help.
    I can tell you from what we learned in Atlanta and have 
learned in the VA, timing is everything, as it is in health 
care and most things, the golden hour we know about in health 
care, but when someone is contemplating suicide, it is not 
something you put off to an appointment on Wednesday or to 
another day. It is something you deal with immediately, you 
deal with quickly, and you expedite the response to it.
    I want to thank the staff for going through the training, 
and just like the Heimlich maneuver has saved many a life in a 
restaurant when somebody was choking and somebody else knew how 
to apply that maneuver which freed their air passages, just 
like CPR has helped people who had untimely heart attacks, just 
like CPR has helped people who might be drowning or might have 
drowned and been brought back to life. But, being aware of the 
training that is necessary to save a life is critically 
important, and we are going to see to it in our Committee that 
we promote this training throughout the VA and throughout the 
government to see to it that we are saving lives and helping 
people to recover and restore their life.
    I want to thank Bob Henke for his commitment to doing it on 
the staff and thank all the staff members for having done it 
and thank the Members of the Committee for their effort as 
well.
    We have two panels today on the issue of suicide. Our first 
panel is Dr. John Daigh, Assistant Inspector General for Health 
Inspections. Second is Craig Bryan, Dr. Craig Bryan, Executive 
Director of National Center for Veterans Studies, University of 
Utah; and Dr. Matthew Kuntz, Executive Director of the National 
Alliance on Mental Health for Montana.
    We appreciate all three of you being here today. You will 
be allowed to give up to 5 minutes of testimony. We do not have 
a whistle that blows at the end of 5 minutes, but after 10, you 
will be in big trouble. [Laughter.]
    All your statements will be printed for the record and be 
memorialized in the record, and that will be by unanimous 
consent.
    With that said, we will start with Dr. Daigh and your 
testimony and go down the list from there. Welcome.

STATEMENT OF JOHN D. DAIGH, JR., M.D., CPA, ASSISTANT INSPECTOR 
    GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR 
          GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Daigh. Thank you, Chairman Isakson, Ranking Member 
Tester, Members of the Committee. It is an honor to testify 
before you today on the subject of suicide prevention. This 
topic is important to Mr. Missal and all of the staff at the 
Office of Inspector General, OIG. We work to ensure veterans 
receive the highest-quality mental health care.
    We have reviewed in-depth facts surrounding the death of 
many veterans who took their own lives. Often we find these 
veterans suffered the effects of chronic mental illness and 
substance abuse disorder.
    In the aftermath of these deaths, we frequently hear from 
members of the veteran's family, significant friends, and VA 
providers that they would have acted sooner or differently, if 
only they had known.
    After the Virginia Tech shooting, a serious review of the 
privacy laws that impact the disclosure of medical information 
was undertaken. My staff met with and talked with a number of 
the individuals who were involved in this review to determine 
if there were lessons learned that could be applied to VA.
    Changes to law seem too difficult to design; however, 
changes in practice that utilize advance directives or similar 
devices may offer a way to improve communication at the 
critical point when the patient needs help the most. I think 
there is a chance to improve communication by expanding the 
situations under which these and similar devices are used.
    VA has thoughtfully derived a model to predict who may 
suicide. The question is, When would an at-risk veteran take 
action to harm themselves or harm others? When would 
intervention be most effective?
    Research using social media and other more timely data has 
shown promise in understanding the human emotional state and, 
therefore, may assist in identifying when intervention for 
these at-risk individuals would be most successful. I think 
research and pilot studies in this has great potential.
    The testimony of others at this table point out that many 
veterans do not obtain their care primarily from the VA 
hospital system, and so an effort to reach those veterans who 
are at risk is most appropriate and essential if we are to make 
a significant improvement in veteran suicide data.
    This concludes my oral testimony, and I would be pleased to 
answer your questions.
    [The prepared statement of Dr. Daigh follows:]
    Prepared Statement of John D. Daigh, Jr., M.D., CPA, Assistant 
   Inspector General for Healthcare Inspections, Office of Inspector 
              General, U.S. Department of Veterans Affairs
    Mr. Chairman, Ranking Member Tester, and Members of the Committee, 
Thank you for the opportunity to discuss the Office of Inspector 
General's (OIG) recent work on VA's efforts to prevent veteran suicide. 
Suicide is a serious public health concern. Beyond the loss of life to 
the victim, suicide takes a profound toll on survivors, caregivers, and 
the community. Likewise, incomplete suicides, taking the form of 
suicide attempts, gestures, and other acute self-destructive behaviors, 
are associated with injury, an emotional toll, and personal and 
societal financial burdens. Therefore, prevention initiatives and 
interventions that might reduce suicidal behaviors are of enormous 
importance.
    Since 2006, the Veterans Health Administration (VHA) has 
implemented several initiatives aimed at suicide prevention, including 
the appointment of a National Suicide Prevention Coordinator (SPC), the 
establishment of the suicide prevention hotline (Veterans Crisis Line 
(VCL)), the development of a patient record flagging system to identify 
high-risk patients, and the creation of suicide prevention programs in 
each facility. In addition, VHA expanded facility SPC roles, requiring 
them to participate in community outreach activities. The purpose of 
these initiatives was to reduce the stigma surrounding mental health 
(MH) conditions, provide access to MH services, and promote public 
awareness of suicide.
    Recognizing the importance of this issue, the OIG has focused 
resources in conducting oversight of VHA's suicide prevention efforts. 
My statement today focuses on some of our more recent reviews 
highlighting opportunities where VHA can strengthen its suicide 
prevention efforts.
   overview of va suicide prevention efforts and data collection \1\
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    \1\ Healthcare Inspection--Overview of VA Suicide Prevention 
Efforts and Data Collection, https://www.va.gov/oig/pubs/VAOIG-16-
00349-369.pdf, September 19, 2017.
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    Our objective for this recent report was to answer several 
questions regarding VA's suicide prevention programs:

     How do you know if the programs are working?
     What percent of veterans who die by suicide have been 
under the care of VHA?
     Are data on suicides turned over to MH providers in real 
time?
     What risk factors associated with higher veteran suicides 
are being explored in depth, and by whom?
     What ways can be identified to gather more reliable 
suicide data?

How do you know if VA's suicide prevention programs are working?
    Whether or not suicide prevention specific policies, programming, 
and strategies are having a positive effect may be ultimately reflected 
in outcome measures, specifically in identification of sustained 
downward trends in completed suicide rates, suicide attempt rates, and 
suicide re-attempt rates. There are limitations to determining the 
outcome measures of VHA's suicide prevention programs. The limitations 
included that VHA staff were not always notified when a veteran died by 
or attempted suicide, and suicide data were only as reliable as the 
information provided on the death certificate.
            Population Based Measurement
    We found that VHA staff tracked suicide rates of all veterans and 
other VHA users by matching suicide deaths from the National Death 
Index (NDI).\2\
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    \2\ The NDI, a self-supporting service of National Center for 
Health Statistics (NCHS), is a component of the National Vital 
Statistics System. NDI is a centralized database of death record 
information compiled from state vital statistics offices. NCHS website, 
www.cdc.gov/nchs/data/factsheets/factsheet_ndi.htm. Accessed 
January 19, 2017.
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    When VHA leaders set up the VHA suicide prevention program, it was 
based on the hypothesis that improving access to high quality, 
evidence-based MH care, supplemented by specific suicide prevention 
programming, would affect suicide rates. However, capturing the impact 
of suicide prevention programming is challenging. While access and 
process measures identified variations in implementation of, or 
adherence to, MH and suicide prevention specific policies and 
programming, quantifying the impact of suicide prevention programming 
was more difficult.
    Several VHA initiatives may have been simultaneously ongoing, 
thereby creating difficulties in teasing out individualized 
programmatic or operational impact at the individual facility and 
Veterans Integrated Service Network (VISN) level. In addition to not 
having a large enough population size to address global effect and co-
occurring programming initiatives, site-to-site variability in 
population size, demography, and other variables rendered site-to-site 
comparisons problematic. For these reasons, evaluation of whether VHA 
efforts were working was most amenable to a national (or population 
level) analysis of the trend of suicide rates over time as a reflection 
of the impact of the portfolio of MH and targeted suicide prevention 
programming.
    On a facility level, site-to-site variability impacted the accuracy 
in program evaluation-outcome analysis. This limitation may in part be 
circumvented by comparing intra-facility (same facility to itself) 
suicide rates over a several year period, or alternatively through use 
of predictive analytics based risk-modeling.
            VHA Staff Measures Completed Suicide and Attempt Rates
    The development and expansion of the joint VA/Department of Defense 
(DOD) Suicide Data Repository allowed for identification of suicide 
rates within the U.S. veteran population and other VHA users. VHA staff 
calculated completed suicide and attempt rates using both internal and 
external sources.

     VHA Data Collection of Known Suicide and Suicide Events. 
In 2008, VHA MH Services established an internal suicide surveillance 
and clinical support system. VHA SPCs enter data on suicides and 
suicide events (non-fatal attempts, serious suicidal ideation, and 
suicide plans) known to VHA into the Suicide Prevention Applications 
Network (SPAN) database, which is maintained on the VHA campus in 
Canandaigua, New York. Coordinators enter multiple data elements 
related to completed and attempted suicides. These data elements 
include the patient's medical and MH diagnoses; whether the patient had 
a history of previous attempts; whether the patient was seen at VA 
within 7 and 30 days of the suicide event; and the patient's military 
era.\3\ The data limitation was that only suicides and attempted 
suicides known by VHA SPCs were captured in the data.
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    \3\ Military era is the period in which a servicemember served in 
the military.
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     VHA Analyses of Known Suicide Attempts and Suicide Re-
events. Each year, the VHA Serious Mental Illness Treatment Resource 
and Evaluation Center and staff funded through the suicide prevention 
program at the Center of Excellence (COE) completes an annual analysis 
of non-fatal suicide attempts and re-attempts.
     Matching to the NDI to Determine Rates among VHA Users. 
The Serious Mental Illness Treatment Resource and Evaluation Center 
staff matched individual VHA services users with individual deaths 
coded as suicides in the Centers for Disease Control and Prevention 
(CDC) National Center for Health Statistics (NCHS) NDI databases as a 
separate effort to calculate suicide rates. Veterans who stopped using 
VHA services in the prior year were considered possible deaths, and 
staff compared these veterans' information to the NDI database to 
determine actual veteran deaths and the subset of suicide deaths.
     Compared to the SPAN data, this methodology expanded the 
numerator from suicide deaths known to VHA to suicide deaths among all 
VHA services users. Compared to the state-based reporting agreement 
initiative, the NDI match captured deaths occurring within the U.S. 
that were reported by all 50 states.
What percent of veterans who die by suicide have been under the care of 
        VHA?
    On August 3, 2016, the VA Office of Suicide Prevention published 
the report, Suicide Among Veterans and Other Americans 2001-2014. This 
report provided a systematic assessment of characteristics of suicide 
among veterans--both those veterans who used VHA services and those who 
did not--and compared veteran suicide data, such as rates, to non-
veteran suicide data. Key findings of the suicide mortality data in the 
report were obtained from the VA/DOD Joint Suicide Data Repository, 
which included:

     VA epidemiologists and other subject matter experts in the 
field conducted analyses of suicide data. The data showed that an 
average of 20 veterans died by suicide each day, 6 of the 20 were 
recent utilizers of VHA services--in the year of their deaths or the 
previous year.
     The risk for suicide was 21 percent higher among veterans 
when compared with U.S. civilian adults after adjusting for differences 
in age and gender.
Are data on suicides turned over to MH providers in real time?
    We found that real time data on suicide, such as statistics on 
suicide rates by age, race/ethnicity, gender, suicide methods, and 
number of suicide attempts, were not available to MH providers in all 
states. Delays in collecting and sharing relevant data occurred in 
states that utilized paper-based reporting systems.
    According to NCHS staff, approximately 75 percent of the vital 
records jurisdictions have implemented electronic death registration 
systems (EDRS). In jurisdictions with fully or partially functioning 
EDRS, funeral directors initiated the process by entering decedent 
demographic data. A medical certifier,\4\ in the case of a natural 
death, or a coroner \5\ or medical examiner,\6\ in the case of an 
unnatural death,\7\ then entered cause of death determinations into a 
computer data system. The completed record was electronically 
transmitted to the appropriate jurisdiction that, in turn, linked the 
information to the state's vital records statistics office. In 
jurisdictions with paper-based death reporting, the coroner, funeral 
director, medical certifier, and/or medical examiner filled out and 
transmitted paper forms via mail to the state's vital statistics 
office. The deployment of an electronic reporting system by all states 
and the use of such a system by funeral directors and medical 
certifiers allowed for the creation of more timely aggregate data. Such 
data was readily available to each state's vital statistics offices and 
to the NDI in near real time.
---------------------------------------------------------------------------
    \4\ A medical certifier can include physicians, nurse 
practitioners, dentists, and physician assistants.
    \5\ Coroners are not required to be physicians and typically have 
varied backgrounds; 80 percent are elected to their position, and they 
typically operate via a county-based system.
    \6\ Medical examiners are forensic pathologist physicians, 
typically appointed, and operate via a statewide system.
    \7\ An unnatural death can include drug overdose, suicide, or 
homicide.
---------------------------------------------------------------------------
What risk factors associated with higher veteran suicides are being 
        explored in depth, and by whom?
    We identified several VA and non-VA research projects and 
initiatives underway that included risk models, analyses of social 
media, and ongoing research by the COE and the Mental Illness Research, 
Education and Clinical Center (MIRECC).
    VA leaders implemented a predictive analytics risk model to enhance 
clinical care. The model identifies which patients are potentially at 
highest risk of suicide and assists clinicians in implementing 
preventive interventions. At the time of our review, VA developed a 
model focused on providing individualized clinical and preventive care 
for patients who were in the highest 0.1 percent at risk for suicide. 
Another model in development focused on patients in the highest 5 
percent at risk using a broader, population-based public health-
oriented intervention.
    We found non-VA researchers conducted pilot studies analyzing 
social media posts, aimed at identifying changes in patients' MH status 
and/or suicidal ideation to determine suicide risk factors. These 
researchers identified research barriers that included access to death 
and death-rate data, limited availability of grant funding, and privacy 
concerns. Other barriers included leaders' and clinicians' concerns 
regarding litigation, social media, and time and productivity 
allocations.
    We found that National Center for Veterans Studies (NCVS) \8\ 
researchers analyzed social media postings of military servicemembers 
who died by suicide and of a demographically matched control group. The 
research revealed that those who died by suicide were more likely to 
avoid interpersonal situations and/or lacked interest in participating 
in activities with others and had more frequent conversations about 
sleep problems. Researchers also found that immediately prior to a 
servicemember's death by suicide, the servicemember expressed 
difficulties related to interpersonal relationships and generalized 
stress. They were also less likely to communicate feelings of anger, 
which may suggest the military servicemembers had ``resigned'' 
themselves to their situation. Researchers found that servicemembers 
who died by suicide were less likely to express anger in their posts, 
but more likely to post about negative employment, access to or 
ownership of firearms, emotional distress, self-help, and implied 
suicide. An identified barrier with the research was the availability 
of grant funding and a ``Catch-22'' situation of needing pilot data to 
obtain grant funding for expanded research.
---------------------------------------------------------------------------
    \8\ NCVS is affiliated with the College of Social and Behavioral 
Science at the University of Utah and is not affiliated with the VA.
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What ways can be identified to gather more reliable suicide data?
    The collection of data related to suicide is useful in identifying 
and determining who is at the highest risk of attempting or completing 
suicide. Types of data collected included, but are not limited to, 
suicide rates by age, race/ethnicity, and gender; suicide methods; and 
number of suicide attempts. Once clinicians are able to determine who 
is at the highest risk for suicide, clinicians can then better target 
intervention and prevention plans.
    We found that ways to gather reliable suicide data include:
            Full Implementation and Use of Standardized Terminology 
                    such as the Self-Directed Violence Classification 
                    System and its Clinical Tool by VHA Clinicians \9\
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    \9\ The Self-Directed Violence Classification System (SDVCS) 
clinical tool is used by clinicians to help themselves, researchers, 
and others classify clinical cases. The tool is broken down into three 
decision trees: suicide thoughts only, behaviors without injury, and 
behaviors with injury.
---------------------------------------------------------------------------
    Several definitions for suicide and non-fatal self-harm have been 
developed over the years. In 2003, CDC staff started work on what they 
called the self-directed violence surveillance that included uniform 
definitions and recommended data elements.\10\
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    \10\ BB Matarrazo, TA Clemons, MM Silverman, LA Brenner. The self-
directed violence classification system and the Columbia classification 
system algorithm for suicide assessment: a crosswalk, Suicide Life 
Threatening Behavior. June 2013; 43(3):235-249.
---------------------------------------------------------------------------
    In 2008, the then VA Secretary, Dr. James B. Peake, formed the 
``Blue Ribbon Work Group on Suicide Prevention in the Veterans 
Population'' in order to improve VHA suicide prevention programs, 
research, and education. Unclear and unstandardized use of terms 
related to suicidal behaviors prompted the work group to recommend the 
adoption of a standard nomenclature for ``suicide definition,'' 
``suicide,'' and ``suicide attempts.''
    In 2009, MIRECC staff and other researchers in the field,\11\ which 
included CDC researchers, collaborated to finalize terms incorporated 
into the Self-Directed Violence Classification System (SDVCS). MIRECC 
staff developed a table to aid clinicians in understanding the SDVCS. 
The table is broken down into types, subtypes, definitions with 
examples, modifiers, and terms. The back of the table includes key 
definitions. MIRECC staff also developed the SDVCS clinical tool to 
help clinicians, researchers, and others classify clinical cases.\12\
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    \11\ CDC and the Senior Advisor to the Suicide Prevention Resource 
Center (and other research team members representing the VISN 19 
MIRECC; the University of Colorado, Denver, School of Medicine; 
Wellstar Health System, Georgia; the University of Georgia; and the 
Department of Biostatistics and Informatics, Colorado School of Public 
Health).
    \12\ Bridgett B. Matarrazzo, Psy.D. The Self-Directed Violence 
Classification System (SDVCS), what it is and why it matters 
(PowerPoint presentation), VHA VISN 19 Mental Illness Research, 
Education and Clinical Center and the University of Colorado, School of 
Medicine Department of Psychiatry, developed in collaboration with CDC.
---------------------------------------------------------------------------
    In 2010, in response to a recommendation \13\ by the Blue Ribbon 
Work Group, VHA announced the adoption of the SDVCS and the SDVCS 
clinical tool, which were adopted later by DOD. Implementation efforts 
have included promoting the use of the SDVCS clinical tool and 
distributing educational materials.
---------------------------------------------------------------------------
    \13\ The recommendation was to adopt a standard nomenclature/
definition for suicide and suicide attempt that was consistent with 
other Federal organizations, such as the CDC and the scientific 
community.
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            Medicolegal Death Investigation Reporting Training for 
                    Those Responsible for Completing the Medical 
                    Portion of the Death Certificate
    A medicolegal death investigation is an investigation of a 
suspicious, violent, unexplained, or unexpected death. A medicolegal 
death investigator is responsible for the evidence and investigation 
related to the deceased person's remains and should have both a medical 
and legal educational background. In some states, centralized state 
medical examiner's offices perform death investigations, while other 
states utilize county/district-based medical examiner offices or a 
county-based mixture of medical examiner and coroner offices or county/
district-based coroner offices. Completion of death reviews vary by 
jurisdiction. Investigators are responsible for determining and 
certifying the cause of death on the death certificate and reporting it 
to vital statistics.
    Medicolegal death reporting is important because it is the 
responsibility of the death investigator to determine a cause of death 
and provide the information to the state's vital statistics department. 
Researchers and VHA staff use the information obtained from state vital 
statistics to determine suicide risk factors, and suicide methods or 
trends, which clinicians use to implement suicide interventions and 
prevention approaches.
    According to NCHS staff, some challenges and training opportunities 
related to the difficulty in reporting suicides may include:

     Stigma--in small communities, medical certifiers may feel 
they are doing the family a favor if they do not choose suicide as 
manner of death. This could be for cultural or religious reasons, or 
because they believe, sometimes correctly, that the family will not 
receive death benefits if the death is ruled a suicide.
     Intent cannot always be determined--especially in deaths 
that involved high-risk behaviors such as single-car automobile crashes 
and drug overdose deaths.
     Some medical certifiers may have overly rigid or even 
incorrect standards by which they judge a death to be a suicide. For 
example, a medical certifier may require the leaving of a suicide note, 
when research has found that at most a third of suicide cases, 
confirmed in other ways, left notes.

    According to National Association for Public Health Statistics and 
Information Systems staff, accurate reporting of the cause and manner 
of death is essential. Therefore, training of those who are responsible 
for completing the medical portion of the death certificate is critical 
to ensure reliable public health data.
            DOD Sharing DOD Suicide Event Report Data with VHA
    The DOD Suicide Event Report (DODSER) is the system of record for 
health surveillance of military servicemembers related to suicide 
deaths, suicide attempts, and suicidal ideation. The November 2014 DOD 
OIG report, Department of Defense Suicide Event Report (DODSER) Data 
Quality Assessment, stated:

        DODSER data is not shared with VA for integration into VA's 
        suicide surveillance database; the System of Record 
        Notification limits DODSER data sharing and has prevented DOD 
        from establishing a routine transfer of relevant information to 
        VA; and VA is, therefore, not able to use DODSER data to better 
        understand how military experience such as deployment history 
        or in-service suicide attempts, impacts post-service suicide 
        behavior.

    The DOD OIG report also noted that section 1635 of Public Law 110-
181 `` . . . mandates accelerated exchange of healthcare information 
sharing between DOD and VA; and DOD Directive 6490.02E, Comprehensive 
Health Surveillance, requires the transfer of health surveillance data 
to VA, at a minimum when military servicemembers separate or retire 
from the service.''
    The DOD OIG report recommended that the Defense Health Agency 
update the appropriate System of Record Notification to:

     Allow for sharing of DODSER data with VHA staff, and
     Coordinate with VHA staff to ensure appropriate 
establishment of privacy policies to manage privacy issues while 
sharing DODSER data.

    VHA staff attempted to obtain access to the DODSER data because it 
may provide useful information to VHA clinicians. Staff at the DOD 
National Center for Telehealth and Technology maintain the data; the 
Defense Suicide Prevention Office has a copy. At the time of our 
review, VHA and DOD Suicide Prevention program staff were developing a 
sharing agreement.
   combined assessment program summary report--evaluation of suicide 
                       prevention programs in vha
    In May 2017, we reported the results of our reviews at 28 VHA 
facilities through our Combined Assessment Program inspections 
conducted from October 1, 2015, through March 31, 2016, regarding 
suicide prevention programs.\14\ We observed many positive practices, 
including that most facilities had a process for responding to 
referrals from the VCL and a process to follow up on high-risk patients 
who missed appointments. Additionally, when patients died from suicide, 
facilities generally created issue briefs and when indicated, completed 
mortality reviews or behavioral autopsies and initiated root cause 
analyses. However, we identified several system weaknesses.
---------------------------------------------------------------------------
    \14\ https://www.va.gov/oig/pubs/VAOIG-16-03808-215.pdf. May 18, 
2017
---------------------------------------------------------------------------
     VHA requires that facilities complete five outreach 
activities each month for community organizations, MH groups, and/or 
other community advocacy groups; 18 percent of the facilities did not 
comply with this requirement.
     VHA requires that clinicians develop SPSPs for patients 
identified as at high risk for suicide; we found that 11 percent of 
high risk patients' EHR did not contain a suicide prevention safety 
plan. We found that clinicians did not document that they gave the 
patient and/or caregiver a copy of the plan 20.2 percent of the time 
for inpatients and 10.5 percent of the time for outpatients.
     VHA requires that facilities use Patient Record Flags 
(PRF) in inpatients' EHRs to identify and track patients at high risk 
for suicide. We identified several areas where improvement was required 
and recommended that when clinicians identify inpatients as at high 
risk for suicide, they place PRFs in the EHRs and notify the SPC of the 
admission. In addition, we recommended that when clinicians identify 
inpatients as at high risk for suicide, the SPC or MH provider evaluate 
the patient at least four times during the first 30 days after 
discharge. Further, when clinicians identify outpatients as at high 
risk for suicide, we recommended that they review the PRFs every 90 
days and document the review and document justification for continuing 
or discontinuing the PRFs.
     VHA requires that primary care and MH providers receive 
training on suicide risk assessments and management of patients at high 
risk for suicide. Facilities generally provided suicide prevention 
training to new non-clinical employees (84.4 percent); however, 45.7 
percent of the time clinicians did not complete suicide risk management 
training within 90 days of hire.

    VHA agreed with our recommendations in this report. They provided 
action plans to address the recommendations and we are waiting for 
documentation of those actions to review and then we will determine if 
we can close the recommendations.
                        the veterans crisis line
    In the past 2 years, we have published two reports \15\ inspecting 
the VCL in response to complaints about its operations. Both reports 
found organizational deficiencies and foundational problems in the VCL. 
All recommendations from the first report have now been addressed. The 
second VCL report, Healthcare Inspection--Evaluation of The Veterans 
Health Administration Veterans Crisis Line \16\ identified a number of 
issues and that VHA is working on addressing the recommendations from 
that report.
---------------------------------------------------------------------------
    \15\ Healthcare Inspection--Veterans Crisis Line Caller Response 
and Quality Assurance Concerns, Canandaigua, New York, https://
www.va.gov/oig/pubs/VAOIG-14-03540-123.pdf, February 11, 2016.
    \16\ Healthcare Inspection--Evaluation of the Veterans Health 
Administration Veterans Crisis Line, https://www.va.gov/oig/pubs/VAOIG-
16-03985-181.pdf, March 20, 2017.
---------------------------------------------------------------------------
Findings to Objective 1: VCL Failure to Respond Adequately to a Veteran 
        Caller
    We found that VCL staff did not respond adequately to a veteran's 
urgent needs during multiple calls to the VCL and its backup call 
centers. In addition to the failure to provide crisis intervention 
during the calls, VCL supervisory staff did not identify the 
deficiencies in their internal review of the matter.
Findings to Objective 2: VCL Governance Structure, Operations, and 
        Quality Assurance Functions Have a Number of Deficiencies
    Our inspection of the VCL governance structure, operations, and 
quality assurance functions identified a number of deficiencies. We 
found deficiencies in the VCL's processes for managing incoming 
telephone calls. We also found deficiencies in governance and oversight 
of VCL operations. The VCL staff did not have the capacity to answer 
all calls received, requiring VHA contract with four backup call 
centers not otherwise affiliated with VA to handle the overflow. We 
found that VHA contracting staff and Member Services and VCL leaders 
lacked an understanding of the contract terms and did not verify 
quality control aspects of contractor performance, resulting in 
deficient oversight. VCL Quality Management (QM) focuses on making and 
measuring improvements to a program with the prevention of problems 
being the primary objective.
    We found continued deficiencies in the VCL QM program.
    VCL policies were not consistent with existing VHA policies for 
veteran safety or risk management and did not incorporate techniques 
for evaluating available data to improve quality, safety, or value, to 
veterans.
Findings to Objective 4: A Number of Issues Raised by a Complainant and 
        Referred by the Office of Special Counsel Were Substantiated
    The OSC referred a complaint to VA on August 25, 2016 alleging 
inadequate training of VCL SSAs that resulted in deficiencies in 
coordinating immediate emergency services needed to prevent harm. We 
partially substantiated the OSC complainant's allegations.
      improve communication between providers and veterans' family
    The OIG has reported on the death of many veterans with diverse 
mental health issues. Often, there is a significant communication gap 
between providers and the veteran's extended family. Communication 
regarding a veteran's mental health issues and related topics between 
providers and the veteran's extended family are restricted by a series 
of laws. The OIG believes that more effort should be devoted toward 
improving this communication. Efforts to pilot the use of advance 
directives and other mechanisms should be explored to determine if 
changes in information flow can improve the chances that a veteran will 
not choose suicide.
                               conclusion
    Strategies that envision extending VHA's efforts to prevent suicide 
to those veterans who do not receive care through VHA, that move beyond 
the prediction of who is at risk to an actionable timeframe when a 
veteran maybe at highest risk to attempt suicide, and efforts to 
advance communication through advance directives and related strategies 
may lessen the risk that a veteran will suicide.

    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or Members of the Committee may have.

    Chairman Isakson. Thank you, Dr. Daigh.
    Mr. Bryan.

  STATEMENT OF CRAIG BRYAN, Psy.D., ABPP, EXECUTIVE DIRECTOR, 
    NATIONAL CENTER FOR VETERANS STUDIES, UNIVERSITY OF UTAH

    Mr. Bryan. Mr. Chairman, Mr. Ranking Member, and Members of 
the Committee, I appreciate the opportunity to appear here 
today to discuss recent advances in veteran suicide prevention.
    I will not read my written testimony in full but will 
highlight a number of key points.
    In response to rising suicide rates, the VA has adopted and 
implemented numerous measures intended to prevent suicide among 
veterans. These efforts have led to improved access to care and 
serves as an example of how an agency can aggressively advance 
the cause of suicide prevention.
    Several new studies reporting suicide-related outcomes 
among military personnel and veterans have been published in 
just the past 2 years. Although most of these studies enrolled 
military personnel, their findings are applicable to the VA and 
the veteran community as a whole.
    As summarized in the attachment to my testimony, all of the 
interventions reduce suicidal ideation, but only two are 
associated with significant reductions in suicidal behavior--
brief cognitive behavioral therapy and crisis response 
planning, which were found to reduce suicidal behavior by 60 to 
76 percent. They are currently the only strategies shown 
scientifically to reduce suicidal behaviors among those who 
have served in the U.S. military. These treatments now serve as 
a foundation for several studies currently under way in the VA 
as well as in the DOD.
    These latest findings not only confirm that suicidal 
behavior can be prevented among military personnel and 
veterans, they also show us how to do it. If these studies tell 
us anything, it is this: Some strategies work better than 
others, and simple things save lives. Tragically, few veterans 
are likely to receive these potentially lifesaving treatments 
for a number of reasons.
    Today, I will focus on one particular barrier: inadequate 
training in mental health professionals. Two recent VA studies 
highlight this issue. In these studies, researchers found that 
a key suicide prevention strategy used by the VA was not 
associated with subsequent reductions in suicidal behavior, as 
was expected. The lack of effectiveness was attributed to poor 
quality implementation.
    Of note, VA personnel often did not implement the procedure 
with sufficient reliability or specificity. Researchers from 
both of these studies concluded that the results pointed to 
insufficient training, and that additional training could 
actually change this course.
    The problem of deficient training is not confined to the 
VA, though. Tragically, deficient training is endemic across 
our Nation's mental health professional training system.
    A recent report from the American Association of 
Suicidology highlights this issue. The main findings of that 
report are also summarized in the attachment to my testimony. 
As you can see, a shockingly low number of mental health 
training programs provide any education or training about 
suicide to its students.
    Furthermore, State licensing boards, the very bodies 
charged with protecting the public's health and safety from 
unqualified professionals, typically do not require any exams 
or demonstration of competency in suicide risk assessment or 
intervention.
    The implications of this report are disturbing. The vast 
majority of our Nation's mental health professionals are 
unprepared to effectively intervene with suicidal veterans. 
This has critical implications for all veterans, both within 
and outside the VA.
    We have long talked about the man barriers that stand in 
the way of a veteran receiving mental health treatment and have 
invested heavily in removing those barriers. What unsettles me 
the most as a veteran is knowing that when a fellow veteran 
overcomes these barriers, he or she is unlikely to receive the 
treatments that are most likely to save their lives.
    The sobering and uncomfortable truth is that we have made 
it easier for veterans to obtain treatment that does not work, 
especially those veterans who receive services from non-VA 
providers in their communities.
    If we want veterans to benefit from the most recent 
advances in suicide prevention research, we will need to ensure 
implementation is accompanied by a comprehensive and robust 
training program.
    Luckily, the past few years have also led to considerable 
advances in our understanding of the most effective ways of 
teaching these methods to others. Much of this knowledge has 
actually been obtained by the VA and their researchers.
    In order to reverse the trend of veteran suicide, we must, 
therefore, think boldly and must be willing to disrupt the 
status quo. We need to adopt the newest strategies that have 
garnered the most scientific support, even though they may 
depart from existing procedures. We need to invest more heavily 
in training clinicians to use these procedures and create new 
initiatives to incentivize and support their implementation in 
clinical settings.
    These changes should not just target the VA and the DOD, 
but all clinicians and all settings, as well as our 
universities and our training programs that are responsible for 
the readiness and preparedness of our mental health 
professionals.
    In conclusion, we are at a critical turning point for 
veteran suicide prevention. Answers are now clear, and 
effective strategies have been identified. We must now take the 
steps needed to ensure these treatments and interventions are 
easily available to all veterans, both within the VA and in our 
communities.
    Thank you very much.
    [The prepared statement of Mr. Bryan follows:]
 Prepared Statement of Craig J. Bryan, PsyD, ABPP, Executive Director, 
 National Center for Veterans Studies, Associate Professor, Department 
   of Psychology, Associate Professor, Department of Psychiatry, The 
                           University of Utah
    Last year, the Department of Veterans Affairs released the results 
of the most comprehensive analysis conducted to date focused on suicide 
among U.S. military Veterans.\1\ Building on previous findings, these 
analyses highlighted the continued problem of increased suicide risk 
among veterans, and yielded the frequently-cited statistic of ``20 
Veterans per day.'' Since 2001, the suicide rate among all Veterans has 
increased faster than the suicide rate among civilians, such that 
Veterans are 20% more likely than civilians to die by suicide. 
Differences across several Veteran subgroups have also been identified. 
Of greatest relevance to the current hearing, from 2001 to 2014 the 
suicide rate among Veterans who do not use VA services increased by 39% 
from 2001 to 2014, whereas the suicide rate among VA users increased by 
only 9%. For comparison, the suicide rate among civilians increased by 
23% during this same period of time.
    Taken together, this suggests a relative benefit for Veterans who 
have accessed and used VA services, although this observation is 
tempered by the fact that the suicide rate has nonetheless increased, 
rather than decreased, among VA users. Further tempering enthusiasm is 
the fact that only 30% of all Veterans who died by suicide were VA 
users, which means the considerable majority of suicides are occurring 
among Veterans external to the VA. This brings to the forefront a 
critical point about Veteran suicide prevention: our efforts must 
extend beyond the walls of our VA facilities. If we confine our efforts 
solely to the VA, we will not have a significant impact on overall 
Veteran suicide rates. We must therefore seek to complement suicide 
prevention efforts in the VA with suicide prevention efforts in the 
community at large.
                        simple things save lives
    Of all the many things we have learned about Veteran suicide over 
the past decade, the most important are the following: (1) some 
interventions work much, much better than others, and (2) simple things 
save lives. The past few years have been marked by dramatic gains in 
suicide prevention for military personnel and Veterans. In just the 
past two years, several treatments studies reporting suicide-related 
outcomes among military personnel and Veterans have been 
published,\2\-\8\proving us with critical information about 
how to most effectively save lives. Three of these studies tested 
treatments explicitly designed to reduce suicidal thoughts and 
behaviors, regardless of diagnosis, gender, age, or 
background.\2\-\4\ Of these three, two proved to be 
especially potent: brief cognitive behavioral therapy,\2\ a 12-session 
therapy that reduced suicide attempts by 60%, and crisis response 
planning,3 a single-session, 30-minute intervention that reduced 
suicide attempters by 76% as compared to typical treatment methods. 
Three other studies entailed PTSD-focused treatments \5\-\7\ 
and one study entailed insomnia-focused treatment.\8\ All found 
significant reductions in suicidal thoughts among servicemembers and 
veterans diagnosed with PTSD and/or insomnia, suggesting that other 
treatments targeting key risk factors among military personnel and 
veterans may also reduce suicide risk.
    These results have prompted a new wave of research studies designed 
to build on these initial gains. For example, we are currently 
conducting a new treatment study in the VA testing a 3-session 
treatment that shares many of the elements of brief cognitive 
behavioral therapy and crisis response planning. In light of our 
previous research findings, we are hopeful that this new study will 
point us to a brief and cost effective method for reducing Veteran 
suicides that can be easily implemented within the VA.
    The findings of the crisis response planning study hold particular 
promise for suicide prevention among Veterans, as this procedure can be 
taught to peer mentors, family members, teachers, and other non-
healthcare providers. Just as we teach cardiopulmonary resuscitation 
(CPR) to non-healthcare providers so they are prepared to save a life 
in the event of a heart attack or other cardiac emergency, so can we 
teach crisis response planning to individuals within our communities to 
intervene with Veterans (and non-Veterans) experiencing mental health 
emergencies. No longer does suicide prevention have to be confined to 
hospitals and mental health clinics; all of us can learn the simple 
procedures involved in saving a Veteran's life.
    The science is now clear: certain treatments save lives. The 
question we now face is how to use this knowledge. Training curriculum 
and methods already exist. We are therefore well-positioned to start 
teaching mental health professionals in the VA and our local 
communities how to put these practices into action.
                   access without quality assurance:
     making it easy for veterans to obtain services that don't work
    In order to advance Veteran suicide prevention, we must ensure that 
VA personnel and other members of the community are ready and able to 
respond appropriately. Over the past decade, the VA has adopted and 
implemented an impressive array of measures intended to prevent suicide 
including the expansion of the Veteran Crisis Line, improved same-day 
access for Veterans with urgent mental health needs, expanded tele-
mental healthcare services, hiring of new mental health professionals 
and crisis hotline staff, and the establishment of collaborative 
relationships with community service providers. These efforts have 
collectively focused on improving access to care for all Veterans, but 
especially those Veterans who are eligible for VA services. 
Unfortunately, many of these initiatives have been aimed at improving 
access to care (i.e., making it easier for Veterans to ``get in the 
door'') with little to no structure or guidance for maximizing the 
effectiveness of these services. As a result, we have made it easier 
for Veterans to access services that do not work.
    A recent study by VA researchers highlights this issue.\9\ In that 
study, VA records were reviewed to assess the quality of safety 
planning, an intervention that is based on crisis response planning 
and, as such, intended to prevent suicidal behavior among high-risk VA 
users. Although the safety plan's efficacy has not yet been tested, it 
has nonetheless been recommended for use with suicidal patients based 
on expert consensus, and was implemented by the VA several years ago as 
a required part of a Veteran's comprehensive suicide prevention plan. 
Results of this study indicated that, on average, safety plans were of 
``moderate quality,'' showed considerable variability in quality, and 
lacked sufficient specificity to maximize its utility. For example, 23% 
of Veterans had ``generic, copied and pasted statements'' and only 29% 
showed evidence of ongoing review of the safety plan. In light of these 
findings, it is perhaps not surprising that safety plans did not 
correlate with the incidence of later suicide attempts. A second study 
conducted by an independent team of VA researchers has yielded similar 
findings.\10\
    Researchers have concluded that high variability in the quality of 
safety plans are most likely attributable to insufficient training 
provided to VA healthcare professionals. In short, the VA mandated and 
implemented a suicide prevention strategy that was based on expert 
recommendations but no program was implemented to teach personnel how 
to effectively implement the strategy. Further compounding this issue 
was the adoption and implementation of standardized forms and 
templates, which fostered an understanding of safety planning as an 
administrative task rather than a suicide prevention intervention. As a 
result, a promising suicide prevention strategy was rendered inert. 
Simply put, creating forms and posting user manuals online are not 
enough to ensure that individuals know how to competently and 
effectively use the procedure. Reading books and filling out forms will 
not save lives; training matters.
                         teaching bad medicine:
          deficits in u.s. mental health professional training
    The aforementioned training deficits associated with VA suicide 
prevention efforts are not entirely the VA's fault. A recent report 
from the American Association of Suicidology (AAS) \11\ brings into 
focus the stunning inadequacies of our Nation's mental health 
professional training programs. As noted in this report, research 
studies have found that only half of psychology training programs, less 
than 25% of social work programs, 6% of marriage and family therapy 
programs, and 2% of counselor education programs provide any amount of 
education or training focused on suicide as a part of their curriculum. 
Relatedly, only 28% of psychiatry program training directors report the 
provision of skills-based suicide-focused to psychiatry residents. When 
such education is available, it is often very limited (i.e., less than 
a few hours over multiple years of training) and does not always 
include applied skills training. The AAS report further notes that 
state licensing boards for most mental health professions--the bodies 
charged with protecting the public's health and safety from unqualified 
professionals--do not require any exams or demonstration of competency 
in suicide risk assessment or intervention.
    The AAS report highlights an urgent and shocking reality: the vast 
majority of our Nation's mental health professionals are stunningly 
unprepared to effectively intervene with suicidal individuals. In 
short, the mental health professionals and trainees hired by the VA are 
unlikely to have any exposure to contemporary, state-of-the-art 
practices in suicide prevention like brief cognitive behavioral therapy 
or crisis response planning, the only interventions to date that are 
proven to reduce suicidal behavior among military personnel and 
veterans.
    Because most of the VA's mental health professionals were trained 
in U.S. programs, the near-complete absence of training and education 
in scientifically-supported methods for suicide risk, PTSD, and other 
such conditions means an unsettling number of VA employees have little 
to no education or practical experience using the most effective 
methods for suicide prevention. As a result, the VA must expend an 
inordinate amount of time, resources, and taxpayer dollars to provide 
training aimed at teaching its personnel the basic principles and 
concepts that should have been provided during graduate or medical 
school.
                next steps in veteran suicide prevention
    If Veterans are to benefit from the most recent advances in suicide 
prevention research, implementation of newer, more effective strategies 
like brief cognitive behavioral therapy and crisis response planning 
must be accompanied by comprehensive and robust training programs. 
Luckily, the past few years have also led to considerable advances in 
our understanding of the most effective ways for teaching these 
methods. Much of this knowledge has been obtained by VA researchers and 
staff as part of its various training programs and initiatives. These 
results and lessons learned can provide critical clues and guidance for 
effectively implementing new strategies and treatments.
    Reversing the trend of Veteran suicide will require bold and 
innovative thinking that will undoubtedly shake up and disrupt the 
status quo. This may require changes to existing policies and 
procedures, and the development and creation of new initiatives. The 
next steps in Veteran suicide prevention will therefore require a 
combination of strategies that might include the following:

