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


            TRAGIC TRENDS: SUICIDE PREVENTION AMONG VETERANS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         MONDAY, APRIL 29, 2019

                               __________

                            Serial No. 116-6

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                           
                           C O N T E N T S

                              ----------                              

                         Monday, April 29, 2019

                                                                   Page

Tragic Trends: Suicide Prevention Among Veterans.................     1

                           OPENING STATEMENTS

Honorable Mark Takano, Chairman..................................     1
    Prepared Statement...........................................    47
Honorable David P. Roe, Ranking Member...........................     4

                               WITNESSES

Dr. Shelli Avenevoli.Deputy Director, National Institutes of 
  Mental Health, National Institutes of Health...................     5
    Prepared Statement...........................................    49

Dr. Richard McKeon, Chief, Suicide Prevention Branch, Substance 
  Abuse and Mental Health Services Administration................     7
    Prepared Statement...........................................    52

Dr. Richard Stone, Executive in Charge, Veterans Health 
  Administration, Department of Veterans Affairs.................     9
    Prepared Statement...........................................    55

        Accompanied by:

    Dr. Keita Franklin, National Director of Suicide Prevention, 
        Department of Veterans Affairs

                       STATEMENTS FOR THE RECORD

American Veterans (AMVETS).......................................    60
Disabled American Veterans (DAV).................................    67
Iraq and Afghanistan Veterans of America (IAVA)..................    71
The American Legion (TAL)........................................    73
Vietnam Veterans of America (VVA)................................    77
Wounded Warrior Project (WWP)....................................    78
Center for Disease Control (CDC).................................    86
Veterans of Foreign Wars (VWF)...................................    88
The Independence Fund............................................    91

                        QUESTIONS FOR THE RECORD

Representative Lauren Underwood to National Institute of Mental 
  Health (NIMH)..................................................    94
Representative Lauren Underwood to Dr. Richard Stone.............    95
Chairman Mark Takano to Veterans Affairs.........................    97
Chairman Mark Takano Regarding the Public Health Model 
  (Generally)....................................................   117
Representative Lauren Underwood to Veterans Affairs..............   122

