    [House Hearing, 116 Congress]
    [From the U.S. Government Publishing Office]

    .
                             [H.A.S.C. No. 116-42]

                         MILITARY AND VETERAN SUICIDE:

                         UNDERSTANDING THE PROBLEM AND

                            PREPARING FOR THE FUTURE

                                   __________

                                 JOINT HEARING

                                   BEFORE THE

                       SUBCOMMITTEE ON MILITARY PERSONNEL

                                     OF THE

                          COMMITTEE ON ARMED SERVICES

                            MEETING JOINTLY WITH THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  HEARING HELD

                                  MAY 21, 2019

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                                   __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    37-528                 WASHINGTON : 2021

    -----------------------------------------------------------------------------------

                          COMMITTEE ON ARMED SERVICES
                       SUBCOMMITTEE ON MILITARY PERSONNEL

                     JACKIE SPEIER, California, Chairwoman

    SUSAN A. DAVIS, California           TRENT KELLY, Mississippi
    RUBEN GALLEGO, Arizona               RALPH LEE ABRAHAM, Louisiana
    GILBERT RAY CISNEROS, Jr.,           LIZ CHENEY, Wyoming
        California, Vice Chair           PAUL MITCHELL, Michigan
    VERONICA ESCOBAR, Texas              JACK BERGMAN, Michigan
    DEBRA A. HAALAND, New Mexico         MATT GAETZ, Florida
    LORI TRAHAN, Massachusetts
    ELAINE G. LURIA, Virginia
                     Glen Diehl, Professional Staff Member
                              Dan Sennott, Counsel
                             Danielle Steitz, Clerk
                                     ------

                         COMMITTEE ON VETERANS' AFFAIRS
                             SUBCOMMITTEE ON HEALTH

                     JULIA BROWNLEY, California, Chairwoman

    CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking
    MIKE LEVIN, California                   Member
    ANTHONY BRINDISI, New York           AMATA COLEMAN RADEWAGEN, American
    MAX ROSE, New York                       Samoa
    GIL CISNEROS, California             ANDY BARR, Kentucky
    COLIN PETERSON, Minnesota            DAN MEUSER, Pennsylvania
                                         GREG STEUBE, Florida
         Raymond Kelley, Staff Director, Committee on Veterans' Affairs
       Elizabeth Austin-Mackenzie, Staff Director, Subcommittee on Health
                          Rasheedah Hasan, Chief Clerk

                                C O N T E N T S

                                  ----------
                                                                       Page

                  STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

    Brownley, Hon. Julia, a Representative from California,
      Chairwoman, Subcommittee on Health, Committee on Veterans'
      Affairs........................................................     3
    Dunn, Hon. Neal P., a Representative from Florida, Ranking
      Member, Subcommittee on Health, Committee on Veterans' Affairs.     5
    Kelly, Hon. Trent, a Representative from Mississippi, Ranking
      Member, Subcommittee on Military Personnel, Committee on Armed
      Services.......................................................     2
    Speier, Hon. Jackie, a Representative from California,
      Chairwoman, Subcommittee on Military Personnel, Committee on
      Armed Services.................................................     1

                                   WITNESSES

    Franklin, Dr. Keita, LCSW, PhD, National Director of Suicide
      Prevention, Department of Veterans Affairs; and Michael Fisher,
      Chief Officer, Readjustment Counseling Service.................     7
    Van Winkle, Dr. Elizabeth P., PhD, Executive Director, Office of
      Force Resiliency, Department of Defense; and CAPT Mike Colston,
      USN, Director, Mental Health Programs, Office of the Assistant
      Secretary of Defense for Health Affairs........................     5

                                    APPENDIX

    Prepared Statements:

        Franklin, Dr. Keita..........................................    54
        Speier, Hon. Jackie..........................................    39
        Van Winkle, Dr. Elizabeth P., joint with CAPT Mike Colston...    41

    Documents Submitted for the Record:

        Article by Representative Seth Moulton.......................    67

    Witness Responses to Questions Asked During the Hearing:

        Mr. Cisneros.................................................    71

    Questions Submitted by Members Post Hearing:

        Mr. Cisneros.................................................    75
        Ms. Escobar..................................................    76

     MILITARY AND VETERAN SUICIDE: UNDERSTANDING THE PROBLEM AND PREPARING
                                 FOR THE FUTURE

                                  ----------

            House of Representatives, Committee on Armed
                Services, Subcommittee on Military Personnel,
                Meeting Jointly with the Committee on Veterans'
                Affairs, Subcommittee on Health, Washington,
                DC, Tuesday, May 21, 2019.

        The subcommittees met, pursuant to call, at 3:22 p.m., in
    room 2118, Rayburn House Office Building, Hon. Jackie Speier
    (chairwoman of the Subcommittee on Military Personnel)
    presiding.

    OPENING STATEMENT OF HON. JACKIE SPEIER, A REPRESENTATIVE FROM
      CALIFORNIA, CHAIRWOMAN, SUBCOMMITTEE ON MILITARY PERSONNEL,
                      COMMITTEE ON ARMED SERVICES

        Ms. Speier. Thank you, ladies and gentlemen.
        The joint hearing of the Military Personnel Subcommittee
    and the Veterans' Affairs Health Committee will come to order.
    I am Jackie Speier, and we will now have a discussion on a very
    serious issue.
        I would like to thank Chairwoman Brownley for partnering
    with us on this incredibly tough issue.
        The statistics are staggering. There were 321 Active Duty
    suicides and 144 Reserve Component suicides in 2018. This is
    the highest number of suicides since 2012. An estimated 20
    service members and veterans combined committed suicide a day.
    It is an epidemic, but it is more than an epidemic and it is
    more than numbers. These are people's lives and the lives of
    their families that are impacted by it. And we have got to come
    up with a means by which we can address this in a holistic
    fashion.
        They are not numbers, but these are service members who
    were willing to die for our country, but took their own lives
    instead, service members we failed. Behind each of them is a
    person and their family, friends, and comrades in arms.
        Two weeks ago, I met with Patrick and Teri Caserta. Their
    son Brandon was an Active Duty sailor in the Navy. He had high
    aspirations for a Navy career, but something changed and
    tragically he took his life. His parents knew something was
    wrong, tried to intervene and were turned away by the Navy. The
    request, so that other parents will not have to endure their
    grief and pain, was that Congress ensure that service members
    and veterans receive the help they need without fear of
    retribution. We must do everything we can to break the chain of
    suicide that has afflicted our military and veteran community.
    This problem could not be more urgent.
        The reason we are here meeting jointly, the subcommittees
    responsible for tackling suicide in the DOD [Department of
    Defense] and VA [Veterans Affairs], is because we need to treat
    service member and veteran suicide as one issue. Veterans are
    about twice as likely as civilians to commit suicide. Military
    service appears to be a causal pathway for increased suicide
    risk, due to the access to and familiarity with firearms, post-
    traumatic stress syndrome, depression, loss of community,
    alienation, head injuries, and substance dependence.
        These factors take root, manifest, and worsen across an
    individual's DOD/VA experience. We need to react to this
    reality by preventing, detecting, and treating suicide risk
    from the moment an individual signs up to well after they leave
    the service.
        Today we will hear from a panel of experts from the
    Department of Defense and the Department of Veterans Affairs to
    help us understand the scope and magnitude of the suicide
    challenge affecting our military and veterans' communities. We
    will also learn about suicide prevention efforts within the
    Department of Defense and Department of Veterans Affairs and
    try to better understand ongoing collaborations and potential
    future partnerships related to suicide prevention efforts
    between the Department of Defense and the Department of
    Veterans Affairs to try and end the epidemic.
        Before I welcome the panel, I would like to ask if Ranking
    Member Kelly would like to say some introductory remarks.
        [The prepared statement of Ms. Speier can be found in the
    Appendix on page 39.]

         STATEMENT OF HON. TRENT KELLY, A REPRESENTATIVE FROM
         MISSISSIPPI, RANKING MEMBER, SUBCOMMITTEE ON MILITARY
                 PERSONNEL, COMMITTEE ON ARMED SERVICES

        Mr. Kelly. Thank you, Madam Chairwoman.
        You know, I would first like to say I have had the
    opportunity to command at the battalion level in combat. And I
    was in Iraq in 2005 as an operations officer, and we lost 29
    soldiers in our formation, our brigade formation.
        Coming back in 2006, we buried way too many in that year
    following who had survived the traumas of war and who came back
    and who are no longer with us. And so unless you have
    experienced that firsthand, it is difficult to understand the
    impact on a family and on the soldiers, and on the hearts and
    minds of the community, knowing that they so bravely served
    this great Nation and then came home and something went awry,
    and we have to fix it. It is that important. I understand why
    we lose soldiers in combat. I cannot understand why we lose
    them when we get home.
        I wish to welcome our witnesses to today's hearing and want
    to thank them for being here. The fact that we are holding a
    joint hearing with both the Department of Defense and
    Department of Veterans Affairs testifying together underscores
    the importance of suicide prevention and the need for a unified
    solution to the problem.
        We are at a crisis point. Last year's suicide rate among
    Active Duty forces was the highest it has been since 2012 and
    ties for the highest on record since the services began
    tracking it. Meanwhile, approximately 20 veterans commit
    suicide each day. This is unacceptable and we all have a
    responsibility to fix this issue.
        I am concerned that the high rate of suicide among service
    members and veterans will soon become a fact of life and that
    we are beginning to accept it as a natural consequence of
    military service. We cannot let that happen. We must take
    decisive action to disrupt the status quo and reverse this
    epidemic.
        When a service member takes his or her own life, it is a
    tragedy for both the surviving family and the unit. While
    suicide has an often irreparable effect on the service member's
    family, it can also cause lasting effects on the unit. In
    addition to the emotional impact on fellow service members, we
    know that one suicide in a unit can sometimes lead to
    additional suicides or the contagion effect. That is why
    suicide must continue to be treated as not just a personal
    mental health issue, but as a readiness issue.
        I am interested to hear from today's witnesses about the
    behavioral health treatment available for service members and
    veterans. Particularly, I am concerned that there continues to
    be a stigma associated with seeking behavioral health
    treatment. In fact, as the VA notes in their written statement,
    over half of those who die by suicide had no mental health
    diagnosis at the time of their deaths.
        I am interested to hear how the services mandate periodic
    behavioral health checkups for all service members and whether
    those interventions are effective. Just like required yearly
    physicals and dental checkups are not an option should a
    substantive session with a behavioral health provider, not just
    an assessment by a medical provider, be required.
        I am also convinced that small unit leaders' involvement is
    critical to identifying behavioral health issues. The services
    must leverage the NCO [noncommissioned officer] leaders closest
    to the service members at the team and squad level to help
    identify self-destructive behaviors and get help for service
    members. I would like to know what training is provided to
    these leaders to help them in identifying problems and getting
    assistance.
        I hope that today's hearing will bring renewed attention to
    the problem of military suicide. While I am interested in the
    actions that the Defense Department and VA have done to prevent
    suicide, I am also focused on the practical things we can do
    today to reverse this disturbing trend.
        Thank you, Madam Chairwoman, and I yield back.
        Ms. Speier. Thank you, Ranking Member Kelly.
        Now we are going to hear from Chairwoman Brownley.

        STATEMENT OF HON. JULIA BROWNLEY, A REPRESENTATIVE FROM
     CALIFORNIA, CHAIRWOMAN, SUBCOMMITTEE ON HEALTH, COMMITTEE ON
                           VETERANS' AFFAIRS

        Ms. Brownley. Thank you, Chairwoman Speier, and thank you
    for hosting us today. Your dedication to the prevention of
    suicide among not only veterans but also our service members is
    evidenced by your willingness to host this joint hearing among
    our subcommittees.
        As a member of the Committee on Veterans' Affairs, our
    jurisdiction is limited to the Department of Veterans Affairs.
    While we may inquire as to the activities of the Department of
    Defense, I cannot remember the last time we had the opportunity
    to receive testimony from the agency, so I thank the DOD for
    being here today.
        Despite this, the actions of the Department of Defense
    significantly impact the lives of our veterans, from the status
    of the service member's discharge to the location of a service
    member's service to the responsibilities of a service member
    while on duty. All of these decisions have been shown to impact
    the likelihood that a veteran will experience suicidality.
        According to VA, of the 20 veterans per day that die by
    suicide, nearly 4 are either Active Duty service members or
    members of a Guard that have never been activated, thus
    ineligible for VA healthcare. Yet, VA is committed to reducing
    this staggering statistic through a public health approach. By
    identifying which individuals are most in need and targeting
    effective preventive interventions to those individuals by
    creating a system of health throughout the population as a
    whole, VA is ensuring our most vulnerable and high-risk
    veterans and service members are surrounded by the resources
    they need most. The quicker VA is able to identify those in
    need and connect them to resources, the more effective suicide
    prevention efforts will become.
        If the Department of Defense is willing to create a fluid
    movement of data between the two agencies, then the efforts of
    VA would only be magnified. VA would be able to identify high-
    risk service members before their transition is complete, and
    DOD would be better able to assist in ensuring vulnerable
    service members are aware of and have access to VA and
    community-provided resources that might reduce the turmoil
    caused by the service member's service and assist the veterans
    in his or her family as the veteran transitions home.
        For instance, VA offers a variety of counseling services to
    Active Duty service members, members of the Guard, veterans and
    their families at Vet Centers throughout its Readjustment
    Counseling Service. However, service members only make up about
    5 percent of the population that Vet Centers serve.
        Also, in 2017, Congress expanded eligibility for mental
    healthcare to certain veterans with other than honorable
    discharge statuses. However, 2 years later, we are seeing in
    the media that veterans have not been adequately notified of
    this benefit. While VA was ultimately tasked with sending
    letters to veterans that may be eligible under the expansion,
    there is no reason the Department of Defense could not assist
    in ensuring that these former service members are connected
    with the care they qualify for.
        Again, I am thankful for today's opportunity to engage in
    this much-needed dialogue and hope it is the beginning of a
    productive relationship between our two committees and our two
    agencies.
        And I yield back, Madam Chair.
        Ms. Speier. Thank you. Thank you, Chair.
        Now we will hear from Ranking Member Dunn.