    1. The adoption of new strategies that have garnered strong 
scientific support (e.g., brief cognitive behavioral therapy, crisis 
response planning), even though these strategies may depart from 
existing procedures;
    2. Investment in mental health professional training to ensure 
competent and effective implementation of these procedures;
    3. Creation of incentive programs that reward mental health 
clinicians for completing training and demonstrating competency in 
effective suicide prevention strategies;
    4. Requiring mental health training programs to provide training in 
scientifically-supported suicide prevention methods;
    5. Encouraging accrediting bodies of graduate and medical training 
programs across mental health disciplines to include requirements for 
the training of suicide risk assessment and intervention to students; 
and
    6. Encouraging state licensing boards to require demonstrations of 
competency specific to suicide risk assessment and intervention.
                        simple things save lives
    Of all the many things we have learned about Veteran suicide over 
the past decade, the most important are the following: (1) some 
interventions work much, much better than others, and (2) simple things 
save lives. The past few years have been marked by dramatic gains in 
suicide prevention for military personnel and Veterans. In just the 
past two years, several treatments studies reporting suicide-related 
outcomes among military personnel and Veterans have been 
published,\2\-\8\proving us with critical information about 
how to most effectively save lives. Three of these studies tested 
treatments explicitly designed to reduce suicidal thoughts and 
behaviors, regardless of diagnosis, gender, age, or 
background.\2\-\4\ Of these three, two proved to be 
especially potent: brief cognitive behavioral therapy,\2\ a 12-session 
therapy that reduced suicide attempts by 60%, and crisis response 
planning,\3\ a single-session, 30-minute intervention that reduced 
suicide attempters by 76% as compared to typical treatment methods. 
Three other studies entailed PTSD-focused treatments \5\-\7\ 
and one study entailed insomnia-focused treatment.\8\ All found 
significant reductions in suicidal thoughts among servicemembers and 
veterans diagnosed with PTSD and/or insomnia, suggesting that other 
treatments targeting key risk factors among military personnel and 
veterans may also reduce suicide risk.


References Cited
1. Department of Veterans Affairs Office of Suicide Prevention (2016). 
            Suicide Among Veterans and Other Americans, 2001-2014. 
            Washington, DC: Department of Veterans Affairs.
2. Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., 
            Young-McCaughan, S., Mintz, J., . . . & Wilkinson, E. 
            (2015). 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, 172, 441-449.
3. Bryan, C. J., Mintz, J., Clemans, T. A., Leeson, B., Burch, T. S., 
            Williams, S. R., . . . & Rudd, M. D. (2017). Effect of 
            crisis response planning vs. contracts for safety on 
            suicide risk in US Army soldiers: a randomized clinical 
            trial. Journal of Affective Disorders, 212, 64-72.
4. Jobes, D.A., Comtois, K.A., Gutierrez, P.M., Brenner, L.A., Huh, D., 
            Chalker, S.A., . . . , & Crow, B. (in press). A randomized 
            controlled trial of the Collaborative Assessment and 
            Management of Suicidality versus enhanced care as usual 
            with suicidal soldiers. Psychiatry: Interpersonal & 
            Biological Processes.
5. Brown, L.A., McLean, C.P., Zang, Y., Zandberg, L., Mintz, J., 
            Yarvis, J.S., . . . , & Foa, E.B. (in press). Does 
            prolonged exposure increase suicide risk? Results from an 
            active duty military sample. Journal of Affective 
            Disorders.
6. Bryan, C.J., Clemans, T.A., Hernandez, A.M., Mintz, J., Peterson, 
            A.L., Yarvis, J.S., & Resick, P.A. (2016). Evaluating 
            potential iatrogenic suicide risk in trauma-focused group 
            cognitive behavioral therapy for the treatment of PTSD in 
            active duty military personnel. Depression and Anxiety, 33, 
            549-557.
7. Resick, P.A., Wachen, J.S., Dondanville, K.A., Pruiksma, K.E., 
            Yarvis, J.S., Peterson, A.L., & Mintz, J. (2017). Effect of 
            group vs individual cognitive processing therapy in active-
            duty military seeking treatment for Post Traumatic Stress 
            Disorder: a randomized clinical trial. JAMA Psychiatry, 74, 
            28-36.
8. Trockel, M., Karlin, B. E., Taylor, C. B., Brown, G. K., & Manber, 
            R. (2015). Effects of cognitive behavioral therapy for 
            insomnia on suicidal ideation in veterans. Sleep, 38, 259-
            265.
9. Gamarra, J.M., Luciano, M.T., Gradus, J.L., & Stirman, S.W. (2015). 
            Assessing variability and implementation fidelity of 
            suicide prevention safety planning in a regional VA 
            Healthcare System. Crisis, 36, 433-439.
10. Green, J.D. , Kearns, J., Marx, B., Nock, M., Rosen, R., & Keane, 
            T. (2016). Evaluating safety plan effectiveness: do safety 
            plans tailored to individual veteran characteristics 
            decrease risk? In D.J. Lee (Chair), Preventing Suicide 
            Among Military and Veteran Population. Paper presented at 
            the annual meeting of the Association for Behavioral and 
            Cognitive Therapies, New York.
11. Schmitz, W.M., Allen, M.H., Feldman, B.N., Gutin, N.J., Jahn, D.R., 
            Kleespies, P.M., Quinnett, P., & Simpson, S. (2012). 
            Preventing suicide through improved training in suicide 
            risk assessment and care: an American Association of 
            Suicidology task force report addressing serious gaps in 
            U.S. mental health training. Suicide and Life-Threatening 
            Behavior, 42, 292-304.

    Chairman Isakson. Thank you very much, Dr. Bryan. We 
appreciate your testimony.
    Now from the great State of Montana, the Executive Director 
of the National Alliance for Mental Illness, NAMI, in Montana, 
Mr. Kuntz.

   STATEMENT OF MATTHEW KUNTZ, EXECUTIVE DIRECTOR, NATIONAL 
             ALLIANCE ON MENTAL ILLNESS FOR MONTANA

    Mr. Kuntz. Yes, sir. Chairman Isakson, Ranking Member 
Tester, and distinguished Members of the Committee, on behalf 
of NAMI Montana and NAMI, I would like to extend our gratitude 
for the opportunity to share with you our views and 
recommendations.
    We applaud the Committee's dedication in addressing the 
critical issues around veteran suicide. As someone who has 
personally lost a family member that was a veteran to PTSD, I 
just want to give you my sincere thanks.
    Montana has the highest suicide rate in the country, with 
68.6 per 100,000. This is significantly higher than both the 
National Veterans Suicide Rate and the Western Region Veteran 
Suicide Rate.
    As an organization that is immersed in suicide prevention, 
we think it is very important that you have a framework to 
understand suicide. The model that we use is the Diathesis 
Stress Model, in which a combination of biological 
susceptibility and environmental factors then lead to 
malfunctioning neuron communications, which develop into 
suicidal ideation behavior and other symptoms.
    Examples of the factors of biological susceptibility are 
genetics and physical trauma. Examples of factors on the 
environmental side are emotional trauma, but on the positive, 
therapy and support of family.
    You will note that I will not be covering lethal means 
restriction because I believe it is incredibly hard to 
legislate that, but it is an important factor.
    Montana is a very rural State, with an average of fewer 
than six persons per square mile. This creates unique 
challenges for our health care providers, and we are deeply in 
need of more mental health providers.
    I will move on to our recommendations; first, to offer 
public health interventions proven to reduce suicide during 
critical points of the military and veteran experience.
    NAMI Montana was influential in bringing the Youth Aware of 
Mental Health program to the United States, and we would like 
to offer it as a template of something that is proven to work 
in other populations. And it would be perfect to bring over to 
this one.
    Second recommendation: establish a clear policy goal to 
improve the diagnostic treatment system. The target that NAMI 
Montana recommends to the Committee is to task the VA to work 
with the Department of Defense, the National Institute of 
Mental Health, and private partners to identify and prepare two 
additional brain diagnostic measurements for clinical work in 
the VA by the fall of 2020.
    Our next recommendation is to develop a plan for treatment-
resistant mental health conditions. Roughly a third of mental 
health conditions do not respond to traditional treatments, and 
this is a big issue. And it is an issue that is not addressed 
in Montana. The Montana VA has nothing in our State to address 
treatment-resistant depression.
    This is very personal to me because I lost a dear friend 
who was a veteran in September 2015 to treatment-resistant 
depression, and to watch his options slowly slip away was one 
of the hardest things I have ever seen.
    Montana Blue Cross and Blue Shield supports TMS treatment 
for treatment-resistant depression. I do not know why the 
Montana VA does not.
    Next recommendation: expand access to tele-psychiatry, then 
make online cognitive behavioral therapy available to all 
veterans.
    We also believe the VA should expand the availability of 
automated suicide risk assessment scales, develop a prize to 
create and validate a medical screening tool to determine which 
patients are at risk of developing side effects from clozapine, 
develop a public-facing online research directory for non-VA 
resources, create a more synergistic relationship between the 
VA and community mental health centers--there are over 1,300 
community health centers across the country, and we should be 
working with those to care for our veterans--increase the VA's 
collaboration with outside researchers, and finally establish a 
continuity of care pipeline for veterans directly from the 
Department of Defense to VA/community providers.
    Thank you again for the opportunity to testify in front of 
this honorable Committee. Your attention to this issue means a 
lot to me, our entire NAMI organization and their families.
    [The prepared statement of Mr. Kuntz follows:]
   Prepared Statement of Matt Kuntz, J.D., Executive Director, NAMI 
              Montana, National Alliance on Mental Illness
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                            i. introduction
    Chairman Isakson, Ranking Member Tester and distinguished Members 
of the Committee, On behalf of NAMI Montana, and NAMI, the National 
Alliance on Mental Illness, I would like to extend our gratitude for 
the opportunity to share with you our views and recommendations 
regarding ``#BeThere: What More Can Be Done to Prevent Veteran 
Suicide?'' NAMI Montana and the entire NAMI community applauds the 
Committee's dedication in addressing the critical issues around 
veterans' suicide. NAMI is the Nation's largest grassroots mental 
health organization dedicated to building better lives for the millions 
of Americans affected by mental illness. NAMI advocates for access to 
services, treatment, support and research, and is steadfast in its 
commitment to raising awareness and building a community of hope for 
all of those in need.
    NAMI Montana is also a member of the Coalition to Heal Invisible 
Wounds (Coalition). The Coalition was founded in February 2017 to 
connect leading public and private scientific investigators of new PTSD 
and Traumatic Brain Injury (TBI) treatments with policymakers working 
to improve care for veterans. Coalition members support innovators at 
all stages of the therapy development life-cycle, from initial research 
to late-stage clinical trials. The Coalition aims to spur strategic 
Federal institution support to create better treatment and care for 
veterans suffering from PTSD and TBI. The Coalition seeks to work with 
VA and the Department of Defense (DOD) on immediate improvements to 
public-private partnerships for:

     Developing and validating PTSD and TBI biomarkers and 
diagnostics;
     Providing research access to PTSD and TBI datasets;
     Providing institution-wide support for PTSD clinical 
trials;
     Improving messaging of relevant policies and practice 
guidelines; and,
     Providing up-to-date education around clinical trial 
endpoints and drug therapy options.

    The Coalition also seeks renewed investment in VA-funded PTSD 
research, and an expansion in the types of research supported. Through 
strategic collaboration between the public and private sectors, the 
Coalition believes that our Nation can improve treatments for 
servicemembers and veterans suffering from PTSD.
                ii. suicide from the montana perspective
A. Montana's Veteran Suicide Rate
    According to the U.S. Department of Veterans Affairs' recently 
released report, Montana has the highest veteran suicide rate in the 
country. This rate of 68.6 per 100,000 is significantly higher than 
both the National Veterans Suicide Rate of 38.4 per 100,000 and the 
Western Region Veteran Suicide Rate of 45.5 per 100,000.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                                                    \1\
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs, ``Veteran Suicide Data 
Sheets,'' https://www. mentalhealth.va.gov/docs/data-sheets/Suicide-
Data-Sheets-VA-States.pdf.

B. General Suicide Prevention Framework
    As an organization immersed in suicide prevention policy, in a 
state that regularly has the country's highest suicide rate, NAMI 
Montana has considered a number of different tools for helping explain 
the complex realities of suicide, suicide prevention, and treatment for 
suicidal behavior. We prefer to use a version of the Diathesis Stress 
Model to explain how suicidal behavior arises via malfunctioning neuron 
communications that stem from a combination of biological 
susceptibility and environmental factors.\2\ This model has held up for 
years for the variety of suicide factor data that has arisen in both 
military and veteran populations. It is easily grasped by a wide 
variety of populations, from families affected by suicide, clinicians, 
and policymakers.
---------------------------------------------------------------------------
    \2\ See e.g., Gandubert, C., et al. ``Biological and psychological 
predictors of Post Traumatic Stress Disorder onset and chronicity. A 
one-year prospective study.'' Neurobiology of stress 3 (2016): 61-67; 
Goforth, Anisa N., Andy V. Pham, and John S. Carlson. ``Diathesis-
stress model.'' Encyclopedia of Child Behavior and Development. 
Springer US, 2011. 502-503.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


    This model also explains other conditions that generally stem from 
malfunctions in neuron communications of the brain, such as depression, 
bipolar disorder, schizophrenia, substance abuse, etc. are substantial 
risk factors for suicide. These conditions can be activated without 
trauma experience and are critical to understanding why some veterans 
are in danger of committing suicide even if they have not been in 
combat.
C. Treatment Challenge and Opportunities in Montana
    Montana is the Nation's fourth largest state with over 147,000 
square miles, and just over one million people residing in Big Sky 
Country. We are honored to have one of the Nation's highest per capita 
rates of military service in the country. Montana is home to more than 
108,000 veterans, representing 16.2% of the total state adult 
population; the second highest population density of veterans in the 
United States.\3\ Additionally, Montana is home to twelve tribal 
nations and seven reservations.\4\ The reservations comprise nine 
percent of the state's land base. Montana is home to over 66,000 people 
of Native American heritage. The majority of Montana's native 
population live on reservations. Montana residents that qualify for 
Indian Health Services (IHS) are served by the Billings Area Indian 
Health Services, which delivers care to over 70,000 people in the 
states of Montana and Wyoming.\5\
---------------------------------------------------------------------------
    \3\ Taken from the State of Montana's recent grant application to 
HRSA
    \4\ Indian Education for All, ``Montana Indians: Their History and 
Location.'' (April 2009) http://opi.mt.gov/pdf/ indianed/resources/
MTIndiansHistoryLocation.pdf
    \5\ ``Montana Department of Public Health and Human Services Report 
to the 2013 Legislature: The Montana Medicaid Program State Fiscal 
Years 2011 and 2012.'' http://www.dphhs.mt.gov/ publications/
2013Medicaidreport.pdf
---------------------------------------------------------------------------
    The very rural nature of the state, with an average of fewer than 
six persons per square mile, creates unique challenges for our 
healthcare providers. It is very hard for rural Montana communities to 
recruit and retain healthcare workers. Our rural healthcare 
professionals have to walk a tightrope between finding enough patients 
to make a living and pay off their student loans, while not being 
overwhelmed by the workload. It is a difficult balance to strike due to 
variable patient rates and a shortage of relief for times of overflow.
    These challenges are especially difficult for treating serious 
mental illness (SMI) because of the complex nature of these illnesses, 
the level of care required for mental health crises, and the ongoing 
treatment needs of persons living with these conditions. Our state is 
in desperate need of more mental health professionals, particularly in 
our more rural communities.
    While the challenge of reducing Montana's veteran suicides can feel 
overwhelming due to the vast rural areas, it is important to point out 
that Montana's most recent Suicide Mortality Review Report illustrated 
that over half of Montana's veteran suicides, during the reporting 
period, occurred in Montana's six most populous 
counties.\6\,\7\ Lewis and Clark County is the least 
populous of those six counties in the state, and it hosts the Montana 
VA Healthcare System headquarters and hospital. The remaining five 
counties has either a Vet Center,\8\ a VA Community-Based Outpatient 
Center (CBOC),\9\ or both. These communities also have psychiatrists, 
psychiatric nurses, and therapists available through private nonprofit 
mental health centers and federally Qualified Health Centers (FQHCs).
---------------------------------------------------------------------------
    \6\ 2016 Montana Suicide Mortality Review Report. Page 49. http://
www.sprc.org/sites/ default/files/resource-program/
2016%20Montana%20Suicide%20Mortality%20Review%20Report.pdf
    \7\ ``Montana Counties by Population,'' https://www.montana-
demographics.com/counties_by_ population
    \8\ ``Montana VA Healthcare System,'' https://www.montana.va.gov/
locations/other_facilities.asp
    \9\ ``Montana VA Healthcare System,'' https://www.montana.va.gov/
locations/Bozeman_VA_ Community_Based_Outpatient_Clinic.asp
---------------------------------------------------------------------------
    It is important to continue to extend effective care out into rural 
communities, but it is also clear that a lack of resources is not 
always the problem. There are many other areas that also need to be 
addressed.
                    iii. suicide among u.s. veterans
    The Interdepartmental Serious Mental Illness Coordinating Council 
(ISMICC), created under the 21st Century Cures Act of which NAMI is a 
non-Federal member, received an initial presentation from John 
McCarthy, Ph.D., M.P.H. of VA Office of Mental Health and Suicide 
Prevention at the Council's first meeting. NAMI Montana and our 
national organization was particularly interested in the data presented 
regarding mental health conditions and suicidality among VHA users. As 
the Committee is well aware, only 6 of the 20 veterans (approximately 
30%) who die each day by suicide receive any care from VHA. The data 
presented and shared below illustrates that bipolar disorder (BPD) is 
consistently the mental health condition affecting most veterans 
utilizing VHA who die by suicide.

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                                                                   \10\
---------------------------------------------------------------------------
    \10\ McCarthy, John. (2017). U.S. Department of Veterans Affairs. 
``Federal Advances to Address Challenges in SMI and SED.'' [Powerpoint 
slides]. Retrieved from: https://www.samhsa.gov/sites/default/files/
meeting/agendas/ismicc-morning-slides.pdf

    Additionally, when examining only female veterans utilizing VHA 
care, the data presented in the corresponding table illustrates a 
statistically significant finding that BPD and schizophrenia are among 
---------------------------------------------------------------------------
the highest associated mental health conditions for suicide risk.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                                                   \11\
---------------------------------------------------------------------------
    \11\ Ilgen, et. al., ``Psychiatric diagnoses and risk of suicide in 
veterans.'' (2010), Arch Gen Psychiatry.

    NAMI Montana would like to underscore that by highlighting this 
data, we're not suggesting any research funding or focus be removed 
from PTSD. Rather, we are seeking to draw the Committee's attention to 
this data to illustrate the need for a more holistic and comprehensive 
research approach around mental health conditions not typically 
associated with the veterans community.
    NAMI Montana applauds Secretary Shulkin for identifying veteran 
suicide prevention as his top clinical priority for VA, and placing it 
among VA's top 5 priorities overall. Considering 70% of veterans who 
die by suicide are not under VA's care, we agree with his assessment 
that VA cannot alone solve this crisis, rather ``[veteran suicide] is a 
national public health issue that requires a concerted, national 
approach.''\12\ While VA has taken positive steps to implement better 
suicide prevention programs at the national level, our organization 
firmly believes that we will not begin to truly make a positive, impact 
in ending this national tragedy until a national effort including all 
public, private and non-profit stakeholders are engaged and working 
together.
---------------------------------------------------------------------------
    \12\ U.S. Department of Veterans Affairs. (March 9, 2016). ``VA 
announces additional steps to reduce Veteran suicide.'' Retrieved from: 
http://www.blogs.va.gov/ VAntage/26330/va-announces-additional-steps-
reduce-veteran-suicide/
---------------------------------------------------------------------------
    An effort we are interested in and believe may have promise to help 
in earlier identification is the REACH VET (Recovery Engagement and 
Coordination for Health--Veterans Enhanced Treatment) Initiative 
launched by VA last fall. As the Committee is aware, REACH VET analyzes 
existing data from the health records of veterans to identify those at 
a statistically elevated risk for suicide, hospitalization, illness or 
other adverse outcomes--which allows providers to deliver, in some 
cases, pre-emptive care and support for veterans. As we know for 
certain and advocate for at NAMI Montana and throughout our larger NAMI 
organization, early identification and intervention of mental health 
conditions is a game changer in the ability to treat, and many times is 
the difference in life or death.
                   iv. highlights and recommendations
A. Offer Public Health Interventions Proven to Reduce Suicide During 
        Critical Points of the Military and Veteran Experience
    In April 2015, The Lancet published an article on the ``The Saving 
and Empowering Young Lives in Europe'' (SEYLE) study. The SEYLE study 
is a multicenter, cluster-randomized controlled trial with a sample 
which consisted of 11,110 adolescent pupils, median age 15 years (IQR 
14-15), recruited from 168 schools in ten European Union countries. In 
this study, the Youth Aware of Mental Health (YAM) program demonstrated 
more than a 50% reduction of incident cases of suicide attempts, and of 
incident cases of severe suicidal ideation and plans, as well as a 
significant reduction by 30% of incident cases with moderate to severe 
depression was observed.\13\
---------------------------------------------------------------------------
    \13\ Wasserman, Danuta, et al. ``School-based suicide prevention 
programmes: the SEYLE cluster-randomised, controlled trial.'' The 
Lancet 385.9977 (2015): 1536-1544.
---------------------------------------------------------------------------
    Dr. Matt Byerly, MD and his team at the Center for Mental Health 
Research and Recovery at Montana State University and the University of 
Texas--Southwestern, brought this innovative five-hour intervention to 
high schools in Montana and Texas during the 2016-2017 school year. The 
evidence resulting from this program was incredibly positive and will 
hopefully spur further expansion into a large randomized controlled 
trial which would support a large-scale roll out of this critical 
intervention.
    NAMI Montana supported the effort to bring YAM to the United 
States. While this particular course is focused on suicide prevention 
in adolescents, there does not appear to be any reason why a similar 
program could not be customized and offered to servicemembers during 
Advanced Individual Training (AIT), and while discharging from the 
military. This five-hour course can be given over a series of three to 
five weeks. A program that had the similar effects as YAM on reducing 
suicide attempts, ideation, and depression among servicemembers and 
veterans could be a great step forward in our shared long-term goal in 
reducing veteran suicides.
B. Establish a Clear Policy Goal to Improve the Diagnostic Treatment 
        System
    In NAMI Montana's experience, effective mental health treatment is 
essential to the long-term reduction of a person's risk of suicide. One 
of the largest challenges in obtaining effective treatment is receiving 
an early and accurate diagnosis. The Federal Government has invested a 
significant amount of funds in a variety of agencies to make the brain 
condition diagnostic process more tangible and accurate than the 
current process, which relies almost solely on patient survey 
questionnaires. However, none of the agencies have received a clear 
policy target from Congress for achieving this goal.
    The target that NAMI Montana recommends for the Senate Veterans' 
Affairs Committee is to task VA to work with DOD, the National 
Institute of Mental Health (NIMH), and private partners to identify and 
prepare two additional brain health diagnostic measurements for 
clinical work at all VA facilities by fall 2020. These tests are not to 
be based upon survey questions of the veteran or their family. Due to 
the short timeframe, the tests would have to be based upon existing 
technology that would support the current diagnostic process, rather 
than developing some new technology that would replace it.
    These tests could be as relatively uncomplicated as a computerized 
executive functioning test, hair cortisol test, or blood inflammation 
test. Or they could be more complicated like an electroencephalography 
(EEG) or functional near infrared spectroscopy (fNIRS) test. 
Researchers at Cohen Veterans Bioscience have analyzed this proposal 
and agree that it is ambitious but doable with the current state of 
technology.
C. Expand the Availability of Telehealth and Automated Care Services as 
        Broadly as Possible
            (1) Expand Access to Telepsychiatry
    Telepsychiatry and other telehealth services are essential to 
providing effective care throughout Montana and other rural states. 
These services have been expanding throughout Montana over the last 
decade through Federal, state, and private investments and they appear 
to be hitting critical mass. The VA, AWARE Inc., American 
Telepsychiatry, and many other clinicians have all provided 
telepsychiatry services to Montanans suffering from SMI. The Montana 
Legislature recently passed a bill which requires all health insurers 
in the state to cover telemedicine services. Montana State Senator Ed 
Buttrey sponsored this legislation that easily passed both houses with 
bipartisan support. The Federal Government's investment in these 
services combined with a firm legal footing and ever-improving 
technology, has given telepsychiatry momentum in the push to provide 
more rural Montanans with effective psychiatric coverage. The VA should 
support these efforts as much as possible.
            (2) Make Online Cognitive Behavioral Therapy (CBT) 
                    available to all Veterans
    Another innovative suicide prevention program in Montana is a 
research project led by Dr. Mark Schure, Ph.D. at Montana State 
University which will complete a randomized controlled trial of THRIVE 
for adults across Montana. THRIVE is an interactive computerized 
Cognitive Behavioral Therapy program (cCBT) that helps people identify 
ways to improve their mood. It is accessed online via computer, tablet 
or smartphone. In other populations, THRIVE has been shown to decrease 
the frequency of depressive symptoms and improve quality of life.\14\ 
In this study, participants will use the program for a year anonymously 
as often as needed during times of scheduled access.
---------------------------------------------------------------------------
    \14\ See e.g., Whiteside U, Richards J, Steinfeld B, et al. Online 
Cognitive Behavioral Therapy for Depressed Primary Care Patients: A 
Pilot Feasibility Project. The Permanente Journal. 2014;18(2):21-27. 
doi:10.7812/TPP/13-155.
---------------------------------------------------------------------------
    This research project, funded by the National Institutes of Health 
(NIH), is a partnership between Montana State University (MSU) 
researchers, One Montana, and WayPoint Health Innovations, the program 
developer. This project is supported from MSU's Center for Mental 
Health Research and Recovery. The purpose of this research is to test 
the effectiveness of the THRIVE program to help Montanans decrease the 
frequency of depressive symptoms and improve their quality of life. 
While it is too early to tell the results of this particular iteration 
of cCBT research, the overall body of research of cognitive behavioral 
therapy (CBT) for health conditions that affect veterans is positive, 
including alcohol abuse.\15\
---------------------------------------------------------------------------
    \15\ Kiluk, Brian D., et al. ``Randomized Trial of Computerized 
Cognitive Behavioral Therapy for Alcohol Use Disorders: Efficacy as a 
Virtual Stand-Alone and Treatment Add-On Compared with Standard 
Outpatient Treatment.'' Alcoholism: Clinical and Experimental Research 
40.9 (2016): 1991-2000.
---------------------------------------------------------------------------
    The VA should embark upon a process to make high-quality, engaging 
cCBT available to all veterans.
            (3) VA Should Partner to Expand the Availability of 
                    Automated Suicide Risk Assessment Scales
    Dr. Eric Arzubi, MD has brought the University of Vermont's 
Automated Suicide Risk Assessment Tool (Assessment Tool) to Montana's 
largest hospital system, the Billings Clinic. The Assessment Tool is 
designed to replicate the thinking of an experienced psychiatrist in 
the evaluation of near-term suicide risk.\16\ The Assessment Tool uses 
a neural network-based algorithm to assess suicide risk in emergency 
department and medical inpatients. For levels of suicide risk, the 
model tool takes less than a minute to predict a psychiatrist's 
assessment at between 91 and 94 percent.\17\ Patients reported that the 
tool was easy to complete.
---------------------------------------------------------------------------
    \16\ Jennifer Nachbur, ``Study Shows UVM Suicide Risk Assessment 
Tool Performs Like Psychiatrist'' (June 8, 2016) https://med.uvm.edu/
com/news/2016/07/12/study_shows_uvm_suicide_ 
risk_assessment_tool_performs_like_psychiatrist
    \17\ Desjardins, Isabelle, et al. ``Suicide Risk Assessment in 
Hospitals: An Expert System-Based Triage Tool.'' The Journal of 
clinical psychiatry 77.7 (2016): e874-82.
---------------------------------------------------------------------------
    The VA can adopt the Assessment Tool, or a similar model tool, in 
its emergency settings and partner with the developers to ensure that 
it can be easily and seamlessly utilized in a variety of electronic 
health record systems throughout the U.S.
D. Develop a Plan for Treatment Resistant Mental Health Conditions
    Treatment resistance in mental health conditions is a significant 
barrier to effective care for recovery from these potentially fatal 
conditions. It is estimated that one-third of people diagnosed with 
schizophrenia have a treatment-resistant form of the condition.\18\ 
Treatment resistance is one of the ``the biggest challenges'' in 
treating bipolar disorder, which as noted above affects many 
veterans.\19\ It is also estimated that roughly one-third of 
individuals with depression ``continue to be resistant to available 
therapeutic options, and hence pose a major therapeutic challenge to 
mental health experts.'' \20\
---------------------------------------------------------------------------
    \18\ Sinclair, Diarmid, and Clive E. Adams. ``Treatment resistant 
schizophrenia: a comprehensive survey of randomised controlled 
trials.'' BMC psychiatry 14.1 (2014): 253.
    \19\ Bauer, Isabelle E., et al. ``The Link between Refractoriness 
and Neuroprogression in Treatment-Resistant Bipolar Disorder.'' 
Neuroprogression in Psychiatric Disorders. Vol. 31. Karger Publishers, 
2017. 10-26.
    \20\ Al-Harbi, Khalid Saad. ``Treatment-resistant depression: 
therapeutic trends, challenges, and future directions.'' Patient 
preference and adherence 6 (2012): 369.
---------------------------------------------------------------------------
    From my position in Montana, it appears that VA does not have a 
strategy to care for veterans with treatment-resistant mental health 
conditions. As an example, VA does not have any means or tools 
available to treat veterans with treatment-resistant depression within 
the state of Montana. The best option that a Montana veteran with 
treatment resistant depression may have to receive care is to travel to 
Wyoming or another state for Electroconvulsive Therapy (ECT). ECT can 
be an effective option for treatment-resistant depression, but it is 
invasive and can be debilitating between treatments, so traveling out-
of-state to receive care can be particularly difficult.
    This issue is dear to my heart because I lost my dear friend, 
colleague, and fellow veteran Mike Franklin to treatment-resistant 
depression in September 2015. In the two years since Mike's suicide, 
private payers and providers in Montana have taken major strides in 
opening up options for clients with treatment-resistant conditions such 
repetitive Transcranial Magnetic Stimulation (rTMS) and Ketamine 
infusions. Unfortunately, the Montana VA has not moved at the same 
brisk pace.
    The Cooperative Studies Program within the U.S. Department of 
Veterans Affairs is launching a randomized control trial of rTMS for 
treatment-resistant major depression in veteran patients.\21\ While 
this a positive step forward, I cannot help but wonder why this tool is 
not being adopted at a faster rate. I am increasingly frustrated by the 
puzzle of why Blue Cross Blue Shield of Montana has agreed that this 
treatment can be critical to the recovery of its members with 
treatment-resistant depression,\22\ but the Montana VA has not. VA must 
work more expediently to provide access to this lifesaving treatment 
for veterans with treatment-resistant mental health conditions.
---------------------------------------------------------------------------
    \21\ Mi, Zhibao, et al. ``Repetitive transcranial magnetic 
stimulation (rTMS) for treatment-resistant major depression (TRMD) 
Veteran patients: study protocol for a randomized controlled trial.'' 
Trials 18.1 (2017): 409.
    \22\ Blue Cross Blue Shield of Montana: Behavioral Health Care 
Management Program, https://www.bcbsmt.com/ provider/clinical-
resources/ behavioral-health-programs
---------------------------------------------------------------------------
E. Prize for a Research Team to Create and Validate a Medical Screening 
        Tool to Determine Which Patients are at Risk of Developing 
        Side-Effects From Clozapine
    The following block quote is taken in its entirety from the article 
``Clozapine: a distinct, poorly understood and under-used molecule'' 
with references from Dr. Ridha Joober, MD and Dr. Patricia Boksa, Ph.D. 
from the Journal of Psychiatry & Neuroscience.