 
            TRAGIC TRENDS: SUICIDE PREVENTION AMONG VETERANS

                              ----------                              


                         Monday, April 29, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 7:15 p.m., in 
Room 1334, Longworth House Office Building, Hon. Mark Takano 
[Chairman of the Committee] presiding.
    Present: Representatives Takano, Brownley, Rice, Lamb, 
Levin, Brindisi, Rose, Pappas, Luria, Lee, Cunningham, 
Cisneros, Peterson, Sablan, Allred, Underwood, Roe, Bilirakis, 
Radewagen, Bost, Bergman, Banks, Barr, Meuser, Watkins, Roy, 
and Steube.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good evening. I call this hearing to order.
    First, I would like to welcome our witnesses this evening: 
Dr. Stone from the Veterans Health Administration, Dr. 
Avenevoli from the National Institutes of Health, Dr. McKeon 
from the Substance Abuse and Mental Health Services 
Administration.
    Today's hearing will be the first of many this Committee 
will hold as it begins the critical work to address veteran 
suicide. I think we can all agree how important it is to take 
care of our veterans, which is why I have made ending veteran 
suicide my number one priority.
    Sadly, America is facing a national public health crisis 
that demands urgency from Congress, the administration, medical 
and clinical professionals, veteran service organizations, and 
veterans themselves.
    This morning we lost another veteran to suicide at a VA 
hospital. Two weeks ago, three veterans committed suicide on VA 
property in just 5 days. Seven veterans have ended their lives 
on VA campuses this year.
    It is clear we are not doing enough to support veterans in 
crisis. While these incidents may be alarming, they do not tell 
the full story of veteran suicide in our country. It is harmful 
to veterans and overly simplistic solely to blame VA for these 
tragedies. We must come together as a Nation to address this 
crisis.
    Too many Americans have been personally touched by this 
troubling trend. For me, it was my own uncle, a Vietnam 
veteran, who died by suicide. I still remember the day that I 
came home in September when I was 10 years old to find out that 
my Uncle Sabato (ph), a Vietnam war veteran, had taken his own 
life, and he lived across the street from my own family. His 
suicide still haunts me from time to time to this day.
    Each day, 20 veterans, servicemembers, reservists, and 
members of the National Guard die by suicide. One veteran lost 
to suicide is one too many, but 20 deaths a day, totaling more 
than 7,300 deaths per year, is unacceptable.
    To put this in perspective, that is 1,800 more deaths per 
year than the 5,429 servicemembers who have been killed in 
action since 2001. Both numbers are surprising and further 
evidence of a frustrating and persistent problem that we fail 
to adequately address.
    When you examine the statistics, barriers to access many 
veterans face become very clear. Only 6.1 of those deaths are 
veterans accessing services at VA, but 10.6 deaths a day are 
veterans not using the VA at all, and 3.8 current Active Duty 
or members of the National Guard are also committing suicide.
    We all have a responsibility to act because there is no 
excuse for failing these veterans here at home. My Republican 
colleague, Ranking Member Roe, often says we haven't moved the 
needle far enough to reduce veteran suicide and he is right. 
That number has held steady at 20 deaths a day since 2014 for 
far too long. It is time for Congress to look at this crisis 
with fresh eyes.
    In 2015, Congress passed the Clay Hunt Suicide Prevention 
for Americans Act, otherwise known as the SAV Act. But this 
well-intentioned effort hasn't done enough. Recently, I met 
with some members of Clay Hunt's unit who identified the 
specific challenges they faced as they transitioned out of the 
military.
    We need to understand why this legislation hasn't done more 
to prevent suicides. We need to expand our understanding of 
mental health among veterans. We need to commit to providing 
the resources needed to implement a comprehensive plan.
    Most importantly, Americans must hear from and listen to 
our veterans. We need to hear from veterans who have attempted 
suicide, understand their circumstances, and find out what they 
believe worked and what failed. These veterans have a story to 
share that can tell us something about our attempt to address 
suicide and how responsive government can be to their 
situation.
    This Committee will not be indifferent to the problem's 