    STATEMENT OF HON. NEAL P. DUNN, A REPRESENTATIVE FROM FLORIDA,
    RANKING MEMBER, SUBCOMMITTEE ON HEALTH, COMMITTEE ON VETERANS'
                                AFFAIRS

        Dr. Dunn. Thank you, Chairwoman Brownley, Chairwoman
    Speier. I am grateful to be here this afternoon with my
    colleagues from the Committee on Veterans' Affairs and the
    Committee on Armed Services to discuss the tragedy of suicide
    among service members and veterans.
        Joint hearings like this are not standard for Congress, but
    the fact that we are holding one here today is testament to our
    dedication to address this crisis.
        Congress has passed legislation and provided funding to
    stem the tide of suicide in military veterans' communities, but
    stubbornly, tragically, these rates have refused to budge. I am
    hopeful that by bringing subject matter experts from both
    departments here together and holding conversation that crosses
    our jurisdictional boundaries of both committees, we will be
    able to shed some new light on this complex topic and start
    saving lives among those who served and are still serving.
        And I thank you, our witnesses, for joining us, and our
    audience for joining us. And, Madam Chair, I yield back.
        Ms. Speier. Thank you, Ranking Member Dunn.
        I ask unanimous consent to allow members not on the
    subcommittee to participate in today's hearing and be allowed
    to ask questions after all subcommittee members have been
    recognized.
        Without objection. All right.
        Now we welcome our panel. Thank you all for joining us. Dr.
    Elizabeth Van Winkle is no stranger to this committee. Thank
    you for joining us. She is the Executive Director of the Office
    of Force Resiliency in the Department of Defense.
        Sitting next to her is Captain Mike Colston, M.D., United
    States Navy, Director of Mental Health Policy and Oversight at
    the Department.
        Next is Dr. Keita Franklin, National Director of Suicide
    Prevention at the Department of Veterans Affairs.
        And finally, Mr. Michael Fisher, Chief Readjustment
    Counseling Officer, Department of Veterans Affairs.
        Welcome to all of you, and I think we will start with Dr.
    Van Winkle.

       STATEMENT OF DR. ELIZABETH P. VAN WINKLE, PHD, EXECUTIVE
     DIRECTOR, OFFICE OF FORCE RESILIENCY, DEPARTMENT OF DEFENSE;
     AND CAPT MIKE COLSTON, USN, DIRECTOR, MENTAL HEALTH PROGRAMS,
    OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS

        Dr. Van Winkle. Thank you. Madam Chairs Speier and
    Brownley, Ranking Members Kelly and Dunn, and distinguished
    members of the subcommittees, thank you for the opportunity to
    appear before you today with our colleagues from the Department
    of Veterans Affairs to discuss the Department of Defense's
    suicide prevention efforts.
        As many of you are aware, I serve as the Executive Director
    of the Office of Force Resiliency, a portfolio that oversees
    several priority efforts, including the Defense Suicide
    Prevention Office, which we commonly refer to as DSPO. As many
    of you also know, the Department recently announced a new
    Director of DSPO, Dr. Karin Orvis. Unfortunately, Dr. Orvis was
    unable to attend today's hearing, but would be happy to meet
    with you or your staff moving forward.
        Today I can discuss the Department's efforts on suicide
    prevention from my role at Force Resiliency, where I oversee
    the Department's policies on the prevention of suicide, sexual
    assault, harassment, hazing, bullying, and drug use. I also
    oversee the DOD/VA Collaboration Office. In this position, I
    recognize the intersection of many of these difficult and
    challenging issues and work to align prevention efforts within
    this continuum.
        Although each of us at the witness table represents
    different efforts within both the DOD and VA, we are all
    committed to the same critical mission of suicide prevention.
    Both departments work in strong partnership.
        With me today is my colleague, Captain Mike Colston, the
    Director of the Mental Health Programs for Health Affairs.
    Captain Colston and I can discuss what we are currently doing
    within the Department to prevent suicide in our ranks.
        We at the Department of Defense have vowed time and time
    again to ensure that we do everything possible to support our
    service members, and all of us work tirelessly to do just that.
    Yet, our rates of suicide are devastating and unacceptable, and
    they are not going in the desired direction.
        Although our data helps drive and improve our efforts in
    this space, my colleagues and I know that every single life
    lost is a tragedy, and each one has a deeply personal story.
    With each death, we know there are families and often children
    with shattered lives. We cannot rest until we have pursued
    every opportunity to prevent this tragedy among our Nation's
    bravest.
        We know this is a shared challenge. Nationwide, suicide
    rates are alarming and increasing. None of us has solved this
    issue and no single case of suicide is identical to any other
    case. The scientific research surrounding prevention of
    suicides is both complex and ever-evolving. Suicide is the
    culmination of complex interactions between biological, social,
    and psychological factors operating at individual, community,
    and societal levels. Our data also tells us it is often a
    sudden and impulsive act.
        To address this complexity, we leverage scientific,
    evidence-informed practices to constantly pull every idea,
    every possible effective initiative into our toolkit to help
    service members and their families. We seek ideas and new
    solutions from everywhere, whether that is within the
    Department or from stakeholders, such as researchers outside of
    the government or within Centers for Disease Control and
    Prevention, and also from Congress. Indeed, your inputs and
    your engagement have been critical to our efforts.
        Because data informs our ability to take meaningful steps
    and fulfill our commitment to transparency with you and the
    American public, the Department will soon expand our reporting
    on suicide-related data. This summer, we will publish our first
    annual suicide report, which will supplement our longstanding
    DOD suicide event report. We address this in our written
    testimony, and I am happy to discuss any questions you may have
    about our reporting and how we use data to inform our research
    and initiatives in the area of suicide prevention.
        We are grateful for the opportunity to speak with you
    today. Suicide prevention is among the most complex challenges
    we face and one of the most devastating to bear. The root
    causes vary from one individual to another, and the signs are
    often difficult to detect for friends, family members, and even
    for clinicians, who work so closely with many of these
    individuals. More than likely, each of us in this room has been
    impacted by suicide, friends, family, loved ones lost to this
    decision that will forever impact our lives, leaving us with
    far more questions than answers and a weight on our shoulder
    that often never recedes.
        Within the military community, this loss reverberates
    beyond the unit, beyond the commander, and beyond the service.
    It is a loss for our country and one we cannot afford and we
    should not accept. Many of you have heard me say this before,
    but we truly must show as much commitment and dedication to the
    well-being of our service members as they have demonstrated on
    the day they stepped forward to volunteer and serve our
    country.
        We must meet that sacred obligation because we need each
    and every woman and man who bravely signs up to fight for this
    Nation. Those who choose to serve are an inspiration to us all.
    They are the front lines. We depend on them and we need them.
    We must fight for their safety at least as hard as they fight
    for ours.
        In closing, we thank you, Chairwomen, Ranking Members, and
    the members of your subcommittees, for your steadfast
    dedication and support of the women, men, and families who
    defend our great Nation. I look forward to the discussion
    today.
        [The joint prepared statement of Dr. Van Winkle and Captain
    Colson can be found in the Appendix on page 41.]
        Ms. Speier. Thank you, Dr. Van Winkle.
        Dr. Colston, do you have a--do not, okay. Let's move then
    to--is it Keita, did I pronounce it?
        Dr. Franklin. Yes.
        Ms. Speier. Dr. Keita Franklin.

     STATEMENT OF DR. KEITA FRANKLIN, LCSW, PHD, NATIONAL DIRECTOR
      OF SUICIDE PREVENTION, DEPARTMENT OF VETERANS AFFAIRS; AND
     MICHAEL FISHER, CHIEF OFFICER, READJUSTMENT COUNSELING SERVICE