          Consensus of opinion is rare in psychiatry. Even in the field 
        of clinical trials, where experimentation is tightly controlled 
        and regulatory bodies scrutinize the proof, controversies are 
        frequent and difficult to resolve.\23\ One issue for which 
        there is a widespread consensus is the unique place that 
        clozapine occupies in the treatment of severe mental illnesses, 
        particularly refractory schizophrenia. This molecule is 
        distinct because of its effectiveness, numerous and sometimes 
        mysterious pharmacologic characteristics, serious side effects 
        and under use.
---------------------------------------------------------------------------
    \23\ Blier P. Do antidepressants really work? J Psychiatry 
Neurosci. 2008;33:89-90.
---------------------------------------------------------------------------
          Historically, clozapine was distinguished by one of its 
        dangerous and sometimes lethal side effects, agranulocytosis, 
        which almost caused its complete banishment from the 
        psychiatric pharmacopoeia.\24\ It was only rescued when its 
        superior therapeutic effects compared with chlorpromazine in 
        patients with refractory schizophrenia were demonstrated.\25\ 
        Since its controlled comeback, clozapine has consistently 
        demonstrated advantages in a variety of clinical situations. 
        Its enhanced therapeutic profile in patients with schizophrenia 
        who respond poorly to other antipsychotic medications, both 
        typical \26\,\27\,\28\ and 
        atypical,\29\,\30\,\31\ have been 
        reported in many studies and encompass many dimensions of the 
        schizophrenia syndrome.\32\,\33\ Positive symptoms 
        are most consistently improved by clozapine, but there are also 
        reports indicating that anxiety, mood and negative symptoms 
        \34\ as well as hostile behaviours \35\ are better controlled 
        with clozapine than with other neuroleptics, although the data 
        are less consistent. Moreover, it has been reported that 
        patients are more likely to remain compliant with clozapine 
        than with other atypical 
        antipsychotics.\36\,\37\,\38\ Clozapine 
        is also the only antipsychotic medication that has shown an 
        anticraving effect for drugs of abuse,\39\ a significant effect 
        in reducing suicide rates in patients with schizophrenia \40\ 
        and an efficacy on refractory mood disorders.\41\ Every 
        clinician who has prescribed clozapine can recount a few 
        experiences of seeing patients emerge from their chaotic 
        psychotic experience. This is one of the most rewarding 
        experiences that a psychiatrist can have in his or her 
        professional life, and it is among the most important strikes 
        we have made against one of the most devastating diseases 
        affecting mankind.
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    \24\ Marder SR, Van PT. Who should receive clozapine? Arch Gen 
Psychiatry. 1988;45:865-7.
    \25\ Kane J, Honigfeld G, Singer J, et al. Clozapine for the 
treatment-resistant schizophrenic. A double-blind comparison with 
chlorpromazine. Arch Gen Psychiatry. 1988;45:789-96.
    \26\ Id.
    \27\ Kane JM, Marder SR, Schooler NR, et al. Clozapine and 
haloperidol in moderately refractory schizophrenia: a 6-month 
randomized and double-blind comparison. Arch Gen Psychiatry. 
2001;58:965-72.
    \28\ Hong CJ, Chen JY, Chiu HJ, et al. A double-blind comparative 
study of clozapine versus chlorpromazine on Chinese patients with 
treatment-refractory schizophrenia. Int Clin Psychopharmacol. 
1997;12:123-30.
    \29\ Kumra S, Kranzler H, Gerbino-Rosen G, et al. Clozapine and 
``high-dose'' olanzapine in refractory early-onset schizophrenia: a 12-
week randomized and double-blind comparison. Biol Psychiatry. 
2008;63:524-9.
    \30\ Azorin JM, Spiegel R, Remington G, et al. A double-blind 
comparative study of clozapine and risperidone in the management of 
severe chronic schizophrenia. Am J Psychiatry. 2001;158:1305-13.
    \31\ Lewis SW, Davies L, Jones PB, et al. Randomised controlled 
trials of conventional antipsychotic versus new atypical drugs, and new 
atypical drugs versus clozapine, in people with schizophrenia 
responding poorly to, or intolerant of, current drug treatment. Health 
Technol Assess. 2006;10:iii-xi.
    \32\ Elkis H. Treatment-resistant schizophrenia. Psychiatr Clin 
North Am. 2007;30:511-33.
    \33\ Tandon R, Belmaker RH, Gattaz WF, et al. World Psychiatric 
Association Pharmacopsychiatry Section statement on comparative 
effectiveness of antipsychotics in the treatment of schizophrenia. 
Schizophr Res. 2008;100:20-38.
    \34\ Breier AF, Malhotra AK, Su TP, et al. Clozapine and 
risperidone in chronic schizophrenia: effects on symptoms, parkinsonian 
side effects, and neuroendocrine response. Am J Psychiatry. 
1999;156:294-8.
    \35\ Citrome L, Volavka J, Czobor P, et al. Effects of clozapine, 
olanzapine, risperidone, and haloperidol on hostility among patients 
with schizophrenia. Psychiatr Serv. 2001;52:1510-4.
    \36\ Cooper D, Moisan J, Gregoire JP. Adherence to atypical 
antipsychotic treatment among newly treated patients: a population-
based study in schizophrenia. J Clin Psychiatry. 2007;68:818-25.
    \37\ Nasrallah HA. The roles of efficacy, safety, and tolerability 
in antipsychotic effectiveness: practical implications of the CATIE 
schizophrenia trial. J Clin Psychiatry. 2007;68 (Suppl 1):
5-11.
    \38\ Ascher-Svanum H, Zhu B, Faries DE, et al. Adherence and 
persistence to typical and atypical antipsychotics in the naturalistic 
treatment of patients with schizophrenia. Patient Prefer Adherence. 
2008;2:67-77.
    \39\ Green AI, Noordsy DL, Brunette MF, et al. Substance abuse and 
schizophrenia: pharmacotherapeutic intervention. J Subst Abuse Treat. 
2008;34:61-71.
    \40\ Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for 
suicidality in schizophrenia: International Suicide Prevention Trial 
(InterSePT) Arch Gen Psychiatry. 2003;60:82-91.
    \41\ Suppes T, Webb A, Paul B, et al. Clinical outcome in a 
randomized 1-year trial of clozapine versus treatment as usual for 
patients with treatment-resistant illness and a history of mania. Am J 
Psychiatry. 1999;156:1164-9.
---------------------------------------------------------------------------
          Expiration of the patent on clozapine in 2007 has lessened 
        the burden of economic constraints against the use of 
        clozapine. However, side effects remain a major issue affecting 
        the choice to use the drug.

    As noted above, schizophrenia is a major risk factor for suicide 
among veterans. The goal of this recommendation is to spur innovation 
by establishing a major cash reward, similar to the original $10 
million dollar X Prize that led to the commercialization of space 
flight, to incentivize the development of a medical screening tool to 
determine who can be prescribed Clozapine without any risk of 
developing dangerous side effects. An effective screening tool would 
make it easier for veterans with schizophrenia to access this 
potentially life-saving therapy. The relatively low cost of Clozapine, 
in comparison to similar medications, would likely also save VA 
critical resources. The potential positive effects of a Clozapine side 
effect screening tool would also dramatically improve the cost of 
caring for individuals with schizophrenia, which is generally covered 
by the Centers for Medicare and Medicaid Services (CMS). The cost 
savings could be dramatic as the current costs of caring for 
schizophrenia are increasingly expensive, with estimated ``annual 
direct and indirect costs of up to US$102 billion.'' \42\
---------------------------------------------------------------------------
    \42\ Wang Y, Iyengar V, Hu J, et al. Predicting Future High-Cost 
Schizophrenia Patients Using High-Dimensional Administrative Data. 
Frontiers in Psychiatry. 2017;8:114. doi:10.3389/ fpsyt.2017.00114.
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F. Better Utilize Non-VA Providers
            (1) Develop an Advanced Analytics Online Directory that is 
                    Continuously Expanded and Culled by veterans and 
                    managed by VACO staff
    On Thursday, September 21 I helped assist a family who had a 
veteran in mental health crisis. The VA staff did an excellent job, and 
was able to receive the veteran into their emergency room, identified 
his need for inpatient treatment and transported him by ambulance to a 
private hospital to receive care. This was generally the correct 
result, but the hospital is an hour and a half away from the people 
that love this veteran on a day-to-day basis. They likely will be 
unable to get time off of work or find childcare in order to visit and 
support his care. The last update I received was that he was escalating 
a few days later on Saturday, September 23, and it was unlikely that 
anyone who cared about him was going to be able to get there to see him 
over the weekend.
    The Montana VA chose not to use the Journey Home, a private 
nonprofit mental health crisis center, that is located in the same town 
as the emergency room the veteran first received care. There may have 
been a medical reason for him to be hospitalized in a different town. 
However, I have reviewed instances where the VA staff processing the 
veteran are simply not aware of the resources available in that 
veteran's community because the resources are either new, or for an 
unknown reason do not fit into the standard community resource manual.
    Similarly, I recently helped assist a Vietnam veteran who had 
become suicidal. There were many real treatment issues involved, but 
there were also unrelenting life issues in that he could not afford 
meals and he was deeply lonely. Both of those issues could be partially 
addressed through the local Area Agency on Aging Senior Meals and 
Support programs. A fellow veteran brought the veteran in crisis there, 
and the services were greatly appreciated.
    There are so many different local services, even in a sparsely 
populated state like Montana, that it is impossible for a single 
clinician, social worker, or peer support specialist to keep them 
straight. Thankfully, the technology for tracking and culling these 
services from a centralized location has gotten much easier.
    For example, NAMI Montana was able to develop a resource guide for 
every county in Montana through the work of a single VISTA volunteer. 
We also developed a resource guide which included every inpatient 
mental health and substance abuse facility in the U.S. for the Family 
Support Foundation on Mental Illnesses. This resource guide is 
available online at treatmentscout.com, and was created by scouring 
open source information and combining publicly available resource 
guides.
    While it sounds daunting, VA should develop a central resource 
guide for community services across the U.S., managed by VACO through a 
creative combination of an advanced analytics program and veterans 
working the phone lines.
            (2) Create a More Synergistic Relationship Between VA and 
                    the Community Health Centers (CHCs)
    There are over 1,300 CHCs distributed across the country.\43\ For 
purposes of this testimony, CHCs include federally Qualified Health 
Centers (FQHCs) and Rural Health Centers (RHCs). CHCs care for a large 
number of patients across the country. In 2015 alone, CHCs had almost 
97 million patient visits.
---------------------------------------------------------------------------
    \43\ ``Community Health Center Delivery Sites and Patient Visits.'' 
Kaiser Family Foundation website, http://www.kff.org/other/state-
indicator/community-health-center-sites-and-visits/? 
currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%2
2asc%22% 7D
---------------------------------------------------------------------------
    As mentioned above, 70 percent of veterans nationally who die by 
suicide had not previously been connected to VA care.\44\ It is likely 
that a portion of the veterans who do not receive care through VA, do 
receive care through CHCs. These CHCs provide comprehensive primary 
care services, but also provide access to mental health and substance 
abuse treatment. Their standard of care is monitored closely by the 
Health Resources and Service Administration (HRSA). They also have a 
billing structure which allows them provide services in underserved 
rural areas, which would help close the gap in providing necessary 
mental health services to rural veterans.
---------------------------------------------------------------------------
    \44\ Hope Yen, ``VA data show veteran suicide highest in US West, 
rural areas,'' Chicago Tribune, September 17, 2017, http://
www.chicagotribune.com/lifestyles/health/sns-bc-us_veterans-affairs-
suicide-20170915-story.html
---------------------------------------------------------------------------
    In an era where we are struggling to figure out how to ensure 
veterans always receive access to high-quality care, Congress should 
take a serious look at how to ensure VA and the CHC's are able to 
seamlessly work together across the U.S. Congress acting on this 
recommendation will specifically enhance our ability to get America's 
veterans the best, mostly timely care.
G. Increase VA's Collaboration with Outside Researchers
    In May, VA and Coalition member Cohen Veterans Bioscience announced 
a public-private partnership alliance, called the Research Alliance for 
PTSD/TBI Innovation and Discovery Diagnostics (RAPID-Dx), ``to enable 
different institutions to coordinate efforts and integrate data across 
dozens of labs and leverage synergistic capabilities for a `big data' 
team-science approach to discover and support development of first-
generation validated biomarkers and diagnostics for PTSD and TBI.'' 
\45\ The partnership will to develop new tools ``to consistently and 
accurately diagnose'' PTSD and TBI, then assess if treatment is 
working. The VA described this partnership as, ``affirming our 
commitment to a new type of radically collaborative science defined by 
data sharing and coordination of efforts toward our shared goal of 
finding clinically-useful diagnostics and treatments for these 
invisible wounds of war.'' Secretary Shulkin reiterated the view of the 
Working Group, noting that ``we're able to accomplish so much more when 
we work strategically with our private and public sector partners.'' 
NAMI Montana and our national office agree with Secretary Shulkin--we 
will be able to serve our Nation's veterans and address their mental 
health needs in a better, more comprehensive way engaging all public 
and private sector stakeholders.
---------------------------------------------------------------------------
    \45\ Cohen Veterans Bioscience, Press Release CVB and the Veterans 
Health Administration Announce Landmark Partnership to Advance the 
Diagnosis and Treatment of Trauma-Related Brain Disorders (May 17, 
2017), http://www.cohenveteransbioscience.org/2017/05/17/cohen- 
veterans-bioscience-and-the-veterans-healthadministration-announce-
landmark-partnership-to- 
advance-the-diagnosis-and-treatment-of-trauma-related-braindisorders/
---------------------------------------------------------------------------
    We encourage this Committee to task VA to maximize the 
effectiveness of this new partnership, as well as the work of similar 
initiatives. This includes the Multidisciplinary Association for 
Psychedelic Studies (MAPS). MAPS, in conjunction with the National 
Institutes of Health (NIH) is conducting a rigorous analysis of several 
Schedule One substances to determine whether they can be clinically 
effective when well-regulated and monitored under a clinician's care. 
Some of MAPS efforts may be opening the door to new pathways to 
effective treatment.\46\
---------------------------------------------------------------------------
    \46\ See e.g., Griffiths RR, Johnson MW, Carducci MA, et al. 
Psilocybin produces substantial and sustained decreases in depression 
and anxiety in patients with life-threatening cancer: A randomized 
double-blind trial. J Psychopharmacol (Oxford). 2016;30(12):1181-1197.
---------------------------------------------------------------------------
    Additionally, we respectfully ask this Committee to work with VA to 
provide researchers outside of VA access to the veteran-specific PTSD 
datasets and biological samples, and provide institution-wide support 
for multi-site PTSD clinical trials.
H. Establish a Continuity of Care Pipeline for Veterans directly from 
        DOD to VA/Community Providers
    When servicemembers leave the military, it can often be a time full 
of life transitions which can cause stress which can exacerbate mental 
health conditions. We have strong reason to believe that the lack of 
this continuity of care ``pipeline'' between DOD and VA healthcare 
systems is resulting in many veterans slipping through the cracks. 
Unfortunate consequences can result in this case, as the ability to 
early identify and provide pre-emptive intervention care for mental 
health conditions is severely delayed, thus making the conditions far 
worse.
    We would like to respectfully recommend this Committee work with 
the Senate Armed Services Committee to task VA to develop a plan with 
DOD to develop a Continuity of Care Pipeline to minimize the number of 
veterans that miss the opportunity to take advantage of VA's 
potentially lifesaving mental health care.
                             vi. conclusion
    Thank you again for the opportunity to testify in front of this 
honorable Committee. Your attention to this issue means a lot to me, 
our entire NAMI organization, veterans and their families. We look 
forward to working with you to save the lives of America's injured 
heroes.

    Chairman Isakson. Thank you, Mr. Kuntz. We appreciate your 
being here today.
    What I am going to do is, I am going to reserve my time 
since we have three Members that are here, and I know we have 
different meetings that are going to take place. I am going to 
go straight to our Members for their questions and will ask 
mine a little later when Senator Tester returns. He is doing a 
presentation at another hearing and will be here for his 
opening statement in just a little bit.
    Let me start off with the senator from Arkansas, John 
Boozman.

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

    Senator Boozman. Thank you very much, Mr. Chairman, and 
thank you for holding such an important hearing, and again, 
also to Senator Tester.
    I cannot think of anything that is more important to 
discuss. Certainly, we all agree that this is a crisis. In 
Arkansas, I think we are number 10 in suicide rate overall. Of 
that group, veterans represent about 8 percent of the 
population, but represent about 20 percent of the suicides. We 
are a State that is like so much of the rest of the country; in 
fact, the rest of the country, period, that is experiencing 
significant problems.
    Dr. Bryan, you mentioned that recent reports have 
highlighted the inadequacies of our Nation's mental health 
professional training. In fact, I was looking at the chart--50 
percent of psychologists, 25 percent of social workers, 2 to 6 
percent of marriage counselors, 28 percent of psychiatrists. 
Only those have really received what we would call even the 
old-fashioned training, perhaps, not to mention the work that 
you and others are doing in such a good way. Those are pretty 
staggering.
    How do we go about--unless we have a metric out there, how 
do we go about solving that problem?
    Mr. Bryan. I will admit that this is----
    Senator Boozman. And also, let me--as you are thinking 
about that--and the rest of you all can jump in too--how do 
we--you know, once we have the new research, once we perhaps 
get a metric, how do we get that, you know, not talked about 
but actually instituted in a timely manner.
    Mr. Bryan. Correct. Both very good questions.
    The first one, I think is a much bigger question, and I 
will admit it. This is a huge issue that would probably require 
a concerted effort in redesigning or potentially really 
reengineering our education and training system in professional 
practice of mental health. We would need to find ways to 
incentivize graduate training programs and medical schools to 
ensure that not only are they providing any amount of training, 
but that training is scientifically supported. This can be 
accomplished in other ways, perhaps looking at grants and other 
Federal incentives and initiatives to encourage certain types 
of curriculum as well as training opportunities, but also, I 
think partnering with and working alongside with various 
accreditation bodies to look at how do we determine whether or 
not an educational system is meeting minimum standards for the 
practice of mental health across these disciplines. If we kind 
of work with those organizations, I think we would be able to 
see some very dramatic shifts in curriculum.
    For your second question regarding dissemination and 
implementation, I think one of the challenges that many of us 
have as scientists is that scientists tend not to be very good 
at communicating their ideas to nonscientists, and so many of 
us in the dissemination field have really talked about how do 
we find opportunities to have researchers and scientists work 
with communications experts on how to convey this information 
not only to the general public, but also to other 
professionals, those who we want to target to be using these 
strategies.
    But, we also need to target the consumer, so the consumer 
is educated and understands which treatments work best, so that 
when they go to a health care provider they can ask the right 
questions to determine if this is an individual who is likely 
to be able to help me.
    Senator Boozman. Right.
    Yes, sir. Go ahead.
    Mr. Kuntz. Yes, sir. You know, one of the things that we 
found to be very important is getting the research to the 
States, creating a pipeline to have those conversations.
    We had to startup a research center in Montana to make that 
happen, and because of the way that the VA structures their 
centralized research, we probably will never have VA research 
in Montana. But, if that pipeline is adjusted, that gets those 
conversations started, which gets people trained.
    The other thing that I would recommend is for the VA to 
make its treatment algorithms for veterans more widely 
available. I think that the transition to the Cerner medical 
records is going to make that more possible, but, you know, get 
those treatment algorithms out to the field so people in non-VA 
facilities can use them.
    Thank you.
    Senator Boozman. Very good.
    Is overmedication a problem?
    Mr. Bryan. I would say my response is overmedication is 
broad.
    What we would see--for instance, a student of mine just 
finished their dissertation. We are about to publish the 
results, finding that there is about a larger than expected 
proportion of veterans who receive benzodiazepines, despite 
being diagnosed with PTSD. Benzodiazepines are not indicated 
for PTSD and can actually interfere with effective treatment 
for PTSD.
    Oftentimes, physicians and other prescribers rely on these 
because first-line treatments have not worked, and so they are 
hoping to provide some kind of symptom relief.
    The unfortunate aspect of this, as my student found, was 
that in those cases, those veterans with PTSD who received 
benzodiazepines, they are almost three times more likely to die 
by suicide, so there is another risk associated with 
contraindicated medications where--I do not know if they are 
overprescribed, but I am not necessarily certain that in all 
cases, veterans and their prescribers are aware of all of the 
risks and are able to weigh them with the benefits of those 
medications.
    Senator Boozman. Right.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator.
    Senator Blumenthal, who I would point out was one of the 
real leaders in the Clay Hunt Suicide Prevention bill and did 
great work on that in the last Congress.
    Richard.

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

    Senator Blumenthal. Thank you. Thanks, Mr. Chairman, and 
thanks for your leadership on this important issue.
    I was, indeed, the lead Democratic cosponsor on the Clay 
Hunt bill along with Senator John McCain on the Republican side 
and believe that it was a start, only a first step in this 
effort. Much more needs to be done.
    Obviously, there are steps that have been taken by the VA 
in furthering this effort, and I know we will hear from Dr. 
Shulkin later, but the more I learn about this problem, the 
more complex and challenging I think it is.
    Dr. Bryan, one of the very important statistics in your 
testimony is that the suicide rate among veterans who do not 
use VA services increased by 39 percent between 2001 and 2014, 
whereas the suicide rate among VA users increased by only 9 
percent.
    Put aside the exact numbers. What I am hearing again and 
again and again is that the suicide rates are increasing among 
veterans who lack access, either because of geographic or other 
difficulties in reaching these services or because they have 
received less than honorable discharges. This has become a 
passion for me because there is a whole group of veterans who 
suffered from PTSD, often undiagnosed, were separated less than 
honorably, and have been cast out and barred from using those 
services and often feel stigmatized and disengaged, not only 
from the VA but from society in general.
    I have met with many of them, and I have worked with the 
Department of Defense on the review process, which has been 
changed as a result of leadership within the Department of 
Defense, commendably, but many of those veterans who were 
discharged less than honorably do not know about it, do not 
know about the changes in policy, do not know about the 
possibility of access to these services. So, it is a vicious 
cycle, a lethal cycle, which can lead to suicide.
    I guess my question to all of you, not only about the less 
than honorably discharged veterans, but women veterans who also 
perhaps do not readily access these services, and their suicide 
rates are increasing. Those segments of the veteran community 
whose suicide rates are increasing need to be reached, and my 
question to each of you is, Do you see that phenomenon as real? 
Do you recognize it, and can you elaborate on it? What are your 
recommendations for addressing it?
    Dr. Daigh. Sir, I agree with you. I think the adequate 
treatment of substance abuse disorder and access to therapy and 
the adequate treatment of depression, as Mr. Kuntz indicated, 
to include pharmacologic treatment and maybe ECT or other 
treatments that are available, is critical.
    If you cannot get people to a competent provider, it is a 
very difficult problem. So, I agree with your statement.
    Mr. Bryan. I have two thoughts in response, the first of 
which is I think what the statistics highlight is that the 
rates are going up, even among VA users, but it is a much 
slower rate. So, the VA is doing something good that is not 
happening for those who do not receive the services.
    A common question is, well, how do we get more veterans 
into the VA, and I think that is an important question. The 
other question, though, I think we need to ask is, Why are 
there not other adequate services available to veterans in 
their communities?
    I think this really came to a head for me several years 
ago. I do not know if you read the New York Times article about 
the Second Battalion, Seventh Marine Regiment (Marine 2/7), who 
has had a very high suicide rate, and a lot of them did not 
have access to the VA. There is a lot of discussion about that, 
and I said, well, the implication of this is some veterans have 
access to really nothing, or they have access to community 
providers who have little to no experience working with 
servicemembers or veterans. They do not know how to treat PTSD. 
They have never seen Traumatic Brain Injury before, and as the 
statistics I show you here, they have no experience with 
suicide risk.
    I think part of the solution will be how do we get more 
veterans into the VA because as the RAND report, recently 
released, highlighted, the quality of care in the VA for mental 
health exceeds that in the private sector.
    But, for those who do not access VA services, whether 
because they are not eligible or because they choose not to--we 
have to keep that in mind. Some veterans choose not do. We need 
to make sure quality services are available to them.
    What we have done in Salt Lake City kind of as a model of 
this is--our center is on the University of Utah campus, right 
across the street from the Salt Lake VA, and what we say is we 
are not a competitor to the VA. We are the augment; the VA 
sometimes sends their patients to us for treatment. There are 
some veterans in the community who cannot go to the VA or are 
unwilling, so they come to us. We can sometimes connect them 
with the VA for other services and benefits that maybe they did 
not know.
    I think we need to look at models like that on how 
different community agencies and the VA can further strengthen 
working together to better meet the needs of all veterans.
    Senator Blumenthal. Thank you.
    Mr. Kuntz. Senator Blumenthal, thank you for bringing up 
the less-than-honorable issue. That was something that came up 
in our family before my stepbrother's death, and it is a really 
big issue.
    I will point out that one of the ways that it was solved in 
Helena, Montana, or improved was by adding a Vet Center to our 
community, and at the time, the VA had fought it because they 
said that, ``You already have a hospital. Everybody that will 
go there, you know, that would go to the Vet Centers already go 
to the hospital,'' and that turned out not to be true.
    I think that part of it is when you are depressed or when 
you have PTSD, the first thing that you cannot stomach is 
bureaucracy, and you just quit. You are faced with bureaucracy, 
you face this red tape, and you give up. The Vet Centers have 
less bureaucracy. The federally qualified health centers, 
FQHCs, have less bureaucracy--in order to get in and start 
treatment. I think that is part of what is not really shown in 
those statistics is the folks that give up because they look at 
the bureaucratic red tape and say, ``I cannot mentally take 
it.''
    Senator Blumenthal. I just want to thank all of you for 
your testimony today. Obviously, we have just scratched the 
surface of this topic. I hope that we can get the latest 
numbers on vet suicide rates, on the differences between VA 
users and non-users.
    I have sponsored legislation with my colleague, Senator 
Blunt, to--it is called the Veteran PEER Act, legislation that 
would establish peer specialists in patient-aligned care teams 
within VA medical centers to do this kind of outreach. The 
peer-to-peer relationship among vets, I think, is an effective 
way to enable more access.
    But, the VA has been doing better, and I commend Dr. 
Shulkin and his team, and we will--as I mentioned, we will be 
hearing from him. But on all counts, the Nation needs to do 
better. Thank you.
    Chairman Isakson. Thank you, Senator Blumenthal.
    For the benefit of the members here, we are going to take 
questions by order of appearance, alternating by party, and our 
next three questioners will be Senator Heller, Senator Manchin, 
and Senator Sullivan, in that order.
    Senator Heller. Mr. Chairman?
    Chairman Isakson. Yes.
    Senator Heller. Thank you.
    Chairman Isakson. You betcha.

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

    Senator Heller. Thank you for this hearing. I want to thank 
those that are witnesses for being with us today, and I want to 
especially thank Senator Tester because I know this is an issue 
that is important to him and an issue that is important to 
Montana. It is unfortunate that Montana leads us in the 
statistic, but the issue is that Nevada is right behind them.
    A question that I continue to ask myself is, what makes 
Montana and Nevada unique? Mr. Kuntz, I will start with you as 
to why we see the stress in the areas of Montana and Nevada, 
maybe a little more unique than the rest of the country.
    Mr. Kuntz. Senator Heller, that is a great question, and I 
will tell you that if I had the perfect answer for that, I 
would probably be making a lot more money.
    But, I would tell you that we do have higher access to 
lethal means in our State. For the most part, when you are 
suicidal, the closer you are to lethal means, then the higher 
your risk of dying by suicide.
    We also have a lot of veterans per capita in our 
communities, and I think that that is an important factor.
    One of the things that is a little bit different about our 
suicide tends--and I do not know if it is the same for Nevada--
is we have more older veterans that are killing themselves, and 
I think that there is national trends saying that it is 
younger. But, if you look at Montana, that age 30 to 65, white 
males, is when we are losing them, and maybe it is just that we 
have a lot of people in that population group.
    I think that it is also an issue of lack of care. We have 
no psychiatric residency program in our State, and I know a lot 
of Nevada rural communities struggle too. So, I think it is a 
number of different factors, and we have got to tackle them one 
at a time.
    Senator Heller. I really do appreciate your comments.
    We had Secretary Shulkin in the State just a month or so 
ago, and he expressed his efforts to tackle this particular 
problem. We have hospitals, both north end and the south end of 
the State. We have a number of clinics that have been opened 
recently because of the efforts and the work of the Secretary 
and the VA, and it is appreciated.
    Let me ask you, Mr. Bryan. They have a resiliency program 
in Israel that they--and maybe we have already discussed this--
where they try to get this on the front end instead of the back 
end, where they actually train their soldiers, both male and 
female, of trying to avoid some of the stressful situations 
they may find themselves in and train them for them. Are we 
doing the same thing here in our country?
    Mr. Bryan. I would say, in general, yes, in the sense that 
if you look at military training, in general, a lot of it is 
designed to foster resiliency, how to endure difficult, adverse 
situations--perform under pressure, manage stress, et cetera.
    Where we have not had much success over the past decade or 
so is when we try to develop new resiliency programs that take 
more of a classroom format, wherein we bring in outside experts 
who then teach or train, sometimes trainers within the units or 
resiliency experts within the units, who are then supposed to 
go and teach these concepts and skills to others within the 
unit. There have been a number of barriers to that, but 
unfortunately, some of the research that has been done on some 
of the larger resiliency programs, such as Comprehensive 
Soldier Fitness, have yielded no benefit.
    We have seen some promise, however, in other resiliency 
methods. The one that has garnered the best, greatest promise 
so far is a program developed by the Army called Battlement 
that was shown to prevent or reduce PTSD symptoms, a small 
degree. It was not large, but it was a small and a noticeable 
degree amongst those who had the greatest and most intense 
levels of combat exposure while deployed, which if you think 
about it in many ways, it makes sense. Where we found the 
effect were the ones who probably needed it the most and the 
ones who had the highest level of trauma exposure while 
deployed.
    So, we have a couple of threads of evidence suggesting that 
certain approaches might help to reduce or prevent, at least 
reduce the severity of PTSD. However, we have not been able to 
large scale implement and further study those different 
strategies.
    Senator Heller. Is there any family training, not just the 
veteran themselves but actual family training so that they can 
identify some of these issues prior and prepare to help that 
veteran?
    Mr. Bryan. Right. There are a number of programs that have 
been created. There is none that sort of rises above the top.
    Where a lot of the family training programs--and this 
actually is very common. The peer issue that you mentioned 
before, a lot of the programs tend to take more of a ``Here is 
a bunch of signs and symptoms of this health condition'' and 
now refer someone to a mental health professional, but what we 
lack is what do the family members do.
    If a veteran is struggling with PTSD and does not want to 
go to treatment or there is a 2-week wait, what are you 
supposed to do in the meantime? We do not currently have any 
programs training that.
    Now, newer research, for instance, the crisis response plan 
that I mentioned before, this is something we have been 
teaching to family members. We have been teaching to peer 
specialists. We have been teaching the non-health care 
providers in the community who are closest to the veteran in 
need to not only recognize when they might need help but also 
what to do about it and doing things that have been 
scientifically shown to prevent suicidal behavior and reduce 
PTSD.
    Senator Heller. Mr. Bryan, thank you, and I want to thank 
all of our panelists.
    Mr. Chairman, thank you.
    I want to thank the Secretary, who is in the audience with 
us today, for his commitment and coming out to the State of 
Nevada and expressing his concerns on these particular issues 
because it does make a difference, and we need to figure this 
out and make that kind of difference.
    Mr. Chairman, thank you very much for the time.
    Chairman Isakson. Thank you, Senator Heller. We appreciate 
it.

     HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. Thank you, Mr. Chairman, and thank you, 
Ranking Member Tester, for having this hearing. I think it is 
very important--I got to turn my mic on first--for all of you 
to be here.
    My first question will be to Mr. Kuntz. As you mentioned in 
your testimony, community health centers are a critical part of 
providing health care in rural areas. Your State and my State 
are pretty rural, and in West Virginia, for instance, community 
health centers treat almost 400,000 patients. That is almost 25 
percent of our population, and out of that, we have 166,000 
veterans in our State. I am sure many of them got treatments 
there rather than traveling a long distance to the VA if they 
lived out in the rural areas of West Virginia.
    I would just like to hear, you are speaking on the 
importance of the community health centers and as mental health 
providers in your research. Are they capable? Do they have the 
personnel, they have the expertise to do that, so we can get--I 
am trying to get the treatment as quickly as possible without 
trying to build a whole other infrastructure to do it, if this 
vehicle is available for us, community health centers.
    Mr. Kuntz. Senator Manchin, thank you for your question.
    It is an amazing point. I would tell you that we have our 
licensing board in the State of Montana, and we have Licensed 
Clinical Social Workers (LCSWs) that work at the FQHCs. We have 
LCSWs that work at the VA. Psychologists too. This is the same 
level of staff. The training may be a little bit different, but 
the FQHCs and the rural health centers are adding mental health 
professionals all the time. They are absolutely at the same 
level of professionalism----
    Senator Manchin. Are you saying the quality of care for our 
veterans can be as adequate there as they will at the VA 
centers?
    Mr. Kuntz. Yes, sir.
    The only thing that they are not that good at is long-term 
care. I think that that short-term turnaround coverage may be 
six sessions of counseling until they are transferred to the 
VA, but if you are in a time crunch, that is exactly a place 
where I send people. If you are struggling to get into the VA, 
go to the FQHC.
    Senator Manchin. OK. Good.
    Mr. Bryan, in your testimony, you highlighted a lack of 
adequate training on suicide prevention methods among the 
mental health professionals, not just among VA providers but 
nationwide, and we know our Nation's veterans are using non-VA 
care, as we just talked about.
    My question would be, if this Committee moves forward on 
efforts to rework the non-VA care, how can we better invest and 
incentivize mental health training? How do we get more people 
with that expertise and on suicide prevention?
    Mr. Bryan. I think it will require a multipronged approach, 
and I think the easiest or sort of most straightforward 
approach is to invest in training workshops. However, I will 
say that will likely have limited impact. If there is one thing 
I have learned over the past decade, training thousands of 
mental health professionals, is going to 2 days of workshops, 
getting continuing education, and a deck of PowerPoint slides, 
oftentimes is not enough for them to actually use the therapy 
in an effective way.
    One of the things we have learned actually from a lot of 
the VA's efforts in educating is you have to provide ongoing 
support. You train people. You supervise them. You meet with 
them on a regular basis. You help them. You teach them how to 
overcome common barriers, and so I think as we look at 
training, we are going to have to look at this from more of a 
long-term support.
    I think the second aspect of this is we will have to look 
at our educational system.
    Another lesson I have learned over the decade of doing this 
training professionals at all levels is that if you teach a 
student how to do good medicine, they spend the next 30 to 40 
years of their life doing good medicine. If you teach a student 
to use unsupported, non-scientifically based interventions, 
they start doing that for 10 or 20 years, and it becomes very 
difficult to get them to change back.
    When I really think of this question, it is not only 
training the current labor force, but we are also going to have 
to look at how do we change how we train and teach the future 
labor force.
    Senator Manchin. OK.
    I have one more question, Mr. Chairman, if I may.
    Dr. Daigh, in your testimony, you brought up the concern 
about confidentiality requirements for sharing a veteran's 
treatment information to coordinate and improve a veteran's 
mental health between the veteran's provider and extended 
family. I am glad you pointed to that issue because, as it 
stands, more than a half a million VA patients are abusing 
opiates, and VA patients overdosed on prescription pain 
medication have more than doubled the national average. And it 
is a horrible problem in my State of West Virginia, as most 
States are dealing with this.
    While the VA has made really significant improvements, I 
still believe the areas--that these are critical areas we must 
work on.
    In March, I introduced the Vet Connect Act of 2017, which 
would streamline the health records sharing between VA and 
community health providers, since we are basically giving more 
services and outside the VA. The bill requires the Veterans 
Health Administration to comply with HIPAA but ensures that 
community providers can make informed decisions based on the 
veteran's holistic medical history.
    My question would be, Can you please elaborate on your 
findings as to why it is so important for the providers, health 
care providers, to have access to this behavioral health 
treatment information for their patients and how the current 
law is undermining the quality of coordinated care and hurting 
our veterans? What do we need to do to change?
    Dr. Daigh. I do not know if I can answer all of that. I 
think that----
    Senator Manchin. Give it a shot.
    Dr. Daigh [continuing]. In the personal relationship that 
exists between veteran and the team at VA that is providing 
care to the veteran, they often know who the significant 
individuals are in that veteran's life, who are not necessarily 
related family members. I think that coming up with 
mechanisms--and VA does currently use advanced directives, but 
could use them more widely and more thoughtfully and consider 
additional situations in which they could be used, so that when 
people get in crisis, VA providers can reach out and talk to 
significant individuals to try to bring that person back in.
    To the second point of sharing medical records across 
systems, I think that the data exchanges have to work in order 
for the VA medical record to communicate with all those other 
medical record systems. Among the vital points going forward, 
that is an extremely vital point.
    I am not advocating that there be some change to the 
privacy rules. I am advocating that we be more creative in 
getting permission so that at the time a person is ill, a 
larger community can be brought into the discussion.
    Senator Manchin. Well, we are going to need your help on 
that because we have had trouble getting past that.
    I will give you one example. We have a bill called Jessie's 
Law, a little girl 30 years of age who was addicted, and she 
overdosed a couple times, and then she died in the hospital. 
She died because when she went into the hospital, she explained 
that she was a recovering addict, and she had asked repeatedly. 
She says, ``Please notify my records. Make sure my records are 
identified, that they know that I am a recovering addict.'' 
Well, there was no such--the records were buried. It was not 
like if you have--allergic to cortisone or any of the other 
types of things that are really stamped and marked. The 
dispensing doctor did not see it, and they gave her 30 
OxyContin. She was dead by one o'clock in the morning.
    We are having a hard time getting through the HIPAA because 
of the patient privacy, and just common sense has to prevail 
and especially with our veterans on the front line now. You 
might be the ones that will help us transition this thing and 
get this piece of legislation and gives you the chance to share 
that, patients within the professional ranks that you can 
better serve them, but you need to speak out on that one.
    Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Manchin.
    The Senator from Montana is back, and we are going to let 
you go ahead and do your opening statement and questions at the 
same time unless--are you ready for your questions now, Senator 
Tillis?
    Senator Tester. Go ahead, Senator. Go ahead.
    Chairman Isakson. Senator Tillis.

       HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA

    Senator Tillis. Well, first, I want to thank Senator Tester 
because we have worked together over the past year or two, 
getting with the Department. We had a good meeting with Dr. 
Shulkin in our office, and I appreciate your continued, very 
valuable contribution to us, keeping track of the 
transformation efforts within the VA. I am sorry that I was not 
here earlier to hear the testimony.
    We will start back on the medical record. Back in North 
Carolina, I sat on the Electronic Health Record Board when we 
were trying to integrate health records among medical providers 
within the State, and since I am here and I am on the Senate 
Armed Services Committee, we were successful with getting a 
provision in the NDAA that makes absolutely certain--and I 
believe that the Department is glad that we did, the VA--makes 
absolutely certain that we do not miss a step as we integrate 
the two electronic medical record platforms that are going to 
be common platforms.
    There is still a lot more work to do. With over 100 or 120 
different instances of medical records in the VA, we have got 
to first make sure there is a good flow from DOD to the VA. 
Then we have got to make sure that we get that right. Then we 
go to the next step, which is all the other providers that 
could be involved in providing a veteran care.
    Senator Manchin, I am glad that you brought that up. I 
think it is critically important. There are ways to do it, and 
we need to push the envelope. We can address the privacy rules, 
but we want to make absolutely certain that the comprehensive 
view of the veteran in terms of their health history is known 
to anybody who may provide them care at any level.
    I am kind of curious about the work that we need. I have 
got the State--the heartbreaking statistics for the State of 
North Carolina, but frankly, they are, in some cases, better 
than the national average and other cases, which led me to 
wonder to what extent do we see a correlation between the 
incidences of suicides in other States and the lack of VA 
resources available to them or other resources.
    In other words, in a State like North Carolina where we 
have such a large military footprint, you have a natural group 
of people that have a therapeutic value just by being around 
other veterans, and then we have brick-and-mortar facilities. 
Have we looked at that to see if there is any correlation 
between footprint and outcomes to your knowledge?
    Dr. Daigh. No, sir. The gentleman who compiles the data may 
be able to answer that question, but I do not have an answer 
for that.
    Senator Tillis. I think it is important because it could be 
instructive as we go through and we take a look at how we are 
prioritizing the footprint, and every one of our States is very 
different. That is why some of the performance of the VA 
differs. It is based on support networks, VSOs, a variety of 
other factors. I think that should be instructive as we look at 
how we deploy resources to increasing our presence.
    I do not know. I saw Senator Blumenthal. I think he was 
probably heading out of the hearing as I was moving in, but I 
was curious if he brought up the issue that he and I share a 
concern with, which has to do with possibly bad paper and not 
tracking the--what more should we do to go back and take a look 
at discharges other than honorable, that if we had had a better 
understanding of what may have occurred during their service 
that could put them at a higher risk and actually could have 
resulted in paper that they should not have been discharged 
with.
    Mr. Bryan. Yes. He did raise that issue, and this is, I 
think, an important issue not only for suicide, but also for a 
host of other social issues that are, I think, of high 
relevance.
    We have seen higher rates of homelessness, higher rates of 
criminal activity in that subgroup as well, other social 
problems, so I think if we address it here with suicide 
prevention, we actually probably would have a much larger 
social impact in other areas as well.
    Senator Tillis. Are you all aware of anything that we 
should view as best practices for going--while we deal with the 
policy issues of how do we go back. There are two pieces to 
this. Prospectively, going forward, how do we make sure that at 
the point in time when we are making a discharge decision that 
we are taking in factors, particularly the invisible wounds of 
war that could have--could have affected that person's behavior 
and resulted in the other than honorable.
    How do you go back? The statistics here show that a lot of 
the suicides that we are seeing are not in the current wars 
that we are fighting, but they are Vietnam War and prior to 
that. Has there been much work done or any bright spots that 
you see that we are going back and going in that veterans 
population and trying to help them, try to clear up their 
record or at least make sure they are getting the care they 
need to avoid the possible suicide?
    Mr. Kuntz. Senator, probably the best one that I have seen 
in the Vet Centers because if you have been in combat, they do 
not care what your paperwork looks like. There is a place where 
people can go. I think that the other policy statement is these 
mental health conditions lead to conduct that eventually can 
get you discharges. If you have been to combat, why is there a 
less-than-honorable status? I mean, I do not know if we can 
scientifically say this did not cause your behavior or did not 
have some kind of effect. So, in my perspective, the tie goes 
to the runner.
    Senator Tillis. Yeah. I will take that at face value, and 
it may be something that we should talk about--and I chair the 
Personnel Subcommittee in Senate Armed Services--but look at it 
in a way that there can clearly be--even in the U.S. military, 
there are people who do things that I think are appropriate for 
a dishonorable discharge. It is a matter of how you get that 
right and how you do based on the circumstances that a soldier 
was exposed to, to where that may be the tiebreaker, is the 
nature of the environment they were exposed to and what you 
could reasonably expect as a medical practitioner, as someone 
who would look at that and say, ``Look, this is probably where 
the tie needs to go to the soldier.''
    Mr. Bryan. Well, one other point that I will add to that is 
when you look at some of these decisions, there are two 
separate processes by which a servicemember is separated from 
military service. There is the medical process, and then there 
is the administrative process. They do not parallel each other. 
They do not necessarily interface with each other, and there 
are--I can speak for myself as a former military psychologist. 
Sometimes there is confusion about who has precedent, because 
both issues are going on, which one goes first, which one goes 
second, and so it can create a lot of confusion and a lot of 
frustration for everyone involved--the commanders, the health 
care providers, and the servicemember and the veteran.
    Perhaps something going forward is how do we create a 
process wherein these two separate parallel tracks maybe work 
together a little bit more explicitly, there are no policies in 
place wherein there is crosstalk among these two stovepipes. 
That right now is not happening, so it is a little easier to 
make these types of decisions, which I think would help to 
reduce a lot of these conflicts and questions.
    Senator Tillis. Thank you all, and thank you, Mr. Chair, 
and thank you, Senator Tester.
    Chairman Isakson. Senator Tester.

               HON. JON TESTER, RANKING MEMBER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman.
    I was not even going to talk about this, but since you 
guys--since Senator Tillis brought it up, I would just tell you 
that the easy thing for the military to do is pitch somebody 
out if they have got behavior problems. The more difficult 
thing to do is talk to people, make an analysis whether combat 
changed them, which I really think is incumbent upon the 
military to do that. This is not the DOD committee, but it is 
VA, and it is important.
    OK. This is for either Mr. Bryan or Dr. Daigh. You do not 
have to both answers, but one or the other. Could you give me 
an idea on what percentage of veterans who have attempted 
suicide were previously diagnosed with mental health issues?
    Mr. Bryan. When you say attempted suicide, they died by 
suicide or they made a nonfatal attempt at suicide?
    Senator Tester. Attempt. They made an attempt.
    Mr. Bryan. I do know the statistics are available. I want 
to say the VA report--please take this with a grain of salt--
said somewhere around 70 percent, give or take.
    Senator Tester. Seventy percent had already been diagnosed 
with a mental illness?
    Mr. Bryan. Right. Yes.
    Senator Tester. OK. Have we seen a correlation between 
combat exposure and suicides?
    Mr. Bryan. We actually published a paper on this a couple 
years ago, and the answer is a little more complex to answer.
    So, is the relationship between deployment in general----
    Senator Tester. Yes.
    Mr. Bryan [continuing]. And suicide? No.
    Senator Tester. That is fine.
    Mr. Bryan. Is there a correlation between exposure to 
certain types of combat-related traumas?
    Senator Tester. Yep.
    Mr. Bryan. Yes.
    Senator Tester. OK.
    Mr. Bryan. It is killing and exposure to death. There was a 
small correlation.
    Senator Tester. OK.
    There has been some research that has indicated that living 
at higher altitudes could impact suicide, depression. Is that--
are you familiar with those studies, and are they real?
    Mr. Bryan. Yes. Actually, a colleague of mine at the 
University of Utah, Perry Renshaw, is really kind of the 
leading scientist in that area.
    Senator Tester. They are real?
    Mr. Bryan. Absolutely.
    Yeah. What seems to happen is at higher altitude, we have 
different oxygenation of----
    Senator Tester. Yeah.
    Mr. Bryan [continuing]. Metabolites in the bloodstream, so 
it affects how our brain processes neurotransmitters and how 
our brain, in essence, works.
    Senator Tester. Interesting.
    Mr. Bryan. Yep.
    Senator Tester. This is, I think, more for you, Matt. 
Veterans have been concerned about when you seek mental health 
care, there is a stigma attached. It could have effects on 
their career, perception by family, friends, right down the 
line. Do you think we are taking the appropriate steps to take 
care of the stigma that is associated with mental health 
issues, or have we done--have we made any progress in the area 
of de-stigmatizing mental illness?
    Mr. Kuntz. Senator Tester, I think we have made some 
progress as a society.
    The one thing I guess I just do not understand is why we do 
not really brag about how some of our best Americans had mental 
health conditions, had Post Traumatic Stress Disorder. Why do 
we not--I mean, when you are talking about Abraham Lincoln, why 
are we not saying that our Nation was blessed because that guy 
had bipolar disorder or depression?
    Senator Tester. Yeah.
    Mr. Kuntz. I mean, I think that some of our greatest 
leaders--like we are bringing a sergeant major from Delta Force 
to Congress in November, and, I mean, people like that need to 
stand up and say, ``In some ways, my condition helped me, but 
on those days where I struggle, you better be there to help me, 
too.''
    Senator Tester. Right on.
    So, you talked about older veteran suicide. Can you give 
me--and this kind of goes back to the question I just asked Mr. 
Kuntz. Can you give me an idea whether the newer generation of 
veterans are seeking mental health care more readily than the 
older generation, or is there no difference?
    Dr. Daigh. I do not have the data on that.
    Senator Tester. You do not?
    Mr. Bryan. My sense--I do not know the data offhand. My 
sense is that there is a decreased likelihood of younger 
generations of veterans who access services at the VA.
    Senator Tester. Oh, really? So, it has actually gotten 
worse?
    Mr. Bryan. That is what I understand. I could be wrong, but 
that was my understanding from some of my VA colleagues. Maybe 
someone else has better data or understanding of the data than 
me.
    Senator Tester. All right.
    One of the things that I think is interesting, we were 
contacted by a veteran from Sidney, Montana--that is in the far 
eastern part of Montana, very rural--who noted that the VA is 
unable or unwilling to include family members in the 
intervention process if a veteran is in crisis. I do not know 
if this is true or not, but if it is true, I think we are 
making a big mistake.
    I would love to hear all of your opinions very briefly, 
because you have only got about a minute left, 30 seconds, on 
what the VA can do better to engage families.
    Let us start with you, Dr. Daigh.
    Dr. Daigh. I think that use of advanced directives or some 
other mechanism that allows providers to talk about otherwise 
prohibited information to families widely when there is a 
crisis would help that intervention process.
    Senator Tester. OK. Dr. Bryan?
    Mr. Bryan. I think there are two key strategies that we 
could work with family members about. The first is a basic 
crisis management, how to talk to someone in crisis and how to 
help them when they are struggling to identify solutions to 
their current problem.
    Senator Tester. Actually working with the families to train 
them so they could recognize what to do?
    Mr. Bryan. Correct. Correct.
    Senator Tester. OK.
    Mr. Bryan. This is something we have been doing at Salt 
Lake City, training family members on what to do.
    The second related piece of that, teaching family members 
and bringing them--involved in the firearms safety aspect, how 
do we work with families to increase safety within the 
household, even maybe during times of non-crisis, because if we 
have a safer household to begin with during a time of crisis, 
everyone in the household is safer overall.
    Senator Tester. Hold it just for a second, Matt.
    Do you have any statistics on how many suicides by veterans 
are committed by guns versus other ways?
    Mr. Bryan. Yeah. The vast majority, close to 70 to 75 
percent are through firearms.
    Senator Tester. OK.
    Matt?
    Mr. Kuntz. Senator Tester, I think telling the families how 
to communicate with the VA, because you can get around HIPAA. I 
mean, ``You need to send us a letter. You need to send it to 
this portal. You can call us. We may not be able to tell you 
about the veteran, but if your veteran is in trouble, this is 
how you communicate to us. This is the way that you do it and a 
way that we will respond.'' We tell our families, ``You do 
written letters to professionals. They start thinking about 
malpractice, and pretty quick, they will get moving.'' But, you 
have to train those families.
    The same thing--we have a Family-to-Family course which 
helps train them in how to interact with the treatment system.
    Senator Tester. Well, thank you all for your testimony. I 
have got--I mean, we could spend all day long on this issue, 
truthfully, and we could spend all week and maybe the next 
month.
    I want to thank you for what you guys are doing. Each one 
of you in your own right are doing some really good work. I 
think you are the key, to be able to partner with folks like 
you, to really move this issue in a way where we have better 
outreach, we have better education, and we have better results.
    Thank you.
    Chairman Isakson. Thank you, Senator Tester.
    I have a couple of quick questions, and we will go to 
Senator Cassidy if he has a question, and then we will go to 
the second panel.
    Real quickly to this panel, Mr. Kuntz, you made reference 
to biological susceptibility. Is that a test? Is there a 
biological susceptibility test you can give someone, a blood 
test or something that have markers or indicators that there 
may be a suicide?
    Mr. Kuntz. Sir, I absolutely wish that there were. There is 
not a test now, but it is important to point out that 
biological susceptibility is something that is also dependent 
on other--you know, it factors into every other health care 
condition. There is not necessarily a biological susceptibility 
test for skin cancer either, but some people are more prone.
    That is one of the things that we have asked the Committee, 
is to ask the VA for more biological indicators by the fall of 
2020, and I think that even if it is not a specific this test 
for that, there are things like computerized executive 
functioning, where we know if that executive functioning is 
getting worse, there is something going on in that brain. It is 
not necessarily PTSD or depression, but there are tests that 
need to be brought forward, and I am hoping that they can be 
rolled in by the fall of 2020.
    Chairman Isakson. The reason I asked the question is, when 
you listen to the testimony of all of you, there are two things 
that pop out: one is, we have not had enough good training in 
the VA for dealing with suicide, and we need to work on that. I 
know Dr. Shulkin is going to do that, and prioritized suicide 
prevention is a main focus of his leadership.
    But, the other thing is that people do not ask the right 
questions, do not report the right--and their timing--our 
timing is never very good. Response timing on suicide 
prevention ought to be immediate and not an appointment 2 weeks 
later down the road.
    That is why I am so proud that all of our staff on the 
majority and the minority side have taken the SAVE course, now 
understand how important it is to look for the signs of 
suicide, to ask the question, ``Are you considering suicide?'' 
and not beat around the bush about it, to validate the 
veteran's experience and to encourage treatment and expedite 
getting help.
    I think if we embrace the SAVE program in the VA and work 
to do it, we will save a lot of lives by simply having the 
awareness in the direction of knowing what to do, and knowing 
what to do is 90 percent of solving the problem; and 100 
percent of solving the problem is identifying it. So, if we are 
better aware of the things we need to look for, the better off 
we will be. We will not need a biological test. Everybody 
wishes there was a biological test, but you are right. Most 
diseases, there is not, per se, a biological test, but there 
are indicators whether it is skin cancer or whatever it might 
be.
    Senator Cassidy, did you have a question?

         HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA

    Senator Cassidy. Yes.
    I apologize, gentlemen, if these questions have already 
been asked. I apologize in advance.
    Dr. Daigh, you mentioned that in your studies that it is 
unclear how do you establish intent. So, let me ask, if 
somebody dies from a drug overdose, say John Belushi, is that 
considered a suicide, or is that considered a drug overdose?
    Dr. Daigh. In the course of our work, sir, we would rely on 
what the medical examiner said in their determination of all 
the relevant facts at the time the death occurred to state 
whether they thought it was an accidental death or an 
intentional death.
    Senator Cassidy. Accidental in the sense that they are 
addicted to drugs, they took too much, they stopped breathing. 
That would not necessarily be a suicide. That, indeed, might be 
considered accidental overdose?
    Dr. Daigh. We would record it that way, yes, sir. We would 
have that interpretation. We would always wonder if we were 
right.
    Senator Cassidy. Got that.
    Mr. Bryan, you mentioned this, but any of you all can 
answer these questions. Again, I am just trying to understand.
    Clearly, you cite the statistic, I believe, the 30 percent 
increased rate of suicide among veterans, but I am not sure. I 
think that is compared to the general population, not to an 
age-, gender-based cohort, and going beyond that, I am not sure 
it is related to socioeconomic class and/or disease burden. 
Intuitively, people with greater disease burden are more likely 
to commit suicide.
    As we understand these statistics, epidemiologically, are 
they matched against a match cohort, or is it against the 
general population? And, if they are not matched against a 
matched cohort, what are the excess rates relative to one which 
is matched?
    Mr. Bryan. Correct. The statistics that I cited was from 
the VA's report from last year. Those are age- and gender-
adjusted for the reasons that you note. Age and gender are----
    Senator Cassidy. What about SEC?
    Mr. Bryan. I was not involved in the analysis. I do not 
know what other variables it may have adjusted for.
    Senator Cassidy. OK. But age and gender----
    Mr. Bryan. Age and gender are the most common adjustments 
that we make when looking at veteran and military suicide 
statistics and comparing it to the U.S. general population.
    Senator Cassidy. For my general knowledge--I do not know--
is suicide more common among certain--clearly, suicide would be 
more common among people who have addictions. That is 
intuitive, right? They are addicted for a reason, but are there 
other kind of breakups? If you were going to match them against 
in the general--in the general population as a whole, are there 
certain things, yes, in this social strata, it is more common, 
or in this disease burden, it is more common? I am asking this 
for my knowledge.
    Mr. Bryan. Right. Yes. If we look, for instance, like in 
the VA report, they broke things down into different age 
groups. They looked at different diagnostic characteristics, 
what type of mental illness does a person have, diagnosis for--
they looked at opioid, opioid abuse as well, and what we are--
men versus women. What we tend to see is that, on a whole, 
veterans have a higher rate of suicide, regardless of the 
categories.
    Senator Cassidy. But I am asking in the general population.
    Mr. Kuntz, are you----
    Mr. Kuntz. Senator Cassidy, I can really speak well to 
Montana, but I think since we are the highest suicide rate in 
the country, there may be something to learn there.
    We created a Montana Suicide Review Team that went through 
all the death certificates in the State for exactly the reasons 
that you are talking about. We cannot solve it unless we know 
it.
    Interestingly enough, the one demographic that really 
jumped out was white males between 30 and 60. Like that was, 
you know, not--and yes----
    Senator Cassidy. Let me stop you, Mr. Kuntz, because there 
is a research out of Princeton, which says in the general 
population, white males, to a lesser extent white females, in 
that demographic are dying. And, it does relate to lower 
socioeconomic class.
    Now, your State, I think has a higher rate of poverty than 
New Jersey.
    Mr. Kuntz. Yes, sir.
    Senator Cassidy. So, have you corrected that for kind of 
economic status or not?
    Mr. Kuntz. Sir, from looking at the economic status, it 
will also say that most of our suicides are from people that 
are economically struggling; in particular, people who have not 
a lot of education, like they are less--likely the higher you 
go up the education totem pole, the less likely you are to 
commit suicide in our State.
    Although I will say that there are some other factors that 
weave into this because, if you have depression, anxiety----
    Senator Cassidy. I totally get it.
    Mr. Kuntz [continuing]. You know, popping people off the 
work, popping people off of the education or----
    Senator Cassidy. Rich people shoot themselves too. I hate 
to say it.
    Mr. Kuntz. Yes, sir.
    Senator Cassidy. Yet, it does sound--then I am sure Dr. 
Shulkin will testify as to whether or not these VA statistics 
are--you know, are these veterans atypically lower 
socioeconomic class, et cetera. How closely do they match this 
Princeton data? If you all know that, I have 10 more seconds, 
and if not, I will wait for Dr. Shulkin.
    Thank you all. I yield back.
    Chairman Isakson. Thank you very much, Doctor.
    Senator Tester.
    Senator Tester. Yeah. I think, Mr. Chairman, I am done with 
this panel. While they are setting up for the next panel, I 
would just like to make a quick statement, if I could.
    Chairman Isakson. We will do that. I want to thank the 
panelists for being here today. Your testimony has been eye-
opening and helpful, and we will continue to focus on this, as 
Dr. Shulkin needs to focus under the VA. We thank you for your 
attendance today, and we will now switch the table around for 
our next panel.
    Senator Tester. If I might, Mr. Chairman, while they are 
doing that, I would just like to give a quick statement.
    Chairman Isakson. The Ranking Member is recognized.
    Senator Tester. Well, thank you, Mr. Chairman.
    I would just say, look, this discussion is very, very 
important today. It continues to be unacceptable that we have 
the number of suicides in our veteran population that we have, 
but make no mistake about it. It is also a national epidemic, 
not specific to veterans, yet we are here to talk about 
veterans.
    In fact, it is the 10th leading cause of death in the 
United States. Since the Chairman dropped the gavel at the 
beginning of this hearing, six people have committed suicide in 
this country.
    Look, VA data suggests that approximately 20 veterans 
commit suicide every day. On average--and this is an important 
statistic for us to know--only six were enrolled in VA health 
care. So, what does that mean? We have got to do a better job 
of outreach, and once we do that job of outreach, we got to 
make sure that those folks have the health care professionals 
on the ground within the VA to get the help they need.
    Why is that important for this Committee? If we are going 
to get health care professionals on the ground in urban and 
rural areas--and I think they are needed in both--it is going 
to cost some money. We have got to have more residency slots. 
We have got to be more aggressive on this. I think it is really 
an important issue moving forward. I think this last panel has 
showed it.
    We need to fill those vacancies within the VA. We need to 
make sure we fully leverage the assets, like our Vet Centers, 
and we can talk about this. I think it is important we talk 
about it and get the facts. But as Matt Kuntz knows--and I do 
not know if Matt left or not. He was on the first panel, but I 
will tell you this guy knows, not only talks the talk, he walks 
the walk. We need to follow his lead and make sure that we 
follow up this Committee hearing with action that actually does 
right by our veterans in this country, which by the way, if we 
do that, I think it helps the civilian population too.
    Thank you very much, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Tester. It was an 
excellent panel, and I appreciate your leadership on this 
entire issue about suicide. We know it is number 1 in your 
State, both with the general populous as well as veterans, and 
we want to do everything we can to make sure we are addressing 
it within the Veterans Administration.
    We know that Dr. Shulkin is focused on preventing--suicide 
prevention is one of the key things he wants to focus on, and 
in the absence of making an introduction, I want to say thank 
you to Dr. Shulkin for a second.
    We worked very hard in the first 9 months of this year, the 
Ranking Member and I and the entire Committee, to bring 
legislation to the floor that was sought by many of us and, in 
some cases, sought by the Secretary to improve the VA. We have 
changed the paradigm of the VA. We have changed the headlines 
of the VA, and we are very proud of that.
    One of the reasons we have done it is the Committee has 
been united, Democrat and Republican alike, to getting the job 
done, and we have done that, but also, because the VA under Dr. 
Shulkin's leadership, is seizing the advantage we have given.
    I just want to acknowledge that this week or last week--
maybe this week, but certainly by last week--was the first use 
of the accountability legislation in the termination of a 
senior member of the staff at the Veterans Administration for 
lack of performance, incompetency, et cetera, et cetera, et 
cetera. That would not have been possible had that legislation 
not passed, nor would it have been possible unless we had a 
Secretary that was willing to take that initiative and to go 
on.
    I want to, on behalf of the Ranking Member and myself and 
everybody on the Committee, thank you for taking advantage of 
the tools you have asked for and we have given you in the 
Veterans Administration. There are a lot more tools in the bag 
that you are going to need to use. We are going to be there to 
support you; we are going to help you with your initiative on 
suicide as well.
    I just wanted to acknowledge publicly and thank you for 
your initiative on accountability last week in the VA.
    Without further ado, Dr. David Shulkin, the Cabinet member 
for the Veterans Administration, and Dr. Carroll to assist him, 
if necessary. I think that is the way it is supposed to be.

   STATEMENT OF HON. DAVID J. SHULKIN, M.D., SECRETARY, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DAVID CARROLL, 
Ph.D., EXECUTIVE DIRECTOR, OFFICE OF MENTAL HEALTH AND SUICIDE 
                           PREVENTION

    Secretary Shulkin. Great, great.
    Thank you, Mr. Chairman, and good morning. Senator Cassidy, 
Senator Murray, nice to see you. Senator Manchin gets the Best 
Attendance Award. Thank you for staying for the whole thing. 
[Laughter.]
    I want to thank you, Mr. Chairman, for several things. 
First of all, I think I could not agree more with your 
comments. I am very proud of this Committee. I think it is the 
best Committee in the Senate. It works together in a bipartisan 
way and working to really get things done, and I am proud to be 
working with you on that.
    I also thank you for having the first panel first because 
they got all the hard questions, and I got to hear all the 
answers. That was terrific.
    But, as you know, we are here today, and this is an 
important hearing because our goal is to eliminate suicide. We 
want to do that through risk identification. We want to do it 
through effective treatments, education, outreach, research, 
and strategic partnerships.
    Senator Tester mentioned right before he left that our 
research shows that 20 veterans a day are dying through 
suicide. He did something by saying that there were six 
Americans who died during the course of our hearing. I think 
about that every day: how many veterans are dying, for us not 
being more effective at the way that we are addressing this 
problem.
    We know veterans are at greater risk for suicide than 
Americans. This is an American public health crisis, but for 
the veteran population even more so, and we do know, as has 
been said several times already this morning, that 14 of those 
20 are not receiving care within the VA system.
    We know from research that VA care saves lives, and we know 
that treatment works. So, this is a matter of trying to get 
more people treated. What we are trying to do is, more 
aggressively than ever before, to outreach to veterans that are 
not getting access to care. But, we cannot help those that we 
do not see. This is where we are extending our help into the 
community to work with community partners.
    We are doing more to reach veterans than ever before. As 
Secretary, I have authorized that we do start providing 
emergency mental health services to those that were other than 
honorably discharged, and that is important, but we can do more 
in that extent with your help.
    We have asked every medical center this month to sign a 
suicide declaration pledge. I am pleased that you signed it 
this morning, Mr. Chairman, along with the Ranking Member. When 
I was out in Nevada, Senator Heller also signed it with his 
community members. So, we are doing that across the country. 
That is a pledge of specific action steps that we want 
leadership to take to be able to help reduce suicide.
    We have developed the largest integrated suicide prevention 
network in the country, over 1,100 professionals who are 
dedicated to suicide prevention, including suicide prevention 
coordinators and other mental health professionals. Our goal 
that I have announced is to hire 1,000 additional mental health 
professionals so we can even do more and to grow that network.
    Our Veterans Crisis Line, which we established in 2007, has 
now answered more than 3 million calls and dispatched 84,000 
emergency ambulances to help people who were in urgent need of 
help. That is incredible. We have had 504,000 referrals to 
suicide prevention coordinators, so we are helping a lot of 
people through that.
    The Veterans Crisis Line number--and I encourage everybody 
to keep this in their phone because you never know when you are 
going to get that 2 a.m. call, and you do not want to be 
looking for this--is 1-800-273-8255, 800-273-8255.
    We have recently appointed, 7 weeks ago, Dr. Matt Miller to 
head up our Veterans Crisis Line. This is the first time we 
have had a clinical psychologist in charge of the Veterans 
Crisis Line, because this is clinical work, and this is not 
just a call center.
    We have expanded telemental health. We have 11 telemental 
health regional hubs throughout the country, and in 2006 alone, 
we had 427,000 telemental health encounters. That is more than 
ever before.
    We have taken from our research enterprises a big data 
analytics program that we call REACH VET that now predicts who 
may be at the greatest risk for suicide, up to 80 times the 
risk of suicide of a regular person, over the next year. Now we 
call them--and this has been done around the country--to 
outreach and see what we can do to proactively help, so not 
waiting until there is a suicide attempt.
    On September 15 of this month, we released State suicide 
data. Many of you have been referencing that data, but we think 
that is going to help people design more effective 
interventions.
    We have continued to develop public-private partnerships 
because VA cannot do it alone. This morning, I was talking to 
the Cohen Veterans Network, as one of those partnerships, but 
many of our VSOs and other groups are here in the room today, 
are those partners that we are working with.
    We continue to invest in two VA center of excellence 
research initiatives to help us understand how to do 
interventions better and to take a population health approach 
toward reducing suicide.
    This month, as you have said, is Suicide Prevention Month. 
That is our #BeThere campaign, where we are reaching out to 
make people aware and try to decrease the stigma of mental 
illness. With that today, I have brought with us our new public 
service announcement. I just want you to listen to it for a 
second. Hopefully, you will recognize who is helping us with 
this.
    [Audio presentation.]

        Audio. ``In the fabric of America, they are the 
        toughest threads, our bravest, and most selfless. They 
        raise their hands, stepped forward, and served for each 
        other, for you, and me.
          ``One of the first things they learned was the code 
        that every servicemember lives by: Leave No One Behind. 
        Now all of us need to live by it too, because some 
        veterans are being left behind. Twenty of them take 
        their own lives every day. Why? It is not simple. It 
        never is.
          ``What matters is that we are there for them, just 
        like they were there for us. The handshake, the phone 
        call, the simple gesture make a big difference to a 
        veteran in crisis.
          ``Learn how to be there for a veteran at 
        bethereforveterans.com. Honor the code. Be there. Leave 
        no one behind.''