veterans face, nor will we turn a blind eye to the many causes 
that lead to veterans committing suicide, and I am glad that we 
could all come together today to begin to tackle this important 
issue. Ultimately, it is up to all of us to reduce and prevent 
veteran suicide because this is not a problem that VA can solve 
alone.
    We know that dedicated doctors, nurses, and VA employees 
saved over 240 veterans from committing suicide on VA campuses 
in recent years. VA briefs me on each suicide at a VA facility, 
and there is still so much that we don't know.
    We must involve partners at the Federal, State, and local 
levels and do a better job of supporting veterans in need 
regardless of whether that need is clinical or social.
    By supporting clinically effective programs and increasing 
access to programs that mitigate the impact of concerns, be 
they financial, marital, substance abuse related, or physical 
health, veterans will feel the support they seek.
    VA must also ensure that every interaction it has, not just 
in a clinical setting, makes veterans feel supported.
    One example from VFW struck me when I was reading the 
statements for the record from the VSOs, and I quote:
    The VFW is working with a veteran who was rushed to a VA 
hospital during a mental health crisis caused by untreated 
bipolar disorder and depression. The veteran was admitted to 
the medical center's inpatient medical health care clinic for 2 
weeks, despite not being eligible for VA health care. The VA 
did save his life, but now he has a $20,000 bill. His mental 
health crisis was exacerbated by unemployment and his inability 
to provide for his family. With proper treatment, he has been 
able to return to work but still lacks the resources to pay the 
VA bill. The VFW is working on having his bill waived, but he 
will never return to VA if he has another mental health 
crisis,'' end quote.
    Now, this is just one more testament to what we already 
know: When a veteran is faced with the sky-high cost of medical 
care, that can be a significant barrier to getting help, the 
help they need.
    To really combat this crisis, we will have to change our 
mission. We must reexamine our approach to suicide prevention, 
exhaust our research possibilities, break the stigma faced by 
those seeking mental health services, and expand the health 
care and support we offer veterans.
    Like all of those in this room, I believe Americans are 
ready to meet this challenge. Countering this crisis will 
require us to shine a national spotlight on veteran suicide, 
and there is still so much that we do not know. We need to 
better understand the root causes driving veteran suicide, hear 
from the families who have lost loved ones, and listen to the 
clinicians and social workers who are on the front lines 
battling to end veteran suicide.
    As Americans, we are proud of the service and sacrifice 
that they have made for our country, but a ``thank you for your 
service'' isn't enough for our veterans in crisis. Instead, we 
must thank and honor our veterans with action, work together to 
deliver top quality health care, provide community support, and 
ensure we offer a stable transition out of military service and 
into quality, sustainable employment.
    Truly, thanking veterans for their service means helping 
them when they need it most and to rise above political 
opportunism to support veterans in crisis. It is my hope that 
together we can curb this crisis.
    Now, before I recognize Ranking Member Roe, I would like to 
point out that May is Mental Health Awareness Month, and we all 
have to do our part. I encourage every Member of this Committee 
to record a suicide prevention public service announcement to 
highlight VA's Be There campaign.
    As the Wounded Warrior Project pointed out, quote, ``If a 
treatment program does not offer a family or a caregiver 
component, and warriors go through clinical processes when they 
return home, it may leave the family or caregiver to feel left 
out, in the dark about what occurred,'' end quote.
    We should all be doing all that we can to ensure family 
members and caregivers not only feel supported, but have access 
to much-needed resources as they help their loved ones recover.
    In addition, I would encourage all of you to meet with both 
veterans who are suicide survivors and speak with families who 
have lost loved ones to suicide to better understand how we can 
work to end this crisis.
    Now at this time I would like to recognize my friend and 
colleague, Dr. Roe, for 5 minutes for any opening remarks that 
he may have.

       OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

    Mr. Roe. Thank you, Mr. Chairman, and thank you for holding 
this hearing tonight and also shining a light on veteran 
suicide.
    Tonight's topic is the most important, most confounding, 
and the most heartbreaking one that we will discuss in this 
Committee.
    While suicide is a tragedy no matter where it happens, it 
is particularly painful when it occurs on the grounds of a 
Department of Veterans Affairs medical facility with help mere 
feet away.
    The last several weeks have seen four incidents of suicide 
on VA campuses, including one just today in Cleveland. My heart 
goes out to the surviving family members and friends of each of 
these veterans, and I want them to know that they are foremost 
on our minds here in this Congress. Their loved ones are a part 
of approximately 20 of our Nation's veterans, Active Duty 
servicemembers, and members of National Guard and Reserve who 
die by suicide each day.
    That rate has remained largely the same since the 1990s 
despite two decades of sincere effort from administrations on 
both sides of the political spectrum and substantial increases 
in funding, staffing, programs, attention, and support for 
mental health care and suicide prevention inside and outside of 
the VA health care system.
    Since 2005 alone, funding for VA mental health care has 
increased 258 percent to a high of $9.4 billion in the most 
recent request.
    Unquestionably, too little progress has been made. 
Unquestionably, a business as usual approach to this crisis is 
not sufficient.
    To be clear, the tragedy of suicide is a societal one that 
is in no way unique to VA or to veterans. Let me just give you 
an anecdotal description of why I know that is true.
    In my State of Tennessee, when I graduated from medical 
school, we had Eastern State, Central State, and Western State 
mental hospitals. Those are all gone.
    As I went across my district and held townhalls and 
roundtables this past 2 weeks, I met an EMT who told me that he 
worked in the ER on weekends. One weekend he had a man there 
who was in a room waiting for a bed in a mental hospital. He 
came back a week later, and the man was still in the emergency 
room.
    For seniors, we have to transport people from Sullivan 
County, Tennessee--you don't know where that is--but to 
Memphis. And I can tell you, it is 500 miles away.
    We do not have the mental health infrastructure not just 
for VA, but for our citizens in this country anymore, and it is 
something we are going to have to learn to deal with as a 
Nation. Of the 20 suicide deaths per day among our Nation's 
heroes, 14 have not received, as the Chairman said, VA health 
care in the 2 years preceding their deaths. This is a clear 
indication that VA alone cannot solve this crisis.
    I commend President Trump for issuing two executive orders 
in the last 2 years to rally Federal, State, and local 
government agencies, as well as nongovernmental organizations, 
around this issue. I look forward to the hearing today about 
how those executive orders are working and how their impact 
will be measured moving forward.
    I am also looking forward to delving into an important 
concept that Secretary Wilkie and his team, including Dr. Stone 
and Dr. Franklin who are both with us tonight, have been 
stressing recently, and that is that suicide is not exclusively 
a matter of mental health. It is quite a bit more complex than 
that, and solving it will require nothing less than harnessing 
the collective efforts of every community around in need long 
before the crisis point is reached.
    Tonight's hearing would be incomplete if it didn't include 
a frank discussion about the role each one of us can play in 
our districts to stem the tragic tide of veteran suicide and 
about the deeper personal and societal issues, such as loss of 
purpose, belonging, and connection, that far too many 
Americans, not to mention veterans, are struggling with. Our 
goal should be more than just preventing suicide. It should be 
helping our veterans to live a life of meaning and joy.
    I would like to also caution us all in having that 
discussion to resist narratives that paint veterans as victims, 
or a tragedy of suicide is insurmountable. We know from 
research and experience that treatment works and recovery is 
possible, and that is the principal message that I hope 
everyone takes home tonight with them.
    I am grateful for all of our witnesses and audience members 
for being here this evening.
    And I yield back, Mr. Chairman.
    The Chairman. Thank you, Dr. Roe.
    Again, appearing before us tonight is Dr. Shelli Avenevoli, 
and she is the Deputy Director of the National Institute of 
Mental Health; Dr. Richard McKeon, Chief, Suicide Prevention 
Branch of the Substance Abuse and Mental Health Services 
Administration; Dr. Richard Stone, Executive in Charge, 
Veterans Health Administration, Department of Veterans Affairs, 
and accompanied by Dr. Keita Franklin, National Director of 
Suicide Prevention, Department of Veterans Affairs.
    And we will begin first with testimony from Dr. Avenevoli.
    And, Dr. Avenevoli, you are recognized for 5 minutes to 
give your opening statement.