        Dr. Franklin. Good afternoon, Chairwoman Speier, Chairwoman
    Brownley, and members of the subcommittees. I appreciate the
    opportunity to discuss the critical work that the VA is
    undertaking to prevent suicide among our Nation's veterans. I
    am accompanied today by Mr. Michael Fisher, Chief Officer,
    Readjustment Counseling Service, who leads our Vet Center work.
        I have been in this permanent position since April of last
    year, but like many in the room today, the military has always
    been a significant aspect of my life. My father is a 20-year
    Navy veteran and my husband is an Air Force veteran.
        Prior to joining the VA, I served as a Director of the
    Defense Suicide Prevention Office, and my career has focused on
    deployment and trauma and how that impacts families and marital
    relationships.
        I am a social worker by training, and I focused on child
    welfare and have led various programs around domestic violence,
    sexual assault, substance abuse, and combat operational stress
    before narrowing in on suicide prevention.
        So this mission at the VA is both critical and personal to
    me, and I understand the urgency of it. At my level, I respond
    to texts, emails, and phone calls from service members,
    veterans, and their family members who are seeking support.
        Just 2 weeks ago, I spent 2 days with one of our partners,
    the Independence Fund, and approximately 80 veterans who
    deployed together. And they faced an incredible amount of
    trauma in that deployment, the 3rd to the 67th Armored
    Regiment, the 4th Infantry Division, and led critical work to
    build resilience in that group. It was great to hear from those
    veterans how access to care and support from peers impacted
    their journey through recovery. And it is these stories that
    keep me focused on the work at hand.
        I am pleased to talk about VA's continued partnership with
    the Department of Defense. Our collaboration with DOD personnel
    and readiness leadership is critical to our success as we
    continue to examine how best to address suicide prevention
    across our entire military and veteran community.
        We are jointly committed to reaching those who have worn
    the uniform where they live, work, and thrive. Already, we have
    worked diligently on a number of important collaborations to
    reach people at risk of falling through the cracks, bolstering
    support for service members as they transition out of service
    and facilitating their access to care, and yet we realize there
    is so much work left to do.
        We look forward to this continued partnership. Suicide is a
    serious public health tragedy. It affects communities across
    the Nation. In the United States alone, we know that there are
    123 people that die each day by suicide. And globally, 800,000
    people die by suicide. That is one person every 40 seconds. And
    we know inside the VA that an average of 20 people who have
    worn the uniform die by suicide. This is a figure that has
    remained relatively stable over the last few years, but that
    has not stopped us from learning everything we can about the
    data.
        Of those 20 tragic deaths, we know only 6 have accessed VA
    healthcare in the 2 years leading up to the death by suicide.
    The majority, 14, have not. And when you look at this data even
    closer, and Chairwoman Brownley already mentioned it, two to
    three of those individuals that have died by suicide are former
    National Guard and Reserve members never federally activated.
    And if you account for the one that is on Active Duty status,
    you come to the four that the chairwoman mentioned.
        This issue cannot be solved through mental healthcare
    alone. In fact, national data shows that more than half of
    Americans who died by suicide in 2016 had no known mental
    health issue at the time of their death. And this is also true
    for our veterans. A massive expansion of mental health
    providers and a world-class mental health access has done
    little to reduce the total number of suicides among veterans.
        Maintaining the integrity of VA's mental healthcare system
    is vitally important, but it is not enough. The VA cannot end
    veteran suicide alone. This understanding is why we have
    expanded our efforts into the public health approach. Our
    national strategy for preventing veteran suicide is a multi-
    year effort that provides the framework for identifying
    priorities, organizing our efforts, and focusing community-
    level resources to prevent suicide. It is intended to move us
    from a focus on crisis intervention to a set of bundled
    strategies across multiple sectors.
        Our Readjustment Counseling Service is a critical element
    in our strategy to provide a wide range of confidential social
    and psychological services to eligible veterans, Active Duty
    service members, and members of the Guard and Reserve, and
    their families. These services are designed to increase
    barriers to care, such as providing services after
    nontraditional hours away from brick-and-mortar facilities. The
    Vet Centers aggressively focus on preventing suicide through
    partnerships, including with the National Guard and the
    Reserve.
        And the Vet Centers have consistently increased services to
    veterans, service members, and families. In 2018 alone, we saw
    that increase by 4 percent with an 18 bump among service
    members. An 8 percent, I am sorry, not 18, 8 percent bump among
    service members.
        We are also working with Federal partners, States, local
    governments to reach veterans in communities nationwide. In
    March 2018, we collaborated with the Department of Health and
    Human Services to launch our Mayor's Challenge. And in October
    of 2018 we took those efforts to the State level and we
    launched a Governor's Challenge. This initiative allows VA to
    work with 7 Governors, 24 local governments, chosen based on
    veteran population and veteran suicide prevalence rates, with a
    focus on all veterans, not just those that come into our VHA
    [Veterans Health Administration] healthcare system.
        We have also recently implemented two Executive orders.
    Under the first one signed in January of 2018, we are
    partnering with the Department of Defense and the Department of
    Homeland Security around transitioning service members, trying
    to get after that first 12 months that we know is critical. We
    also executed a second one called PREVENTS [President's Roadmap
    to Empower Veterans and End a National Tragedy of Suicide]
    signed in March 2019 to further our efforts in this space
    through the development of a national roadmap. So we recognize
    that we must partner, empower, and engage communities to reach
    all veterans, not just the ones that come into VA for
    healthcare.
        Our objective is to empower veterans where they live, work,
    and thrive whenever and wherever they are. So we thank the
    committees for their support of this mission, including the
    Members of Congress who have recently helped us to spread
    awareness of veteran suicide through our PSA [public service
    announcement] drive. Together, we know that we can make a
    difference.
        Ms. Chairwoman, this concludes my statement. My colleagues
    and I are prepared to answer any questions you may have for us.
        [The prepared statement of Dr. Franklin can be found in the
    Appendix on page 54.]
        Ms. Speier. Thank you, Dr. Franklin.
        Mr. Fisher.
        Mr. Fisher. No statement, ma'am.
        Ms. Speier. Okay. I would like to start by asking a few
    questions. And, unfortunately, at 4 o'clock I am going to have
    to leave for a meeting with the chair of the full committee, so
    I will turn it over to Ms. Brownley at that time.
        Dr. Van Winkle, let me start off with the question of
    embedding behavioral health personnel within the units. Have we
    seen any benefit associated with doing that?
        Dr. Van Winkle. Thank you for the question. And certainly,
    Captain Colston can talk specifically about that. I think
    anytime that we provide the opportunity for service members to
    receive support, we are working to prevent suicide. We do have
    embedded behavioral health, mental health individuals that
    Captain Colston can talk about. We also embed military family
    life counselors to provide support, and we allow for surge
    capacity if there has been a suicide in the ranks, that we
    provide more military family life counselors to support the
    unit at large.
        And I can turn it over to Captain Colston to talk about the
    embedded behavioral health.
        Captain Colston. So, ma'am, we embed behavioral health both
    into primary care clinics and into line units. I found in----
        Ms. Speier. How many? Can you tell us how many you have in
    the line units?
        Captain Colston. Of the 10,000 providers, it is over a
    thousand right now, ma'am.
        Ms. Speier. In units?
        Captain Colston. Yes, ma'am, or in primary care clinics. So
    we have 10,000 providers right now.
        It is really useful. In some ways it is a loss leader
    because, of course, you are not seeing patients in and out in
    the clinic all day; but it really speaks to what Mr. Kelly
    spoke about, and that is interaction with those line
    commanders, that is vitally important, and really getting a
    pulse of the unit.
        I found that my interaction with both commanders and
    chaplains in a deployed setting was really, really important.
    And it is something that we have endeavored to get into
    doctrine and standardize and optimize.
        Ms. Speier. I was stunned to find out that there is such a
    high percentage of those who commit suicide who have never been
    deployed. So what can you say to that?
        Captain Colston. So just historically in what I have seen,
    over 40 percent of people who commit suicide haven't deployed.
    They are white. They are male. They have GEDs or high school
    degrees, GEDs, and they are enlisted. The suicide rate in folks
    with GEDs was over 50 in the last DODSER [Department of Defense
    Suicide Event Report] in 2016.
        One thing that I have seen over my service--and I was a
    line guy before I was a doc--is we have really tried to treat
    people, treat people on station. We used to separate over 4,000
    people a year for personality disorders or adjustment
    disorders, under that type of rubric, a nonmedical separation.
    We have reduced that to 300 per year. And I think that
    finding--meeting people where they are, meeting those needs is
    going to be part of the suicide prevention equation.
        Ms. Speier. Have you, in your evaluation of this
    population, determined what percentage of those that commit
    suicide commit suicide in basic training?
        Captain Colston. It does happen, ma'am. And certainly, I
    have seen it. It is a very small number. And the only reason
    that it is a small number is because there is a great deal of
    supervision in basic training. And there are specific
    procedures in basic training. For instance, if you have a
    headache, you are only going to get 10 Tylenol. You are going
    to be monitored by your squad leader, things along those lines.
    It is the A schools and after that we really struggle.
        Ms. Speier. And can you provide any light on the fact that
    there is a higher incidence of mental health services in the
    last year of service?
        Captain Colston. Yes, ma'am. Our DMDC [Defense Manpower
    Data Center] records show that about 25 percent of folks avail
    themselves to care in the year before they leave. I think that
    is a good number inasmuch as it helps for continuity of care
    with our VA partners. But it also speaks to an opportunity that
    we missed, perhaps, in why didn't they come in earlier if they
    were struggling, or how was care stigmatized in a manner that
    made it hard for them to seek care earlier.
        Ms. Speier. And have you asked those questions?
        Captain Colston. Oh, certainly, ma'am. And I have certainly
    asked them as a clinician. You know, I think one of the
    things--let me just bring up an example. The incidence of
    depression in women is about 33 percent. And I have spoken to
    many women right before they leave service and, you know, why
    didn't you get care earlier? Well, you know, I think that care
    was stigmatized for them in one way or another. And certainly,
    we have made an effort to meet patients where they are. And,
    you know, just like we need to make sure that we take care of
    gynecological care for women, we need to make sure that we take
    care of mental healthcare for women.
        Ms. Speier. Thank you.
        Chairwoman Brownley.
        Ms. Brownley. Thank you, Chairwoman.
        Over the weekend, there was yet another tragedy suicide on
    the campus of one of our VA facilities. And at that same
    facility, it was reported--I have an article here--reported
    that a veteran seeking mental healthcare was repeatedly, at
    least the article alleges, was misinformed of his eligibility
    due to his other than honorable discharge status.
        So I wanted to first, Dr. Franklin, ask you, in terms of
    the VA's efforts, beyond letters, you know, what other
    initiatives are we taking to ensure that our veteran community
    are aware of the change in eligibility regarding other than
    honorable discharges?
        Dr. Franklin. Thank you. I appreciate the question, because
    it is an at-risk population group. We know that when people are
    leaving the military in a bad way, back in the day bad paper
    discharge they would call it, is definitely a high-risk group.
        And we did mail out close to 500,000 letters. And of those,
    you should know 3,500 have come into care. And I have the
    breakout in terms of those, how many have come into mental
    healthcare and/or had a diagnosis. It is 1,413 have a mental
    health diagnosis, and the other group have come in for some
    form of care and/or treatment.
        And I think that there is work to be done to continue to
    get the word out. So far, above and beyond just the letters, we
    are educating all 400 of our local suicide prevention
    coordinators so that they know they have a requirement to do 5
    outreach events a month. So if you just do the math, over 400
    of them, 5 a month at key places across a State or a community
    where there are known populations at risk, where they are
    educating community members on the fact that if people leave
    with this type of discharge that they can access care and that
    we want them to access care. Otherwise, we are trying to hit
    the media with broad articles and educational spots, where we
    describe the fact that we are open to this type of care.
        I don't know if Mike Fisher, you may have some other
    specific examples.
        Mr. Fisher. Absolutely. Thank you. Our focus is also on
    outreach, and our definition of outreach is going out and
    creating face-to-face connections with those that we are trying
    to create access to care. About 99 percent of our outreach
    workers are fellow combat veterans, so we are able to speak
    that same language. Last year we did 35,000 outreach events,
    where we were able to create those face-to-face connections.
        And actually, Vet Centers have had the ability to provide
    services to people with problematic discharges for several
    years, and that, really, we make sure that we focus explaining
    that when we go out. And then also now with the updates over on
    the medical center side is making those connections as well.
        Ms. Brownley. Thank you.
        And just the same question to Dr. Van Winkle. I feel like
    this can be a collaborative effort in terms of outreach and
    certainly before someone leaves the military that may be
    dishonorably discharged. How can you help us to inform this
    population of veterans?
        Dr. Van Winkle. Thank you for the question. I think that as
    we start to work within the transition space in some of our
    governance structures, including the Joint Executive Committee,
    we have been having these conversations with the VA about how
    can the Department work better to transition our folks and
    provide them all the information that they need.
        One of the things that we have been doing, and I have been
    working directly with the Veteran Benefits Administration under
    the guidance of the Joint Executive Committee, is to codify a
    transition framework that goes from 365 days prior to
    separation to the 365 days post separation.
        And the goal of this is to make sure that service members
    leave the military with an understanding of and easy access to
    all of the benefits and resources that they require. And this
    includes those subpopulations who may have been other than
    honorably discharged or dishonorably discharged.
        We are considering those subpopulations and making sure
    that the Department of Defense and the VA has the burden to get
    this to a place where they have that access, that it is not up
    to the service member to have to do the legwork to figure out