    Secretary Shulkin. We are grateful to Tom Hanks for lending 
his credibility to help us get this message out, and you will 
begin to see this national PSA with a video starting in about 
30 days.
    Despite all this progress that we are making, we still have 
so much more work to do. That is why, as you said, Mr. 
Chairman, this is my number 1 priority. This is what we are 
focusing on to make a difference, but we do need your help. It 
would not be a hearing if we did not ask for your help. There 
are three things that I think that we could use your help on.
    First, we have to figure out a way to recruit more mental 
health professionals, and frankly not just for the VA but for 
the country at large to be able to train more. I have 
identified we need 1,000 more, and we are not making the 
progress that I need to make in recruiting them.
    Second, we want you to be part of helping us spread the 
word in the #BeThere campaign. Thank you again for signing the 
declaration, but you are, as well-respected members in the 
Senate, very helpful in spreading that word with us.
    Third, we need more research in this. I think many of you 
have identified there are no blood tests, the biomarkers. We 
need to be able to do this better. We need better research in 
genomics to be able to make a difference, and VA has that 
capability with your additional support.
    Thank you for holding this hearing today, and I would be 
glad to take any questions along with Dr. Carroll.
    [The prepared statement of Secretary Shulkin follows:]
     Prepared Statement of Hon. David J. Shulkin, M.D., Secretary, 
                  U.S. Department of Veterans Affairs
    Good morning, Chairman Isakson, Ranking Member Tester, and 
distinguished Members of the Committee. Thank you for the opportunity 
to discuss the Department of Veterans Affairs' (VA) suicide prevention 
programs, including the implementation of the Clay Hunt Suicide 
Prevention for American Veterans (SAV) Act (Public Law 114-2). I am 
accompanied today by Dr. David Carroll, Executive Director, Office of 
Mental Health and Suicide Prevention.
                              introduction
    Recent research suggests that 20 Veterans die by suicide each day, 
putting Veterans at even greater risk than the general public. VA is 
committed to ensuring the safety of our Veterans, especially when they 
are in crisis. Losing one Veteran to suicide shatters their family, 
loved ones, and caregivers. Veterans who are at risk or reach out for 
help must receive assistance when and where they need it in terms that 
they value. Our commitment is to do everything possible to prevent 
suicide among the Veterans we serve and to reach all Veterans through 
partnerships and collaboration.
    September is Suicide Prevention Month. VA is closely working with 
the Department of Defense (DOD) and other stakeholders, including 
families who have lost loved ones to suicide, to do everything we can 
to be there for Veterans to prevent suicide. We have held a month of 
facility Suicide Prevention Declaration signings. Veterans Service 
Organizations (VSO) participated in the declaration signing at the 
Suicide Prevention Advisory Group meeting. We are also partnering with 
the Substance Abuse and Mental Health Services Administration to 
establish Mayor Challenge programs in seven communities and local 
outreach and partnership activities in 20 more. VA's Readjustment 
Counseling Service, Canteen Service, Pharmacy, Chaplains, and many 
other programs are all playing a role in supporting Suicide Prevention 
Month and our on-going initiative so we connect with Veterans in as 
many different ways as possible.
                      suicide prevention overview
    VA has developed the largest integrated suicide prevention program 
in the country. We have over 1,100 dedicated and passionate employees, 
including Suicide Prevention Coordinators, Mental Health providers, 
Veterans Crisis Line staff, epidemiologists, and researchers, who spend 
each and every day working on suicide prevention efforts and care for 
our Veterans. Screening and assessment processes have been set up 
throughout the system to assist in the identification of patients at 
risk for suicide. VA also has developed a chart ``flagging'' system to 
ensure continuity of care and provide awareness among providers about 
Veterans with known high risk of suicide. Patients who have been 
identified as being at high risk receive an enhanced level of care, 
including missed appointment follow ups, safety planning, weekly 
follow-up visits, and care plans that directly address their 
suicidality.
    We also have two centers devoted to research, education, and 
clinical practice in the area of suicide prevention. VA's Veterans 
Integrated Service Network (VISN) 2 Center of Excellence in 
Canandaigua, New York, develops and tests clinical and public health 
intervention strategies for suicide prevention. VA's VISN 19 Mental 
Illness Research Education and Clinical Center in Denver, Colorado, 
focuses on: (1) clinical conditions and neurobiological underpinnings 
that can lead to increased suicide risk; (2) the implementation of 
interventions aimed at decreasing negative outcomes; and (3) training 
future leaders in the area of VA suicide prevention.
    Every Veteran suicide is a tragic outcome, regardless of the 
numbers or rates; one Veteran suicide is too many. We continue to 
spread the word throughout VA that ``Suicide Prevention Is Everyone's 
Business.'' The ultimate goal is to eliminate suicide among Veterans 
via strategic community partnerships, identification of risk, training, 
treatment engagement, effective treatment, lethal means education, 
research, and data science. Although we understand why some Veterans 
may be at increased risk, we continue to investigate and take proactive 
steps to understand all risk factors for all Veterans. VA's strategy 
for suicide prevention requires ready access to high-quality mental 
health services supplemented by programs designed to help individuals 
and families engage in care and to address suicide prevention as a 
public health issue for all Veterans.
    Suicide prevention is VA's highest clinical priority. As part of 
VA's commitment to make resources, services, and technology available 
to reduce Veteran suicide, VA initiated Recovery Engagement and 
Coordination for Health Veterans Enhanced Treatment (REACH VET) in 
November 2016, and fully implemented it by February 2017. REACH VET 
uses a new predictive model to analyze existing data from Veterans' 
health records to identify those who are at a statistically elevated 
risk for suicide, hospitalization, illnesses, and other adverse 
outcomes. Once a Veteran is identified, his or her mental health or 
primary care provider reviews the Veteran's treatment plan and current 
condition(s) to determine if any enhanced care options are indicated. 
The provider will then reach out to Veterans to check on their well-
being and inform them that they have been identified as a patient who 
may benefit from enhanced care. This allows the Veteran to participate 
in a collaborative discussion about his or her health care, including 
specific clinical interventions to help reduce suicidal risk.
    DOD and VA have a new joint effort to institute a public health 
approach to suicide prevention, intervention, and postvention using a 
range of medical and non-medical resources through data and 
surveillance, messaging and outreach, evidence-based practices, 
workforce development, and Federal and non-government organization 
partnerships. We know that 14 of the 20 Veterans who die by suicide on 
average each day did not receive care within VA in the past two years. 
We need to find a way to provide care or assistance to all of these 
individuals. Therefore, VA is expanding access to emergent mental 
health care for former Servicemembers with other than honorable (OTH) 
administrative discharges. This initiative specifically focuses on 
expanding access to assist former Servicemembers with OTH 
administrative discharges who are in mental health distress and may be 
at risk for suicide or other adverse behaviors. It is estimated that 
there are a little more than 500,000 former Servicemembers with OTH 
administrative discharges. As part of the initiative, former 
Servicemembers with OTH administrative discharges who present to VA 
seeking mental health care in emergency circumstances for a condition 
the former Servicemember asserts is related to military service would 
be eligible for evaluation and treatment for their mental health 
condition.
    VA has authority to furnish care for service-connected conditions 
for former Servicemembers with OTH administrative discharges if those 
individuals are not subject to a statutory bar to benefits. Individuals 
with OTH discharges may access the system for emergency mental health 
services by visiting a VA emergency room, outpatient clinic, or Vet 
Center or by calling the Veterans Crisis Line. Services may include 
assessment, medication management/pharmacotherapy, lab work, case 
management, psycho-education, and psychotherapy. We may also provide 
services via telehealth.
    At VA, we have the opportunity and the responsibility, to 
anticipate the needs of returning Veterans. As they reintegrate into 
their communities, we must ensure that all Veterans have access to 
quality mental health care. To serve the growing number of Veterans 
seeking mental health care, VA has deployed significant resources and 
increased its staff for mental health services. The number of Veterans 
receiving specialized mental health treatment from VA has risen each 
year, from over 900,000 in fiscal year (FY) 2006 to more than 1.65 
million in FY 2016.
    We anticipate the need for VA to provide this level of mental 
health care will continue to grow for a decade or more after current 
operational missions have come to an end. VA has taken aggressive 
action to recruit, hire, and retain mental health professionals to 
improve Veterans' access to mental health care. As part of our ongoing 
comprehensive review of mental health operations, VA has considered a 
number of factors to determine additional staffing levels distributed 
across the system, including: Veteran population in the service area; 
the mental health needs of Veterans in that population; and the range 
and complexity of mental health services provided in the service area.
    Since there are no industry standards defining appropriate mental 
health staffing ratios, VA is setting the standard, as we have for 
other dimensions of mental health care. VA has developed a prototype 
staffing model for general mental health and is expanding the model to 
include specialty mental health. VA will buildupon the successes of the 
primary care staffing model and apply these principles to mental health 
practices. VA has developed and implemented an aggressive recruitment 
and marketing effort to fill specialty mental health care occupations. 
Key initiatives include targeted advertising and outreach, aggressive 
recruitment of qualified trainees/residents to leverage against mission 
critical mental health vacancies, and providing consultative services 
to VISN and VA stakeholders.
    Earlier this year VA announced plans to hire 1,000 additional 
mental health employees. VA expects to meet the goal of hiring 1,000 
new mental health FTE by December and expects to continue hiring to 
meet the recommended levels beyond that date. This initiative began in 
January 2017. As of September 1, VA has hired 649 new mental health 
providers, including 173 psychiatrists, 198 psychologists, 118 social 
workers specifically in mental health, 87 mental health registered 
nurses, 39 counselors, and 34 in various other occupations.
    VA is committed to working with public and private partners across 
the country to support full hiring to ensure that no matter where a 
Veteran lives, he or she can access quality, timely mental health care. 
VA is working with its partners to expand the ways it engages with 
Veterans through innovation, social media, and new technologies. VA is 
also working within its facilities and with DOD, Service Organizations, 
and other partners to advance and promote lethal means safety.
                    clay hunt sav act implementation
    Since its enactment in 2015, VA has been aggressively implementing 
the Clay Hunt SAV Act, as amended, participating in a third party 
evaluation of mental health programs, developing a publicly available 
resource tool, and fostering an abundance of public and private 
partnerships, all in support of VA's goal to eliminate Veteran suicide.
    VA has contracted with an independent evaluator to conduct an 
evaluation of the VA mental health and suicide prevention programs to 
determine the effectiveness, cost effectiveness and Veteran 
satisfaction with VA mental health and suicide prevention programs. An 
interim report was dispatched to Congress last year and a second 
interim report is due at the end of this month. The first annual report 
with findings from the independent evaluation will be delivered to 
Congress in December 2018. We plan to use the results of this 
evaluation to improve the mental health care and services that VA 
provides to Veterans. In addition, VA has VA Resource Locator tools 
that include information regarding Post Traumatic Stress Disorder 
(PTSD), substance use disorder, and Vet Center programs, as well as 
contact and resource information. This tool is accessible at 
www.vets.gov and on www.MaketheConnection.net. VA is also making 
strides in implementing the pilot program to repay psychiatrist student 
loans as a recruitment incentive, as required by section 4 of the Clay 
Hunt SAV Act. VA published regulations for this pilot program in the 
first quarter of 2017, 81 FR 66815. VA is currently finalizing the 
advertisement, application policy, and procedures. Recruitment will 
target medical residents in their final year in the next cycle of 
residency applications in July, 2018. The Clay Hunt SAV Act prohibited 
additional appropriations for its implementation, so VA is working to 
identify sources of funding for this initiative.
    VA has set up community peer support networks in five VISNs where 
there are large numbers of Servicemembers transitioning to Veteran 
status. Since January 2016, networks have been developed in Virginia, 
Arkansas, Texas, Arizona, and California. Outreach teams of Peer 
Specialists and their supervisors have formed coalitions with VSOs, 
employers, educational institutions, community mental health providers, 
military installations, and existing VA and DOD transition teams to 
connect Veterans in the community with mental health assistance when 
necessary. This has included providing community partners with training 
on Veteran and military culture, peer support skills, and 
interventions, as well as invitations to annual mental health summits.
    VA is working with and/or building new partnerships with non-
Federal mental health organizations around suicide prevention. Areas 
for collaboration include patient and provider marketing of educational 
materials and research. VA has partnered with Psych Armor, a non-profit 
devoted to free, online training for non-VA providers to better serve 
Veterans. Psych Armor uses VA expertise to help inform its course 
content, which is geared toward health care providers, employers, 
caregivers and families, volunteers, and educators. These types of 
partnerships are a powerful strategy to increase outreach to vulnerable 
Veterans. Under the Expanded Period of Eligibility provided by the Clay 
Hunt Act, 1,192 combat Veterans discharged between January 1, 2009, and 
January 1, 2011, who did not enroll in the VA health care during their 
initial 5-year period of eligibility have enrolled in VA care under 
this additional enrollment opportunity.
                         mental health programs
    VA is committed to providing timely access to high-quality; 
recovery-oriented, evidence-based mental health care that anticipates 
and responds to Veterans' needs and supports the reintegration of 
returning Servicemembers into their communities.
    While focusing on suicide prevention, we know that preventing 
suicide for the population we serve does not begin with an intervention 
as someone is about to take an action that could end his or her life. 
Just as we work to prevent fatal heart attacks, we must similarly focus 
on prevention, which includes addressing many factors that contribute 
to someone feeling suicidal. We are aware that access to mental health 
care is one significant part of preventing suicide. VA is determined to 
address systemic problems with access to care in general and to mental 
health care in particular. VA has recommitted to a culture that puts 
the Veteran first. To serve the growing number of Veterans seeking 
mental health care, VA has deployed significant resources and increased 
staff in mental health services. Between 2005 and 2016, the number of 
Veterans who received mental health care from VA grew by more than 80 
percent. This rate of increase is more than three times that seen in 
the overall number of VA users. This reflects VA's concerted efforts to 
engage Veterans who are new to our system and stimulate better access 
to mental health services for Veterans within our system. In addition, 
this reflects VA's efforts to eliminate barriers to receiving mental 
health care, including reducing the stigma associated with receiving 
mental health care.
    Making it easier for Veterans to receive care from mental health 
providers also has allowed more Veterans to receive care. VA is 
leveraging telemental health care by establishing eleven regional 
telemental health hubs across the VA health care system. Hubs are 
located in Seattle, WA; Long Beach, CA; Salt Lake City, UT; Harlingen, 
TX; Charleston, SC; Sioux Falls, SD; Battle Creek, MI; Pittsburgh, PA; 
Brooklyn, NY; West Haven, CT; and Honolulu, HI. VA telemental health 
provided more than 427,000 encounters to over 133,500 Veterans in 2016. 
Telemental health reaches Veterans where and when they are best served. 
VA is a leader across the United States and internationally in these 
efforts. VA's www.Makethe Connection.net, Suicide Prevention campaigns, 
and the PTSD mobile app (which has been downloaded over 280,000 times) 
contribute to increasing mental health access and utilization. VA has 
also created a suite of award-winning tools that can be utilized as 
self-help resources or as an adjunct to active mental health services.
    Additionally, in 2007, VA began national implementation of 
integrated mental health services in primary care clinics. Primary 
Care-Mental Health Integration (PC-MHI) services include co-located 
collaborative functions and evidence-based care management, as well as 
a telephone-based modality of care. By co-locating mental health 
providers within primary care clinics, VA is able to introduce Veterans 
on the same day to their primary care team and a mental health provider 
in the clinic, thereby reducing wait times and no show rates for mental 
health services. Additionally, integration of mental health providers 
within primary care has been shown to improve the identification of 
mental health disorders and increase the rates of treatment. Several 
studies of the program have also shown that treatment within PC-MHI 
increases the likelihood of attending future mental health appointments 
and engaging in specialty mental health treatment. Finally, the 
integration of primary care and mental health has shown consistent 
improvement of quality of care and outcomes, including patient 
satisfaction. The PC-MHI program continues to expand, and through 
May 2017, VA has provided over 7.2 million PC-MHI clinic encounters, 
serving over 1.6 million individuals since October 1, 2007.
                       veterans crisis line (vcl)
    VA recognizes the importance of VCL as a life-saving resource for 
our Nation's Veterans who find themselves at risk of suicide. Of all 
the Veterans we serve, we most want those in crisis to know that 
dedicated, expert VA staff, many of whom are Veterans themselves, will 
be there when they are needed. The primary mission of VCL is to provide 
24/7, world class, suicide prevention and crisis intervention services 
to Veterans, Servicemembers, and their family members. However, any 
person concerned for a Veteran's or Servicemember's safety or crisis 
status may call VCL.
    VCL is the strongest it has been since its inception in 2007. VCL 
staff has forwarded over 504,000 referrals to local Suicide Prevention 
Coordinators on behalf of Veterans to ensure continuity of care with 
their local VA providers. Initially housed in 2007 at the Canandaigua 
VA Medical Center (VAMC) in New York, it began with 14 responders and 
two health care technicians answering four phone lines. Since 2007, VCL 
has answered over 3 million calls and dispatched emergency services to 
callers in crisis more than 84,000 times. Consistent with our mission, 
we have implemented a series of initiatives to provide the best 
customer service for every caller, making notable advances to improve 
access and the quality of crisis care available to our Veterans, such 
as:

     Launching ``Veterans Chat'' in 2009, an online, one-to-one 
chat service for Veterans who prefer reaching out for assistance using 
the Internet. Since its inception, we have answered nearly 359,000 
requests for chat.
     Expanding modalities to our Veteran population by adding 
text services in November 2011, resulting in nearly 78,000 requests for 
text services.
     Opening a second VCL site in Atlanta in October 2016, with 
over 250 crisis responders and support staff.
     Hiring a permanent VCL director in July 2017, 
psychologist, Dr. Matthew Miller.

    Prior to the opening of our new Atlanta call center in 
October 2016, VCL had a call rollover rate to back-up call centers of 
more than 30 percent. Currently, the average rate is 1.24 percent, with 
calls being answered by the VCL within an average of 8 seconds. 
Overall, VCL performance is above the National Emergency Number 
Association service level standard of answering greater than 95 percent 
of calls in less than 20 seconds; specifically, the VCL's average 
service level exceeds 98 percent. VCL continues to exceed these 
metrics, despite overall call volume continuing to rise. Overall call 
volume has increased 12 percent since April 2017, and increased 15 
percent over the course of the 2 weeks marked by notable adverse 
weather events earlier this month.
    Today, the combined VCL facilities employ more than 500 
professionals, and VA is hiring more to handle the growing volume of 
calls. VA will also be opening a third VCL site in Topeka, Kansas, 
which will give VCL the additional capacity needed as we expand the 
`automatic transfer' function, Press 7, to all of its community-based 
outpatient clinics (CBOC) and Vet Centers. Despite all of these 
accomplishments and plans, there still is more that we can do.
    The No Veterans Crisis Line Call Should Go Unanswered Act (Public 
Law 114-247) directed VA to develop a quality assurance document to use 
in carrying out VCL. It also required VA to develop a plan to ensure 
that each telephone call, text message, and other communication 
received by VCL, including at a backup call center, is answered in a 
timely manner by a person. This is consistent with the guidance 
established by the American Association of Suicidology. In addition to 
adhering to the requirements of the law, VCL has enhanced the workforce 
with qualified responders to eliminate routine rollover of calls to the 
contracted backup center. We also implemented a quality management 
system, to monitor the effectiveness of the services provided by VCL. 
This will also enable us to identify opportunities for continued 
improvement. As required by law, VA submitted a report containing this 
document and the required plan to the House and Senate Veterans' 
Affairs Committees on May 23, 2017. The Veterans Crisis line can be 
reached by dialing 1-800-273-8255, Press 1.
     peer support and vet centers (readjustment counseling service)
    Peer support is integral to VA mental health care. The introduction 
of Peer Specialists to the mental health workforce provides unique 
opportunities for engaging Veterans in care. VA has nearly 1,100 peers 
providing services at VAMCs and CBOCs. Peer support programming has 
been implemented at every VAMC and very large CBOCs since 2013. Peers 
provide services in mental health programs and some primary care 
clinics. Certified peer specialists are Veterans who have recovered 
from or are recovering from a mental health condition and who have been 
certified by a non-profit engaged in peer specialist training or by a 
State as having satisfied relevant State requirements for a peer 
specialist position. These peer specialists are employed by VA to 
provide support and advocacy for Veterans coming to VA for treatment of 
mental health conditions, including PTSD. Crisis intervention and 
suicide prevention are skills that peer specialists apply from the 
moment they first meet Veterans coming in for treatment and throughout 
their treatment cycles. Working with Veterans who have recovered from 
mental health conditions, including many who have also survived 
suicidal ideation or attempts themselves, demonstrates to other 
Veterans that there is hope for recovery and a quality life after 
treatment.
    VA's Office of Readjustment Counseling Service (RCS) operates VA 
Vet Centers (www.vetcenter.va.gov), which are welcoming community-based 
counseling centers situated apart from larger VA medical facilities and 
placed in convenient, easily accessible locations. Based on the Veteran 
peer model, clinical staff at these Centers provide confidential 
professional mental health services and psychosocial counseling 
services as needed to help assist Veterans and active duty 
Servicemembers (ADSM) (including members of the National Guard and 
Reserve components) who served in a combat-theater or area of 
hostilities achieve a successful readjustment to civilian life. 
Readjustment counseling services and other services (e.g., 
consultation, counseling, training, and mental health services) are 
available to their family members if essential to the effective 
treatment and readjustment of the Veteran or ADSM. Readjustment 
counseling services include, but are not limited to, individual 
counseling, group counseling, marital and family counseling for 
military-related readjustment issues. Use of non-professional Veteran 
peer counselors at the Vet Centers also helps contribute to the RCS 
mission. Readjustment counseling services are provided through 300 Vet 
Centers, 80 Mobile Vet Centers, and the Vet Center Call Center. In FY 
2016, Vet Centers provided over 258,000 Veterans, ADSMs, and their 
families with 1,797,000 visits.
    In addition, Vet Center staff facilitates community outreach and 
the brokering of services with community agencies that link Veterans 
and ADSMs with other VA and non-VA services that can help with their 
successful readjustment to civilian life. One of the Vet Center core 
values is reducing barriers to access to readjustment counseling 
services. To this end, all Vet Centers offer services during non-
traditional times such as early mornings, evenings, and weekends. 
Barriers to access based on distance (i.e., communities distant from 
the 300 ``brick and mortar'' Vet Centers) are ameliorated by having Vet 
Center staff regularly deliver readjustment counseling services in Vet 
Center Community Access Points (CAP). Generally speaking, CAPs are 
established when community partners, pursuant to a no-cost arrangement, 
permit Vet Center counselors to provide readjustment counseling 
services on their premises on a regular recurring schedule (ranging 
from service provision once a month to several times a week). CAPs 
allow Vet Center clinicians to provide services at a level that is in 
line with the fluid readjustment demands and needs of that community. 
Currently, Vet Center staff operates over 820 CAPs. In FY 2016, Vet 
Center CAPs provided 236, 435 readjustment counseling visits, a 6% 
increase over FY 2015.
    RCS leadership is also working in close collaboration with Veterans 
Health Administration's Office of Mental Health and Suicide Prevention 
to implement improved collaboration to better improve coordination and 
referral between Vet Centers and VA medical facilities. A memorandum of 
understanding was signed in August 2017 to formalize this relationship 
and outline improved communication processes, training, collaboration, 
and access to important suicide predictive data to help decrease 
suicide within the Veteran population. Vet Center counselors are 
trained, as part of assessment, to identify Veterans or ADSMs who are 
at high risk of harm or suicide. They refer these clients to their 
treating mental health providers (or for emergency services, if 
appropriate). And if a Veteran client is getting his/her care through 
VA, Vet Center staff refers the shared Veteran client to the local VAMC 
and the Vet Center counselor also contacts the facility's Suicide 
Prevention Coordinator to ensure that enhanced care delivery procedures 
for suicide prevention are in effect.
                               conclusion
    Mr. Chairman, all of us at VA are saddened by the crisis of suicide 
among Veterans. We remain focused on providing the highest quality care 
our Veterans have earned and deserve and that our Nation trusts us to 
provide. Our work to effectively treat Veterans who desire or need 
mental health care continues to be a top priority. We emphasize that we 
remain committed to preventing Veteran suicide, and aware that 
prevention requires our system-wide support and intervention in 
preventing precursors of suicide. We appreciate the support of Congress 
and look forward to responding to any questions you may have.

    Chairman Isakson. Thank you very much, Dr. Shulkin.
    The Ranking Member asked that Senator Manchin be recognized 
first, and so to honor that, Senator Manchin?
    Senator Manchin. Mr. Chairman, I cannot thank you enough. I 
am so sorry. I have a hard 11:30 meeting with about 100 
children here, but I wanted to ask a couple of questions.
    Secretary Shulkin. Sure.
    Senator Manchin. Dr. Shulkin, I know that you are aware, 
and there are more and more stories in the news about veteran 
suicides. The most alarming one is they are doing it in parking 
lots. They are doing it coming to the VA facilities and doing 
that. We just had one in Clarksburg.
    Secretary Shulkin. Yeah.
    Senator Manchin. I do not know what you can do to train 
your security in this, in that. I just do not know how to do 
it, but I know there is some timing involved here. Everything 
goes in lockdown if it is on the property, but it is becoming 
more of an occurrence than we ever thought it could be. I do 
not know if you all have taken steps, if it has been at a high 
enough level to where you know it is a problem around the 
country.
    Secretary Shulkin. Yeah. Oh, believe me, we are extremely 
aware of this. It is so painful to hear each of these stories.
    You are right that what we are seeing is that people are 
coming onto VA property, and we are doing a number of things. 
Part of these declarations that every one of our facility 
leadership are signing are 10 action steps. One of them is to 
train, just like this Committee, every one of our staff members 
in suicide prevention and risk identification and what to do, 
and we are establishing much off of what we learned in our 
homeless program that you do this through a no-wrong-door 
approach.
    So, a veteran who is at risk and somebody identifies them 
should know where and what to do and have a responsibility to 
follow through.
    Senator Manchin. Can I ask this question, if I may, real 
quick?
    Secretary Shulkin. Yes. Yep.
    Senator Manchin. What I am concerned about----
    Secretary Shulkin. Yeah.
    Senator Manchin [continuing]. And it is alarming, you know, 
this in people--it is not well publicized, as you know. It is 
becoming more and more, and when it happens in a small rural 
State such as West Virginia in a parking lot at a VA that a lot 
of--we have an awful lot of veterans in our State. I am 
concerned about maybe this being taken inside the hospital to 
where it is more than just that person doing harm to themselves 
because they need help.
    Secretary Shulkin. Mm-hmm.
    Senator Manchin. I do not know how you secure that. Are we 
securing the hospitals? Can we secure the--because we all have 
to come through. To come onto VA property, we have to have a 
stop. There is a checkpoint.
    Secretary Shulkin. Right.
    Senator Manchin. I do not know, but I would hope you would 
consider that.
    Secretary Shulkin. Right.
    Senator Manchin. But I want to go to another question---
    Secretary Shulkin. Yes.
    Senator Manchin [continuing]. Very quick, if I can.
    Secretary Shulkin. Sure.
    Senator Manchin. I am just saying please at the highest 
element you can. I am concerned.
    You talked about 1,000 additional mental health 
professionals. OK. I am talking about a rural West Virginia, a 
rural Montana, this and that.
    We had one vacancy for a psychiatrist in Clarksburg that 
was posted in January 2017. We had another vacancy for a 
psychiatrist to oversee the addiction program in Martinsburg. 
That has been posted since October 2016. And another vacancy 
for our psychiatrist in Martinsburg just posted within the last 
5 or 6 months, and there is vacancies for mental health 
counselors at both Beckley and Princeton. So are you having a 
harder time in rural--can you tell me, of the 690--649 people 
that have been hired, what is the ratio between rural and 
urban? Because it is probably a lot easier to get somebody----
    Secretary Shulkin. Yep.
    Senator Manchin [continuing]. In an urban area than a 
rural, so we are going to have to put more effort in that.
    Secretary Shulkin. Yeah. Well, I think you have it right.
    Martinsburg is actually, believe it or not, a success 
story.
    Senator Manchin. Yeah.
    Secretary Shulkin. We have--about a year and one-half ago, 
I was really concerned about their staffing levels. They have 
done a great job of bringing people on, but in general, it is 
harder to recruit in rural areas. There is no doubt.
    Our urban areas, where there are more trainees and younger 
people are staying, that is where we are establishing our 11 
telemental health hubs to be able to help support the rural 
areas.
    But, you know, this is where we want to see expanded 
graduate medical education programs in those rural areas.
    Senator Manchin. Do you have a loan forgiveness program?
    Secretary Shulkin. We do. That is part of the Clay Hunt 
Act. We use up all of our dollars that you allow us to use. We 
would like to use more because it is a very effective program, 
and in the Clay Hunt program, you have asked us to do that 
more. But, you did not appropriate money for us, so we are 
trying to find the additional dollars that will be in July 
2018.
    Senator Manchin. I have more questions, but I will go ahead 
and give them later. I want to thank you all so much for the 
job you are doing. Thank you.
    Secretary Shulkin. Yes.
    Chairman Isakson. I think I have got this right. We are 
going to go to Senator Moran, then to Senator Murray, then to 
Senator Rounds, then to Senator Tester, and I will finish up.

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

    Senator Moran. Mr. Chairman, thank you very much.
    Secretary, thank you for joining us this morning on a 
hugely significant and unfortunately so timely topic.
    First of all, I want to highlight the hearing that our 
Appropriations Subcommittee had in April on this topic, but I 
want to remind you, Mr. Secretary--and I understand that 
Senator Murray has a question for you about VA follow-through 
on a commitment that was made at that hearing. It was committed 
by the VA that we would get monthly reports in regard to your 
efforts, the Department's efforts, to comply with the Inspector 
General's recommendations and failures at the VA in regard to 
suicide. We have not received those reports on a monthly basis.
    I will defer to Senator Murray, but I would join her in her 
request that what was promised would actually be followed 
through on.
    Let me then talk about another topic that Senator Tester 
and I have worked on. We have been trying for a long time--and 
in fact, in 2010, now 7 years ago, gave the VA the authority to 
hire marriage and family therapists and licensed professional 
mandatory counselors. The results of that authority have not 
resulted in any significant hiring of either one of those 
professionals. I would guess that Senator Tester and I are 
interested in this reason for the scarcity of professionals 
generally but especially, as you were indicating, in rural 
communities, and so we have sought and have provided 
congressional authority for the VA to hire. You indicate you 
are in the process of hiring 1,000 additional professionals, 
but I would tell you that after 7 years, those two categories 
only account for 2 percent of the mental health workforce at 
the Department of Veterans Affairs.
    Senator Tester, I, and others have a letter to you in this 
regard that was sent to you just a few days ago, but in this 
hiring, would you again commit to filling these positions with 
those professionals, something that has not happened? If so, 
how many of those are going to be--what would your prediction 
be would fit a Marriage and Family Therapist (MFT) or a 
Licensed Professional Mental Health Counselor (LPMHC), and 
would you provide me with those numbers as you fill those 
positions? I assume that there will be a priority given in 
regard to places that are hard to recruit professionals.
    I also know that you have hiring authorities that are 
difficult. I do not know what your expedited hiring authorities 
are. What are they? Do you currently--what do you have at your 
disposal, and do they apply to mental health professionals? 
What needs to happen to fix this problem?
    We have noticed so many times that the things that are 
having to be posted do not result in any kind of quick response 
for hiring at the VA.
    We discussed this topic with Dr. Stephanie Davis who 
testified. She is at the eastern part of our Kansas VISN. She 
testified before our Appropriations Subcommittee in April, jobs 
are posted at USAjobs.com, where applications can linger for 4 
or 5 months. People find other jobs in the meantime, and it 
becomes even more impossible to recruit and retain. We know 
that positions sit vacant for months or even years while 
providers go through the process of the Federal hiring 
mechanism. What can you do to get that process expedited?
    Finally, Mr. Secretary, I wanted to tell you that I was 
just within--earlier this month at the Phoenix VA, where I saw 
one of the pilot programs under the Clay Hunt Act. They are 
called Be Connected. I was impressed. What this is about is 
having those who have similar circumstances, who have served 
our country, who are veterans themselves who have had PTSD and 
other problems, as the counselors for those who are calling the 
number. I would be interested in knowing what the VA is doing 
to support Be Connected, and are there others plans--are there 
plans to expand that program elsewhere?
    Secretary Shulkin. A lot of questions, so I am going to go 
really quickly, and anything I do not do an adequate job on, I 
will follow up.
    First of all, on the issue that you talked about us not 
providing timely follow-up--and if Senator Murray is going to 
comment on that too--look, that is unacceptable. If we say we 
are going to commit to something, my expectation is that we 
commit to it. So I appreciate you letting me know about it. I 
can assure you my staff will be knowing about that, but we will 
do better. That is just not the way that I want the Department 
run. So, we will make sure that you get that.
    On the marriage and mental health counselors, I look 
forward to the letter. I am aware that we continually hear 
about VA's strictness on our accreditation issue. This is 
particularly a training issue, since there are two 
accreditation programs. We are committed to bringing on 
marriage and family therapists.
    If Dr. Carroll has any specific information on numbers, I 
would defer to him in a second.
    On the issue of hiring, look, it is the single most 
challenging thing that I know of in VA. It should not be that 
hard to get people on board.
    In the Accountability Act that the Chairman referred to 
that we passed together not too long ago, you gave direct 
hiring authority to medical center directors. That is really 
helpful to us. It allows us to skip over a lot of the red tape. 
I want that authority for all of our critical health 
professionals. I would urge us to work together on that. It is 
just too hard to get people hired into the VA.
    Senator Moran. Do you have the authority under the 
Accountability Act to do what you need to do?
    Secretary Shulkin. Only under medical center directors.
    Senator Moran. OK.
    Secretary Shulkin. If we could work on expanding that, I 
would love to target it for mental health, you know, but we 
have other health needs as well. I would love to work with you 
on that.
    On the Be Connected program, peer support is something that 
we are really committed to. We think this works, particularly 
for veterans who understand what they have gone through. Thank 
you for your visit. Thank you for mentioning that, IT is 
something that we are going full force on.
    Senator Moran. Do you have other plans for that program 
elsewhere?
    Secretary Shulkin. Yes. We already have about 1,100 peer 
support counselors, and much of our Vet Center model is 
actually based on that model. We know it works, and Vet Center 
growth has been continuing to go up each year.
    Senator Moran. Thank you.
    Chairman Isakson. I know Dr. Shulkin wants to be sure we 
point out, since the resident State of Senator Moran is Kansas, 
that the third mental health hotline center----
    Secretary Shulkin. Yes.
    Chairman Isakson [continuing]. Is being set up in Topeka, 
KS, if I am not mistaken.
    Secretary Shulkin. You are absolutely correct.
    Senator Moran. We are delighted to have you.
    Chairman Isakson. Senator Murray.

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

    Senator Murray. Mr. Chairman, thank you so much for having 
this hearing. It really is such an important topic. I was able 
to listen to much of the first panel from my office between 
meetings. It really was good, and I appreciate it.
    Secretary Shulkin, thank you for being here. Thank you for 
your testimony, and thank you for saying in your testimony this 
is the number 1 priority, because it is.
    Secretary Shulkin. Mm-hmm.
    Senator Murray. But, I do remain deeply troubled by the 
IG's findings from May 2017 that VA is not complying with a 
number of policies, including 18 percent of facilities not 
meeting the requirement for five outreach activities each 
month, 11 percent of high-risk patients' medical records did 
not have a suicide prevent safety plan, and for 20 percent of 
inpatients and 10 percent of outpatients, no documentation the 
patient was provided a copy of the safety plan. There were 
several shortcomings in the use of patient record flags, 
coordination of care for patients at a high risk of suicide, 
and critical improvements to follow up for high-risk patients 
after discharge. Sixteen percent of non-clinical employees did 
not receive suicide prevention training, and more than 45 
percent of clinicians did not complete suicide risk management 
training in their first 90 days.
    When it comes to suicide prevent policy, to me anything 
less than 100 percent is not acceptable. When will all the IG's 
recommendations be fully implemented?
    Secretary Shulkin. Well, first of all, this is exactly why 
the IG is valuable, pointing this out. I have no other 
mechanism to get data that comprehensive. We have committed to 
addressing the IG concerns.
    The reason why we have made suicide prevention the number 1 
priority and made all of our leadership this month sign off on 
the declaration is to fix those issues. We have committed to 
training.
    Over this year--look, 100 percent is the right goal, but I 
cannot tell you exactly what date we are going to reach that. 
We are going to be working really hard to get as close to that 
as possible as quickly as possible.
    Senator Murray. Well, as Senator Moran alluded to at the 
veterans suicide hearing at the VA Approps Committee back in 
April----
    Secretary Shulkin. Mm-hmm.
    Senator Murray [continuing]. I asked for monthly updates 
until all of the problems of the crisis line are resolved. VA 
has not done that, and that is really unacceptable. So, I want 
a commitment from you today----
    Secretary Shulkin. Mm-hmm.
    Senator Murray [continuing]. To all of us that we will get 
those updates starting right now.
    Secretary Shulkin. I think you have that commitment. Yes.
    Senator Murray. OK. Well, we will intend to see that 
happen.
    Let me ask about women veterans. This is something I have 
asked about many times. I am really disturbed by the increase 
in suicide rate among our women veterans. Between 2001 and 
2014, the rate of suicide for women veterans who do not use VA 
care increased by 98 percent.
    Now, I have heard from women veterans many times about how 
they do not think of themselves as veterans, and I hear far too 
often from women who do not feel welcome at our VA facilities, 
just do not feel like that is their place. It is a significant 
problem, actually, that the RAND Corporation testified in April 
as well, but this increase in suicide is the most important 
reason yet that I believe VA has to redouble its efforts to 
reach out to women and get them into care. So, I wanted to ask 
you, what are we doing to address that?
    Secretary Shulkin. Well, you gave a really important 
statistic, which is that those that over the last 15 years, 
between 2001 and 2014, those women that did not receive care in 
the VA, that the rate of suicide went up by an extraordinary 
number. You said 98 percent.
    Those that did use the VA, we actually saw a decrease, a 
decrease in suicide rates over that 15-year period of 2.6 
percent. We know that particularly in this population, but it 
is for all veterans, getting care and access to care makes a 
difference and saves lives.
    The issue about making the VA more welcoming to women is a 
critical issue. It is a cultural issue, and we have worked hard 
to create women centers and to change the culture and 
environment. I speak about this, so does our Center for Women 
Veterans, all the time.
    But, of course, we are absolutely, as this is our number 1 
priority, committed to doing much more and to be more 
aggressive and to put more resources into this.
    Senator Murray. OK. Well, this is something we have to keep 
working on because if a women does not consider herself as a 
veteran, she does not think about going to the VA.
    Secretary Shulkin. Right.
    Senator Murray. If she is not welcome at the VA or does not 
feel that the veteran facility is welcoming to her, she will 
not go. If she has other issues--child care, work--it is doubly 
hard. This is not an easy problem to solve, but we really have 
to put hearts, minds, resources, and as a country really 
recognize women veterans.
    Secretary Shulkin. I agree.
    Senator Murray. I feel very strongly about that.
    I just have a couple seconds left. I wanted to, if I can, 
just to ask about the VA's REACH VET initiative, to use 
predictive models to identify veterans who may be at risk of 
suicide before it happens. I wanted just if you could quickly 
tell us how that model works, but also 14 of the 20 veterans 
who die each day by suicide do not come to the VA for care. 
Again, I want to ask, how does that work for folks who are not 
coming to the VA?
    Secretary Shulkin. All right. Very quickly, REACH VET is a 
big data analytic research project that when I was Under 
Secretary, I said, ``It is time to stop researching it and 
start putting it into practice,'' validating Senator Tester's 
point about every day we delay, there is going to be more 
deaths.
    We have moved it into the clinical setting. Our suicide 
prevention coordinators get lists of veterans' names that are 
in the highest, 0.1 percent risk of suicide, 80 times higher 
risk than a person who is not on the list, and they proactively 
are calling out every day saying, ``How are you doing? How can 
we potentially help you in anything that you need help with?'' 
and connecting with them.
    I meet with those people. Dr. Carroll has more contact, of 
course. It is making a difference, though I do not have 
statistics.
    Senator Murray. Are you working with local groups and 
providers and non-VA agencies to use the program?
    Secretary Shulkin. No. We do not have that data. REACH VET 
data, because of its limitation, uses VA user data off of our 
electronic medical records. We have no way of identifying the 
14 in the community. That is a big issue for us.
    Senator Murray. Yeah.
    Secretary Shulkin. I think expanding VA access in mental 
health will save lives. That is why I made the decision on 
other than honorable discharges to do that.
    We have a big hole here. One of the big holes is with the 
Department of Defense. What we are working with now with them--
and they are being very cooperative--is essentially an auto 
enrollment program, so nobody leaves active service without 
knowing where they can get their mental health care. I think 
that is going to be a big deal in eliminating a gap right now 
that we have.
    Senator Murray. OK. Thanks very much. Appreciate it.
    Chairman Isakson. Senator Cassidy.
    Senator Cassidy. Dr. Shulkin, again, let me just echo 
others' praises for the changes you have made in your reign so 
far, so, anyway, thank you for that.
    I had mentioned earlier with the earlier panel, there is a 
professor of economics out of Princeton, Anne Case, who is--I 
will quote the article, ``rising morbidity and mortality in 
midlife among white non-Hispanic Americans in the 21st 
century.'' What I am trying to figure out is what we are 
looking at as a specific veterans' phenomena or it is just 
reflective of the cohort within the VA but is also throughout. 
Are you with me?
    Secretary Shulkin. Yes, I am.
    Senator Cassidy. They find among this population that the 
increase for whites was largely accounted for by increasing 
death rates from drug and alcohol poisoning, suicide, chronic 
liver disease, and cirrhosis, although all education groups saw 
increases in mortality from suicide and poisoning. I could go 
on.
    I guess what I am trying to figure out is how much of this 
is unique for the VA relative to this study as opposed to it is 
just kind of what we are seeing in society?
    Secretary Shulkin. Right. Well, first of all, your 
questions before were excellent. We do not adjust by 
socioeconomic status because the way that we collect the data 
off the National Data--Death Index and from the CDC data and VA 
data does not have a socioeconomic status.
    Senator Cassidy. Now, let me ask, though, because as a 
physician, when I used to practice----
    Secretary Shulkin. Yes.
    Senator Cassidy [continuing]. I would find that usually 
folks who are a little bit more well-to-do did not go to the VA 
for their health care.
    Secretary Shulkin. Yeah. Well, our eligibility does not 
allow it unless they are service-connected.
    Senator Cassidy. But even though the service-connected who 
actually had, you know, more money, may have preferred a 
different facility for whatever reason.
    Secretary Shulkin. Mm-hmm.
    Senator Cassidy. Do you know the mean socioeconomic class 
of your typical VA attendee versus the general population?
    Secretary Shulkin. Yes, yes. We are definitely more a 
safety-net organization, in general.
    Senator Cassidy. So, by proxy, we can assume----
    Secretary Shulkin. Yes.
    Senator Cassidy [continuing]. That you have a higher death 
rate among those being seen, that that would probably reflect 
your overall population?
    Secretary Shulkin. Yeah, yeah. You know, my background is 
not hepatology; it is health services research. So, I am going 
to give you my best guess, you know, educated guess.
    There is a socioeconomic status component that I think you 
are identifying, but the veteran population is more than that. 
You would not see as large a difference. I think it is both in 
here. I think----
    Senator Cassidy. Now, we tease that out----
    Secretary Shulkin. Yeah.
    Senator Cassidy [continuing]. Because, again, if it is 
merely reflective of the larger population, that is tragic.
    Secretary Shulkin. Mm-hmm.
    Senator Cassidy. But, VA represents the hope.
    Secretary Shulkin. Right.
    Senator Cassidy. If it is not, being a veteran in the VA 
system is an additional risk factor, then that is something to 
be identified and corrected.
    Secretary Shulkin. We will give that to our health services 
research team to see if we can do that.
    We published 75 articles on suicide and suicide prevention 
last year, and we have a good team on this that I think could 
maybe tease some of that out.
    Senator Cassidy. Now, let me ask--my staff has just given 
me, but I have not yet comprehended it, a spreadsheet that has 
been distributed, the Mental Health Domain Composite Summary, 
Fiscal Year 2017, Quarter 3. I have status for Louisiana. I 
cannot say I comprehend them yet, but I know you have done that 
analysis.
    Secretary Shulkin. Mm-hmm.
    Senator Cassidy. Is there a difference in suicide rates 
associated with different facilities? Again, hopefully 
correcting for that each population is the same, but I am 
assuming it is roughly a homogenous population.
    Secretary Shulkin. I have seen the analysis by State, not 
by facility.
    Dr. Carroll, have you seen that?
    Mr. Carroll. No. The analysis is by State, and the veteran 
population is not homogenous from one State to the other, nor 
is the general population. There are State differences in the 
population, both at large and for veterans.
    Senator Cassidy. I accept that. But probably, broadly, 
Louisiana has a higher African-American population, and some 
States have a higher Hispanic. So, there is going to be that 
broad demographic.
    But, Dr. Casey pointed out that it is among non-Hispanic 
whites that we are really seeing a bump in the general 
population.
    Dr. Carroll, have you done any kind of very rough--as I was 
told in the previous panel, yes, we have it for age and gender. 
I could see throwing race in there because that is usually 
pretty apparent. Do we have any sort of, kind of rough estimate 
on that?
    Mr. Carroll. Those analyses are ongoing, so we are looking 
at ethnicity and race as part of the ongoing evaluation of the 
data.
    Senator Cassidy. Now, let me ask as well, because you are 
sending out this data--but thank you very much--looking at 
specific facilities. I am presuming that most vets, not all, 
but most vets have a facility of choice.
    Secretary Shulkin. Yes.
    Senator Cassidy. Does your analysis--is your analysis going 
to include the rate of--corrected for all these other factors, 
how each specific facility is doing? Senator Murray pointed out 
that we are not getting 100 percent of these being passed out, 
but I suspect that that would vary from facility to facility as 
well.
    Secretary Shulkin. Yeah, yeah. I think the type of 
statistics that Senator Murray was talking about, about 
compliance with screening, absolutely is done not only at the 
facility level, but by the specific provider.
    Senator Cassidy. Oh, yes. That would be good.
    Secretary Shulkin. Yeah, yeah. Because you have electronic 
medical record data on that.
    The broader statistics, which include the National Death 
Index and other things, may be harder to do by facility, but 
chances are we could----
    Senator Cassidy. But you could at least do it by State and 
by catchment area----
    Secretary Shulkin. Absolutely, yes.
    Senator Cassidy [continuing]. Because I think we need to 
know is this a VA issue or does it just reflect broader 
society.
    Secretary Shulkin. Yeah.
    Senator Cassidy. If it is a VA issue, we need to give you 
tools. As a broader society, we need to correct, do something 
more broadly. Does that make sense?
    Secretary Shulkin. Right. You do have--you do know about 
the difference between veterans who are getting care in the VA 
and not in the VA.
    Senator Cassidy. I saw that.
    Secretary Shulkin. Yeah.
    Senator Cassidy. Clearly, you would want to correct for 
that.
    Secretary Shulkin. Yeah.
    Senator Cassidy. You mentioned your safety net, and we 
suspect that--my suspicion is in some places, you are serving 
as a safety net, and in some places, there is inadequacy----
    Secretary Shulkin. Yeah.
    Senator Cassidy [continuing]. In which case we have to 
identify that and address it.
    Secretary Shulkin. Right.
    Senator Cassidy. If you need tools, we have to give them to 
you.
    Secretary Shulkin. Mm-hmm.
    Senator Cassidy. Thank you all very much. I yield back.
    Secretary Shulkin. Thank you.
    Chairman Isakson. Senator Brown.