                 STATEMENT OF SHELLI AVENEVOLI

    Ms. Avenevoli. Thank you. Good evening, Chairman Takano, 
Ranking Member Roe, and distinguished Members of the Committee. 
I am Dr. Shelli Avenevoli, the Deputy Director of the National 
Institute of Mental Health within the National Institutes of 
Health. It is an honor to appear before you today alongside my 
colleagues from SAMHSA and the VA.
    Given the troubling rise in the national suicide rate in 
the past decades, suicide prevention research is an urgent 
priority for the NIH. As the lead Federal agency for research 
on mental disorders, NIMH's portfolio includes projects aimed 
at identifying who is most at risk for suicide, understanding 
the causes of suicide risk, developing interventions, and 
testing the effectiveness of suicide prevention services in 
real world settings. In collaboration with our Federal and 
private partners, we work to translate these research findings 
into evidence-based practices.
    Today I want to highlight research that has identified 
promising suicide prevention tools ripe for implementation 
within health care systems. When used effectively and in 
combination, these tools may increase the number of lives saved 
among veterans and among all Americans.
    Healthcare settings are important for two reasons--access 
and opportunity. Nearly half of individuals who die by suicide 
had some type of medical visit in the 30 days prior to death, 
and around 80 percent did so in the year before death. In 
addition, about half of people who die by suicide had at least 
one emergency department visit in the year before death.
    NIMH-funded research has identified a growing number of 
evidence-based suicide prevention tools that can be used right 
now in these health care settings. I would like to walk you 
through a scenario that showcases how the health care system, 
using some of these tools, can identify more people at risk for 
suicide, provide effective treatment, and ensure appropriate 
follow-up care.
    So let's say you are depressed and feeling suicidal, but 
you haven't told anyone about these feelings. One day you have 
severe abdominal pain and you go to the emergency room. Your 
conversation with the doctor focuses on your physical pain, but 
because this emergency room screens all patients for suicide 
risk, the doctor asks you if you have had suicidal thoughts or 
attempted suicide.
    Our funded research shows that screening all patients 
doubles the number of people we can identify who are in need of 
help for suicide risk.
    So when you tell this doctor that you have been considering 
suicide, the doctor connects you with a social worker. The 
social worker asks questions to assess your level of risk, 
discusses treatment options with you, and works with you to 
develop a personalized safety plan. This safety plan describes 
approaches for reducing your access to lethal means, identifies 
specific coping strategies to decrease your risk, and lists 
people and resources that could help you in crisis.
    Safety planning is an evidence-based intervention, and we 
are currently supporting research in the best ways to deliver 
this in various settings and populations.
    As part of that safety plan, the social worker links you 
with a local crisis center that is part of the National Suicide 
Prevention Lifeline system. This crisis center works with your 
hospital to keep in contact with you by telephone over the next 
few months, a very high-risk time for suicide.
    An NIMH-funded study has shown that this combination of 
screening, brief prevention, and follow-up contact reduced 
suicide attempts in the next year by about 30 percent.
    A growing number of health care systems are implementing 
many of these evidence-based practices, but we know there is 
more we can do. Through the National Action Alliance for 
Suicide Prevention, the NIMH, SAMHSA, CDC, VA, and other public 
and private partners are working towards a goal of zero suicide 
deaths in health care in which health systems implement these 
and other evidence-based practices. The zero-suicide framework 
includes comprehensive tracking of patient outcomes so we can 
monitor progress and identify additional ways to save lives.
    Today I have highlighted just some of the suicide 
prevention tools our researchers have tested in the health care 
system. We are committed to working with our partners and 
stakeholders to ensure these evidence-based tools are 
implemented and accessible to all. Moving forward, we will 
continue to provide hope by supporting research to prevent 
suicide.
    I want to thank the Committee again for bringing us 
together, and I am happy to address any questions you may have.