    all the different resources available to them. So this is
    something we are working on and the Joint Executive Committee
    has taken on.
        Ms. Brownley. Thank you. I wanted to ask another question.
    This is with regards to MST [military sexual trauma]. And there
    has been peer-reviewed research that repeatedly finds that the
    experience of MST elevates the risk of suicide. And the risk is
    even higher for MST survivors who are also members of
    marginalized groups, women, racial minorities, LGBTQ [lesbian,
    gay, bisexual, transgender, and queer or questioning], service
    members.
        So in over half of the service members who report MST
    experience retaliation by their chains of command. So this is--
    you know, I know it is a question that is always asked, but I
    think we have to keep asking it, because it is such a huge
    cultural change within the military.
        But what are we doing to help to create that environment in
    the military to make it safe, safe for survivors, and really
    safe for anyone to reach out for help?
        Dr. Van Winkle. So I appreciate that question as well,
    considering my position where sexual assault policies and the
    suicide policies both fall under me, as well as the policies on
    harassment, hazing, bullying, drug use, and the reason being is
    because we know there is an intersection between all of these
    behaviors. And when you have an individual who has experienced
    a sexual assault, this is extremely fragmenting and shattering,
    and often they may cope by drinking more or having other
    experiences which will put them in a place of experiencing
    depression and potential suicidal ideation/attempts.
        We work within this space on the policy level under the
    Prevention Collaboration Forum which I run, where all of these
    policy offices work together to align our prevention strategy,
    so that we make sure we close any loopholes for those
    individuals who may be experiencing multiple issues at once.
        In the Prevention Collaboration Forum is also the Family
    Advocacy Program, talking about domestic violence, the care
    that we provide to our families and to our children. And that
    is one of the structures that we use in order to address these
    co-occurring issues.
        Captain Colston also can talk a little bit about the
    behavioral health treatment targeting towards these
    individuals.
        Captain Colston. So every evidence-based treatment for
    sexual assault trauma is available in DOD: cognitive processing
    therapy; prolonged exposure therapy, which is an especially
    good therapy, from Edna Foa's lab in University of
    Pennsylvania; medication; and certainly wraparound services for
    these folks.
        Ms. Brownley. I am convinced that there are lots of
    programs and supports around there. I still just continue to be
    concerned around the environment. And I just think there is a
    lot more--I hear it anecdotally time and time and time again
    about retaliation and the chain of command.
        And I just think that we have to, I mean, truly address
    that in a way that we are really drilling down every single
    place within the military that it is just unacceptable that
    that would happen. And I still hear over and over again that
    members of the military, men and women, around mental health or
    MST, the fear of just reaching out to ask for help.
        And so I know cultural changes are really, really hard, but
    unless the leadership is completely committed to it, it is not
    going to happen. And certainly on the VA side, we have, you
    know, the same kind of cultural issues, you know, that we have
    to address.
        So I feel like I have never been in a committee where the
    chairpeople weren't limited by time. So I want to be respectful
    of the time, so I will yield back.
        Ms. Speier. Captain Colston, along those same lines, I
    visited a VA program in Menlo Park for MST survivors. Not one
    of them was going to be able to leave the program and go to a
    home. They were all homeless when they were going to leave the
    facility.
        And I am also concerned that for a long time--I don't know
    if we are still doing that and maybe one of you can enlighten
    us--many of them were discharged with what was called a
    personality disorder. And I am curious whether or not they
    were, in that status, able to access services?
        Captain Colston. So under that rubric, they got a general
    discharge. But we did make a very large effort to address
    injustices in that regard. I think that I have spoken in other
    committee meetings about how we have evolved around that
    particular type of discharge, going from 4,000 a year to 300
    folks a year.
        In about 2013, Secretary Panetta made a promise at Senate
    Appropriations Committee that we would review all of those
    cases. And, in fact, we did. So we looked at over 200,000
    instances where folks didn't leave with medical benefits where
    they left less than 30 percent by our Physical Disability Board
    of Review.
        And the Physical Disability Board of Review, which was run
    by the Air Force and overseen by Personnel and Readiness,
    scrubbed cases over 3 years and got benefits to lots of folks.
    And they also did a lot of outreach. So they went to homeless
    shelters and looked for those folks.
        We have Boards of Correction for military records, and
    there is a presumption in those Boards of Correction that a
    mistake may have been made. So we have given specific guidance
    around those types of cases to our Boards of Correction.
        Ms. Speier. All right. Maybe for the record, you could just
    provide us with the numbers. If you have looked at 200,000,
    could you let us know how many were changed?
        Captain Colston. Yes, ma'am. I just got a FOIA [Freedom of
    Information Act] request on it so I think I have it.
        [The information referred to was not available at the time
    of printing.]
        Mr. Kelly. I would ask that there be equal time. And I know
    that the minority party probably is not entitled to any
    comments whatsoever, but this is ridiculous that we have gone
    through many, many minutes and we have not even been referred
    to, and it is very passive-aggressive behavior and
    intentionally leaving the minority out.
        And this is not the first hearing, and I just ask that
    equal time be represented in this hearing and all other
    hearings.
        Ms. Speier. Mr. Kelly, you are recognized, and you have as
    much time as you would like to ask your questions, as we always
    do in our committee hearings.
        Mr. Kelly. Thank you, Madam Chair. Generally, it is the
    chair, ranking member, chair, ranking member, in all 4 years
    that I have been in every committee and subcommittee that I
    have been on.
        With that being said, I would first say that I am very
    concerned about our Reserve Component service members and
    veterans, who return to their civilian communities where there
    may not always be good access to behavioral health resources
    and the support systems you find on military installations.
        There is also the issue when Reserve Components come back,
    National Guard and Reserve, they don't demob [demobilize] at
    the same time. They go home to different locations. There is
    not that unit cohesiveness and the ability to talk with the
    soldiers that they serve with while they have done so.
        What are we doing to reach out to the Reserve and National
    Guard and make sure that these veterans are getting the help
    that they need?
        Dr. Van Winkle. Thank you for the question. We do have
    those concerns that you mentioned about the Reserves and the
    National Guard. Simply pragmatically, they don't have the
    access to the same resources that you may have in the Active
    Duty when you are under our purview 24/7. So that is on us to
    make sure that we provide them all of those resources.
        And we do this in a number of ways. We do provide all of
    our resources in terms of the crisis lines and military family
    life counseling and peer-to-peer support that they can call in.
    We provide that. It is on us to make sure they recognize that
    that resource is available to them.
        Captain Colston can talk a bit about how they target their
    efforts to the reservists and National Guard, and Mr. Fisher
    can talk also about the Vet Centers, which are available to our
    reservists and our National Guard.
        Mr. Fisher. Thank you. One of the things that we are
    working on within Vet Centers is actually an initiative with
    the National Guard Bureau, where we are taking our assets, both
    our counseling staff, our outreach staff, our mobile Vet
    Centers, and we are going out to drilling units and spending
    time with them when it makes sense for them on a drill weekend.
    Our real job there is to go out and make those connections like
    we talked about before, but if they need services, connect them
    into services or provide the services on the ground.
        Now, we recognize that there will be individuals that are
    not truly eligible for Vet Center services that we meet. And if
    they are in crisis we will meet that need, but our job then
    becomes where can we make that referral to, whether that is the
    VA or our partners in DOD, the National Guard Bureau, or other
    places within the community.
        As we roll out the National Guard, our next step then is to
    go into the Reserve forces and do the same thing, but get
    connection to those locations. And really, what we are doing is
    we want to build relationships with leadership, so that when we
    are not there we can create bidirectional referrals.
        Mr. Kelly. I thank you all. I just ask that you look at the
    soldier level, especially on combat veterans or like
    experiences, because I will tell you many combat veterans will
    not talk to noncombat veterans. More specifically, that subset
    is even smaller, the folks, the platoon or the squad that they
    actually serve with, they are willing to share with those like
    family members when they won't share with anyone else. So that
    is the key to identifying the issue is those small subsets
    which they will only share.
        Dr. Van Winkle, thank you for your work in this area. What
    type of training did junior leaders in the military receive to
    help identify behavior in their troops that may be a sign of
    greater behavioral health issues, specifically suicide?
        Dr. Van Winkle. There are a number of training efforts that
    we provide to both our junior leaders as well as our commanders
    and service members writ large. The idea is to make everybody
    part of the solution. And so when we talk about risk factors,
    we are looking at often situational factors that cause stress
    and can often predict whether somebody is going to get
    depressed and go on to die by suicide or attempt suicide. Those
    include relationship problems, financial problems, legal
    issues. And so when those issues arise and a commander or a
    lower level leader, the first-line supervisor is made aware of
    it, it is a call to action that we may need to provide
    additional support to that individual. But we have broadened
    that to be the service members themselves as well as the
    families to, again, be part of that solution.
        Mr. Kelly. And I think, Doctor, Captain Colston, you made
    an interesting comment. And I can tell you in 33 years of
    military service and through going through PHAs [periodic
    health assessments] and everything else that we have had to go
    through on a yearly basis and also doing post-deployment stuff
    and seeing other soldiers do those, there is a reason that
    people wait until you are 19 or their last year before they
    report anything--and that is not just behavioral health issues,
    that is physical issues--and it is from the fear of being
    removed from the service. And that is the stigma which we must
    figure out how to stamp out, because they won't tell you they
    are hurting, they won't tell you either physically or
    internally, because they are scared that it will impact their
    career.
        What can we do to make sure that they disclose this earlier
    to remove that stigma and that fear of being removed from
    service?
        Captain Colston. I think the first thing is is we
    absolutely need to get the word out that it is almost
    impossible to lose your security clearance from endorsing a
    mental health history on your SF-86 question 21. And we really
    have data, a couple dozen out of nearly 10 million security
    clearances.
        So when we look at the process of, okay, let's get down to
    the data, are we going to kick you out for having a mental
    health condition? Probably not. And, in fact, there is a
    presumption of nondisclosure with commanders. As a commander,
    do I want to know absolutely everything about anybody, any of
    my troops? I do. But there are all kinds of things that to
    create an environment of trust and an environment where you can
    come to see me that we need to delimit things that we speak to
    commanding officers about. So that is imminent harm to self,
    imminent harm to others, severe substance use disorders. But we
    really need to have something that is, you know, very private
    between clinicians and soldiers.
        Mr. Kelly. And I would ask the rest of you all submit that
    for the record so we can have other people ask some questions,
    but I would also, one thing for the record. Just someone give
    us the information on what the disparity and percentages for
    women and men committing suicide. I know there is a smaller
    number of women, but I would love to know the difference in
    women or any other differences that you can do for the record.
        Thank you, Madam Chair.
        [The information referred to was not available at the time
    of printing.]
        Ms. Brownley [presiding]. Thank you, Mr. Kelly.
        And, Dr. Dunn, you have as much time also you need.
        Dr. Dunn. Thank you, Madam Chair.
        Dr. Franklin, please elaborate on some of the specific
    changes you are making to VA suicide prevention programs.
        Dr. Franklin. Sure. Absolutely. We have made a number of
    changes in the last year that I would be pleased to tell you
    about. I mean, the first is putting pen to paper on a national
    strategy. I think in times past, the VA's approach to suicide
    prevention has largely been focused on the veteran crisis line
    and on providing the best mental healthcare ever. And that
    alone we know will not prevent suicide.
        And so this strategy really gets after making sure that we
    are doing broad sector engagement, and we are moving outside
    the four walls of the VA hospital system, which is new.
    Traditionally, we have, like I said, had an approach where
    folks come to us and we provide them the best care we can.
        Dr. Dunn. Do you have metrics you are following those
    changes?
        Dr. Franklin. Yes. So this is all brand new within the last
    year. And our ultimate metric that we have come up with on this
    or the ultimate metric is to lower the 20 a day.
        But left of that metric is a set of bundled metrics that we
    have come up with, and it is everything from making sure that
    we have an all-hands approach in terms of training. So a metric
    tied to training. We have a metric tied to increasing access to
    healthcare. We have a metric tied to our predictive analytics
    approach. When we identify through our predictive modeling--
    maybe you have heard of it, REACH VET [Recovery Engagement and
    Coordination for Health--Veterans Enhanced Treatment]--that we
    get those folks into care, the high-risk folks.
        Dr. Dunn. I think we would like to see some of that.
        Dr. Franklin. Absolutely.
        Dr. Dunn. Just a white paper kind of answer at your
    convenience.
        Mr. Fisher, here is a little good news for you. H.R. 1812,
    that allows the Guard and Reserve to access Vet Centers if they
    have been activated for national disasters, civil disorder, or
    drug interdiction operations, just passed the House by a voice
    vote.
        Mr. Fisher. That is great news, sir. Thank you.
        Dr. Dunn. In that vein, what percentage of your Vet Center
    counseling is provided to Active Duty or Guard?
        Mr. Fisher. Well, like the chairwoman said before, last
    year it was 5 percent of the total uniques coming in were for
    Active Duty service members. The Guard is a little less than
    that. But what we are seeing is increases in those two
    populations.
        So last year, we had a 9 percent increase in Active Duty
    service members coming--excuse me, an 8 percent increase in
    Active Duty service members come in. And over this past year,
    as we roll out this National Guard initiative, we have seen a 9
    percent increase in National Guard individuals coming into Vet
    Centers or connecting with those individuals.
        Dr. Dunn. Thank you. Captain Colston, what kind of outreach
    does DOD do to make sure that the Active Duty troops know that
