[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.]

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

                           A P P E N D I X

                              May 21, 2019
      
=======================================================================


              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                              May 21, 2019

=======================================================================
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]	
      
=======================================================================


                   DOCUMENTS SUBMITTED FOR THE RECORD

                              May 21, 2019

=======================================================================
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]	

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


              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                              May 21, 2019

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

      

             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.]

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


              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                              May 21, 2019

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

      

                  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.]

                                  [all]