    [The prepared statement of Shelli Avenevoli appears in the 
Appendix]

    The Chairman. Thank you, Dr. Avenevoli.
    Dr. McKeon, you are recognized for 5 minutes to give your 
opening statement.

                  STATEMENT OF RICHARD MCKEON

    Mr. McKeon. Thank you. Chairman Takano, Ranking Member Roe, 
Members of the Committee, thank you for inviting the Substance 
Abuse and Mental Health Services Administration to participate 
in this extremely important hearing on suicide prevention for 
America's veterans. I am Dr. Richard McKeon, Chief of the 
Suicide Prevention Branch at SAMHSA.
    An American dies by suicide every 11.1 minutes. Suicide is 
the tenth-leading cause of death in the United States and the 
second-leading cause of death between ages 10 and 34. We lost 
over 47,000 Americans to suicide in 2017, almost the same 
number we lost to opioid overdoses. For each of these tragic 
deaths, there are grief-stricken families and friends, impacted 
workplaces and schools, and the diminishment of our 
communities.
    SAMHSA's National Survey on Drug Use and Health has also 
shown that approximately 1.4 million American adults report 
attempting suicide each year, and over 10 million adults report 
seriously considering suicide.
    As painful as these numbers are, our concern is intensified 
by the CDC's report that suicide has been increasing in 49 of 
the 50 States, with 25 of the States experiencing increases of 
more than 30 percent.
    While Federal efforts to prevent suicide have been steadily 
increasing over time, thus far they have been insufficient to 
halt this tragic rise. We can only halt this rise nationally if 
we are also reducing suicide among the estimated 20 veterans a 
day who die by suicide, including those not in the care of the 
U.S. Department of Veterans Affairs.
    All of us must be engaged in this effort, and for this 
reason, SAMHSA includes language in our suicide prevention 
funding opportunities prioritizing veterans and has worked 
actively with VA on suicide prevention since 2007.
    While we have not as of yet been able to halt this tragic 
rise, we have seen that concerted, sustained, and coordinated 
efforts can save lives.
    One area where such a concerted national effort has been 
made is youth suicide prevention. Cross-site evaluation of our 
Garrett Lee Smith Youth Suicide Prevention grants has shown 
that counties that were implementing grant-supported suicide 
prevention activities had fewer youth suicides and suicide 
attempts than matched counties that were not. However, this 
life-saving impacts fades 2 years after the activities have 
ended. This underscores the need to embed suicide prevention in 
the infrastructure of States and communities.
    Congress has also provided SAMHSA $11 million to focus on 
adult suicide prevention, with $9 million appropriated to the 
Zero Suicide initiative.
    This is an effort, as my colleague has expressed, to 
promote a systematic, evidence-based approach to suicide 
prevention and health care systems using the most recent 
findings from controlled scientific studies as part of a 
package of interventions that move suicide prevention from 
being a highly variable and inconsistently implemented 
individual clinical activity to a systemized and prioritized 
effort. It uses the most recent science on screening, risk 
assessment, safety planning, care protocols, and evidence-based 
treatment.
    We have also been working through all of our suicide 
prevention grant programs to improve post-discharge follow-up 
since multiple studies have shown that rapid contact after 
discharge from EDs and in-patient units is a time of high risk.
    The SAMHSA suicide prevention program that touches the 
greatest number of people is the National Suicide Prevention 
Lifeline, a network of 165 crisis centers across the country. 
The National Suicide Prevention Lifeline includes a special 
link to the Veterans Crisis Line, which is accessed by pressing 
1. Last year, more than 2.2 million calls were answered through 
the lifeline, and that number has continued to grow at a rate 
of about 15 percent per year. However, the increasing call 
volume is also straining the lifeline system of community 
crisis centers which are responsible for responding to calls.
    More recently, SAMHSA and VA have worked together to fund a 
series of mayor's challenges and governor's challenges to 
prevent suicide among all veterans, servicemembers, and their 
families. We have convened cities and States and policy 
academies and implementation academies to promote comprehensive 
suicide prevention for veterans. Multiple public and private 
partners are engaged in this effort.
    As an example, in the Richmond Mayor's Challenge, the 
McGuire VA Medical Center and the Public Mental Health Center, 
Richmond Behavioral Health Authority, have developed a 
coordination and referral process to assure that veterans at 
risk don't fall through the cracks between VHA and community 
system. That work is now being implemented elsewhere in 
Virginia as part of the governor's challenge. We believe that 
this type of strong continuing interdepartmental effort that 
incorporates States and communities as partners is necessary to 
reduce veteran suicide.
    In summary, SAMHSA is engaged in an unprecedented amount of 
suicide prevention activities, but we know we need to do more 
to play our role in halting the tragic rise in loss of life we 
are experiencing across the country.
    In particular, we know we need to be engaged in a strong 
continuing collaborative effort with the Veterans 
Administration and others to reduce suicide among our Nation's 
veterans. We know we must be constantly looking to improve our 
efforts and to learn from both our successes and our failures.
    We owe it to those who have served this Nation and to all 
those we have lost, as well as to those that love them, to 
continually strive to improve until suicide among veterans and 
among all Americans is dramatically reduced.