    they can use the Vet Centers?
        Captain Colston. So all kinds of outreach. I think with
    regard to military--all types of outreach. So in regard to
    military sexual trauma, Vet Centers have long been available.
    We make an effort to ensure that folks know there is continuity
    of care, that we have a warm handoff between our side and the
    VA side or our side and an ongoing TRICARE relationship or our
    side and the civilian side.
        Dr. Dunn. I think your troops might be more interested in
    finding out there is confidentiality rather than continuity of
    care when they go to a Vet Center.
        Captain Colston. And I agree with you, sir. And I think
    that is an important part of everything that we do. And also as
    providers, I think there needs to be a presumption of
    nondisclosure.
        Dr. Dunn. So General Kelly mentioned that, you know, that
    people are afraid to self-report. And I can tell you that you
    know it is true, you don't need to hear from me, they are
    afraid to self-report.
        Dr. Franklin, understanding the public perceptions are
    powerful, and that one of the VA's goals is to support
    responsible reporting of suicide, what advice do you have for
    media outlets reporting on this hearing and for our audience
    and members sitting here today?
        Dr. Franklin. They are critically important. I think the
    average public doesn't realize how much they can influence the
    suicide prevention space by safe reporting.
        So I have all sorts of advice. I mean, first and foremost,
    I don't want the general public to think that the VA is ever
    limiting how folks should report, but following the national
    safe reporting guidelines is critically important. So making
    sure that headlines are accurate, that they are factual but
    that they don't glamorize, and making sure that we don't get
    into the details of the method. It is not important for the
    media, whether reporting out what type of--the method that
    occurred when the death occurred. I am hesitant to not want to
    say it just----
        Dr. Dunn. I understand. Do you have a bullet point list
    like you would give----
        Dr. Franklin. Yes. We have safe reporting guidelines. We
    just published them in the last few months, and we are trying
    to get them out near and far so every reporter in the Nation
    knows. And we are also holding a media roundtable next week
    where we are bringing in all sorts of media outlets, and we are
    partnering with the national entities in this space to really
    just do an increased awareness and try to help us get it right
    session.
        Dr. Dunn. I would, once again, appreciate sort of that in
    written to the VA Health Committee.
        Dr. Franklin. Yes, sir.
        Dr. Dunn. We would be grateful.
        And, Madam Chair, I yield back. Thank you.
        Ms. Brownley. Thank you, Dr. Dunn.
        Mr. Gallego, you are recognized for 5 minutes.
        Mr. Gallego. Thank you.
        Captain Colston or Dr. Van Winkle, I know that service
    members own firearms at a higher rate, and they come, of
    course, in contact with guns more regularly than the general
    population, and that guns are the particular preference in
    terms of use for deadly suicides.
        Are there red flag powers that DOD has to seize guns from
    service members if they are deemed a risk? Obviously not the
    weapon you take out of the armory, but when I was in the
    Marines, even on base you were allowed to carry a personal
    weapon, provided you told your command about it.
        Dr. Van Winkle. Thank you for the question. And Captain
    Colston can talk a little bit about how commanders work with
    behavioral health folks to make sure that they are making good
    decisions within the space.
        Firearms are part of the conversation only insofar as they
    are the most common method by which a suicide will occur. They
    are the most lethal means by which you can attempt a suicide.
    And certainly, commanders have a responsibility to protect the
    military members under them.
        If somebody is showing signs of imminent risk to themselves
    or another person, we always want to make sure that we take
    action across the board. And it is not only firearms,
    prescription drugs, any other method, but it is not done in
    exclusion of working with behavioral health individuals.
        Captain Colston. And in regard to safety and care of
    service members, of course, commanders have an abiding interest
    in that. And as a psychiatrist, most of the time that someone
    is acutely suicidal, that precipitates an admission, an in-
    patient psychiatric admission.
        Developing rapport with folks and rapport with commanders
    is really important to execute that. Certainly in policy, we
    have things along the lines of command-directed mental health
    evaluations. And, you know, certainly a young male patient who
    is acutely suicidal and has a weapon is someone that you are
    concerned about clinically.
        Mr. Gallego. I guess, you know, what I am asking is if
    there is a formal process for this. I am sure some commanders
    understand that, you know, they have the right to do it, but is
    there some formal process or training that you could give to
    these commanders saying, like, if someone is suicidal, please,
    you know, inquire if they have a weapon in their dormitory or
    whatever they have?
        Just because I feel, at least on the private sector side,
    what I have seen that has been successful when family members
    have identified people that are potentially suicidal, that they
    take their weapon away from them until they are stabilized
    again. And I am just curious to see if at least on the on-base
    side if there is something of that nature or some program we
    could teach these commanders the process to go through.
        Captain Colston. So means safety is part of all
    interactions with command, not only weapons, ligature risks,
    sharps, medications, things along those lines, and it is just
    part of the way that we do business.
        Mr. Gallego. Okay. Is there any type of data that has been
    collected for us to be able to tell whether members of the
    military that saw combat have higher rates of suicide or just
    lower rates of suicide? Because I have seen conflicting data.
        Captain Colston. Well, you are absolutely right,
    Congressman, so the data are conflicting. Reger, et al., did
    not find a nexus between deployment histories and subsequent
    suicides. There was a recent study, a STARRS [Study to Assess
    Risk and Resilience in Servicemembers] study, an Army STARRS
    study published by Ursano, et al., that said for folks who had
    deployed exactly two times, folks who deployed before the 12-
    month point or had less than 6 months of dwell time had higher
    suicide rates.
        Mr. Gallego. And I guess this just has to be just purely
    asked. What is, in your opinion, the cause of the higher rates
    of suicide that has occurred in the last year?
        Captain Colston. I have got to give you my very honest
    answer, Congressman, and that is that I----
        Mr. Gallego. We appreciate that in Congress once in a
    while.
        Dr. Colston [continuing]. I do not know. Obviously, there
    is a disturbing secular trend. We have seen our suicide rate
    double between 1999 and 2016, while the secular rate increased
    25 percent, increasing in every State.
        You know, when I was an intern, suicide rate was low.
    Military service was actually protective for suicide. So
    obviously, some set of circumstances have changed.
        Mr. Gallego. Right.
        Captain Colston. One thing I would say about suicide is
    there is over 300 separate forensic risk factors for suicide.
        Mr. Gallego. Dr. Van Winkle, do you have an opinion?
        Dr. Van Winkle. So I would concur with my colleague that
    when we are talking about suicide, it is an intersection of a
    variety of factors that are social, biological, psychological,
    that operate at the individual, community, societal levels. It
    is fairly complex and often difficult to determine exactly what
    is occurring within a whole population and even within
    subpopulations where I think there are unique considerations.
        Mr. Gallego. Thank you. Thank you, Madam Chair.
        Ms. Brownley. Thank you, Mr. Gallego.
        Mrs. Radewagen, you have 5 minutes.
        Mrs. Radewagen. Talofa. I represent American Samoa, and we
    have a very high percentage of veterans in our beautiful
    islands, and we will have perhaps even more in the future
    because we have such a very high enlistment rate in our Armed
    Forces. And, you know, it just breaks my heart to think of any
    of our veterans losing hope or struggling alone.
        The problem of veteran suicides is a national tragedy, as
    we all know, and I do want to thank Chairwoman Brownley and
    Ranking Member Dunn for their ongoing efforts on this issue. I
    also want to thank Chairwoman Speier and Ranking Member Kelly
    for holding this joint hearing. And I want to thank you and
    welcome the panel, everyone here, for their work on behalf of
    veterans.
        A single veteran suicide is too many, and it is my hope
    that we can make some real changes this Congress. My question
    has been partially answered, but let me first direct it at
    Captain Colston on behalf of DOD and then to Dr. Franklin for
    the VA perspective.
        Now, as I understand it, mental health is as complicated,
    if not more so, than bodily health, and varies from patient to
    patient. For example, some individuals respond well to
    pharmaceuticals, while others can suffer adverse side effects.
        You may have touched on this in your statement so far, but
    could you please elaborate on the different types of treatments
    that each department makes available to service members and
    veterans? And what systems or procedures do you have in place
    for identifying whether a treatment option isn't working and
    adapting care to each individual patient's responsiveness?
        Captain Colston. Thank you, Congresswoman. Well, first of
    all, we have a behavioral health data portal, so we measure
    outcomes on folks in regard to whatever the treatment regimen
    is. So for suicide, there are many approaches. There is
    cognitive behavioral therapy, there is problem-solving therapy.
    You can treat underlying depression.
        As a psychiatrist, I see severely mentally ill people. So
    people with schizophrenia respond to a drug called clozapine.
    There are probably 12 evidence-based treatments for suicidal
    folks. The thing that we struggle with is they all have really
    small effect sizes, so you need to treat a lot of people to
    really help one person become less suicidal or, in fact, you
    know, not commit suicide.
        So establishing a nexus between our treatments and a
    decrease in suicide has been extremely hard, and at the
    population level, we just haven't seen a signal yet.
        Mrs. Radewagen. Dr. Franklin.
        Dr. Franklin. Yes. The good news is that we use the same
    treatment methodologies as the DOD, so we train our providers
    together. We have the annual conferences and annual mini
    residencies where they are trained on the same set of evidence-
    based practices and protocols. And so that is, for what it is
    worth, part of the story in terms of how we train them on the
    evidence-based practices that Captain Colston spoke about.
        From there, in terms of the latter part of your question
    which was really tied to how do you know what you are doing is
    working, we have a system in place similarly to this behavioral
    health portal that the captain mentioned that gets after
    quality reviews and monitoring sort of up the chain. And that
    occurs at the very local level in supervision between
    clinicians and mental health leadership, and then is monitored
    all the way up to VACO [Veterans Affairs Central Office] to
    make sure that the evidence-based practices are implemented
    with a high degree of fidelity to the model, sort of making
    sure they are implemented the way they were designed, the way
    that we know will produce the best results and get the client
    going in the right direction in relief of symptoms.
        But Captain Colston is absolutely right. The sample--the
    efficacy is difficult over time, and the work needs to continue
    in this space. And I further offer that that is why we need to
    focus on additional capabilities in the fight for suicide,
    because the mental health work definitely is essential and
    needs to continue. We need to make sure they leave our offices
    with the veteran crisis phone number in hand, but then they
    need life supports throughout the course of the week. We need
    to make sure that our veterans are employed, that they have
    homes, that they are engaged in meaningful--in life that brings
    them purpose and passion, and that they have the supports to
    thrive during life above and beyond their mental health
    therapy.
        Mrs. Radewagen. Thank you, Madam Chair. I yield back.
        Ms. Brownley. Thank you, Mrs. Radewagen.
        Mr. Cisneros, you are recognized for 5 minutes.
        Mr. Cisneros. Thank you all for being here today.
        Dr. Van Winkle, first, how much funding does the DOD
    dedicate to suicide prevention research?
        Dr. Van Winkle. I have to take that question for the record
    to get you an accurate number on that.
        [The information referred to can be found in the Appendix
    on page 71.]
        Mr. Cisneros. All right. Dr. Franklin, can I get the same
    question, how much does the VA dedicate to suicide prevention
    research?
        Dr. Franklin. Just research? I would have to pull the
    thread on that as well and get it back. I have the entire
    budget here with me, but just research, I need to pull.
        [The information referred to was not available at the time
    of printing.]
        Mr. Cisneros. Okay. I would appreciate that.
        Dr. Franklin. Yes, sir.
        Mr. Cisneros. Thank you.
        What is the process, you know, Dr. Carlson or Captain
    Carlson--you said there was a handoff. Well, actually let me go
    back and ask this question.
        When an individual is--whether they are coming back from
    overseas after serving in combat or they are getting ready to
    separate from Active Duty service, what is the process for
    helping to identify whether or not they are suffering from PTSD
    [post-traumatic stress disorder] or some other mental health
    issue? Are they self-identifying or do we actually have a
    process to figure this out?
        Captain Colston. Well, both, sir. So the DOD cohort is the
    most screened cohort of folks in human history. So you will be
    asked about suicidality, PTSD, depression, and generalized
    anxiety disorder in a periodic health assessment, in a
    separation health assessment. And you will also be asked every
    time you go to the primary care doc. So when I just went to
    Walter Reed, all those questions got asked. So that is one
    opportunity where you are self-identifying through screening.
        But it is also DOD policy that there is a warm handoff
    between clinicians. So you have an obligation as a clinician,
    including as a deployed clinician, to make sure, because we are
    all using the same health system, and I have access to the
    electronic health record as a deployed physician, to do
    everything that you can to make sure that there is a clinic-to-
    clinic handoff, if not a provider-to-provider handoff.
        Mr. Cisneros. So once an individual is separating, and you
    talked about this warm handoff, and they are getting out, they
    are no longer seeking or getting DOD military healthcare and
    they are going to the VA, how is that handoff being done from
    DOD to the VA to making sure that that individual is going to
    continue to get care?
        Because one of the things that really does disturb me is a
    number of those individuals that are killing themselves out of
    that 20 per day are not seeking VA healthcare. So how are we
    doing this handoff to make sure those individuals continue to
    get care?
        Captain Colston. Well, first of all, we need to meet the
    patients where they are at, so they need to continue the type
    of care that they want to continue. A number of my patients who
    have severe mental illness will continue care at a high level,
    so psychiatrist to psychiatrist. And that would include a
    discharge summary, making sure that our formularies are
    aligned, which they are, between DOD and VHA, making sure the
    patient has enough meds when he goes to the next place.
        But the folks who--the predominance of suicide risk in the
    population is in folks who are less mentally ill. And, in fact,
    we need to meet those patients where they are at, whether that
    is in credentialed healthcare, or like my colleague, Mr.
    Fisher, in confidential healthcare in Vet Centers or elsewhere
    or in community-based health.
        Mr. Cisneros. Dr. Franklin, how do you receive those
    individuals that need that healthcare or need that mental
    healthcare coming from the DOD?