           HON. SHERROD BROWN, U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, and thanks to the Ranking Member, 
too, for yielding me the time.
    I want to follow up on Senator Murray and Senator Cassidy, 
too, who talked about the suicide report, and I first thank you 
for being here. Thanks to Dr. Carroll, too.
    I do not really understand. In my State, 244 veterans took 
their own lives in 2014. I want to talk about them and the 
thousands around the country. I am not really clear on why you 
would release that State-by-State report on a Friday afternoon 
at five o'clock. That is not really my question. I do not 
understand why you would do that.
    But, talk to me about how you share this data State by 
State, how you share it with veterans, with medical centers, 
with CBOCs, with community providers, with academia, and to 
address what you called the national public health issue.
    Secretary Shulkin. Yeah. We have--this analysis, which was 
released on September 15, a Friday, at five o'clock, is really 
the first time that we have released that type of specific 
data. We are actively trying to get that out and to share it 
with the groups that you have mentioned.
    There was no attempt to downplay this issue. If there was, 
it was a bad strategy because what we are seeing all around the 
country is that data getting out there and being picked up by 
the press, being discussed in forums. It is exactly what we 
want to have happen. We are actively disseminating it, because 
if you do not know your data, like you know 244--and to the 
point of Senator Cassidy, I want every medical center director 
knowing what their number is, how many veterans they lost last 
year, last month, last day. You cannot design as effective 
intervention as this.
    Senator Brown. That means not just a patient from that 
medical center. It means that----
    Secretary Shulkin. It is population.
    Senator Brown [continuing]. Never got into the VA system in 
Franklin County or whatever.
    Secretary Shulkin. Yeah. The catchment areas, the 
populations.
    Senator Brown. OK, OK.
    Secretary Shulkin. Yeah.
    Senator Brown. Talk through how the new PSA implores the 
country to leave no vet behind. It is my understanding that 14 
out of the 20 vets who take their lives each day do not use VA 
care. Talk to us, if you would, about the REACH VET initiative, 
what metrics you have in place to see how it is working, what 
your--what the process to get those 14 who then will not take 
their lives if they get VA care.
    Secretary Shulkin. The REACH VET program is not for the--is 
not for those that are not using VA. It is for those that are 
using VA that we know are at high risk.
    We are beginning to start tackling the 14 that are not 
using VA through other strategies. Letting other-than-honorable 
discharges have emergency mental health is a strategy that will 
bring some of those 14 into the VA.
    For others that are not eligible or choose not to go to VA, 
we are working with community partners, we are working with 
veteran service organizations, and working with the churches 
and the synagogues to make sure that they understand that they 
have a responsibility in this.
    The PSA message, essentially, is suicide prevention is 
everybody's business, and we need family members, friends, 
coworkers to be able to identify people at risk to get them 
help, whether it is at VA or outside VA.
    Senator Brown. Thank you.
    Thank you, Mr. Chairman.
    Chairman Isakson. Senator Blumenthal.
    Senator Blumenthal. Thank you, Dr. Shulkin, for your work 
on this issue, and you heard a number of my questions earlier 
today, as you were here----
    Secretary Shulkin. I did.
    Senator Blumenthal [continuing]. About that difference 
between the veterans who have used the VA and the veterans who 
have not done so. I know you have been asked a number of 
questions about that issue so far.
    I want to focus on the less-than-honorable discharge group. 
Do you have any thoughts about how----
    Secretary Shulkin. Yeah.
    Senator Blumenthal [continuing]. That cohort can be better 
accessed and how they can be encouraged to come forward?
    Secretary Shulkin. Yeah.
    Senator Blumenthal. Because I think that the knowledge 
about them is also lacking.
    Secretary Shulkin. Yeah. Well, quite frankly, I did what I 
could. It was one of the first things I did as Secretary, which 
is just to use the authorities that I had to offer emergency 
mental health services, because I thought it was wrong that we 
were not providing access, we are letting them out there. They 
are at higher risk for suicide, as homeless veterans I believe 
are at higher risk.
    But, I did as much as I can. Now, I actually need your 
help. We are going to need legislative changes to allow us to 
offer other-than-honorable discharges to be able to access our 
full array of mental health and physical services. All that I 
was able to do was to offer 90 days of emergency treatment, and 
then I am trying to find them other places to get care working 
in the community.
    We are going to do everything we can, but it is not the 
ideal approach. We could use your help in this, Senator.
    Senator Blumenthal. Well, I would like to work with you.
    Secretary Shulkin. Yeah.
    Senator Blumenthal. I have other questions, so I would----
    Secretary Shulkin. Sure.
    Senator Blumenthal [continuing]. Hope we can pursue this 
issue as to all of the veterans who right now are, through no 
fault of their own, perhaps, not part of the VA system.
    Secretary Shulkin. Yeah.
    Senator Blumenthal. I know you have been asked about the 
Clay Hunt Suicide Prevention Act.
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal. I would also like to follow up on that, 
particularly as to the funding that is necessary.
    Secretary Shulkin. Mm-hmm.
    Senator Blumenthal. The President has signed a number of 
measures dealing with veterans issues. Those pieces of 
legislation have been long in the works, and we have devoted a 
lot of time and attention to them. And I hope that his apparent 
commitment to those issues will translate into funding, which 
is really the test.
    It is fine to wield a pen on measures that were started 
well before his presidency. Now is the test of his commitment, 
and I think that applies to issues like the Veterans Crisis 
Line, the Clay Hunt veteran suicide prevention measure, and I 
would like to again ask you about women veterans and what 
expanded or enhanced efforts you contemplate involving women 
veterans.
    Secretary Shulkin. Mm-hmm. Well, first of all, thank you 
for highlighting, I think, all these issues that are important.
    The President's budget, the requested budget, actually has 
increased funding for both mental health care and women's 
health care issues, both critically important. I think that he 
does share that commitment that you have to seeing us do better 
in these areas.
    Senator Blumenthal. Is that amount of money, in your view, 
sufficient?
    Secretary Shulkin. I was very pleased with the President's 
budget. I think that many of the issues that we are dealing 
with were not financial issues solely, but in areas that we 
have to do better in, I am not only seeking additional funds, 
as we saw in the President's budget, but I am actually moving 
current budget funds into higher-priority areas. I do think 
that we have sufficient resources this next year, should the 
President's budget get approved.
    Senator Blumenthal. I would be remiss if I did not ask you 
about the West Haven veterans facility. You and I have talked 
about it. It was built in the 1950s. It is out of date 
structurally. It needs more than just rehabilitation. It really 
needs rebuilding, and I wonder where it stands on the list----
    Secretary Shulkin. Yeah.
    Senator Blumenthal [continuing]. Of priorities and whether 
the President's budget is sufficient to cover the capital 
improvement there and elsewhere.
    Secretary Shulkin. Yeah. As you know, you and I stood 
outside that building, and I think your assessment is generous.
    I trained at the West Haven VA, and I do not think it has 
changed too much since I was there.
    We are still undercapitalized in the VA. We have a very old 
infrastructure, but I think realistically, we cannot expect to 
take decades of essentially underfunding and fix it all at 
once. So we are putting more funds--we have requested more 
funds into the modernization of VA. I have announced that I 
want to dispose of 1,100 facilities that are not being utilized 
well by veterans to put back into facilities that are busy, 
like the West Haven VA.
    I do not have a specific number of where the projects are, 
but certainly, I am going to support fixing the West Haven VA 
and other facilities that are not modernized. Part of that is 
we are going to have to redo our matrix on how we make capital 
decisions, because right now I will tell you, the number 1 
weighted factor and where the money goes is to seismic 
improvements.
    And while that is really important--and I am not going to 
say that that is not critical--you are not on a fault line, and 
it puts facilities like West Haven at a disadvantage. So we are 
going to be looking at that.
    Senator Blumenthal. Well, I hope I can be generous in 
pushing West Haven to a higher level on the list. As you noted, 
I was being generous. It has really changed little, if at all. 
There are some cosmetic----
    Secretary Shulkin. Right.
    Senator Blumenthal [continuing]. Improvements, but you well 
know the level of dissatisfaction that----
    Secretary Shulkin. Yes.
    Senator Blumenthal [continuing]. Exists about it, and I 
would add that it is dissatisfaction with the structure----
    Secretary Shulkin. Yes.
    Senator Blumenthal [continuing]. And the capital facility, 
not with the staff.
    Secretary Shulkin. I agree.
    Senator Blumenthal. I want to just give a shout-out to the 
very dedicated men and women who work for the VA in 
Connecticut, and I have no authority to speak on behalf of 
veterans in Connecticut, but generally, I find a high level of 
approval and satisfaction. So they deserve our thanks, and they 
work under conditions that should be better for them and for 
our veterans.
    Secretary Shulkin. Yeah. No, I am sure they will appreciate 
both of those sentiments. Yes.
    Senator Blumenthal. I would like to invite you to come 
visit again and be at that facility with me again. And I want 
to thank you for----
    Secretary Shulkin. I do have a visit scheduled. I will let 
you know----
    Senator Blumenthal. OK.
    Secretary Shulkin [continuing]. When that is, so we can get 
there together.
    Senator Blumenthal. Wonderful.
    I thank you, by the way, in the meantime for the work that 
is being done on the Wi-Fi Internet connections, which is very 
important there and at VA facilities around the country.
    Secretary Shulkin. Exactly.
    Senator Blumenthal. So, thank you.
    Secretary Shulkin. Thank you.
    Chairman Isakson. I want to add to your answer a second 
ago, and if I am wrong, I want you to tell me. That as you go 
through your 1,100-location evaluation of underutilized 
facilities, to rearrange your capital to invest in places that 
need more help, you are going to consider rural locations, 
rural States, population density, and things of that matter, so 
that North Dakota and Montana and States of the like population 
do not lose out on a statistic in terms of the availability of 
CBOCs and clinic association?
    Secretary Shulkin. What I announced is that--first of all, 
I share the sentiment that we do not want policy that 
discriminates against locations because they are rural or 
because they are not on seismic fault lines.
    But, what I announced previously was that in the State home 
money distribution that the rural areas were never getting--
from the bottom of the list. I committed to re-looking at those 
criteria because the State home grant monies really were going 
only to very small numbers of States, essentially.
    I do want to make sure that we are modernizing the 
facilities in an equal way across the country.
    Chairman Isakson. I want the Ranking Member to make sure we 
knew we were looking after his interests as well.
    Secretary Shulkin. Yeah.
    Chairman Isakson. Senator Tillis.
    Senator Tillis. Thank you. That is why you are such a good 
Chair, Mr. Chair.
    I was going to end with the capital projects, but let me go 
to that because I think this is critically important. You have 
said that you believe--I believe the President has a real 
commitment to veterans in accelerating some things and frankly 
did not move as quickly as I would have liked for them to have 
in the past couple of years, but I have the same view in my 
role at Senate Armed Services. We are always going to have 
fewer resources than you want.
    Secretary Shulkin. Right.
    Senator Tillis. And shame on any Member of Congress who 
advocates for moving something up ahead of line where the data 
does not say it is the best way to provide care to the 
communities that need it.
    I am in North Carolina. I am in a 50 percent urban, 50 
percent rural State, with over a million veterans--10 percent 
of my population. But, if you told me Montana is where the 
resources need to go to serve that population, that is where I 
want them to go.
    Along with that, when you are taking a look at optimizing 
capital projects, shame on any member who tries to come up with 
a statutory protection for something that you do not think is 
in the interest of supporting the veterans.
    I every once in a while will call up a VA facility the 
night before I just happen to be in town and want to stop in 
and see them. I say, ``This is not a surprise visit. I just 
want to talk to you all.''
    I stopped in one a year or so ago who said that they have 
made a proposal to actually consolidate two operations that 
were only about 40 minutes apart. It made total sense. They 
thought they could provide better care to the veterans by 
consolidating these resources and getting more leverage out of 
them.
    But, we had a Member of Congress stop that because it 
happened to affect 75 jobs in their district. That is not the 
way we should be thinking if we are going to get out of the way 
and let you support veterans in a more appropriate manner.
    So, we need to make sure that--I need to make sure that I 
have your commitment that at any time you see us doing 
something that is at odds with what in your best professional 
judgment is getting the resources to the communities that need 
it most and making optimal the resources that we are giving 
you, I want to know who that is because I think they should be 
held accountable.
    Now on the electronic medical record. I want to go back to 
the questions I asked the first panel. Actually, I want to 
thank you for being here because I was rushing in and I 
mistakenly thought you were on the first panel. But, it does 
not surprise me that you and your team were here to hear that 
testimony, and I thank you for that commitment.
    I like the decision that you made for the baseline system 
because I think it is an accelerating between DOD an VA, but 
similar to the question I asked you the question when you were 
here last, we know that we have got over 120 instances that 
have to be consolidated within VA. But even more importantly, 
we have non-VA care providers out there. We have choice 
providers out there.
    I believe that as you get further into the implementation 
plan that we discussed in my office that you are going to 
identify that you need other layers in the technology stack to 
make sure that we know how prescriptions are being dispensed, 
whether there is any dangerous interactions, other indicators 
that you can use to make that a more productive experience for 
the provider and for the patient.
    Have you gotten to a point now where you are thinking 
through how you--as you are looking at your implementation 
priorities and your broader transformation plan, the remainder 
of the stick--or we used to call it ``glue-ware''--the other, 
either custom efforts or hopefully buy and configure tools you 
are going to need to kind of flesh out that technology sector?
    Secretary Shulkin. Yeah. We have gotten to essentially the 
principles that you have talked about, saying a system that is 
going to work into the future is going to have to have the 
components that, frankly, you have done a good job of 
outlining.
    We have not gotten to defining which specific tools they 
are yet and how we are going to meet those needs, as we have 
talked about the days of VA being a software developer are 
over----
    Senator Tillis. Good.
    Secretary Shulkin [continuing]. And we are going to be 
looking at off-the-shelf current technologies. But, there is 
going to be a lot more definition on that.
    I think yesterday we released to Congress, to you, the 30-
day notice of an award of a contract. We are keeping on the 
timeline that we talked about. We are marching forward. We have 
the principles. I have some updates to share with you on the 
strategic IT plan, because I think we are making a lot of 
progress with that.
    We are going to announce that we will--in this IT 
conversion with obviously your support, we will be sunsetting 
80 percent of the projects that were currently under 
development. So this will be not only, I think, the right thing 
for clinical care, but it will also be the right thing for 
taxpayers.
    Senator Tillis. That is great to hear.
    Secretary Shulkin. Yeah.
    Senator Tillis. I am going to hold to my time because I 
guess I am the last, the last Member to speak, but we do have a 
number of questions for the record on suicide prevention issue. 
We are--I took note in the first panel, and I have asked my 
staff to get with the Senate Armed Services staff because I 
would like to have a Committee hearing at the Subcommittee 
level to talk about Traumatic Brain Injury, PTSD, and things 
that we are doing to do a better job of detecting and treating. 
I would like to add a second panel that then talks about the 
veterans who may actually--first off, how do we track those who 
get an honorable discharge and make sure that we are trying to 
anticipate or provide interventions for ones who may be at risk 
of suicide? Then, for the ones who have other than honorable 
discharge, what are we doing to make their experience when they 
were in the military instructive to any decision about what 
category of discharge they get? Finally, we have to come back 
to the VA and get your advice on----
    Secretary Shulkin. Yeah.
    Senator Tillis [continuing]. How we do that for those who 
have already received that paper and they need care.
    Secretary Shulkin. OK.
    Senator Tillis. Thank you for pushing the envelope.
    Secretary Shulkin. Yeah.
    Senator Tillis. I heard you loud and clear. It is time for 
Congress to give you more tools so that you can provide more 
veterans with care.
    Secretary Shulkin. Thank you.
    Senator Tillis. Thank you.
    Thank you, Mr. Chair.
    Chairman Isakson. Senator Tillis, are you on the way out 
the door, or do you have 5 more minutes?
    Senator Tillis. All right.
    Chairman Isakson. I want to ask you a favor, if you will 
gavel the meeting out. I am going to have to leave. Senator 
Tester will have some questions he wants to ask and I do not 
want to cut him off.
    Senator Tillis. Yes, sir.
    Chairman Isakson. I have got one I want to be sure is for 
the record.
    Your great move of Cerner, to adopt the same software that 
is being used by DOD health care, is a huge step forward, and 
you have been commended for that. Does that merger also allow 
you access to the same information that DOD has regarding the 
Warrior Transition Units?
    Secretary Shulkin. Yes.
    Chairman Isakson. Because our warriors, when they leave the 
battlefield or leave deployment in battlefield areas, they are 
asked questions on a computer. They answer by computer. It does 
not have a stigma to it. They are answering a computer 
question, and there are questions that give indicators of where 
there may be somebody at risk for suicide. You will now--
because you have interoperability software 1 day soon----
    Secretary Shulkin. Yeah.
    Chairman Isakson [continuing]. Will also have 
interoperability access to that type of information. Is that 
correct?
    Secretary Shulkin. Yeah. There are certainly some 
exceptions with DOD. One of the things I just learned 
recently--I do not know if you know this--the Coast Guard does 
not have--it was not in their contract. So, we are going to 
have to figure out a way to be interoperable with them or get 
them into this. There are some small exceptions, and we are 
working through those.
    Our relationship with DOD is extremely cooperative on this 
project, and I think we are helping them in their 
implementation. They are certainly helping us. But, those types 
of data sources are extremely valuable to us.
    Chairman Isakson. You are to be commended for that move, 
and we are very proud of it.
    I am going to turn it over to the Ranking Member for his 
questions and then ask Senator Tillis to adjourn the meeting.
    Secretary Shulkin. Thank you.
    Chairman Isakson. I appreciate your patience, Mr. 
Secretary.
    Secretary Shulkin. Thank you, Mr. Chairman.
    Senator Tester. Thank you, Mr. Chairman. I want to thank 
you fellows for being here, as well as the first panel.
    I just want to touch on BRAC really quick because I think 
there is some opportunity to get rid of some facilities that 
are not being used, but you would agree that manpower and 
recruitment of manpower is a continuing challenge, would you 
not?
    Secretary Shulkin. Absolutely.
    Senator Tester. OK. I would just tell you, as we look for 
ways to save money in common-sense ways, what I am really 
concerned about is--and I know that you are not a part of this, 
and if you are, let me know--that they will come in and 
potentially--if we do it in Congress or if you do it 
administratively--do a BRAC and say, ``You know what?''--and I 
will just pick a town, Glasgow, MT. They have got a CBOC. They 
have not had a doc for years. You walk in and say, ``Well, gee, 
the vets are not using this,'' and close it down. The same 
thing could be said for Senator Rounds' South Dakota. if 
something like that were to happen, I guarantee you, there 
would be a bipartisan explosion on this Committee, which would 
not be a good thing.
    I just bring that to your attention. I am all for making 
sure that you are getting rid of properties you do not use 
anymore and have outlived their usefulness and utilizing those 
dollars. I think it makes--that is a good government thing, and 
I applaud those efforts. But, when we get into the really--
because I am going to tell you, I know there are some people 
that want to do a full-blown BRAC, and I am going to tell you 
that some of the metrics out there are not going to speak too 
well, not because these are not good facilities, but because 
they have not been staffed.
    Secretary Shulkin. Right.
    Senator Tester. I just want to bring that up.
    In your testimony, you cited that suicide prevention was a 
top priority.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. You also mentioned that VA has integrated 
mental health services into the primary care at Vet centers and 
at CBOCs. Tell me what that means in Montana.
    Secretary Shulkin. Well, what it means is that VA by far is 
leading the strategy across the country where if you are in 
your primary care office, you do not have to say, ``I have been 
given a number to go and to call for a mental health 
appointment,'' and then go down the street to the mental health 
department. You get that behavioral health care as part of your 
primary care office experience. The----
    Senator Tester. And how are you----
    Secretary Shulkin. Yeah.
    Senator Tester. How are you going to--I agree it is----
    Secretary Shulkin. This is about de-stigmatizing.
    Senator Tester. I know, but how are you going to do it when 
you have got to have somebody there that knows the issue, 
right?
    Secretary Shulkin. You have to have the--you have to have 
the mental health professionals with our primary care people.
    Senator Tester. OK.
    Secretary Shulkin. Collocated.
    Senator Tester. And in a small-population State like 
Montana, we are about 20 short right now.
    Secretary Shulkin. Yeah.
    Senator Tester. I mean, the best-laid plans without the 
people, infrastructure, so it is going----
    Secretary Shulkin. Well, it gets back to what you were 
saying. We have a manpower issue. It is not--and it is 
geographically distinct, particularly in areas that do not have 
a lot of medical schools and other places that train 
professionals.
    Senator Tester. Right. Senator Moran, even though I was not 
here for his questions, talked about other opportunities that 
are out there that could get us--besides psychiatrists and 
psychologists--some other----
    Secretary Shulkin. Yeah.
    Senator Tester [continuing]. Folks out there that could 
help. Is that proceeding, and is it proceeding well? Are we 
making some inroads? Because I am going to tell you that we 
have talked about a lot of metrics today, about what population 
is committing suicide and what altitude and all this stuff. We 
have got to get our arms around the whole baby before we can 
even get to a point where we are talking about----
    Secretary Shulkin. Well, look, no other health system that 
I am aware of has suicide prevention coordinators. That is a VA 
strategy that I think is super effective.
    Senator Tester. Yep.
    Secretary Shulkin. We are using peer support specialists in 
a way that no other health system is using, and of course, we 
are trying to hire traditional mental health professionals, 
licensed social workers, psychologists, and psychiatrists.
    Dr. Carroll, do you have any comment on the marriage 
therapist and family therapist?
    Mr. Carroll. I think we are encouraging, as strongly as we 
can, facilities to hire them.
    Senator Tester. OK.
    Mr. Carroll. That is part of their--within their purview.
    The other thing that we are doing, to your question about 
primary care, mental health integration, is using telemental 
health, using our telemental health system to provide providers 
into places where they may not be able to hire a mandatory 
professional.
    Senator Tester. Can you tell me, CBOCs overall, do they all 
have telehealth capabilities?
    Secretary Shulkin. Not all of them. We list them on our 
website, first of all, which ones do, but certainly, the rural 
ones will be much more likely to have it than you would have in 
New York City where----
    Senator Tester. Really?
    Secretary Shulkin. But, one of the cool things--I do not 
know if you have ever seen it--that just amazes me is you go 
into a primary care office in a CBOC or a medical center, and 
right there is a digital display. That if the primary care 
doctor wants to dial in an psychologist or psychiatrist, they 
can do it right from their office, while the patient is there. 
I do not see that in many places in the private sector. That is 
that integration you were talking about.
    Senator Tester. Yeah. That is good.
    I want to go back to manpower for just second.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. Earlier in the year, you testified that you 
were going to try to get 1,000 additional mental health 
providers this year.
    Secretary Shulkin. Mm-hmm.
    Senator Tester. Your testimony today says that you have 
hired over 600 new mental health providers. I am not going to 
ask what the difference between additional and new are, but has 
there been a net increase in the number of VA mental health 
clinicians in that----
    Secretary Shulkin. Well, you just asked it, then; and the 
answer is no. The 623 is just keeping us even. We are not 
succeeding at that 1,000 net new professionals. I need help in 
doing that.
    Senator Tester. Doctor?
    Secretary Shulkin. Yes.
    Senator Tester. What do we need to do?
    Secretary Shulkin. What we need to do is to, A, give us 
more direct hiring authority, just like you did in the 
Accountability Act for my medical center directors. Make it 
easier for me to hire.
    We talked about the fact that our recruitment and retention 
dollars were actually cut in half. That was shortsighted, quite 
frankly. We need the tools that the private sector has to be 
able to recruit the very best health care professionals. If we 
are serious about tackling this, let us--do not tie one of my 
hands behind my back.
    Senator Tester. Well, I just want to be clear.
    Secretary Shulkin. Yeah.
    Senator Tester. Did we cut your recruitment and retention 
dollars?
    Secretary Shulkin. To pay for the CARA legislation, yes, 
sir. Yes.
    Senator Tester. Boy, we ought to be taken out and beaten. 
Keep going.
    Secretary Shulkin. I need, a competitive process so I can 
hire quicker and----
    Senator Tester. Yeah. Recruitment dollars?
    Secretary Shulkin. Recruitment dollars and the flexibility 
to be able to help expand training. Those are the three areas 
that would really make a difference.
    Look, there is a national shortage here, so, you know, I 
think we all worry about not just what is happening in VA, but 
everywhere. These are all important strategies, particularly 
the training one.
    Senator Tester. Yeah.
    I will just make one side comment, and you know this better 
than I do. You are right. It is a national problem, but with 
veterans----
    Secretary Shulkin. Mm-hmm.
    Senator Tester [continuing]. We made a promise to them.
    Secretary Shulkin. Yes.
    Senator Tester. So, we cannot have a bunch of excuses. We 
have got to have more solutions than excuses.
    Secretary Shulkin. Right, right.
    Senator Tester. I appreciate you guys being here. Thank 
you.
    Secretary Shulkin. Thank you.
    Senator Tillis [presiding]. Just on the last point--we are 
about to adjourn. I am not going to ask other questions, 
although I will have them for the record. But, I remember this 
discussion with then Secretary McDonald. I think there was a 
series of news stories that some of our Members got tempted 
into amplifying that had to do with training and retention 
programs that you thought were critically important, and I 
think what we need to do is understand if you are going to make 
this an attractive place for professionals to come to, then you 
better have professional development and a retention program 
similar to the private sector.
    When I see some of the dollars that you were spending on 
training, I am sure I could find something that was not a good 
idea. I saw the number that the VA was spending on a per-
employee basis, and it was pennies on the dollar compared to 
what I would have spent as a partner at Pricewaterhouse.
    Secretary Shulkin. Right.
    Senator Tillis. You are never going to get to that ratio, 
but we need to make sure we are not talking out of both sides 
of our mouth; on the one hand, saying we need to give you 
recruiting and retention resources, and then we want to 
micromanage how you go about spending it.
    I have never been the head of a major health system before. 
You have, and now you are the head of one of the biggest in the 
world.
    Secretary Shulkin. Mm-hmm.
    Senator Tillis. I trust you to make a decision about how 
you have therapists and doctors and technicians and other 
people that you want to attract and have a value proposition so 
you are getting your fair share of the best resources out there 
in the private sector.
    That is another one where when we hear us say one thing and 
do another thing here, please give me your commitment that you 
will say, ``That is not a good idea.''
    Secretary Shulkin. Thank you.
    Senator Tillis. We are going to adjourn the Committee 
hearing, and we are going to leave the record open for 1 week 
for questions for the record.
    I thank the first panel for being here. It is always a 
pleasure to see the leadership from the VA.
    This meeting is adjourned.
    Secretary Shulkin. Thank you.
    [Whereupon, at 12:20 p.m., the Committee was adjourned.]

                                ------                                

Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
     John D. Daigh, Jr. M.D., CPA, Assistant Inspector General for 
Healthcare Inspections, Office of Inspector General, U.S. Department of 
                            Veterans Affairs
    Can you share with the Committee your thoughts on how the expansion 
of telemental health through the VA can assist in suicide prevention 
and your assessment of the VA's use of telemedicine for this purpose?
    Response. Veterans with depression, Post Traumatic Stress Disorder, 
substance use disorder, and a variety of other mental health conditions 
are at high risk of suicide. Most mental health care is provided by 
primary care providers who lack expertise in the determination that an 
individual has the characteristics (age, sex, clinical diagnosis, 
access to firearms, etc.) that may put them at high risk of suicide. 
The telehealth system can give primary care providers access to expert 
advice on both the management of a veteran's mental health disorders, 
as well as identifying which veterans may be at increased risk of 
suicide and determining what steps should be taken to address this 
risk. The OIG has not evaluated the telemedicine program with respect 
to the provision of specialty care that is not available locally.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
 Craig Bryan, National Center for Veterans Studies, the University of 
                                  Utah
                               telehealth
    Introduction: VA's testimony notes that telemental health provided 
more than 427,000 encounters to over 133,500 Veterans in 2016. 
Telemental health reaches veterans where and when they are best served 
however legal barriers for VA providers remain which is why I sponsored 
a bill with Sen. Ernst to allow allowing VA health officials to 
practice telemedicine across state lines if they are qualified and 
practice within the scope of their authorized Federal duties.

    Question 1. Can you share with the Committee your thoughts on how 
the expansion of telemental health through the VA can assist in suicide 
prevention and your assessment of the VA's use of telemedicine for this 
purpose?
    Response. The VA is a national leader in the use of telemental 
health, which is a critical tool for making access to mental health 
services accessible to veterans who live in geographically remote 
areas. A growing body of research indicates that the outcomes 
associated with telemental health are comparable to the outcomes 
obtained from visiting with healthcare providers face-to-face. The 
impact of telemental health is therefore largely limited by the same 
limiting factors that characterize mental healthcare in general: 
insufficient use of empirically-supported treatments. As noted in my 
testimony, enhancing access to care without addressing quality of care 
just makes it easier for veterans to receive services that don't work. 
We must therefore ensure that telemental health service providers are 
trained to provide the latest and most advanced treatments available.
    There is one especially noteworthy problem with how telemental 
health services are often employed: they regularly exclude suicidal 
veterans. The typical rationale for this is that high-risk veterans are 
better served via in-person services. We therefore withhold telemental 
health services from those veterans who most need them due to concerns 
about safety. The irony and tragedy of this mindset is that the highest 
risk veterans often do not access VA services, but instead of finding 
ways to make it easier for them to receive services, we preserve the 
very barriers that contribute to their high risk state. This is an area 
of potential improvement for the VA.
                   female veterans and sexual trauma
    Introduction: I've had discussions with female veterans in my state 
of Hawaii, and there is a sense that VA is not doing enough to assist 
female combat veterans suffering from PTSD or TBI.

    Question 2. What is your assessment of VHA's overall approach to 
help our female veterans facing mental health issues, especially those 
who have experienced sexual assault or trauma? What recommendations do 
you have to better equip VA to provide the appropriate gender-specific 
mental health care for sexual trauma victims?
    Response. Many VA's have established women's health centers and 
clinics to meet this need, and have established specialty programs for 
female veterans struggling with the consequences of sexual trauma. The 
most important barrier to quality care for female veterans is the 
limited use of scientifically-supported treatments for PTSD secondary 
to sexual trauma. Only two treatments are recommended for the treatment 
of sexually-based PTSD: prolonged exposure therapy and cognitive 
processing therapy. Both of these treatments were developed to treat 
PTSD among female sexual assault survivors and were later modified and 
adapted for combat and military trauma. Unfortunately, these treatments 
are not always available to female veterans. On top of this issue, many 
mental health professionals carry the perspective that military sexual 
trauma cannot be effectively treated. As a result, an unsettling number 
of mental health professionals--the very individuals who are supposed 
to be trained to effectively treat PTSD and sexual trauma--convey a 
sense of hopelessness to female veterans, telling them that there is 
nothing that can be done to help improve their lives.
    This contradicts a large body of research and the experience of 
many of us who have been treating female veterans for years. Sexually-
based PTSD can be effectively treated, but too few mental health 
professionals know how to do these treatments. We need to ensure that 
mental health professionals know about these treatments while they are 
still in graduate and medical school, which will lead to a much better-
prepared pool of mental health professionals from which the VA can 
hire.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
Matthew Kuntz, Executive Director, National Alliance on Mental Illness 
                              for Montana
                               telehealth
    Introduction: VA's testimony notes that telemental health provided 
more than 427,000 encounters to over 133,500 Veterans in 2016. 
Telemental health reaches veterans where and when they are best served 
however legal barriers for VA providers remain which is why I sponsored 
a bill with Sen. Ernst to allow allowing VA health officials to 
practice telemedicine across state lines if they are qualified and 
practice within the scope of their authorized Federal duties.

    Question 1. Can you share with the Committee your thoughts on how 
the expansion of telemental health through the VA can assist in suicide 
prevention and your assessment of the VA's use of telemedicine for this 
purpose?
    Response. Senator Hirono, mahalo for the question. You are correct 
that Telemental health is critical to care in frontier states within 
the Continental United States, like Montana, and geographically 
separated states like Hawaii and Alaska. NAMI Montana and others work 
very hard to make our states hospitable to new clinicians, but there is 
a critical need to have qualified clinicians be able to easily serve 
our veterans from other locations.
    The VA has been a pioneer in Telemental health services in Montana, 
particularly in our tribal communities, and I fully agree with you and 
Senator Ernst that legal barriers around this solution for effective 
treatment in provider-scarce communities need to be taken down.
                   female veterans and sexual trauma
    Introduction: I've had discussions with female veterans in my state 
of Hawaii, and there is a sense that VA is not doing enough to assist 
female combat veterans suffering from PTSD or TBI.

    Question 2. What is your assessment of VHA's overall approach to 
help our female veterans facing mental health issues, especially those 
who have experienced sexual assault or trauma? What recommendations do 
you have to better equip VA to provide the appropriate gender-specific 
mental health care for sexual trauma victims?
    Response. While I cannot speak for this on a national level, there 
may be some insights from the Montana experience that would be helpful. 
I have seen the VHA in Montana take great strides in the past few years 
in their response to female veterans who have experienced sexual 
trauma. Kelly Downing Keil, the Military Sexual Trauma Coordinator in 
our community, is exceptional. She has definitely raised the awareness 
of this issue and providers personal high quality care for women 
veterans.
    However, I still feel that more resources are necessary to provide 
effective care for women veterans who have been impacted by sexual 
trauma. Some of those resources should certainly be located in the 
geographic location of the veteran, but I think that it also would be 
helpful to have more national expertise such as telemental health and 
inpatient care that supported this specialty need for veterans.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Question 1. Dr. Shulkin, in encouraging veterans to seek mental 
health care, are we making appropriate progress in addressing the 
stigma attached to mental health care? What additional steps does VA 
need to take?
    Response. VA is taking a multi-faceted approach to address the 
stigma associated with mental health and seeking mental health care, 
including a Nation-wide outreach campaign, technological innovations to 
reduce barriers to seeking care and providing care in alternative 
settings. We are making progress on this issue, but need to continue 
these efforts as robustly as possible in order to continue these 
advancements. Truly addressing mental health stigma requires changing 
the conversation and changing culture across the U.S.
    National Awareness and Outreach: Make the Connection (www. 
maketheconnection.net) is VA's national public awareness and outreach 
campaign that highlights Veterans' true and inspiring stories of mental 
health recovery and connects Veterans and their family members with 
mental health resources in their communities. Make the Connection 
provides personal stories of hope and recovery from hundreds of 
Veterans as well as resources and information that help Veterans who 
are experiencing mental health challenges discover ways to improve 
their lives. Make the Connection is specifically designed to address 
the stigma associated with mental health and seeking mental health 
care. Since its launch, Make the Connection has seen tremendous 
engagement among Veterans and their family members and supporters. Via 
the MakeTheConnection.net website, the campaign's outreach efforts, and 
social media properties including Facebook and YouTube pages, the 
campaign has garnered:

     Over 13.1 million website visits
     400,000 resource locator uses (to find local VA and other 
community-based sources of support)
     27.7 million video views
     39,476 YouTube subscribers
     2.9 million ``likes'' on the campaign's Facebook page, 
making it one of the largest U.S. Government Facebook communities
     Over 56 million Facebook engagements (``likes,'' comments, 
and/or shares)
     Over 377,000 airings of the 11 public service 
announcements (PSA) for over 2.2 billion impressions and equaling more 
than $36 million in equivalent paid media value.
     During the month of May, highly successful Mental Health 
Awareness Month campaign to increase awareness of VA mental resources 
and the Make the Connection campaign.