    [The prepared statement of Richard McKeon appears in the 
Appendix]

    The Chairman. Thank you, Dr. McKeon.
    We will now hear from Dr. Stone, who will be recognized for 
5 minutes to give his opening statement.

                   STATEMENT OF RICHARD STONE

    Dr. Stone. Good evening, Chairman Takano, Ranking Member 
Roe, and Members of the Committee. I appreciate the opportunity 
to be here to discuss the critical work VA is undertaking to 
prevent suicide among our Nation's veterans. I am accompanied 
today by Dr. Keita Franklin, Executive Director of the VA 
Suicide Prevention Program.
    Suicide is a serious public health tragedy that affects 
communities across this Nation, and recently this tragedy has 
occurred on the grounds of our VA health care facilities. In 
the last 6 weeks, six veterans have ended their lives on our 
health care facilities. Our facilities are designed to be 
places of safe haven for those who defended our Nation.
    Although less than one half of 1 percent of suicides occur 
at both VA and civilian health care facilities, these events 
highlight the important discussion that we will have here 
tonight. All of us at VA feel these losses as we have dedicated 
our professional lives to provide health care and enhance the 
resilience of our Nation's veterans.
    The 2018 National Strategy for Preventing Veteran Suicide 
is a multi-year strategy that provides a framework for 
identifying priorities, organizing efforts, and focusing 
community resources to prevent suicide among veterans. This 
approach has four key areas.
    First, primary prevention that focuses on preventing 
suicidal behavior before it reaches the level of individual 
self-harm. Second, a whole-health approach that considers 
factors beyond just mental health. Third, application of data 
and research that emphasizes evidence-based interventions. And 
fourth, collaboration that educates and empowers communities to 
propagate suicide prevention efforts beyond the VA.
    These efforts should move us from a crisis intervention 
focus to one that enhances the relational skills and resilience 
of our heroes.
    We know that an average of 20 veterans die by suicide every 
day. This number has remained relatively stable over the last 
several years. Of those 20, only 6 have used VA health care in 
the 2 years prior to their death while the majority, 14, have 
not.
    In addition, we know from national data that more than half 
of Americans who died by suicide in 2016 had no mental health 
diagnosis at the time of their death. This is also true for our 
veterans.
    We also know that a massive expansion of VA mental health 
providers and increased mental health access has done little to 
reduce the total number of suicides among America's veterans.
    While there is still much to learn, there are some things 
that we know: Suicide is preventable, treatment actually works, 
and there is always hope.
    Maintaining the integrity of VA's mental health care system 
is vitally important, but clearly, this is not enough. VA 
alone, without the help of all of you, cannot end veteran 
suicide.
    The VA has expanded its suicide prevention efforts into a 
public health approach while maintaining and expanding our 
crisis intervention services. We ask all of you to help, and we 
appreciate the public service announcements many of you have 
already recorded.
    VA is expanding our understanding of what defines health 
care by developing a whole-health approach that engages, 
empowers, and equips our veterans for lifelong health, improved 
resilience, and improved well-being. VA is uniquely positioned 
to make this a reality for our veterans and for our Nation. 
This effort is about enhancing individual resilience.
    On March 5, 2019, the President signed Executive Order 
13861, a national roadmap to empower veterans and end suicide, 
in order to improve the quality of life for our Nation's 
veterans and develop a national public health roadmap to lower 
the veteran suicide rate. This executive order will further 
VA's efforts to collaborate with partners and communities 
nationwide and to use the best available information to support 
all veterans.
    We must partner with, empower, and energize all communities 
to engage veterans who do not use VA services. We are committed 
to advancing our outreach, prevention, empowerment, and 
treatment efforts, and we will continue to improve access to 
care. Our objective, however, is to give our Nation's veterans 
the top-quality care that they have earned, wherever and 
whenever they choose to receive it.
    Mr. Chairman, this concludes my statement. My colleague and 
I are prepared to respond to your questions.
    With your tolerance, sir, I would like to do something that 
I did before, and I would like everyone that has not done so 
already to take your phone out and to type in the Veteran 
Crisis Line, 1-800-273-8255. 1-800-273-8255. You will be 
prompted to press 1 if you are a veteran, and you will be 
connected to our professionals. You can also text 838255, 
838255, to connect with a VA responder.
    Mr. Chairman, thank you.

    [The prepared statement of Richard Stone appears in the 
Appendix]