        Dr. Franklin. Certainly. There is a program in the DOD
    called inTransition, and this is a capability that recognizes
    when people are on Active Duty status and they have a known
    mental health problem, they fall into this program. It is one
    word, the title of the program, inTransition, and this is a
    program that then carries them through over to the VA with
    frequent caring outreach and contact where they are getting
    actual phone calls and coached into the VA system. Above and
    beyond this process that Captain Colston talked about, which is
    provider to provider across DOD to VA, there is also this
    additional safety net, they call it, of this inTransition
    program.
        But I think what you are getting at is this other part of
    the population that ties back to this other question that was
    asked earlier, which is when we have a known population that
    doesn't get mental healthcare over the course of their whole
    career and/or doesn't unpack it, doesn't have a known mental
    health problem at the time that they leave, they don't fall in
    inTransition. They don't fall clinician to clinician. There is
    no warm handoff because they are not known. Then they leave the
    DOD, and then life circumstances happen, unemployment,
    childbirth, divorce, good and bad that are stressful, and then
    the challenge is getting them into care at that point, if that
    makes sense, and I think that is where we could do better. We
    have work to do in that space, I think.
        Mr. Cisneros. All right. Yeah. You know, one of the worst
    things I had to do in my military service was to go home--or
    not go home but to go to a mother and tell her son--that he had
    committed suicide. I feel for these families that are doing
    this and those individuals that are going through this, so we
    need to figure out what the problem is and get to that. So
    thank you very much.
        My time has expired.
        Ms. Brownley. Thank you, Mr. Cisneros.
        Mr. Gaetz, you are recognized for 5 minutes.
        Mr. Gaetz. Thank you, Madam Chair. And I want to thank the
    chairs for coordinating this hearing.
        I represent the district that has the highest concentration
    of Active Duty military and one of the highest concentrations
    of veterans in the country, and so this is very much a kitchen
    table issue in my district.
        My first question, Dr. Van Winkle, is what do we know about
    the percentage of veterans who commit suicide who struggle with
    opioid addiction?
        Dr. Van Winkle. I would have to take that for the record,
    unless Captain Colston has those numbers offhand. But I will
    say that the Drug Demand Reduction Program falls to me, so we
    certainly have ongoing concerns about opioid use in the
    military.
        [The information referred to was not available at the time
    of printing.]
        Mr. Gaetz. Would anyone on the panel disagree with the
    conclusion that opioid addiction contributes to suicide?
        Captain Colston. I would agree with that, Congressman.
        Mr. Gaetz. You would agree with that.
        Captain Colston. The prevalence of opioid addiction in
    Active Duty military service members is----
        Mr. Gaetz. What is our current most effective strategy to
    deal with opioid addiction?
        Captain Colston. Medication-assisted therapy.
    Buprenorphine, methadone, or naltrexone.
        Mr. Gaetz. So more pharmaceutical drugs. You know, I don't
    have--I mean, I--let me ask this question. Will access to
    medical cannabis reduce veteran suicides?
        Captain Colston. In my view, there is far more research to
    be done, so there is insufficient evidence for or against that
    position.
        Mr. Gaetz. Are you unpersuaded by the evidence by the
    National Academy of Sciences citing examples in Minnesota and
    other States where access to medical cannabis reduces the
    prescription rates of opioids and the use of schedule I drugs
    broadly?
        Captain Colston. Well, certainly we are open to all types
    of research.
        Mr. Gaetz. Okay. So you said more research needs to be
    done. What is that?
        Captain Colston. Well, first of all, there are over 300
    psychoactive substances in cannabis sativa, so----
        Mr. Gaetz. How many psychoactive substances are in the
    medical therapies that we are using to replace opioids?
        Captain Colston. There are no cannabis sativa----
        Mr. Gaetz. No, no, no. Not cannabis sativa but psychoactive
    substances.
        Captain Colston. So the three psychoactive substances are
    methadone, which is another opioid, a long-acting opioid;
    buprenorphine, which is an opioid agonist/antagonist, so it is
    an opioid that essentially you can't overdose on; and
    naltrexone, which is an opioid antagonist, which, in essence,
    takes the drug off of the brain receptors.
        Mr. Gaetz. Right. So that is the current off-ramp for
    opioid addiction that we use. What evidence do we have that
    that is a more effective off-ramp than medical cannabis?
        Captain Colston. I just think those are the three evidence-
    based therapies right now that meet the medical bar. Obviously,
    more research can change that.
        Mr. Gaetz. How would you describe the VA's approach to
    researching the extent to which medical cannabis could be an
    alternative off-ramp for opioid addiction? Because, clearly,
    what we are doing now isn't working.
        Captain Colston. Well, there is certainly no prohibition to
    any research around medical cannabis. And, in fact, there are
    two chemicals--or there is a chemical in CBD that is used for
    two pediatric seizure disorders right now.
        Mr. Gaetz. So at the VA, can--at a local VA, can a
    physician recommend medical cannabis, if it is in a State where
    those recommendations are permissible under State law?
        Captain Colston. I would defer that question to my
    colleagues.
        Dr. Franklin. No, they cannot at this time. There is a
    Federal law against it right now.
        Mr. Gaetz. Right. So Federal laws prohibit--do those same
    Federal laws that you cite that prohibit prescription prohibit
    research?
        Dr. Franklin. No, they do not.
        Mr. Gaetz. So you are saying that the VA is willing to
    engage in this research, willing now to post what federally
    approved clinical trials are available? Would the VA be willing
    to do that?
        Dr. Franklin. We have two ongoing research studies going on
    right now in this space, and so I think we are open to
    research, yes.
        Mr. Gaetz. So the question is does any existing law
    prohibit the VA from publishing what federally approved
    clinical trials are underway or seeking participants?
        Dr. Franklin. You know, I am not a lawyer, so I don't know
    about the Federal law that may----
        Mr. Gaetz. Is there any law of any kind that would prohibit
    the VA in any way from publicizing what federally approved
    clinical trials are available in the cannabis space?
        Dr. Franklin. I probably have to take that for the record.
    I am just not 100 percent clear on the exact laws.
        [The information referred to was not available at the time
    of printing.]
        Mr. Gaetz. Well, see--yeah, I don't think anybody is clear,
    which is the source of my frustration, because I think that
    there are a lot of these clinical trials that are seeking
    veterans. The VA, due to a lack of clarity, won't publicize
    that information or make it available, and then we are unable
    to do the research that Captain Colston says is necessary to
    advance additional options for veterans trying to get off
    opioids and to stop them from killing themselves.
        In my district, there is overwhelming anecdotal evidence
    that when they are given the combat cocktail, when they are
    given heavy barbiturates when they come home, they are more
    likely to trip into addiction, and if they have other therapies
    for PTSD or to alleviate that addiction that it is helpful. So
    I am very interested in getting that.
        And, Madam Chair, I have a unanimous consent request that
    the op-ed written by our colleague, Congressman Seth Moulton,
    in the Washington Examiner entitled ``Let's talk about cannabis
    and the VA'' in which he details three bipartisan bills that he
    and I are sponsoring to advance the work of the VA in the areas
    of research and medical cannabis.
        Ms. Brownley. So ordered.
        [The information referred to can be found in the Appendix
    on page 67.]
        Dr. Franklin. Yes, sir.
        Mr. Gaetz. Thank you, Madam Chair. I yield back.
        Ms. Brownley. Thank you, Mr. Gaetz.
        Mr. Lamb, you are recognized.
        Mr. Lamb. Thank you very much, Madam Chair.
        I do want to address the opioid topic first. And thank you
    all for your participation, especially Dr. Franklin, who we
    have had the chance to see and hear testify and meet with
    several times. You have brought a lot of energy to this office
    and this position, so thank you for that, and we look forward
    to working with you on this going forward.
        On the opioid issue, I would say, Captain Colston, would
    you agree that we actually--we do have plenty of evidence that
    these three drugs that you talked about that are provided as
    medically assisted treatment, we have plenty of evidence that
    they work. First of all, just the model of how those drugs act
    on the brain compared to the opioids that were being abused is
    part of why they are used and used so successfully. Isn't that
    right?
        Captain Colston. Yes, sir.
        Mr. Lamb. Okay. And I would actually say that from where I
    sit in western Pennsylvania where the opioid crisis has really
    hit hard, the problem is really access. It is not that we don't
    know how to treat these people. You know, I have a friend who
    is a treatment provider who has told me if you are able to
    combine medically assisted treatment with some of the more
    traditional counseling and group-based therapies for folks, you
    can move the needle of survival and the ability to quit the
    addiction maybe from 10 percent to 25 percent or 30 percent.
    You may not save everyone the first time, but you are going to
    dramatically increase the odds that someone will survive and
    beat this disease.
        Have you seen something similar?
        Captain Colston. Yes, sir. That is absolutely true. And,
    you know, we have certainly on the Federal level done things to
    make it easier for prescribers to get buprenorphine in the
    hands of patients. And I think that has been, you know, a
    successful public health effort.
        Probably one that is equally successful is the ability to
    get naloxone in the hands of first responders. And, in fact,
    cops and firefighters have saved numerous lives in this
    scourge; 47,000 opioid overdose deaths in America last year,
    47,000 suicide deaths. These are national scourges that are on
    the order of swine flu.
        Mr. Lamb. No. You are absolutely right, and it has been a
    great success. In our part of the world, we have had some of
    the highest death rates of anywhere in the country. And this
    year, for the first year, we are seeing reductions in many of
    the places that were the worst in deaths I would say probably
    almost completely due to the increase in naloxone, again,
    because the more complicated and sustained forms of treatment
    are not yet available. However, the VA provides it, and the VA
    can make this accessible to people who otherwise wouldn't get
    it.
        I served with a Marine who came off of Active Duty addicted
    to a painkiller because he had been hurt in some training right
    before he left, and I don't believe he was medically
    discharged. I think he just sort of got through the injury and
    then left the service with a normal discharge, but he still
    carried with him the addiction to the opiate, and he went home
    and became addicted to heroin.
        He showed up at the VA in Pittsburgh after having enough
    self-awareness to realize he didn't want to die that way, and
    at our VA, they gave him 30 days of detox and treatment and
    then moved him over to the other VA for another up to 6 months
    of treatment, ongoing therapy, and they actually gave him a
    place to live. He stayed there, and it is amazing. They had a
    community. They had a little rank structure. He was like the
    vice president of their group of folks that lived there.
        And I learned all this because I just went to the VA for a
    normal tour and ran into him. I hadn't seen him in like 6
    years.
        So I always sort of hold up the VA as an example of the
    fact that we do actually know how to save people if we make the
    right treatment available. It just takes a really long time,
    and it is expensive and difficult, and it may take more than
    one round.
        So the only thing I wanted to ask about that was, for this
    guy, I am not aware of whether any information was shared from
    DOD to the VA about the prescription painkillers that he
    received as a risk factor. I know, Dr. Franklin, you mentioned
    inTransition, which sounded like, from what you said, had to do
    with people who were actually receiving treatment on Active
    Duty for a mental health condition.
        Do we have anything right now that would have constituted a
    warning from DOD to VA, here is a guy who received a heavy dose
    of painkillers. Someone might want to check once he gets out if
    he is enrolled in VA healthcare yet?
        Captain Colston. So in the last year, we, DOD, takes part
    in PDMP, Prescription Drug Monitoring Program, so now that
    flashes for everyone. And it is an incredibly powerful tool,
    especially as you mentioned, General Kelly, for Guard and
    Reserve folks who are getting civilian care somewhere. Now I am
    able to look and see what their opiate history is, and a lot of
    times you don't get endorsements. You don't get someone who
    says, yeah, hey, I am struggling right now.
        So it has been an incredibly powerful tool, and it is one
    that we have really only had online for about 9 months, but I
    think will save lives.
        Mr. Lamb. Thank you.
        And very quickly, time is expiring. Dr. Franklin, do you
    know, for someone like him, if he had never showed up for VA
    healthcare on his own, is there any way right now for VA as an
    institution to know about him and know either for the VA or the
    Vet Center, someone to sort of reach out and say, hey, you
    might want to enroll here just to make sure everything is okay?
        Dr. Franklin. You perfectly described the nexus of our
    issue. We need to get out there and find those people and get
    them into our service delivery, whether that is through our
    suicide prevention outreach people that do five outreach
    events, our Vet Center outreach efforts that get outside the
    gates, our homeless outreach coordinators, our veteran justice.
    I am not sure if he was involved in the court system, but we
    have justice outreach. It is all hands on deck. We have got to,
    like, find these people and do everything we can to wrap our
    arms around them.
        Mr. Lamb. Thank you.
        And, Madam Chairwoman, I yield back. Thank you.
        Ms. Brownley. Thank you, Mr. Lamb.
        Mr. Barr, you are recognized for 5 minutes.
        Mr. Barr. Thank you, Madam Chairwoman. And thank you to
    Chairwoman Brownley and Chairwoman Speier for your leadership.
    And also, Ranking Member Dunn and Ranking Member Kelly, thank
    you for hosting this joint hearing. I think it is excellent to
    continue to shine the light on this national tragedy of 20
    suicides a day.
        Let me start with Dr. Van Winkle since I haven't had the
    benefit of your testimony as a member of the Veterans' Affairs
    Committee. I do want the DOD perspective here. As we are
    nearing 20 years of engagement in Iraq and Afghanistan, our
    longest engagement in U.S. history, it is my understanding that
    soldiers, particularly those in the Army, are deploying longer
    and for multiple deployments.
        As the director of the Office of Resiliency, how is your
    office taking into account the effect of these multiple
    deployments on service members and their families, these long
    deployments? I know it is very, very difficult for a lot of the
    veterans in my district.
        Dr. Van Winkle. Thank you for the question. It is certainly
    something that we are tracking, and with our collaborations
    with the family programs, we also track the impact on the
    families, understanding that that is an additional stress when
    the military member is overseas or deployed.
        Within the suicide space, as mentioned, there is no simple
    and direct connection between suicide and deployments at the
    aggregate level, but what we know is this is an individual
    stressor, that for some, when we talk about suicide as a
    combination of individual factors that we are tracking, this
    can certainly be a stressor that impacts them negatively.
        And so part of our work is certainly within the behavioral
    health side and within our leadership to have those