    Technological Innovations to Reduce Barriers to Care: VA has 
created a suite of award-winning tools that can serve as self-help 
resources or as adjuncts to mental health services. These tools are 
available as web-based courses and smart phone mobile applications. 
Veterans and their loves ones can anonymously access these resources at 
any time and from any location. In 2014, VA launched an online Veteran 
Training portal for web-based self-help resources 
(www.veterantraining.va.gov) to provide ``one-stop shopping'' for 
Veterans and their families. The courses include an educational and 
life-coaching program that teaches problem-solving skills to help 
Veterans better handle life's challenges (www.veterantraining.va.gov/
moving forward), a course to help parents learn how to address both 
everyday parenting challenges and family issues unique to military 
families (www. veterantraining.va.gov/parenting) and a course on anger 
and irritability management skills that offers a wide range of 
practical skills and tools to manage anger and develop self-control 
over thoughts and actions (www.veterantraining.va.gov/aims/).
    VA has also deployed a suite of award-winning mobile apps to 
support Veterans and their families with tools to help them manage 
emotional and behavioral concerns. These apps are divided into two 
primary categories: those for use by Veterans to support personal work 
on issues such as coping with PTSD symptoms or stopping smoking, and 
those used with a mental health provider to support Veterans' use of 
skills learned in psychotherapy. Enabling Veterans to engage in self-
help before their problems reach a level of needing professional 
assistance can be empowering to Veterans and their families and allow 
them to access information and resources privately to learn about 
support and treatment. VA's mobile apps address common mental health 
and related problems such as Post Traumatic Stress Disorder, 
depression, insomnia, smoking, problem solving, anger management and 
parenting.
    Providing care in alternative settings: To further reduce stigma 
Veterans may feel in seeking mental health care, VA has integrated 
mental health into primary care settings to provide much of the care 
that is needed for those with the most common mental health conditions 
in non-traditional settings, when appropriate. Mental health services 
are incorporated into VA's primary care to Patient Aligned Care Teams 
(PACT), an interdisciplinary model to organize a site for holistic care 
of the Veteran in a single primary health care location.
    All of these efforts are aimed at empowering and engaging Veterans 
to seek mental health services when needed.

    Question 2. When it comes to the provision of mental health care, 
how does the VA measure progress?
    Response. VA has a broad, multi-level data-based management system 
that it uses to monitor, evaluate, and improve provision of mental 
health care. The top layer of this system consists of a ``Mental Health 
Balanced Scorecard'' (AKA MH Domain of SAIL), a composite measure that 
combines information about three key domains into a single overall 
assessment of mental health care access and quality. The Mental Health 
Balanced Scorecard addresses three core components of mental health 
care delivery: (1) Population Coverage--assessing whether patients with 
indications for mental health treatment are able to successfully access 
evidence-based services for their condition across the spectrum of 
mental health treatments, (2) Continuity of Care--assessing whether 
patients who start treatment get full courses of proactive, coordinated 
care delivered safely and effectively, and (3) Experience of Care--
assessing whether patients and providers feel they can access or 
provide the treatments they believe are needed, and receive high 
quality care. In brief, it measures whether a patient can receive the 
services most appropriate for their disorder, delivered in a safe and 
effective manner, in a manner that is satisfactory to both patients and 
mental health professions. The scores on this measure are posted 
publicly at https://www.va.gov/QUALITYOFCARE/measureup/
Strategic_Analytics_for_ Improvement_and_Learning_SAIL.asp. VA sets 
goals for improvement and resets scores to 0 at the start of the year, 
and then tracks improvement over the year from that baseline. 
Improvement in mental health care delivery is supported through a 
detailed program of data-based management tools and expert technical 
assistance. Managers can drill down the Mental Health Balanced 
Scorecard to identify specific areas of weakness, and tools and expert 
support are available to isolate gaps and problems and recommend and 
implement improvements. VA has improved on this global indicator of 
mental health access and quality every year since it was instituted in 
2014.
    The Mental Health Balanced Scorecard assumes that Veterans will 
benefit if VA provides mental health services consistent with research 
literature on effective treatments. VA is also monitoring Veterans 
symptoms, functioning and improvements in the early stages of treatment 
engagement through the Veterans Outcomes Assessment (VOA) program. The 
VOA conducts telephone assessments with a sample of patients as they 
start a new episode of mental health care in VA and then 3 months 
later. This program provides information on Veterans needs as they 
start in treatment, and provides feedback on how patients are 
progressing in early treatment. VA uses this data to understand what 
programming is most effective for rapidly stabilizing Veterans with 
mental health needs and to plan longer-term programming to ensure 
services are available to help Veterans address mental health and 
behavioral challenges where recovery requires prolonged effort and 
support.

    Question 3. VA's goal is to end suicide among veterans regardless 
of whether they seek treatment at VA. With that in mind, what 
innovative steps is VA taking to reach veterans not already connected 
to VA?
    Response. Suicide prevention is VA's number one clinical priority. 
In consultation with Veterans, Service Organizations, subject matter 
experts, national and community partners, and field leaders, VA has 
developed a comprehensive strategy--the #BeThere for Veterans Suicide 
Prevention Initiative.
    The strategy has five key domains--Improve Transition, Know All 
Veterans, Partner Across Communities, Lethal Means Safety, and Improve 
Access to Care.
Improve Transition
     VA's collaboration is stronger than ever with DOD. We are 
facilitating enrollment in VA care for eligible transitioning 
Servicemembers and formalizing our partnership to enhance sharing of 
best clinical practices, data, and outreach efforts.
Know All Veterans
     On September 15, VA released a breakdown of Veteran 
suicide data by state. It includes Veteran suicide counts and rates for 
each state and the District of Columbia. These data will help us better 
address suicide risk factors for all Veterans.
     Using Predictive Analytics to Identify Those at Risk and 
Intervene Early
Partner Across Communities
     VA is leveraging strategic partnerships with community, 
Federal partners, and the entire Department of Veterans Affairs to 
reach Veterans not in VA care.
     VA has partnered with the PsychArmor Institute to create a 
web-based suicide prevention training that will be free and available 
to the public.
     VA is partnering with Johnson & Johnson to create an 
integrated marketing campaign that will include a national public 
service announcement.
     In October VA will launch a national initiative with 
Substance Abuse and Mental Health Services Administration (SAMHSA) to 
engage Mayors in a Suicide Prevention Challenge and employers in 
suicide prevention training.
     VA is developing partnerships including the Semper Fi 
Fund, Cohen Veterans Network, Department of Homeland Security, and 
Veterans & First Responders Healthcare; those will all promote the 
reach of information and resources to assist Veterans who are not in VA 
care.
     Leveraging VA Vet Centers and Readjustment Counselors
Lethal Means Safety
     Lethal means safety is a key component in preventing 
suicide and accidental overdose. VA has distributed over 3 million gun 
locks since 2010 and more than 100,000 naloxone kits since 
November 2014.
     VA is sponsoring a Gun Safety Matters Challenge in 
partnership with VA Center for Innovation (VACI) and National 
Aeronautics and Space Administration (NASA) to seek Veteran-centric 
ideas and solutions for safer gun storage.
     Suicide Prevention training is now mandatory each year for 
all VHA employees and will soon be mandatory for VBA and NCA employees. 
The goal is for every single VA employee to be trained to recognize 
someone who may be in crisis and who may be at risk for suicide and to 
know how to help that person get appropriate care right away.
Improve Access to Care
     Nationwide, our system of over 400 VA Suicide Prevention 
Coordinators participated in 14,135 outreach events that touched over 
1.5 million people who play a role in Preventing Veteran suicide.
     A Community Toolkit was distributed through the Veteran 
Experience Office--https://www.va.gov/nace/docs/
myVAoutreachToolkitPreventingVeteranSuicideIs EveryonesBusiness.pdf
     VA is leveraging telemental health care by establishing 
four regional telemental health hubs across the VA health care system. 
VA telemental health innovations provided more than 427,000 encounters 
to over 133,500 Veterans in 2016. VA is a leader across the United 
States and internationally in these efforts.
     VA's MaketheConnection.net, Suicide Prevention campaigns, 
and mobile apps (e.g. Posttraumatic Stress Disorder (PTSD) Coach has 
been downloaded over 280,000 times) contribute to increasing mental 
health access and utilization. VA has also created a suite of award-
winning tools that can be utilized as self-help resources or as an 
adjunct to active mental health services (www.veteran training.va.gov).
     For Veterans unable (e.g., rural Veterans) to engage in 
traditional mental health treatment, web-based, self-guided 
interventions for health conditions associated with suicide risk, offer 
a potentially effective means of overcoming treatment barriers and 
preventing ``downstream'' suicides. The Rocky Mountain MIRECC is 
piloting a two-year project on this.
     VA is expanding access to emergent mental health care for 
former Servicemembers with other than honorable (OTH) administrative 
discharges.
     Free Mobile Apps to Help Veterans and Their Families.
Veterans Crisis Line (VCL)
     VCL is available to all Veterans and Servicemembers 24 
hours a day/365 days a year, including holidays.
     Facilitates connecting Veterans to national and local 
resources, as well as VA services.
     Since its launch in 2007 through August 2017, the Veterans 
Crisis Line has answered over 3.1 million calls and initiated the 
dispatch of emergency services to callers in imminent crisis nearly 
87,000 times.
     Since launching chat in 2009 and text services in 
November 2011, the VCL has answered nearly 362,000 and nearly 79,000 
requests for chat and text services respectively.
     Year to date data:

        - Average Rollover Rate: 1.25%
        - Average Speed of Answer: 8 seconds
        - Veterans Crisis Line is expanding to a third site in Topeka, 
        with training classes expected to begin November 2017 and a go 
        live date of January 2018.

    Question 4. Understanding the shortage of mental health 
professionals isn't specific to the VA, particularly in rural areas, 
what can VA do to fundamentally address chronic workforce shortages?
    Response. VA is authorized by Title 38 Section 7302 to provide 
clinical education and training programs for developing health 
professionals. VA conducts the largest education and training effort 
for health professionals in the United States. VA's physician education 
program is conducted in collaboration with 135 of 144 allopathic 
medical schools and 30 of 33 osteopathic medical schools. In addition, 
over forty other clinical health professions education programs are 
represented by affiliations with over 1,800 unique colleges and 
universities. Among these institutions are Minority Serving 
Institutions such as Hispanic Serving Institutions and Historically 
Black Colleges and Universities.
    VA health professions education programs have a major impact on the 
healthcare workforce in VA. For example, roughly 70% of current VA 
optometrists and psychologists and 60% of physicians participated in VA 
training programs prior to employment. VA's involvement in health 
professions education has thus been shown to be an effective mechanism 
to support VA's patient care mission.
    Given that over 120,000 health professions trainees receive 
clinical training in VA each year, it is vital that VHA look to the 
trainee pipeline to fundamentally address chronic workforce shortages. 
For example, the Veterans Access Choice and Accountability Act 
legislation in 2014 established an additional 1500 new Graduate Medical 
Education positions for VA. Over 750 of these positions are filled, 
with 2/3 of the positions allocated to Primary Care and Mental Health. 
The Office of Academic Affiliations, in partnership with the Office of 
Mental Health and Suicide Prevention, has also been engaged in a 6-
year, phased expansion of mental health training positions in VA. Since 
2012, an additional 750 mental health trainee positions have been 
authorized and funded.
    For the agency's most hard-to-fill clinical vacancies, VHA 
currently utilizes multiple strategies and tools to address workforce 
shortages. The National Healthcare Recruitment Service's (NHRS) 
National Recruitment Program (NRP) provides VA with an in-house team of 
18 skilled and experienced professional physician recruiters called 
National Healthcare Recruitment Consultants. NHRS has recently added a 
National Nurse Recruitment & Retention division, with two full-time 
experienced nurse recruiters to develop plans for critical nursing 
vacancies. VHA has developed a national-level clinical and healthcare 
executive recruiting contract (blanket purchase agreement) that can be 
used both nationally and locally to aid in filling hard-to-fill 
vacancies. When recruiting providers for rural opportunities, NHRS 
develops marketing ads that highlight unique features associated with 
smaller communities and key amenities within reasonable proximity, 
directs sourcing efforts to providers with direct ties to the targeted 
rural locations (by birth, training, previous employment, education, 
etc.) or an expressed preference for rural community practice, and 
partners with national/regional associations dedicated to rural health 
(i.e. National Rural Recruitment & Retention Network/3RNet- a nonprofit 
organization that connects health professionals searching for jobs in 
rural or underserved areas with healthcare organizations.). NHRS also 
advises the maximum utilization and leveraging of recruitment 
incentives, benefits, and compensation packages to secure the long-term 
needs of well-qualified candidates such as relocation, sign-on bonus, 
continuing medical education, etc.
    Additionally, VHA utilizes both education loan repayment and 
scholarship programs to recruit and retain healthcare providers in 
difficult to fill positions. The Education Debt Reduction Program 
(EDRP) is offered to repay education loans for healthcare professionals 
in VA's most critical positions that have been determined to be 
difficult for recruitment and retention. Over the last five fiscal 
years, FY 2013-2017, VHA has awarded 423 EDRP awards to participants in 
rural stations. The number of awards to rural stations continues 
increase each year; in FY 2013, 30 new awards were made to participants 
in rural stations, while 97 new awards were made in FY 2017. From FY 
2013 to FY 2017, VHA has awarded 543 new scholarships to employees 
located at rural facilities. VA has implemented regional telehealth 
resource centers in urban areas of the country, where recruiting 
specialty providers is easier, to serve Veterans in rural areas where 
recruiting is more difficult.
    As noted in OIG Determination of VHA Occupational Staffing 
Shortages, Report #17-00936-385, staffing models are being created to 
assist healthcare systems to identify where these shortages exist. VHA 
has initiated a comprehensive review of all defined VHA staffing models 
to further enhance workforce planning and projection tools and 
conducted a regrettable loss analysis in 2017 which included loss rates 
at rural healthcare sites for mission critical occupations (MCO). VHA 
is currently conducting additional analysis of loss rates in rural 
areas and working with subject matter experts to determine strategies 
to address recruiting and retaining staff in these areas. Furthermore, 
while not a critical occupation need in the recent OIG report, Human 
Resources is ranked third on VHA's 2017 MCO list after physicians and 
registered nurses. One-quarter of facilities noted that shortages in 
this occupation create staffing barriers for other occupations and H.R. 
total loss rates for FY 2016 were 11.2%, higher than any other mission 
critical occupations in VHA. Identifying priorities to improve 
recruitment and retention for this occupation will assist VHA with the 
ability to onboard potential employees in an effective and efficient 
manner to meet VHA's medical center and Veteran patient needs.

    Question 5. To what extent does VA work with other Federal agencies 
on collaborative efforts to train and recruit medical personnel, or to 
incorporate best practices to address medical workforce shortages?
    Response. VHA collaborates extensively with other Federal partners 
on health professional workforce issues, and continues to seek and 
develop collaborative efforts. For example, the National Academic 
Affiliations Council, a federally Chartered Advisory Committee, has 
membership from VA, Health Resources and Service Administration (HRSA), 
and Department of Defense (DOD). This forum allows for planning and 
brainstorming of collaborative activities. VHA also has a Memorandum of 
Understanding signed with HRSA that allows extensive collaboration. 
With the Department of Defense, VA has historically encouraged health 
professions trainee exchanges between DOD and VA facilities and is also 
actively engaged in an exploration of using the Uniformed Services of 
the Health Sciences University for VA-obligated medical students. A 
Memorandum of Understanding has been signed with Health and Human 
Services (Public Health Services) in order to directly assign Public 
Health Officers to VA facilities. Last, VA's Office of Academic 
Affiliations is working directly with Indian Health Services on 
building their academic affiliations.

    Question 6. Understanding there is no standardized treatment when 
it comes to mental health, does VA have an appropriate diversity of 
mental health professionals--whether its counselors, family therapists, 
psychologists or whomever--to meet the individualized mental or 
behavioral health needs of veterans?
    Response. VA is committed to promoting a diverse, well-qualified 
mental health work force, which includes representation from all mental 
health disciplines. As of 9/21/17, excluding VHACO staff, VHA employed 
21,863 mental health professionals that are specifically clinical and/
or have documented outpatient mental health direct care encounters. 
Mental Health professionals include psychiatrists, Advance Practice 
Registered Nurses, Physician Assistants, Clinical Nurse Specialists, 
pharmacists, psychologists, social workers, Licensed Professional 
Mental Health Counselors, Marriage and Family Therapists, Addiction 
Therapists, Peer Support Specialists, and Registered Nurses. 
Additionally, many Mental Health programs utilize occupational 
therapists, recreational therapists, art therapists, among other 
professionals within their inpatient, residential, and outpatient 
services.
    Currently, approximately 46% of the mental health workforce is 
comprised of psychologists (25.5%) and social workers (20.5%). 
Registered Nurses and psychiatrists each comprise of approximately 15% 
of the VHA mental health workforce. There are currently over 1,100 Peer 
Support Specialists (5%) in the mental health workforce. Since 2010, VA 
facilities have been authorized to hire Licensed Professional Mental 
Health Counselors (LPMNC) and Marriage and Family Therapists (MFTs) as 
specialty providers in mental health, and these professionals currently 
make up approximately 1% of the workforce.
    Different sites have different needs, so VHA does not have a 
formula to determine the most desirable mix of provider types. Instead, 
we allow local leadership to fulfill their needs within the resources 
available to them locally. To this end, VHA has focused efforts to 
encourage professional diversity at the local level in the following 
ways:

     Within the mental health professions, a number of services 
can be provided by multiple professions, and sites are encouraged to 
extend hiring considerations to focus on the needed skillset rather 
than a specific profession. For example, psychologists, social workers, 
Licensed Professional Mental Health Counselors, and Marriage and Family 
Therapists may all have training and advanced skills in providing 
couples therapy. With this, facilities are encouraged to expand the 
hiring consideration to all these professions rather than focusing the 
hiring effort on a single specialty.
     To promote professional diversity at the facility level, 
VHA established as policy that all mental health professions must be 
considered when hiring mental health leadership positions. This has 
served to diversify mental health leadership in VHA which not only 
promotes professional and leadership development, but this diversity 
strengthens the clinical programs.
     Educational training has been a vital component in 
increasing diversity and succession planning. For 70 years, VA has 
provided clinical training to build a pipeline of highly qualified 
mental health professionals who consider serving Veterans at VA as a 
career. The VA Office of Academic Affiliations (OAA) annually supports 
the training of more than 7,500 mental health professionals, and about 
70 percent of VA psychiatrists and psychologists received at least some 
of their clinical training at a VA facility. Nationally, nearly one in 
five VA psychologists completes their doctoral internships in VA 
facilities. VA is recognized for preparing mental health professionals 
who work in both VA and other U.S. health care settings, expanding 
specialized expertise in providing care to Veterans and their families 
beyond our walls.
     The VA Office of Academic Affiliations has expanded mental 
health training opportunities through a 5-year program called the 
Mental Health Education Expansion (MHEE).
     The MHEE increases the number of slots in existing 
training programs and establishes new training opportunities, 
particularly in highly rural areas where it is often difficult to 
recruit mental health professionals without a training program. When 
the MHEE was launched, not all regions of the country had psychology 
training, but in academic year 2017--18, VA psychology internship 
training programs were available in all states, the District of 
Columbia, and Puerto Rico.
     The 5-year MHEE has added 750 mental training slots across 
the country. The MHEE has encouraged multidisciplinary training 
encompassing mental health professions such as psychiatrists, 
psychologists, nurses, nurse practitioners, physician assistants, 
social workers, licensed professional mental health counselors, 
marriage and family therapists, and advanced mental health specialists 
such as pharmacists, chaplains, and other clinicians.
     VHA has supported local LPMHC and MFT hiring efforts by 
creating new clinical training opportunities. To start this process, a 
special Request for Proposals to the facilities was released in 
April 2015, which led to 18 positions being awarded for LPMHC training 
programs at seven VA medical centers. Fewer applications were received 
for MFT internships on this first call for proposals. Three MFT intern 
positions were awarded to one VA medical center to begin in academic 
year 2016-17. To support these newly funded programs, the profession-
specific monthly calls have continued to assist facility training 
directors in establishing and maintaining their internship programs. To 
further expand LPMHC and MFT internship training opportunities, the 
next phase of the MHEE (which began in Q4FY2016) solicited LPMHC and 
MFT training expansion along with expansion of four other MH 
professionals including chaplains, pharmacists, psychologists, and 
social workers. For all professions, experienced mentors are available 
from other VA facilities that have existing funded internship programs 
to coach applicant sites through the proposal process.
     In the 2016--17 academic year, the Office of Academic 
Affiliations and National Physician Assistant (PA) Services established 
the new Mental Health PA Residency program. This unique training will 
prepare PAs, who are normally trained to work in primary care, to join 
other professionals in providing mental health care as prescribing 
providers.
     VA is committed to working with public and private 
partners across the country to support full hiring and to make sure 
Veterans can access high-quality, timely mental health care, no matter 
where they live. For example, multiple professional organizations, such 
as the American Psychiatric Association and American Psychological 
Association, deliver announcements to their members about VA's 
rewarding career opportunities in mental health care.
     VA is committed to attracting and retaining the most 
qualified providers. To better recruit and retain psychiatrists amid a 
national shortage and stiff competition from Federal partners, academic 
programs, and state and private systems, VA has increased the pay level 
for psychiatrists and increased flexibility for medical center leaders 
to match pay to local circumstances.
     VA has expanded its psychiatry fellowship programs because 
psychiatrists who train within VA are more likely to make their careers 
there.
     New educational loan debt reduction opportunities created 
as part of the Clay Hunt Suicide Prevention Act will improve VA's 
ability to attract promising new psychiatrists in their final year of 
training.

    Question 7. During the Committee's hearing in 2015 regarding mental 
health care, there was discussion of the high no-show rate for veterans 
at their mental health care appointments. Please provide updated 
statistics on no-show rates and what actions VA has been taking to 
minimize the no-show rate at VA and non-VA appointments?
    Response. The no-show rate in mental health is substantially higher 
than no-show rates in other clinics, likely as a consequence of the 
additional logistical and clinical barriers to treatment adherence 
posed by mental health conditions (e.g. anxiety, depression, legal 
issues, homelessness, cognitive and organizational problems). General 
efforts to improve no-show rates across VHA clinical programs have 
produced some incremental improvements in mental health no-show rates. 
Specifically, in FY 2015Q1, the national mental health no-show rate 
(MOP12) was 19.26% with 43 health care systems over 20%. In FY 2017Q3, 
the national mental health no-show rate was 18.89% with 29 health care 
systems over 20%.
    VA's National Initiative to Reduce Missed Opportunities (NIRMO) 
included 10 strategies to reduce no-show rates or improve clinic 
utilization in spite of no-shows. These include using a Recall Reminder 
System to help patients schedule appointments closer to the planned 
date of the visit, negotiating all visit times with the patient to 
ensure that they are scheduled at a time the patient can realistically 
come, coordinating appointments with other visits to the health care 
system and arranging transportation, using an open access model and 
scheduling appointments in the near the appointment date, using novel 
health care delivery models such as telehealth to reduce travel-related 
barriers to care, reducing wait times in waiting rooms, and improving 
patient-clinician relationships and interactions so that patients are 
more motivated to come for care. One particularly effective method 
includes making live reminder calls to patients at high risk of no-
show. To support this effort, VA developed a predictive model to 
identify patients likely to not show up for an appointment. Clinics use 
this list to prioritize phone calls with the patients most likely to 
no-show to provide reminders and trouble-shoot possible causes for non-
attendance.
    Mental Health has taken some specific efforts to address no-shows 
beyond the overall VHA initiative. Mental Health provided national 
business operations trainings to teach clinic managers NIRMO 
strategies, and mental health technical assistance specialists assigned 
to each VISN provide hands-on support for facilities in implementing 
these practices. The Office of Mental Health and Suicide Prevention has 
quarterly calls with MH leadership within each VISN where missed 
opportunities rates are reviewed. Sites with exceptional rates are 
asked to share their practices with other sites, and teams problem-
solve and suggest improvements for sites with high no-show rates.
    To address the special challenges with treatment attendance among 
mental health patients, VA just developed a mental health specific no-
show predictive model that incorporates clinical information about 
mental health conditions, treatments, and status. This should improve 
our ability to anticipate and prevent no shows. Tools using this model 
be rolled out in VA clinics in the coming months to improve upon the 
original general NIRMO predictive modeling-based interventions.

    Question 8. Women's suicide numbers are beyond understanding. Does 
VA see a link between the higher rate of suicide among women veterans 
and the lower rate of VA utilization among this population? How is VA 
expanding outreach to women veterans to address this?
    Response. Veteran suicide is VA's top clinical priority, and VA is 
committed to eliminating suicide among all Veterans, whether or not 
they are enrolled in VA care. It is of great concern that female 
Veterans die by suicide at a rate 2.5 times that of civilians, although 
this statistic is much lower than the previously estimated 7 times 
higher. Since 2001, there has been a relative decrease in suicide rates 
among female Veterans who use VHA care, and relative increase in 
suicide among female Veterans who do not use VHA care. Suicide is a 
complex phenomenon and there are likely many factors related to these 
trends in rates over time. VA remains committed to providing a full 
continuum of mental health services to women Veterans, including 
outpatient and residential programs that accommodate and support women 
Veterans with safety, privacy, and respect.
    VA is committed to expanding outreach to women Veterans, in order 
to ensure that all Veterans receive the care and support they've 
earned. Our network of 400+ Suicide Prevention Coordinators partner 
with community organizations at the local level in order to expand VA's 
reach and meet the specific local needs of each community's women 
Veterans. In addition, partnerships with public and private 
organizations at the national level are aimed at expanding our reach to 
women Veterans. For example, the Department of Veterans Affairs (VA) is 
partnering with Department of Defense (DOD) to improve the military to 
civilian transition by expanding pre and post separation services and 
expediting VA enrollment. By doing this, VA will reach more at risk 
women Veterans who otherwise may have not come to VA for services.

    Question 9. Has VA examined whether Vet Centers have the capacity 
and capability to help veterans who didn't deploy to a combat theater? 
Would there be a way to use any excess capacity to help them?
    Response. Readjustment Counseling Service (RCS), through Vet 
Centers, already provide services to specific individuals (active Duty 
Servicemember, Veteran, National Guard, and Reserve) who have not 
deployed to a combat theater. These individuals' experiences include 
service in designated area of hostilities, experiencing a military 
sexual trauma, providing direct assistance to the casualties of war 
from outside the war zone (doctors, nurses, mortuary affairs, etc.), 
and unmanned aerial crews (drones). RCS was created by Congress to 
serve a specific and unique function designed to assist individuals to 
transition from combat service or other potentially traumatic 
situations, such as experiencing a military sexual trauma. There is 
concern of significant mission creep in providing services to others 
than the individuals and situations listed above and this 
recommendation is not consistent with the purposeful design of RCS. In 
addition, RCS has future capacity concerns in providing services to 
additional cohorts given our current eligible Veteran, Servicemember, 
and family growth trends.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Bill Cassidy to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    A recent study by Anne Case and her husband, Angus Deaton, found 
that there is a negative trend in the life expectancy of white 
Americans aged 45 to 54. This trend can be attributed to an increase in 
deaths of despair, including suicide, chronic liver diseases, 
cirrhosis, and drug or alcohol poisoning. I am curious if this trend 
for certain subgroups of society matches the trends experienced in the 
same subgroups of the veteran population. Unfortunately, the suicide 
data provided in the recent report issued by the VA accounts only for 
differences in rates by location, age, and sex. It does not take into 
consideration other important demographics, including education, 
economics, or race.

    Question 10. In light of the above, it begs the question: is the 
increased suicide rate among Veterans greater than or similar to 
Veterans in the same catchment area who are not receiving care in the 
VA system and to non-Veterans in the same catchment area matched in 
other demographics? Once this is answered, it allows comparisons of how 
different VA facilities perform relative to one another and within 
their catchment area addressing deaths of despair.
    Response. VA does not have the data necessary to respond to this 
question. VA and the Centers for Disease Control and Prevention are 
exploring ways to build capacities to enable such analyses.

    Question 11. The question and request is if the VA will perform an 
analysis as per the above? This is beyond the academic and allows 
comparisons that can aid in improving systems of care and pin pointing 
geographic and programmatic areas of excellence. In regards to a data 
set to compare the VA population to, Case and Deaton reference the 
following: ``CDC Wonder Compressed and Detailed Mortality files as well 
as from individual death records from 1989 to 2013. For population by 
ethnicity and educational status, we extracted data from American 
Community Surveys and, before 2000, from Current Population Surveys.''
    Although I do not know this, perhaps Drs. Case and Deaton would 
assist in the analysis. I think this would aid Congress tremendously in 
working with the VA to improve the lives of Veterans.
    Response. VA does not have the data necessary to respond to this 
question. VA and the Centers for Disease Control and Prevention are 
exploring ways to build capacities to enable such analyses.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to 
  Hon. David J. Shulkin, M.D., Secretary, U.S. Department of Veterans 
                                Affairs
    Question 12. In a letter earlier this year, Senator Tester and I 
expressed concern over the implementation of the Department's new 
policy to extend emergency mental health coverage to veterans with 
other-than-honorable discharges, particularly because over-promising 
and under-delivering on something as critical as mental health is 
dangerous. My questions on this issue are threefold:

    a. Now that you have had time to implement this policy, do you have 
any data on the number of veterans who have received care under this 
interpretation of the already existing authority?
    Response. As of October 21, 2017, more than 2,000 former 
Servicemembers who have Other than Honorable administrative discharges 
have sought care from VA. VA is working on an IT solution that will 
improve its ability to track the care furnished to these former 
Servicemembers.
    b. In your letter to me, you stated that if a veteran shows up who 
does not have a service-connected injury, VA will take another look at 
their records for injuries and their character of discharge. If you 
cannot rule favorably, you are going to bill a veteran for any 
treatment provided by the VA. How long is it taking you to look at 
these veterans records? And, how many have been billed for their 
treatment?
    Response. The procedures for character of discharge determinations 
and disability ratings are set forth in the M21-1 Manual. When a VHA 
facility requests a character of discharge determination from VBA, VBA 
requests that the claimant submit an application and then adjudicates 
the claim. If VBA determines the claimant's character of discharge is 
disqualifying for VA purposes, it will also adjudicate the claim to 
determine whether the claimant has a service-connected disability for 
which VHA will furnish health care, notwithstanding the otherwise 
disqualifying character of discharge. Once VBA renders a decision, a 
copy of the character of discharge and rating decision is provided to 
VHA and notification is provided to the claimant.
    Under this initiative, the Secretary has requested that these 
eligibility determinations be given priority processing during the 90-
day period of emergency mental health care treatment. VBA has 
centralized review of these requests to two regional offices, Winston-
Salem and Nashville. Based on the pending workload, these offices 
complete these cases within 90 days.
    As of November 20, 2017, VBA has identified 14 requests for 
character of service determinations received through this initiative. 
Eight of these cases have been processed. Seven were found eligible for 
health care and one was found Dishonorable for VA Purposes (DVA). VHA 
is looking into whether the former Servicemember determined to be DVA 
has been billed for care furnished under this initiative.
    c. Also in your letter, you said that VA Medical Center directors 
were provided with the number of Other than Honorable veterans in their 
catchment area. Can we get a copy of that document?
    Response. The number of Servicemembers whose discharge character 
was exclusively ``other than honorable'' was estimated from the 
administrative database that is developed in the office of Data 
Governance and Analytics under the VA Office of Enterprise Integration. 
This administrative database contains demographic and military service 
information from the Department of Defense and from the VA for those 
who have ever received VA services or benefits.

    Question 13. The State data released to our staff regarding veteran 
suicide is from 2014. While I appreciate this data, I would like 
something more recent. Is there more data that is more recent and when 
can Congress anticipate another update?
    Response. VA used the most current data available at the time. VA 
now has and is currently analyzing National Death Index data through 
2015, but extensive analytic work is needed before we will have an 
update to release.

    Question 14. On the West Virginia veterans suicide data in deaths 
by method section, 27.5% of veteran suicides in my state are 
categorized as ``other, poisoning, suffocation'' but that category is 
not represented at all in the overall West Virginia suicides chart. Do 
you know what is included in the ``other'' category and if not, can you 
get back to me on an explanation of that data?
    Response. The specific categories presented are defined as follows:

     Firearm: ICD-10 codes X72 to X74
     Poisoning: ICD-10 codes X60 to X69
     Suffocation (including strangulation): X70
     Other: all intentional self-harm codes not captured in the 
above categories (X71, X75-X84, Y87.0), including cut/pierce, drowning, 
fall, fire/flame, other land transport, struck by/against, and other 
specified or unspecified injury.

    In cases where the number of deaths in any one of the above 
categories was <10, the categories with the smallest numbers were 
combined until the minimum count of 10 was reached, and are presented 
in the lighter shade of blue. So, e.g. for West Virginia State 
Veterans, the category ``other, poisoning, suffocation'' collapses the 
Other, Poisoning and Suffocation categories listed above into 1 
category. All data points in the sheets are presented suppressing any 
counts fewer than 10 to maintain confidentiality of the information.

    Question 15. In the past, you have said that a repeal of the 
Affordable Care Act could lead to an uptick in enrollment in the VA. As 
the leader of the biggest integrated health network in the country, 
what role have you played in policy discussions around the future of 
the Affordable Care Act?
    Response. VA has not played a role in policy discussions regarding 
national healthcare reform.

    Question 16. In the next few weeks, there will be hopefully a new 
bill concerning how we fix non-VA care authorities. How are we 
equipping non-VA care providers with the military cultural awareness 
and training so that they can identify when something is wrong? In 
future legislation, what is needed to help outside of the VA providers 
be a more integral part in preventing veteran suicide?
    Response. VA has proactively worked to equip non-VA providers with 
the skills they need in order to effectively recognize and respond to 
the challenges many Servicemembers and Veterans face. These efforts 
include several strategies, including widespread dissemination of a two 
hour gatekeeper training called SAVE to veterans and those who serve 
veterans (SAVE is available at the following link: https://www.va.gov/
nace/MyVA/). In addition, in partnership with Psych Armor Institute, 
SAVE will become an online course available to any interested provider 
free of charge. VA also provides online resources on military culture 
training, suicide risk assessment, and suicide prevention safety 
planning tools. Access to VA's military culture training, with free 
continuing education credits, is available through TRAIN, a catalog of 
military culture training, at www.TRAIN.org. Other relevant resources 
are available to the public via the Veteran Outreach Toolkit: Veteran 
Suicide Prevention in Everyone's Business, A Community Call to Action, 
which is available here: https://www.va.gov/nace/docs/
myVAoutreachToolkitPreventingVeteranSuicide IsEveryonesBusiness.pdf. 
Finally, to ensure that we are able to measure the impact of these 
efforts, VA has included metrics in our written agreements with our 
strategic partners to document that non-VA providers have access to the 
necessary resources to successfully treat Veterans and Servicemembers.
    In order to help non-VA providers be better equipped to prevent 
Veteran suicide, future efforts should focus on continuing to 
disseminate military culture training, including the specific 
challenges that Servicemembers and Veterans may face across the 
lifespan, to all health care providers, with an emphasis on those in 
mental health and primacy care. In addition, non-VA providers would 
benefit from training on suicide risk assessment and safety planning, 
including how to counsel at risk Veterans and Servicemembers and their 
families about lethal means safety.