    conversations about the impact of deployment. And Captain
    Colston can talk a little bit more about how the deployment and
    behavioral health work together.
        Captain Colston. One of the things that I just want to
    emphasize is we really make sure that we embed mental
    healthcare on deployments, so at the division level there will
    be a psychiatrist deploying with the unit. And, in fact, that
    is important because 18- to 25-year-olds often struggle with
    things like not just suicidality, the first break psychosis,
    first break mania, things that are dangerous in folks who are
    there to kill the enemy. So it is vitally important that we do
    that.
        Mr. Barr. Well, thank you for that. And I appreciate DOD
    paying attention that obviously operational tempo could play a
    role in some of the suicide issues.
        Our colleague, Brian Mast, who, of course, is a combat
    veteran, a wounded warrior himself, he approached me last
    Congress with an idea and legislation to require an oath of
    exit so that service members obviously who are part of a team,
    part of a unit, a band of brothers who feel a strong sense of
    loyalty to each other would basically take an oath upon a
    transition and discharge to each other that before they would
    cause harm to themselves, they would at least contact one of
    their former brothers in arms and let them know in advance. I
    thought that was a good idea, and my understanding is that DOD
    has kind of taken on that idea.
        Is that a good idea? Is that something that DOD is
    considering, an oath of exit so that, you know, men and women,
    service members who leave the military are pledging an oath to
    each other that before they take their own lives or before they
    harm themselves, they will contact one of their former soldiers
    or sailors or airmen?
        Captain Colston. Well, I think in regard to all issues
    around safety, certainly, you know, for those of us that have
    deployed, you know, we met our affiliative needs with those
    folks that we were in the barracks with, that we were out in
    the field with, so yes. I mean, I think in regard to things
    like safety planning, which we do for suicidal people, that is
    a critical part of it. Telling your brothers and sisters that
    you are in pain is an important part of, you know, what we do.
        Mr. Barr. I think that is something we ought to pursue.
        Finally, Dr. Franklin, you talked about the inTransition
    program, but let me talk specifically about medical records. I
    know we have increased a real effort to have that
    interoperability between medical records. But if a service
    member commits an act of self-harm or attempts to commit
    suicide while in the military, how is that information or
    medical documentation of that transferred to the VA?
        Dr. Franklin. As we stand right now, not under the new
    system is what you are asking me? If they have made an attempt
    of harm to self, harm to others, it is in their medical record,
    and it travels with them as they leave the DOD over to the VA
    side through all the methods that we have discussed earlier.
        Mr. Barr. Do we have confidence in that, that we are
    catching all of that?
        Dr. Franklin. I have quite a bit of confidence in it, but I
    am happy to also do a review, if that is something that would
    help, like just to do a random review. I can work with our DOD
    colleagues to scrub that.
        Mr. Barr. Well, thanks. My time has expired, but obviously,
    it is critically important that as a soldier or sailor is
    passed on to the VA, that their history of suicidality would be
    also transferred with those medical records.
        Dr. Franklin. One of the highest risk factors for suicide
    is a prior attempt, so absolutely.
        Mr. Barr. I yield back. Thank you.
        Ms. Brownley. Thank you, Mr. Barr.
        Mrs. Davis, you are recognized.
        Mrs. Davis. Thank you, Madam Chair.
        And thank you all for being here. I am sorry I missed your
    testimony, but I think I have a sense of all that you have been
    trying to do lately, and a lot of that has to do with how well
    we connect in terms of the interagency, intra-agency, and what
    you see on the horizon.
        What is it that you have felt you haven't been able to move
    forward with? You have talked about your aligning prescriptions
    and some of the issues about trying to catch individuals who
    might be really at risk. I am just wondering what is it that
    you feel has been a bit of frustration?
        And maybe I can share with you having--I believe Dr.
    Franklin is familiar with some friends of mine, actually, who
    have been very engaged as parents in trying to be proactive,
    trying to find kind of a key, if you will, to keeping families,
    parents, particularly, engaged with the recruitment, with the
    service, with the deployments, and back home again transition
    so that they are more aware and can be more helpful to a loved
    one who may be a suicidal risk.
        Are we doing more in that area? Are we just so prohibited
    because of privacy regulations that it is really difficult to
    do that?
        Dr. Van Winkle. So I can speak to that latter point. We
    have been working with family members on a network of support,
    and I can provide you more information about where we are on
    that. But we know that one of the protective factors is simply
    the feeling of connectedness, often within the unit, but also
    ensuring that family and friends understand the military
    experience in a way that they can support the military member.
        So we have been working on the network of support option.
    And I can provide--I can take for the record where we are with
    that.
        [The information referred to was not available at the time
    of printing.]
        Mrs. Davis. Anybody else want to comment on that?
        Dr. Franklin. I do continue to make contact with the
    Summers. Thank you very much, Chairman Davis, for introducing
    them to me so many years ago. I definitely appreciate it, and I
    probably hear from them once or twice a month. And lived
    experience is important in making sure we learn everything we
    can from moms and dads and brothers and sisters.
        And the DOD and the VA has a joint panel now, since we last
    spoke, called the Lived Experience Panel, where we collectively
    bring leaders together and we pulse parents and survivors just
    to make sure our policies are right. Are we doing everything we
    can? Is there some small thing that a mom or dad could teach us
    so that we could do better? So that is important.
        In terms of the first part of your question about what
    gives, what are your challenges that remain? I just offer to
    you that we have talked in the panel today about how complex
    suicide is, and it does call for bundled approaches, and it
    calls for them at full force over time, like, full throttle,
    like, we have got to move out with educating every single
    family member in the Nation, and there are a lot of them.
        Now that I am on the VA side, there is 20 million veterans,
    and they all have family members, and making sure that we have
    wrapped that into our protocol. And then just the bundled
    approaches have got to be pushed out over time. And I think
    about that in the context of leadership support. So on the DOD
    side, military leaders recognize their role on suicide
    prevention. And on the VA side, hospital leaders recognize
    their role. But I think there is work to be done on other
    sectors and making sure all leaders recognize their role and
    help with this work.
        Mrs. Davis. Yeah. Thank you. And I know that a lot of work
    has been done in identifying the fact that mental health is
    physical health is everyone's health and the need to not be
    intimidated by sort of this perception of stigma. And yet at
    the same time, I often talk to people in the service, and they
    still raise those questions, that families are afraid to
    identify. So, you know, I think that we still have more work to
    do in that area as well. And I appreciate what you have been
    trying to do along those lines as well.
        Do we know whether or not individuals who are able to
    transition relatively quickly, whether it is in something that
    is totally new to them, they have had training while they are
    waiting to complete their service? Are they doing better if
    they are actually in a job that they feel that they, even if
    recently, have been trained for versus they are still
    questioning what their future looks like? I know it is a
    complex issue, but is that better?
        Dr. Franklin. Yes. Those that are engaged in meaningful
    employment, not just any random job, but meaningful employment
    where they feel like they are part of a mission, and this is, I
    think, what is one of our most recent findings across the two
    organizations. We have a governance structure that we spoke
    about earlier. Dr. Van Winkle mentioned the JEC, this Joint
    Executive Council, and we have really been, over the last year,
    spent a significant amount of time tending to the social
    aspects of transition.
        And so meaningful employment is part of that and just
    recognizing what it means to no longer wear the uniform as a
    community member.
        Mrs. Davis. And I guess also, I would add quickly because
    of time, and also training business people to be able to
    identify and work with an individual as well as their family.
        Dr. Franklin. Those leaders, yes.
        Mrs. Davis. Thank you very much. I yield back my time.
        Ms. Brownley. Thank you, Mrs. Davis.
        Mr. Kelly has requested a few more minutes.
        Mr. Kelly.
        Mr. Kelly. I first thank the chairwoman, but I want to
    thank Mrs. Davis for her efforts, not only in this arena, but
    several arenas that are so important in military personnel, and
    she is such a great leader on this subcommittee in trying to
    get to solutions. I just want to thank you.
        Second, on the PDMP [Prescription Drug Monitoring Program],
    as a former district attorney, there was a time when the VA did
    not share with other doctors, which led to them going and
    getting at two different locations, so I thank you for that,
    and it helps with treatment as well as. And so I just thank you
    for doing that.
        One of the things I think that is very confusing is on
    Guard and Reserve, and probably one-term enlistees on Active
    Duty don't understand what their veteran status is. And I know
    when I de-mobed in 2005 or 2006, they told us if you don't get
    a checkup every year, you lose your VA benefits, although I had
    spent a full year in a combat zone and 20-plus years in the
    military before. If that is still the case, we need to change
    it, because many of these problems don't manifest until years
    after. So if we are denying them because they didn't go get,
    quite frankly, a stupid checkup just to go in every year, they
    have earned their veteran status. They shouldn't lose that. Is
    that still the case, Dr. Franklin or Mr. Fisher?
        Dr. Franklin. I have to turn this over to Michael Fisher.
        Mr. Fisher. I can speak to within Vet Centers. So Vet
    Center eligibility is lifelong, and it doesn't matter if you
    are accessing it today or 15 years from now. So you can leave--
    you can come into services, you can exit services, you can come
    back, and we can pick up wherever you left off.
        Part of our job also is that if we identify other things
    together, other benefit services that you as a service member
    or former service member could benefit from, it is making those
    connections. That includes going back over to the VA medical
    centers, getting connected to a veteran service officer to work
    out claims issues so you can access the medical centers and
    those kind of things.
        Dr. Franklin. But I think you are absolutely right in terms
    of being onto something. If there is confusion on the status
    when they leave, it becomes a barrier to care and an access to
    care issue. And so if we inside the VA can do a better job of
    an awareness campaign and some educational rollout that
    educates people on the complexities of what their title is and
    what their access to before they leave in partnership with the
    DOD to make that access to care easier so that we are all
    clear, I take that for action.
        Mr. Kelly. And I would just ask that--you know, like I
    said, I left in 2006, and that was the guidance we were given.
    And as a very high ranking officer, as an attorney and a Member
    of Congress, if I don't understand it, I assure you those 22-
    year-olds that left then probably don't, so let's do a good
    job.
        And with that, I yield back, Madam Chair.
        Ms. Brownley. Thank you, Mr. Kelly. And I think before we
    adjourn, I just had a couple of quick questions that I wanted
    to ask as well.
        Dr. Franklin, in your response to an earlier question, you
    were talking about the various metrics that the VA has set up.
    I was just wondering if you had a basic metric for a warm
    handoff. You know, I don't know quite how to quantify that, but
    do you understand what I am saying? You know, how are we
    measuring that in terms of men and women leaving the military,
    warm handoff, you receiving them, and then it may be another
    warm handoff after that? But it is mainly that transition
    between military and the VA.
        Dr. Franklin. Yes. So we get handoffs from other people
    other than DOD, but if you are wanting a figure on total number
    of warm handoffs that come from the DOD to the VA by type of
    handoff, mental health, primary care, the like, I am sure that
    we have that in our dataset.
        Ms. Brownley. So you would have that all in your----
        Dr. Franklin. I believe we do, yes, ma'am.
        Ms. Brownley. And so where do you receive other handoffs
    from?
        Dr. Franklin. So community members might refer veterans.
        Ms. Brownley. I see.
        Dr. Franklin. VSOs [veterans service organizations]. There
    is a whole----
        Ms. Brownley. And do you collect that data also?
        Dr. Franklin. You know, that is a piece I need to check by
    referral source.
        Ms. Brownley. Okay.
        Dr. Franklin. Over the years, as a mental health clinician
    in the field at the local level, I know that we captured it,
    but I need to make sure we are capturing it at the VACO level.
    I can check.
        [The information referred to was not available at the time
    of printing.]
        Ms. Brownley. Great.
        And, Dr. Van Winkle, I just wanted to know, so in a
    deployed setting, have any service members been sent home or to
    a military hospital because of a mental illness like you would
    if you had an injury and you might be sent to Germany or you
    might be sent back here to Walter Reed or----
        Dr. Van Winkle. So that is a good question, and I would
    have to take it for the record. I think that there are
    certainly a spectrum when we talk about mental illness in terms
    of severity of mental illness and the impact on the mission and
    on the member themselves.
        [The information referred to was not available at the time
    of printing.]
        Dr. Van Winkle. Captain Colston, I don't know if you have
    any information.
        Captain Colston. By all means. We have air evaced folks for
    mental health conditions, and the most common condition is
    actually not suicidality. In my experience, it was first break
    psychosis, first break mania. A lot of 18- to 25-year-olds
    there who had a predisposition for severe mental illness and
    then get in a really stressful type of situation and it
    manifests.
        Ms. Brownley. Thank you. Do you have the data on that? Is
    that something that you collect?
        Captain Colston. I would imagine that it would be possible
    to do a dive, ma'am. I certainly don't have it on hand. I could
    take that for the record.
        [The information referred to was not available at the time
    of printing.]
        Ms. Brownley. Very good.
        Well, you know, I want to thank all the witnesses. I have a
    lot more questions, but I hope that we can have another meeting
    like this with both the VA and the DOD together. I know that
    with the Executive orders coming from the President's office,
    there is going to be more collaboration and more articulation,
    I think, about that collaboration in that first year outside of
    the military. And I am looking forward to hearing more about
    that as you make progress.
        But we all agree in this room that this is a real crisis
    and, you know, we must, we must make inroads, we must make
    progress. And one suicide a day is one suicide too many. And I
    know both of you sitting here on the dais are very dedicated to
    that, and I am looking forward to continuing that work.
        So, again, thank you for providing the testimony today. And
    there is no further business, the subcommittee will be
    adjourned.
        [Whereupon, at 4:59 p.m., the subcommittees adjourned.]

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                               A P P E N D I X

                                  May 21, 2019

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                  PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                                  May 21, 2019

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                       DOCUMENTS SUBMITTED FOR THE RECORD

                                  May 21, 2019

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                  WITNESS RESPONSES TO QUESTIONS ASKED DURING

                                  THE HEARING

                                  May 21, 2019

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                 RESPONSE TO QUESTION SUBMITTED BY MR. CISNEROS

        Dr. Van Winkle. The Department of Defense spends approximately
    $127M on suicide prevention research annually.   [See page 22.]

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                  QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                                  May 21, 2019

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                      QUESTIONS SUBMITTED BY MR. CISNEROS

        Mr. Cisneros. Explain how DOD screens and evaluates active-duty
    service members for susceptibility or risk factors for suicide prior to
    separation.
        Dr. Van Winkle. The Department's suicide prevention efforts
    leverage a public health approach, which involves continuous
    surveillance of known risk factors (e.g., separation from service,
    types of separation including other than honorable discharge status) in
    an effort to prevent suicide. There is a standard process to screen all
    recruits for mental health issues, which is one of the leading reasons
    for separation during recruit training, at Military Entrance Processing
    Stations. Periodic health assessments, completed annually, are used to
    continue to assess mental health readiness while in service. Further,
    in response to Executive Order (EO) 13822, the Department has
    implemented a mandatory separation health assessment for all
    transitioning Service members prior to separation, which includes a
    mental health component to identify those at-risk and take appropriate
    action.
        Mr. Cisneros. What are DOD and VA's responsibilities for carrying
    out a ``warm handover'' of a service member from DOD to VA care?
        Dr. Van Winkle. It is DOD policy that any Service member in active
    clinical care gets a warm handover to the next portal of care in the
    Department of Veterans Affairs (VA) or elsewhere. A health care liaison
    collects transitioning Service members' medical records, makes initial
    appointments in an appropriate VA medical center, and facilitates the
    handover to the new facility. DOD is also enhancing its programs and
    systems to improve and streamline the warm handover of Service members
    to VA resources in response to EO 13822. The new separation health
    assessment includes a mental health component, and those identified as
    at-risk or in need of additional support receive a warm handover to VA
    and/or other appropriate resources. The inTransition program provides
    post-service referrals (including to the VA), for transitioning Service
    members who have been identified with a mental illness or have sought
    mental health resources in the previous year. The Department has also
    enhanced the Transition Assistance Program (TAP), including adding
    facilitated registration for VA health care during the mandatory VA
    Benefits briefing. Additionally, an in-person warm handover to a VA
    Veterans Benefits Advisor (VBA) is initiated for transitioning Service
    members who are in need of additional support (e.g., with their VA
    benefits; those who have been identified to be at risk for homelessness
    by a transition counselor or Commander, etc.)
        Mr. Cisneros. Recognizing that there are a number of service
    members who do not self-report when in need of care, what are DOD and
    VA's policies and plans for pro-actively engaging and seeking out non-
    reporters?
        Dr. Van Winkle. DOD promotes help-seeking and access to care by
    implementing a range of programs and activities to remove stigma to
    seeking care. DOD offers programs that build unit cohesion, target
    efforts to at-risk Service members, and provide quality behavioral
    health care across a Service member's military life cycle.
    Additionally, the Department has implemented a mandatory separation
    health assessment for all transitioning Service members prior to
    separation, which includes a mental health component to identify those
    at-risk and take appropriate action. One new program, currently being
    piloted, the Resources Exist and Can Help training, is designed to help
    Service members become more familiar with care-seeking resources by
    identifying different resources and addressing misperceptions of
    seeking care.
        Mr. Cisneros. Are there any suicide prevention initiatives or
    programs that DOD has not undertaken because of cost?
        Dr. Van Winkle. Cost is not a factor in determining suicide
    prevention initiatives or programs. The DOD is expending significant
    resources to implement and evaluate existing suicide prevention
    programs, as well as piloting new evidence-informed initiatives and
    programs. If new initiatives and programs are shown to be effective in
    preventing suicide, the Department will explore how to best implement
    them across the Military Services.
        Mr. Cisneros. When asked what explains the increase in the number
    of suicides in 2018, both DOD and VA witnesses did not have an answer.
    What plans do each of the departments have to investigate the reasons
    for the increase in the number of suicides among service members?
        Dr. Van Winkle. Suicide is complex. Many biological, social, and
    psychological factors at the individual, community, and societal levels
    contribute to suicide. In recognition of this complexity, the DOD
    continues to implement a comprehensive public health approach to
    suicide prevention and conduct robust research and program evaluation
    efforts. The DOD is consistently analyzing suicide death data trends
    and reviews suicide death cases as an ongoing effort. In 2019, the DOD
    began piloting a comprehensive, 360-degree suicide death review process
    that will examine suicide cases from each of the Services.
    Additionally, the Department is publishing the inaugural Annual Suicide
    Report in summer 2019 that includes suicide rates for CY 2018, as well
    as trends over time.
        Mr. Cisneros. The DOD repeatedly mentioned the need to meet
    ``patients where they're at.'' What is the Department doing to ensure
    they are meeting patients ``where they're at''?
        Dr. Van Winkle. In order to meet patients where they are, DOD has
    embedded behavioral health providers within operational units in each
    of the Services. These embedded providers can be found both in non-
    deployed and deployed settings. Because of their proximity and
    immediate availability to Service members, embedded providers are able
    to identify and treat initial signs and symptoms of behavioral health
    issues with the goal of rectifying the issues before they develop into
    larger problems. In addition, embedded providers' daily proximity to,
    and familiarity with, Service members helps to reduce the stigma
    associated with receiving behavioral health care. DOD has also
    integrated behavioral health providers into Primary Care clinics in
    order to meet Service members at a place they are most likely to be
    seen for related medical concerns, especially if they have mental
    health concerns and are hesitant to seek mental health care. This
    allows Service members easy access to Integrated Behavioral Health
    Specialists (IBHC) who are part of the Primary Care team. The IBHC can
    quickly address symptoms, reduce the stigma of mental health care, and
    provide health care that includes mental health care in a one stop
    location. DOD also provides treatments tailored to each individual
    patient's needs. Treatment tailoring includes matching treatments to
    symptomatology and symptom severity, accounting for prior effective
    and/or ineffective treatments, and respecting patient preferences,
    strengths, and limitations. In the future, tailored care will include
    precision medicine approaches across demographic cohorts that comport
    with available evidence. Each of the Military Services also has a
    Combat Operational Stress Control (COSC) program. COSC providers work
    to identify and manage the physiological and psychological stress that
    may be experienced by Service members during combat in order to prevent
    the development of harmful stress reactions, and to mitigate the
    potential development of mental health disorders post-deployment. COSC
    providers, including seasoned psychiatrists, are located forward with
    the Service member, typically in deployed locations.
        Mr. Cisneros. What are DOD and VA's responsibilities for carrying
    out a ``warm handover'' of a service member from DOD to VA care?
        Dr. Franklin. [No answer was available at the time of printing.]
        Mr. Cisneros. Recognizing that there are a number of service
    members who do not self-report when in need of care, what are DOD and
    VA's policies and plans for pro-actively engaging and seeking out non-
    reporters?
        Dr. Franklin. [No answer was available at the time of printing.]
        Mr. Cisneros. It was indicated that 500,000 letters were sent out
    to veterans with an other than honorable discharge to clarify their
    eligibility for care, but only 3,500 came into care. Why is that number
    so low and what can be done to increase the number of veterans in that
    group to enter care?
        Dr. Franklin. [No answer was available at the time of printing.]
        Mr. Cisneros. When asked what explains the increase in the number
    of suicides in 2018, both DOD and VA witnesses did not have an answer.
    What plans do each of the departments have to investigate the reasons
    for the increase in the number of suicides among service members?
        Dr. Franklin. [No answer was available at the time of printing.]
                                     ______

                       QUESTIONS SUBMITTED BY MS. ESCOBAR
        Ms. Escobar. Fort Bliss has exhibited heightened suicide rates over
    the past year. The Bliss population accounts for more than 5% of the
    Army's end strength and a disproportionate 11% of Army suicides. What
    are you doing to understand the cause of this alarming trend? What are
    the impact points for local commanders and Army leadership
    respectively?
        Dr. Van Winkle. Because suicide is complex with many factors--and
    no two suicides are identical, the Department takes a comprehensive
    approach to suicide prevention, focusing on getting Service members to
    seek help and check in with each other, reducing barriers to care,
    while using simple safety measures and precautions to reduce the risk
    of suicide. Our comprehensive public health approach involves
    continuous surveillance of known risk and protective factors in an
    effort to develop, test, implement, and evaluate specific suicide
    prevention programs. The Army is currently conducting a Suicide
    Prevention Pilot at several installations, including Fort Bliss.
    Initiatives being executed through the pilot include Leader Education
    and Training and Command Visibility Tools. These initiatives are
    designed to augment leader capabilities and increase leader visibility
    of behavioral health problems. The Army's goal for these efforts is to
    see increased resilience, reduction in suicide and suicidal behaviors,
    and improved psychological health of our Soldiers. Army leadership is
    actively engaged in the Department's suicide prevention efforts through
    the Suicide Prevention General Officer Steering Committee (SPGOSC). The
    SPGOSC addresses present and future suicide prevention needs, employing
    data-driven, evidence-informed practices that are aligned with the
    Defense Strategy for Suicide Prevention and have DOD-wide
    applicability. Local commanders have a wide variety of clinical and
    non-clinical tools at their disposal for suicide prevention. In
    addition to military mental health treatment, commanders can make use
    of chaplains, embedded Military and Family Life Counselors, and other
    well-being programs focused on addressing stressors before they become
    crises (e.g., Military OneSource, financial readiness, family support
    programs).
        Ms. Escobar. Suicidal ideation rates at Bliss have increased 2.5
    times over the 2016-2018 period. Some observers suggest this may
    indicate improved access to services and/or comfort accessing services.
    If true, increased access is of course positive. How we can leverage
    that contact to improve outcomes for service members?
        Dr. Van Winkle. Suicide is a complex interaction of factors; while
    there is no one ``fix,'' we are fully committed to preventing suicide
    and ending this tragedy. The Department has a number of efforts
    underway to support Service members who come forward and seek help. We
    are leveraging evidence-informed practices and implementing a range of
    prevention programs that have shown promise in the civilian sector.
          The DOD utilizes a comprehensive portfolio of suicide
    prevention initiatives and is committed to ensuring our Service members
    have ready access to quality mental health treatment, with effective
    and trustworthy providers.
          The DOD recently partnered with VA to complete a Clinical
    Practice Guideline (CPG) on the assessment and management of suicide.
    This evidence review found clinical practices that can reduce suicide--
    particularly in specific high-risk patient populations. The CPG is
    designed to ensure those who do come forward and seek help have high-
    quality, evidence-based care.
        Ms. Escobar. I noted the high prevalence of gunshot wounds in
    reported suicide data for Fort Bliss. What, if any, policy
    prescriptions does this indicate could improve service member safety?
        Dr. Van Winkle. Data shows that the most common method of suicide
    death among Service members is by firearm. Gunshot wounds were reported
    in 62.5% of suicide deaths at Fort Bliss. This aligns with data on
    suicide deaths within the force at large. In CY 2018, 60.0% of Active
    Component suicide deaths, 61.7% of Reserve suicide deaths, and 69.6% of
    National Guard suicide deaths were by firearm. We have policies that
    allow commanders to refer, in a compulsory manner if necessary, Service
    members who need help for suicidality. Each Service has its own,
    specific regulations under the umbrella of DOD policy, but, generally,
    commanders are responsible for the temporary storage and accountability
    of privately owned fire arms and ammunition voluntarily relinquished by
    Service members, in coordination with installation law enforcement and
    in accordance with local installation procedures. All policies and
    procedures are, and must be, in compliance with Public Laws. In the
    Navy, guidance has been issued to go beyond the regular promotion of
    the voluntary use of gun locks and other safe storage methods.
    Commanders and health professionals may inquire about, collect, and
    record information about a Service member's privately-owned firearms,
    ammunition, or other weapons if the commander or health professional
    has reasonable grounds to believe the Service member is at risk for
    suicide or causing harm to others. Air Force commanders use Time-Based
    Prevention, which is an approach to suicide prevention focused on the
    means most often used during fatal suicide completions--personal
    firearms. Time-Based Prevention efforts are intended to eliminate the
    hazard of firearms being readily available during the first five
    minutes when an individual decides to perform a suicidal act. It is
    important to note Time-Based Prevention efforts do not limit or
    prohibit the legal ownership or use of firearms in any manner for
    individuals. Army commanders must establish and publicize procedures
    for registering, transporting, and storing privately owned weapons.
    Soldiers, Family members, and personnel living on installations must
    register their privately owned firearm and ammunition within 24 hours.
    All privately owned firearms and ammunition will be stored in unit arms
    rooms.
        Ms. Escobar. Fort Bliss has exhibited heightened suicide rates over
    the past year. The Bliss population accounts for more than 5% of the
    Army's end strength and a disproportionate 11% of Army suicides. What
    are you doing to understand the cause of this alarming trend? What are
    the impact points for local commanders and Army leadership
    respectively?
        Captain Colston. The MHS embeds evidence-based suicide prevention
    programs, which are supported by an interagency collaboration with the
    VA, in the delivery of mental health care services through a
    combination of policy, guidelines, and initiative implementation.
    Suicide prevention policies and programs within the MHS focus on
    preventing suicide deaths through the dissemination of effective
    interventions. Suicide Prevention Programs (SPPs) are administered by
    each military department, and include aspects of prevention within
    basic unit training. SPPs consist of a dedicated program office
    responsible for the application of a comprehensive public health
    approach to suicide prevention across DOD. Additionally, SPPs utilize
    clinical measures that monitor suicide risk for Service members
    accessing mental health care in the direct care system.
        Ms. Escobar. Suicidal ideation rates at Bliss have increased 2.5
    times over the 2016-2018 period. Some observers suggest this may
    indicate improved access to services and/or comfort accessing services.
    If true, increased access is of course positive. How we can leverage
    that contact to improve outcomes for service members?
        Captain Colston. There are a number of ways increased access to
    care can be leveraged to improve outcomes for service members. The DOD
    has invested in a number of programs that increase access to mental
    health care for Service members who are experiencing symptoms of a
    psychological health condition in order to improve outcomes. Service
    members are eligible to receive free, comprehensive behavioral health
    care (including clinical assessment, psychotherapy, and psychiatric
    treatment) at their local military medical treatment facilities. We
    also have programs that increase access to care by embedding
    psychological health providers in operational units to assist Service
    members in their everyday work environments. Access to care is
    increased by the primary care medical homes that provide follow-up when
    Service members disclose psychological health concerns to their primary
    care provider. Military OneSource is our 24/7 resource to connect
    Service members to information about their psychological health, non-
    medical counseling for stress management, and referrals to healthcare
    providers to increase access to care and improve outcomes.
        Ms. Escobar. I noted the high prevalence of gunshot wounds in
    reported suicide data for Fort Bliss. What, if any, policy
    prescriptions does this indicate could improve service member safety?
        Captain Colston. The DOD aims to eliminate on and off-duty mishaps
    and related deaths, injuries, occupational illnesses, and lost mission
    capability and resources. Policy is currently in place, which: (1)
    Protect DOD personnel from accidental death, injury, or occupational
    illness; (2) Apply risk management strategies to eliminate occupational
    injury or illness and loss of mission capability and resources both on
    and off duty. (3) Perform analysis of safety and occupational data to
    highlight high-risk behaviors and facilitate risk-reduction measures;
    and (4) Engages at the operational level to seek initiatives and
    projects to reduce risk in areas of concern common to all Military
    Services.
        Ms. Escobar. We know from veteran data that suicide rates decline
    as contact with VA system increases. What lessons learned can the DOD
    can benefit from and seek to implement in their programming?
        Dr. Franklin. [No answer was available at the time of printing.]
        Ms. Escobar. We've seen a series of unfortunate stories about
    veterans taking their own lives on VA premises. Often a firearm is
    used. How will the VA address this troubling pattern to help keep
    veterans safe at their most vulnerable moments?
        Dr. Franklin. [No answer was available at the time of printing.]
        Ms. Escobar. We know from veteran data that suicide rates decline
    as contact with VA system increases. What lessons learned can the DOD
    can benefit from and seek to implement in their programming?
        Mr. Fisher. [No answer was available at the time of prining.]
        Ms. Escobar. We've seen a series of unfortunate stories about
    veterans taking their own lives on VA premises. Often a firearm is
    used. How will the VA address this troubling pattern to help keep
    veterans safe at their most vulnerable moments?
        Mr. Fisher. [No answer was available at the time of printing.]
        Ms. Escobar. I found the December 2018 reports of unspent VA
    suicide prevention outreach funds highly troubling. It's upsetting to
    think about how many more lives that $6.2 million, if put to good use,
    might have saved. But in the interest of moving forward: How can we do
    better at outreach? How else should we support veterans who may be
    struggling with suicidal ideation?
        Mr. Fisher. [No answer was available at the time of printing.]

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