    Question 17. In August, a report came out from the IG that said 
that there were issues doing oversight on community care providers with 
opioids. In that the report the IG recommended several steps. Knowing 
that the Acting Undersecretary for Health concurred with these 
recommendations, what is your progress on responding to these 
recommendations?
    Response. The responses below outline progress on each 
recommendation from the Department of Veterans Affairs Office of 
Inspector General, Report No. 17-01846-316, ``Healthcare Inspection 
Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care,'' 
published July 31, 2017.
                            recommendations:
     We recommended that the Acting Under Secretary for Health 
require all participating VA purchased care providers receive and 
review the evidence-based guidelines outlined in the Opioid Safety 
Initiative.
    PROGRESS: VHA Office of Community Care will provide evidence-based 
guidelines for prescribing opioids, as outlined in the Opioid Safety 
Initiative (OSI). The guidelines will be provided to VA's third party 
administrators (TPAs) and will include a requirement to share these 
with all participating community care providers. Providers must confirm 
receipt of this requirement and review them. For those providers who 
have contracted directly with a VA Medical Center (VAMC) (e.g., sharing 
agreements, affiliate agreements, and direct contracts), VHA Office of 
Community Care will develop a distribution and confirmation policy and 
procedure for VAMC use. A module for community providers in the TRAIN 
system is being developed and is scheduled to deploy in late in 
October 2017. The TPA and the field will be given letters for 
distribution to all providers regarding OSI and the module, as well as 
information on accessing the clinical guidelines.
     We recommended that the Acting Under Secretary for Health 
implement a process to ensure all purchased care consults for non-VA 
care include a complete up-to-date list of medications and medical 
history until a more permanent electronic record sharing solution can 
be implemented.
    PROGRESS: VA's consult process requirements currently specify that 
a complete up-to-date list of medications and all applicable medical 
history information ( i.e., prior pain management treatment, controlled 
substance agreements, applicable behavior health flags) be included 
with community care consults sent to the TPAs and shared with VA 
community care providers. VHA Office of Community Care has recently 
implemented a medical documentation tool that simplifies the process of 
gathering and organizing all applicable medical history information and 
a complete up-to-date list of medications into one uniform document 
identified as the Referral Documentation Tool (REFDOC). This complete 
package is automated; therefore, assuring complete information is 
transmitted to the Non-VA provider. We currently have 123 sites 
utilizing the technology, with planned full deployment by the end of 
the calendar year.
     We recommended that the Acting Under Secretary for Health 
require non-VA providers to submit opioid prescriptions directly to a 
VA pharmacy for dispensing and recording of the prescriptions in the 
patient's VA electronic health record.
    PROGRESS: Under the current Veterans Choice Program contract, VA is 
primarily responsible for supplying Veterans with all non-urgent/non-
emergent medications prescribed in accordance with the VHA National 
Formulary Handbook, and as part of the health care treatment authorized 
by the VA. VA agrees that Veterans receiving community care should fill 
as many prescriptions as possible through VA pharmacies and will work 
with non-VA providers and Veterans to ensure greater awareness of this 
objective. VA developed a letter describing the OSI and also reminding 
community providers to return all prescriptions to the pharmacy is 
being distributed to the full network by the end of the October 2017. 
In addition, similar to private industry, VA will be limiting urgent/
emergent prescriptions (which can be filled in the community) to a 7 
day fill instead of 14 days with the new pharmaceutical contracts 
included within the Community Care Network contracts, with estimated 
award by late FY 2018.
     We recommended that the Acting Under Secretary for Health 
ensure that if facility leaders determine that a non-VA provider's 
opioid prescribing practices are in conflict with Opioid Safety 
Initiative guidelines, immediate action is taken to ensure the safety 
of all veterans receiving care from the non-VA provider.
    PROGRESS: There is a pilot in VISN 4 in which the local VAMC and 
VISN patient safety structure will begin to address patient safety 
reported events and perform necessary investigations. The OCC Patient 
Safety Guidebook is being finalized through this pilot and will be 
adopted as an appendix to the National Center for Patient Safety's 
handbook. After VISN 4, OCC staff will work to deploy this new effort 
across additional VISNs with the expectation that our current and 
future contracting partners will continue to be involved. 
Implementation is targeted in a staggered timeline throughout FY 2018. 
As with other patient safety concerns, all concerns regarding community 
provider prescribing practices can be reported through the VA patient 
safety infrastructure and action will be taken accordingly. It should 
be noted that VA must recognize the possibility that differences in 
opioid prescribing and monitoring practices disparities can/do exist 
between the VA and non-VA community providers. Reasoning includes a 
lack of comprehensive pain treatment modalities in many communities 
(e.g. acupuncture, pain specialists, etc.). Therefore, while VA agrees 
that our community providers should be educated and should attempt to 
adopt the evidence-based guidelines as outlined in the Opioid Safety 
Initiative. It is not assumed that their lack of adoption reflects poor 
quality of care without any evidence of egregious activity.

    Question 18. In your testimony, you stated that ``VA developed a 
chart ``flagging'' system to ensure continuity of care and provide 
awareness among providers about Veterans with known high risk of 
suicide. Do you know if DOD has a similar flagging system for 
servicemembers who are high risk for suicide on their Cerner EHR 
platform? As the VA transitions to the Cerner platform, what will the 
department be doing to ensure that this flagging system works both 
within the VA and with non-VA partners?
    Response. VA's VistA has a number of Patient Record Flag (PRF) to 
alert the healthcare provider, to include one to identify individuals 
who are at risk for suicide. It is labeled ``HIGH RISK FOR SUICIDE.'' 
In VA and DOD the clinical staff see each agency's national level flags 
and postings, from their EHR, in a single view from the Joint Legacy 
Viewer (JLV). Every time a clinician conducts patient search in JLV, a 
pop-up is displayed with all of the national level VA and DOD flags and 
postings. The DOD flag is called the ``Behavioral Health 2--Harm to 
Self'' that is received and displayed by JLV.
    VA and DOD are moving toward using a single Joint EHR, which DOD 
has already deployed to several locations in Washington State. In the 
future, at any DOD and/or VA site that has the new Joint EHR, both 
agencies' staff will see the exact same patient record any associated 
Flags. As the VA transitions to the new EHR Modernization platform, we 
will ensure the VA Patient Record Flag is viewable in the new system 
and the legacy system during transition. Additionally, both VA and the 
Community Care Providers should also be able to exchange messages that 
can alert each other's systems that a Veteran is at high risk for 
suicide.

                            A P P E N D I X

                              ----------                              


      Prepared Statement of Ken Falke, Chairman, Boulder Crest & 
                         EOD Warrior Foundation
    The first week of October marks our Nation's 16th consecutive year 
of war--the longest stretch of conflict in our Nation's history. Over 
that period of time, we have lost more servicemembers and veterans to 
suicide than we have on the battlefield. This is true despite a great 
deal of attention and even more resources being poured into solving 
this scourge across the public and private sector.
    As a 21-year Navy combat veteran, and the Chairman of the EOD 
Warrior Foundation and two privately-funded wellness centers--Boulder 
Crest Retreat Virginia and Boulder Crest Retreat Arizona--that serve 
combat veterans and family members struggling with suicidal thoughts 
and PTSD, we have gained a unique perspective not only on the question 
of why suicides continue to happen, but how we can prevent them.
                   the challenge of veterans suicide
    The data related to veterans' suicide paints an incredibly 
distressing picture. Only 6 of the 20 veterans who die by their own 
hand each day are active users of VA treatment. Only 50 percent of 
those in need of mental health care pursue it. Only 20 percent of those 
who do pursue mental health treatment complete their protocols. Only 40 
percent experience benefits from their treatment; and fewer than 3 
percent actually lose their PTSD diagnosis.
    In short, our mental health system is not proving effective with 
PTSD or suicide prevention. These views are not my opinions, but the 
findings of the world's most prestigious medical journal--the Journal 
of the American Medical Association (JAMA). In August 2015, JAMA called 
for a new and innovative approach to PTSD for veterans. In 
January 2017, JAMA Psychiatry declared that, ``These findings point to 
the ongoing crisis in PTSD care for servicemembers and veterans. 
Despite the large increase in availability of evidence-based 
treatments, considerable room exists for improvement in treatment 
efficacy, and satisfaction appears bleak based on low treatment 
retention . . . we have probably come about as far as we can with 
current dominant clinical approaches.''
    Since opening Boulder Crest Retreat Virginia in September 2013, we 
have hosted more than 2,800 combat veterans and family members, and run 
more than 80 short-duration, high-impact programs. Before, during, and 
after those visits and programs, we have spoken with guests about their 
struggles, their experiences with the mental health system, and why 
they pursued a non-clinical approach. The insights they offered, 
integrated into our work at Boulder Crest, provide a powerful roadmap 
for ensuring that we end the epidemic of veterans suicides, and more 
significantly, enable veterans to create lives worth living--the true 
opposite of suicide.
    1. Veterans report that they have been trained not to acknowledge 
weakness and are experts at suffering in silence. Seeking mental health 
treatment while on active duty is often a career ender, and that 
thinking follows them out of the military.
    2. Veterans are often unable to connect with their providers (often 
civilians who lack a strong understanding of the military culture and 
who have no basis for understanding combat experiences); this results 
in a lack of trust, safety, and an unwillingness to return for further 
treatment.
    3. Veterans report that mental health treatments focus on helping 
them manage and mitigate their symptoms through a combination of talk 
therapy and medicine, rather than on living a great life. The majority 
of veterans are not interested in learning how to live as a diminished 
version of themselves.
    4. Veterans report that a diagnosis-focused approach means that 
therapists and clinicians only want to hear enough to label and judge 
them, and have little interest in listening to them.
    5. Veterans are seeking direction and purpose, and find that 
consistently talking about past experiences leaves them stuck in their 
struggle, and unable to move forward.
    6. Veterans report that most programs and therapies they experience 
are catch-and-release. They feel better while they are at a program or 
in treatment, but as soon as it ends, they return back to their prior 
baseline.
     a new, innovative, and effective approach to ptsd and suicide
    In response to the input and feedback we received from guests in 
Virginia, we launched Warrior PATHH (Progressive and Alternative 
Training for Healing Heroes) in June 2014. Warrior PATHH is the 
Nation's first-ever program designed to cultivate and facilitate 
Posttraumatic Growth (PTG) amongst combat veterans. PTG is a decades-
old science that provides a platform for transforming deep struggle 
into profound strength and lifelong growth. The underlying notion of 
PTG is best captured in the words of Nietzsche: ``That which does not 
kill me makes me stronger.''
    Warrior PATHH is an 18-month program that begins with a 7-day 
intensive and immersive residential initiation. Warrior PATHH trains 
combat veterans through the proven framework of PTG: educating them 
about the value of struggle and what stress and trauma do to the mind, 
body, heart, and spirit; teaching proven non-pharmacological techniques 
designed to regulate thoughts and emotions; creating an environment of 
trust and safety to facilitate disclosure of past challenges from 
combat and pre-combat experiences; beginning to craft a new story that 
harnesses the lessons of the past and looks forward; and a renewed 
commitment to service--to one's family, community, and country--here at 
home.
    In January 2016, after more than two years of research, 
development, piloting, and success, the Marcus Foundation funded the 
development of the first-ever curriculum effort designed to cultivate 
and facilitate Posttraumatic Growth. The curriculum effort included 
Student and Instructor Guides, a Journal, Syllabus, and Schedule; four 
pilot programs; and an 18-month longitudinal study.
    Now more than six months into the longitudinal study, conducted by 
UNC-Charlotte's Dr. Richard Tedeschi (the father of Posttraumatic 
Growth) and Dr. Bret Moore, a twice-deployed former Army psychologist, 
Warrior PATHH is delivering sustained results that far outpace the 
status quo approaches to PTSD:

     100% of participants recommended Warrior PATHH to friends;
     0% dropout rate
     40-60% sustained reduction in PCL (PTSD Checklist) Scores;
     50% sustained reduction in depression and anxiety (DASS-
21);
     40% sustained reduction in stress (DASS-21);
     35% sustained improvement in participants' experiencing 
positive emotions; 28% reduction in negative emotions;
     31% sustained improvement in couples satisfaction;
     75% sustained improvements in participants' level of 
psychological, spiritual/existential and relationship growth (PTGI-X)

    In short, Warrior PATHH is delivering results that far surpass 
traditional mental health treatments for veterans struggling with 
suicidal thoughts and PTSD. All 200 Warrior PATHH graduates are walking 
their path, and working toward lives worth living. No Warrior PATHH 
participant has ever dropped out or died by suicide, despite comparing 
the intensive 7-day Initiation to Navy SEAL Hell Week and Army Ranger 
School.
                        why warrior pathh works
    Warrior PATHH is modeled on military-style training. It is 
intensive, immersive, team-based, and provides participants with a new 
fire team to support their road to wellness, strength, and thriving.
    Warrior PATHH is based on the decades-old science of Posttraumatic 
Growth, and provides veterans with a pathway to a life that is more 
authentic, fulfilling, and purposeful than ever before. This 
opportunity to continue growing and contributing speaks to the deepest 
needs of veterans, and allows them to feel valued and needed on the 
home front.
    Warrior PATHH is delivered by a team of combat veteran peers, 
world-class life coaches, and therapists
    Warrior PATHH is sustained over 18 months, and ensures that 
participants build connection, confidence, and capabilities over the 
long-term. The impact of this approach is demonstrated in the program 
evaluation study.
    Warrior PATHH focuses on training not treatment, allowing veterans 
to harness the power of the military training and combat experiences 
and be Warriors and leaders in their own lives, and the lives of their 
families, communities, and country.
                the importance of community partnerships
    As was noted during the September 27th Senate Veterans' Affairs 
Committee hearing, the VA cannot and will not solve the suicide crisis 
amongst veterans on their own. Based on our experiences working 
primarily with veterans who have unsuccessfully been through treatment 
and those who will never seek it, it is clear that we must expand the 
scope of our work to include effective and proven alternative 
approaches. This is particularly true in the case of approaches that 
address the major barriers to veterans seeking and continuing 
treatment.
    As we do so, we must be disciplined, data-informed, comprehensive, 
and supported by empirical data. To that end, we have engaged in 
meaningful conversations with many elements of the mental health 
community, including the VA, and we remain committed to doing so.
    As we reflect on a potential roadmap for sustained collaboration, 
we see three critical paths.
    1) The first is to engage in robust training for mental health 
providers, as well as for non-clinicians working in mental health on 
several key subjects: military culture, Posttraumatic Growth, Adverse 
Childhood Experiences (ACES), and Common Factors (including training 
into how to connect with veteran clients). In January 2018, we are 
launching the Boulder Crest Institute to provide precisely that 
training, leveraging our experience, success, and a blended team of 
combat veterans, civilian coaches, trained mental health professionals, 
and world-class psychologists.
    2) The second is to expand the continuum of mental health 
treatments, and create a new front door for the world of mental health. 
This new front door would begin by focusing on non-clinical, non-
pharmacological approaches to begin training (not treatment) for those 
struggling, and provide veterans with an accessible alternative to the 
often foreign world of mental health that they are clearly resisting. 
This pathway would expand available care options for veterans, and 
provide primary care doctors and nurses with alternatives to a mental 
health referral. We believe that PATHH, as well as other proven, 
effective, and empirically based programs, are an excellent option in 
that regard. There are a handful of instances where both DOD and VA 
therapists have referred patients to PATHH, and the result has been 
overwhelming success. In fact, we have received emails from therapists 
in Missouri and New York asking, ``What did you do to my client?'' They 
note that either their patient no longer requires treatment, or returns 
with an open mind and a focus and commitment previously lacking.
    3) The third pathway references my previous experience in the world 
of improvised explosive devices, and the notion of prevention. In EOD 
(explosive ordnance disposal) parlance, the term is ``left of boom.'' 
We have to look at how we prevent people from getting to the point of 
suicidal thoughts and intentions, and put in place approaches that stop 
issues before they ever emerge. Doing so in this context requires us to 
look in two areas: how we train our troops, and their leaders, to 
ensure that they are well in mind, body, finance, and spirit while on 
active duty; and how we transition our servicemembers. We have had 
countless instances of a veteran who has transitioned poorly, self-
medicated in response, damaged relationships in the process, and found 
themselves in a mental health office. They are medicated, turn to 
disability payments, and become unproductive, unfulfilled, unworthy, 
and suicidal. What was a temporary issue of adjustment became a 
permanent diagnosis. We can and must do better to prepare transitioning 
servicemembers not just for a post-military job; we must prepare them 
for a post-military life. Critical elements of our program, 
particularly focused on education, could be used to that end, and a 
clear-eyed look of how transition goes wrong is critical to 
understanding how veterans end up at the brink of suicide. While we are 
part of VA efforts to explore changes in transition, in truth, this is 
far more of a Department of Defense (DOD) challenge.
                               conclusion
    As a retired Master Chief Petty Officer and service-connected 
disabled combat veteran, I know the power of military experience and 
the challenges associated with combat experiences. I also know that I 
am the man I am because of the United States Navy. More than two 
thousand years ago, the Athenian general and philosopher Thucydides 
said it best: ``We must remember that one man is much the same as 
another, and that he is best who is trained in the severest school.''
    Combat veterans represent the finest among us, and we have only to 
look at the remarkable and enduring service of Generals Kelly, 
McMaster, and Mattis to see evidence of this fact. Rather than focusing 
on suicide prevention, we should be focused on ensuring veterans can 
live great lives at home--lives filled with joy, passion, love, 
service, and purpose. We should ensure my fellow veterans can use the 
great military training they receive as a launching pad for a 
productive and purposeful life as a Warrior at home. We must ensure 
that, to paraphrase the words of a Marine General friend, their time in 
military service should not be the last great thing that they do.
    Doing so requires an integrated and collaborative approach, and we 
look forward to being a part of the solution.
                                 ______
                                 
   Prepared Statement of Kayda Keleher, Associate Director, National 
   Legislative Service, Veterans of Foreign Wars of the United States
    Chairman Isakson, Ranking Member Tester and Members of the 
Committee, On behalf of the men and women of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to provide our remarks on suicide prevention.
    Veteran suicide is a topic that plagues the veteran community. It 
is also something the VFW takes very seriously. There is no reason for 
suicide to be one of the top 10 reasons Americans die, and there is 
without doubt zero reason why the veteran population should be 
overrepresented in the death by suicide population--22 percent as of 
2010. Since 2001, the veteran rate of death by suicide has increased by 
32 percent, more than 10 percent higher than non-civilians. Yet, 
correlation is not causation. Post-9/11 veterans are at risk of 
suicide, but they are not the population that needs the most attention 
if we intend to decrease veteran suicide.
    The VFW believes that in order to address veteran suicide, the 
Senate and Department of Veterans Affairs (VA) must invest in more 
research, an increase in mental health providers at VA, better outreach 
to Pre-9/11 veterans and women, providing technical improvements to the 
Veteran Crisis Line (VCL), and expanding public-private partnerships in 
areas where VA does not have the authority or resources to provide 
veterans in need.
                                research
    In summer 2016, VA released the Nation's largest analysis of 
veteran suicide ever conducted. While this data is incredibly critical 
in addressing, and hopefully ending, veteran suicide, we need more 
analysis of the available data. From the data released in 2016, VA 
found that of the average 20 veterans who die by suicide each day, only 
six of those veterans are actively using VA. VA defines those six as 
veterans who have enrolled in or used VA within a year from the date 
they died. VA, veterans' service organizations, the Senate and the 
House need to know more about the 14 veterans not actively enrolled in 
VA. 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 
unfortunate problem. 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 during the era of ``Don't 
Ask, Don't Tell?'' If we are going to honestly combat veteran suicide, 
we must know more about the 14 veterans who die each day without using 
VA.
    As technology continues to increase, VA must continue researching 
new ways to reach those in need of mental health care. Over time, VA 
has excelled at making sure to offer user-friendly apps, 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. Studies must continue to be conducted to find reliable 
statistics regarding what platforms of technology veterans prefer for 
all era's 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 crisis 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 at schools such as Massachusetts Institute of 
Technology have found there are words used at increased frequency when 
individuals are experiencing suicidal ideations and mental health 
crisis. These words are not the ``cliche'' words taught to us in the 
military or at local high schools. This would be instrumental for 
providers and the general public to be aware of when being mindful of 
veterans and loved ones in a possible mental health crisis.
    With the number of VA opioid prescriptions decreasing and the 
increased number of providers receiving training on effective 
psychotherapies specific to Post Traumatic Stress Disorder (PTSD) 
patients, the VFW believes VA has made great strides in treating this 
population. Yet, it still has more work to do.
    Throughout the years, research on mental health issues associated 
with combat or sexual trauma, such as PTSD and Traumatic Brain Injury 
(TBI), has allowed doctors and researchers to understand and diagnose 
mental health disorders in ways never before possible. The VFW urges VA 
to continue this research to better understand biological implications 
for the diagnosis of PTSD and TBI to avoid misdiagnoses and treatment. 
The VFW also urges the Senate and VA to work together to incorporate 
new technologies and to research new and/or alternative forms of 
treatment, such as medicinal marijuana.
    For veterans who are uninterested or do not believe traditional, 
empirically proven methods will work, VA must partner with more private 
organizations and groups to offer veterans the opportunity to partake 
in alternative and non-traditional therapy options. Psychosomatics and 
the placebo effect are very alive and real. The VFW believes veterans 
should have the opportunity to partake in whatever form of safe 
treatment is available, whether VA has the ability to provide it or 
not. This includes partnering with organizations that provide 
complementary and integrated medicine which has been proven to work as 
non-pharmaceutical alternatives to opioid therapy.
                           increase providers
    The entire nation is experiencing a shortage of medical providers, 
and that is an even bigger issue for mental health care. Since the 2014 
Phoenix crisis, applications to work at VA have significantly dropped 
and VA has struggled to meet the demand of veterans in need. The Senate 
must provide VA with the appropriations and authority the secretary 
needs to increase the number of mental health care providers within VA. 
This is critically important in addressing suicide as we know that out 
of the 20 veterans who die by suicide every day, only six of them are 
actively using VA. If more providers are available, more veterans can 
seek timely treatment at VA facilities.
    Veterans who seek treatment for mental health at VA report that 
their treatment was effective, but this is not disregarding access to 
care issues VA has struggled with in the past. Veterans who choose to 
use VA for their health care must have access to treatment--
particularly veterans struggling with mental health conditions such as 
PTSD.
    VA is the largest integrated mental health care system in the 
United States with specialized treatment for PTSD. The number of 
veterans seeking treatment at VA for PTSD has continued to increase as 
more veterans from Iraq and Afghanistan leave the military and 
transition to civilian life. This is part of the cost of war. The 
Senate and VA must ensure those seeking these treatments are provided 
timely access to VA care.
    Mental health staff members within VA have increasingly continued 
to receive 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 being monitored for 
addiction and other negative consequences.
    The VFW has long advocated for the expansion of VA's peer support 
specialists program. VA peer support specialists are 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. They are actively engaged in their own recovery and 
provide support services to others in similar treatment at VA. Veterans 
who obtain assistance from peer support specialists value the 
assistance they receive.
    The VFW urges the Senate to make sure VA has the resources required 
to continue expanding this effective, low-cost form of assistance to 
veterans in need. To ensure VA is offering a holistic approach in 
effectively addressing PTSD within the veteran population, VA must have 
the ability to provide peer specialists outside of traditional 
behavioral health clinics. Veterans overcoming homelessness, veterans 
seeking employment, and veterans in mental health crisis going to the 
emergency room or urgent care center could all benefit from peer 
support services.
    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 are 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 and older veterans
    Outreach works. In August 2017, the 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.
    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 rates of suicide are males over the age of 
50, and women veterans who do not use VA.
    Since 2001, the rate of suicide among women veterans who use VA 
services increased by 4.6 percent, yet for women veterans who have not 
used VA their rate of suicide increased by 98 percent. The rate of 
female veteran suicide since 2001 has increased by nearly 100 percent 
for women who either choose not to use VA or are ineligible. To the 
VFW, that is atrocious and completely unacceptable.
    Women veterans seeking mental health treatment often times face 
unique barriers or challenges. While people of all genders struggle 
with mental health for the same reasons, mental health conditions 
linked to sexual violence, such as PTSD, affects women at a much higher 
ratio than others in the veteran population. As the population of women 
veterans continues to rise, it is of the utmost importance that VA 
continues to prioritize their often overlooked health care needs.
    The VFW urges the Senate and VA to continue expanding telemental 
health programs. These programs are often invaluable in decreasing risk 
of suicide to women veterans wanting to use group therapy for mental 
health linked to sexual violence. In VA's where there may not be enough 
women to get a group therapy session started, telemental health 
provides this opportunity. The VFW also urges VA to do two things. 
First, begin taking sex more seriously into consideration before 
prescribing psychopharmaceutical treatments. Medications have different 
effects on people of different sexes. The VFW asks VA to serve as a 
good example in prioritizing this factor. Second, VA must continue 
training mental health providers and employees on treatments and proper 
handling of patients with PTSD due to sexual trauma.
    Better outreach must also be conducted to veterans who served prior 
to 9/11. Both in the civilian population and the veteran population, 
individuals over the age of 50 are the majority of those who die by 
suicide. Currently, veterans who are 50 or older make up approximately 
65 percent of the total population of veteran suicide. For the civilian 
population, adults between the ages of 45 and 64 have the highest rates 
of death by suicide. More must be done to reach these populations. 
Post-9/11 veterans are more likely to enroll in VA, and since the 
recent conflicts VA has really excelled at providing access and doing 
outreach to this population. Now it is time to expand these outreach 
initiatives and increase access to women and middle aged men.
                          veterans crisis line
    In 2007, the Department of Veterans Affairs Health Administration 
(VHA) established a suicide hotline. The hotline, which later became 
known as the VCL, 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 begin 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 the estimated 20 veterans 
who die by suicide each day. The VCL answers more than 2.5 million 
calls, responds to more than 62,000 text messages and initiates the 
dispatch of emergency services more than 66,000 times each year. Since 
opening its doors in 2007, VCL has expanded to three locations. 
Beginning in Canadaigua, New York. VA expanded to its second location 
in Atlanta during fall 2016. This was done to assure the increased 
number of veterans calling into the VCL were having their calls 
answered in a timely manner and receiving the intervention they needed. 
A third call center recently opened in September 2017. This call center 
is located in Topeka, Kansas.
    Access to the VCL is plentiful, and the VFW believes VA has been 
successful in performing outreach to educate veterans about the crisis 
line. Still, the VFW believes there is room for improvement. If a 
veteran currently calls VA medical centers (VAMC) and some Community 
Based Outpatient Clinics (CBOC), the veteran hears the option to press 
the number seven on their phone for an automatic transfer to the VCL. 
This has proven to be successful for VA, but there are still CBOCs 
without the technology requirements to implement the ``Press Seven'' 
option. The VFW believes all VAMCs, CBOCs and Vet Centers need to have 
this option for veterans calling in.
    With that said, there are always unintended consequences. Precise 
numbers of non-veterans and veterans not in a mental health crisis 
calling VCL are unknown. Last year it was publicized that four callers 
were calling and harassing VCL employees thousands of times. Estimates 
of four percent of incoming calls were to harass VCL responders. Other 
veterans admit to calling VCL when not in mental health crisis because 
it is the first phone number they see publicly available. They have 
called in hopes of being able to schedule appointments or to complain 
about unsatisfactory care they received. Recent data reports show since 
VA's White House Hotline opened its lines in June 2017, VCL has 
experienced approximately an eight percent increase in non-crisis 
calls. Fortunately, VA's call centers have the ability to transfer 
callers to the right call line and staff are trained on how to handle 
callers not on the appropriate line for their need. Completely 
screening these calls and assuring only individuals in crisis are 
calling the VCL is not practical, and most callers are in need of some 
level of intervention. Crisis is defined individually, and everyone in 
crisis deserves support. Yet, the VFW is concerned some of the calls 
not being answered by VCL responders may be due to non-crisis callers 
clogging the system.
    The VFW believes expanding VA's Office of Patient Advocacy would 
greatly benefit the VCL. By improving and expanding the patient 
advocacy offices throughout VA, employees of these offices would have 
better visibility and means to assist non-crisis patients. If veterans 
become more aware of the patient advocate mission and capabilities, 
non-crisis callers to the VCL would decrease. The VFW has been working 
to expand and improve patient advocacy within VA and we will continue 
to monitor progress. The VFW urges this Committee to conduct extensive 
oversight of the VA Patient Advocate Program to ensure veterans are 
able to have their non-emergent concerns addressed without having to 
call the VCL.
    Employees at VCL undergo extensive training before being allowed to 
answer calls, and it takes at least six months before they may begin 
training to also answer chat and text conversations with veterans in 
crisis. Yet, it was not until late December 2016 that the VCL had the 
capability to record and monitor their calls. Without this crucial 
technological capability, there was no way for calls to be truly 
monitored for quality control. Now that this capability is available, 
the technology must be properly utilized. Staff at VHA and the VCL 
monitor some ongoing calls for quality assurance, but a better, 
constant process must be implemented to ensure these recordings are 
being used to improve the training and capabilities of VCL responders. 
This would not only improve crisis intervention, but would assist with 
ending allegations of responders not understanding or following 
protocol, instructions, and resources.
    The VFW firmly believes the VCL has improved and will continue to 
improve. Though that improvement will continue to be slow, frustrating 
and life-endangering if the VCL does not begin collaborating with 
others. Aside from working with patient advocacy offices to cut down on 
non-crisis calls and VHA Member Services to readjust the advisory board 
and increase clinicians, the VCL must also work more closely with the 
Office of Suicide Prevention (OSP).
    Member Services has undoubtedly assisted the VCL in quantity 
control, but OSP can also assist the VCL in quality control. If the 
goal of the VCL is to intervene for veterans in need of immediate 
assistance while they are in the middle of a mental health crisis, the 
VCL should be working with the subject matter experts and leaders in 
suicide prevention and outreach for VA. If all three offices could 
collaborate together, with better guidelines, Member Services would be 
able to continue improving the VCL call center expertise and business, 
while OSP could make sure the VCL is up-to-date with the most current 
clinical expertise on suicide prevention and outreach.
                      public/private partnerships
    Since the enactment of Public Law 114-2, Clay Hunt SAV Act, VA has 
entered into new relationships with many private sector organizations 
to address PTSD within the veteran population as well as to combat 
veteran suicide. Some of these organizations include Bristol-Myers 
Squibb Foundation. This foundation has awarded over $15 million in 
grants to veterans service organizations and academic teaching hospital 
partners working to develop and improve innovative models of community-
based care and support to improve the mental health and community 
reintegration of veterans. The VFW is also among the many organizations 
who have signed on to partner with VA.
    This past year, the VFW launched a Mental Wellness Campaign to 
change the narrative in which America discusses mental health. We 
teamed with Give an Hour providers, One Mind researchers, the peer-to-
peer group PatientsLikeMe, the family caregiver-focused Elizabeth Dole 
Foundation, the Nation's largest pharmacy Walgreens, and the Department 
of Veterans Affairs to promote mental health awareness, to dispel 
misconceptions about seeking help, and to connect more veterans with 
lifesaving resources. The goal of the VFW campaign is to destigmatize 
mental health, teach our local communities how to identify mental 
distress and what local resources are available to those struggling to 
cope with mental health conditions. To do this, VFW Posts and VA 
employees from Richmond, Virginia to Lakeside, California, and 
everywhere in-between, have held mental wellness workshops to spread 
awareness of VA's mental health care services, as well as how to 
properly identify a fellow veteran in distress. The VFW and VA talked 
with local veterans about the Campaign to Change Direction and their 
five signs of mental distress--personality change, agitated, 
withdrawal, poor self-care and hopelessness.
    We know this campaign has saved lives. Our members have told us so. 
Veterans have told us of how they were suicidal--gun in hand--but they 
put the gun down when they saw the pamphlet from the Campaign to Change 
Direction. Those veterans are still alive after they called the 
Veterans Crisis Line and received help. That is the power of the 
public-private partnerships VA is continuing to develop.
    Education is empowering. The more VA partners with private sector 
organizations and conducts outreach to educate people on signs of 
mental health crisis, ways to intervene and that the majority of 
Americans struggle at some point in their life with mental health, the 
more empowered people will be. By empowering veterans and their fellow 
Americans we help destigmatize mental health, and by doing that we 
allow for more open and honest conversations to comfortably take place. 
The VFW sincerely believes by talking and taking care of one another we 
can help lower the rate of veteran suicide. But nobody, not the VFW, 
not VA, not the House or Senate can totally eradicate veteran suicide 
without everyone working together to holistically address the problem 
at hand.
                                 ______
                                 
         Letter from Paul Lloyd, State Adjutant, Department of 
                New Hampshire, Veterans of Foreign Wars
             New Hampshire's ``Ask the Question'' Campaign
             Preventing Suicides by Engaging the Community
    Lt. Col. Stephanie Riley of the New Hampshire Air National Guard 
worked in an emergency room of a New Hampshire hospital in 2013. She 
often witnessed individuals presenting with symptoms of headaches, 
dizziness or hearing loss. These patients were diagnosed with a 
migraine, when they were actually veterans suffering with a Traumatic 
Brain Injury. They were not diagnosed accurately because they were 
never identified as a veteran during intake.
    Later that same year, a veteran met with Lt. Col. Riley at the 
National Guard Medical Command Unit. This veteran had been to three 
different healthcare facilities in New Hampshire and not one of them 
asked if he had ever served in the military. By the time this veteran 
reached out to Lt. Col. Riley, it was too little, too late. And this 
veteran died by suicide.
    Across our Country, over two-thirds of our veterans receive care in 
the community--and not from the Veterans Administration. As the VA 
continues to struggle with bureaucracy and service challenges, the 
number of veterans seeking care outside the VA continues to rise.
    Our communities need to respond to this crisis.
    20 veterans die by suicide each day. 6 of these veterans receive 
care at the VA; and 14 do not. While we know that the majority of our 
veterans receive care in the community, we also know that veterans 
don't feel completely understood by civilian, VA or military health 
care professionals. The New Hampshire Legislative Committee on PTSD and 
TBI conducted a survey of New Hampshire veterans asking about barriers 
in accessing care. The New Hampshire Veterans of Foreign Wars was 
honored to fund and support this survey. Survey results indicated that 
the top barrier identified was stigma, embarrassment and shame. The 2nd 
highest barrier in accessing care was a consistent comment from New 
Hampshire veterans stating, ``I do not feel understood by the providers 
who serve me.''
    New Hampshire is working hard to keep our veterans safe and 
connected with the ``Ask the Question'' Campaign. The ``Ask the 
Question'' Campaign encourages all service providers to ask the 
question, ``Have you or a family member ever served in the military?'' 
This simple question can open the door to greater communication. And 
communication and understanding is at the heart of good care and 
services.
    New Hampshire's Community Mental Health Center (CMHC) Military 
Liaison Initiative is a powerful example of how one healthcare system 
in New Hampshire has ``operationalized'' the ``Ask the Question'' 
Campaign--as part of their successful efforts to support our military. 
Through ``Ask the Question,'' we now know that 15% of clients served at 
the 10 New Hampshire Mental Health Centers are military connected. This 
new data is helping to create ``intentional'' strategies to serve our 
military by generating military culture trainings, developing internal 
military staff meetings, coordinating client referrals with the VA and 
providing greater supports for military families. The Mental Health 
Centers also created an internal Military Liaison in each of the 10 
Centers to help move this initiative forward.
    HOW we ask the question is critical to engaging our military. Not 
all veterans identify as a veteran, so it is important to ask, ``Have 
you or a family member ever served in the military?'' By asking the 
question, we are also acknowledging that military service is important. 
Many of us know a Vietnam Veteran or Korean War Veteran who may have 
served in the military for only a few years, yet his or her service 
defines who they are and how they lived and many continue to serve 
their Communities by being members of the Veterans of Foreign Wars or 
other Veteran Service Organizations.
    New Hampshire has learned that in order to best serve our military, 
we need to first identify them. And we need to identify them within our 
hospitals, mental health centers, senior centers, employment offices, 
law enforcement, courts and schools.
    Veterans are often hesitant to ask for help because of pride, shame 
or stigma. Many veterans don't ask for help because they want to save 
that help for their brother or sister who served. The ``Ask the 
Question'' Campaign puts the responsibility on the service provider--
removing possible barriers from the veteran, servicemember or their 
families.
    The ``Ask the Question'' Campaign truly opens the door to how we 
define a veteran, and creates opportunities to better understand our 
military community--through communication, resources and connections.
    Lt. Col. Stephanie Riley of the New Hampshire Air National Guard 
Riley died of cancer in December 2014. But she continues to serve her 
Country through the ``Ask the Question'' Campaign.
    The ``Ask the Question'' Campaign was recently approved to be 
included in the National Suicide Prevention Plan.
    Thank you, Lt. Col. Riley, for your service to our State and your 
service to our Country.
            Respectfully,
                                        Paul Lloyd,
                                            State Adjutant,
                                       Department of New Hampshire,
                                          Veterans of Foreign Wars.
                                 ______
                                 
  Prepared Statement of Kenny Smoker Jr., Director, Fort Peck Tribes 
  Health Promotion/Disease Prevention, Fort Peck Indian Reservation, 
                            Poplar, Montana
    My name is Kenny Smoker, Jr., the Director of the Fort Peck Tribes' 
HPDP program located on the Fort Peck Indian Reservation in Poplar, 
Montana. I have been a long time employee in health care systems on the 
Fort Peck Reservation and have collaborated with several tribes across 
Montana to improve health care for all people on reservations.
    Montana has been at or near the top in the Nation for the rate of 
suicide for nearly four decades. From January 1, 2014 to March 1, 2016 
there were 556 suicides in Montana. The number of veterans that died by 
suicide during this time was 42, of which 8 were American Indians. 
Nationally 18% of suicides are veterans. In Montana, 22% of suicides 
are veterans. In Montana, 19% of suicides are American Indian Veterans.
    Some of the challenges Montana tribal veterans face as it relates 
to mental health are:

     Access to health care and mental health services
     Addressing on-going Substance Abuse issues--56% of 
American Indian suicide completions had alcohol in their system
     Lack of individual drive to seek care due to depression

    The VA can do to better with local communities and providers to 
enhance access to these critical services by implementing a few key 
strategies:

     Supporting Tribal Veteran Centers:
          - Support an Army of VISTA's to assist communities in 
        building capacity for local Tribal Veteran's Representatives 
        alongside community professional and natural support in order 
        to provide outreach and assistance for veterans to access 
        needed services such as face to face mental health provider 
        encounters, transportation, and developing camaraderie groups 
        to safely engage other veterans in shared experiences
          - Increase access to tele-psychiatry and other health 
        services
          - Support wraparound services to empower individuals to seek 
        care, utilizing the Social Determinates of Health concept
          - Increase peer to peer supports to build capacity for 
        seeking and accessing care by veterans
     Increase support for Tribal Veteran's Representatives
     Increase communication and collaboration between Tribal, 
State and Federal programs to engage all veterans in rural and tribal 
areas from within their own cultural context in order to serve them 
better- a culturally matched transition from soldier to veteran
     Give Veterans a ``Sense of Purpose''
     Assessing the right fit for employment opportunities
Resources:
    Montana Strategic Suicide Prevention Plan--
http://dphhs.mt.gov/suicideprevention
                                 ______
                                 
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