    The Chairman. Thank you, Dr. Stone.
    Let me say that Dr. Avenevoli, Dr. McKeon, and Dr. Stone's 
full written testimony will be included in the hearing record.
    Let's move on to the questions. I will begin with myself. I 
recognize myself for 5 minutes. And my first question is for 
Dr. Stone.
    Dr. Stone, VFW's statement provides an example where a 
veteran sought immediate treatment at a VA mental health clinic 
because, quote, she feared that she would take her own life, 
end quote.
    The front desk clerk told her that she couldn't be seen 
immediately because she had completed a mental health 
appointment the previous day, and the next available 
appointment wasn't ready for a week.
    Thankfully, this veteran survived despite failing to 
receive the appropriate care.
    In contrast, at VA hospitals throughout the country 
employees have responded by saving 240 veterans' lives when 
they walked through the hospital doors needing help.
    But let's put ourselves in the shoes of this woman for a 
moment. That interaction with the front desk clerk or a nurse 
or a police officer could have led to her life being saved or 
led to that veteran going to the parking lot and committing 
suicide. How should the front desk clerk have responded- And 
how is every VA employee trained to recognize the signs of a 
veteran in crisis?
    Dr. Stone. Mr. Chairman, clearly this veteran should have 
been seen. I would be happy to review the events related to 
that if they can be provided to me by your staff.
    Secondly, let me reference the bill that was created for 
the veteran that you referenced. Certainly I am very pleased 
that this veteran was admitted for a 2-week period of time, or 
at least that is my understanding.
    I am deeply disappointed that the first I have heard about 
this bill is in this hearing. I think it would have been 
helpful when I had breakfast with that VSO 2 weeks ago and 
discussed suicide if we could have brought this to my 
attention. We could have alleviated 2 weeks of suffering for 
that veteran and his family. We will be happy to work with 
this.
    I can only assume that the lack of eligibility for payment 
for those services through our normal budgeting reflects 
something in the veteran's background that made him or her 
ineligible.
    But what should that front desk clerk have done- That front 
desk clerk has, in all likelihood, gone through SAV training, 
which is training that we give to our nonclinical personnel to 
recognize issues that veterans should have been seen and then 
evaluated by a medical professional.
    It is notable that our police officers go through 30 hours 
of mental health training in order to recognize veterans in 
crisis. They also go through approximately 20 hours of actual 
scenario-based study in which they demonstrate their capability 
to diffuse and deescalate situations. That has been recognized 
at our training academy, and a number of other Federal agencies 
and police agencies have sought that training from us.
    I will defer to Dr. Franklin if she has additional 
comments.
    Ms. Franklin. The only other piece I would add is that I 
appreciate the context of the question with regard to the front 
desk, because everybody has a role when it comes to preventing 
suicide, and anybody in the hospital system can do the right 
thing, and we are teaching them that through the training. We 
are teaching them to know the signs, know the symptoms, know 
what a risk is, and to take action at their level regardless of 
what level that is.
    The Chairman. Dr. Franklin and Dr. Stone, if I were to ask 
any VA employee at a VA hospital how they should respond when a 
veteran in crisis walks through the door, what answer would I 
get?
    Dr. Stone. The answer should be yes. The answer should 
always be yes and we welcome veterans to be seen. Every one of 
our sites, more than a thousand sites, have same day access for 
mental health services, regardless of veteran status.
    The Chairman. Is every employee trained to recognize the 
signs of a veteran in crisis and to treat that veteran with 
compassion and respect?
    Dr. Stone. Yes.
    The Chairman. So Dr. Stone, I appreciate that you brought 
up earlier the issue with the $20,000 hospital bill. My 
question was, how does VA prevent veterans from relapsing into 
crisis upon discharge, including the way in which VA bills 
veterans for the care that they receive--My question would be, 
wouldn't sending a veteran a $20,000 hospital bill send the 
veteran into crisis and create another barrier for care?
    Dr. Stone. We certainly know--and this is part of my 
opening testimony--we certainly know that many of the issues 
facing veterans that lead to suicide relate to relational 
problems, relationship problems, as well as financial problems, 
and it is deeply troubling that we would generate this bill if 
there wasn't a secondary insurance that should have been 
billed.
    The Chairman. So it is very important that VA is able to 
exercise its role as a central coordinator of care in these 
cases.
    Dr. Stone. Absolutely, sir.
    The Chairman. My time is up, and I would now like to turn 
to Mrs. Radewagen for 5 minutes.
    Mrs. Radewagen. Thank you, Mr. Chairman, and thank you, 
Ranking Member Dr. Roe, for holding this very important 
hearing.
    I also want to welcome the panel. Thank you for all you do.
    My question is for Dr. Stone, and if anyone else has any 
comments, that would be appreciated.
    There has been a tremendous amount of attention devoted to 
the three recent incidents of suicide on VA campuses. Do you 
see any connection among these incidents? And do you have any 
evidence that they are symptoms of an increase of suicide among 
veterans either in general or on VA property?
    Dr. Stone. Each one of these incidences is a tragedy, and 
each one is an individual that we lost. What is difficult to 
understand is that a number of these incidences have occurred 
in individuals that we hadn't seen for a number of years, but 
yet they arrived on our campus and underwent an act of self-
harm resulting in their death.
    Clearly, as the Ranking Member pointed out in his comments, 
the fact that help was a few feet away is deeply troubling. But 
yet even if we fix that problem, 99.6 percent of veteran 
suicides are not occurring on our campuses.
    Now, what do we know? We know that America has a problem on 
inpatient services, especially in psychiatric units, when there 
are not door alarms and weight alarms that can prevent 
suicides.
    We learned that lesson tragically in West Palm Beach less 
than a month ago when a veteran actually timed our nurses 
walking through to check on them and then committed an act of 
self-harm resulting in his death immediately after the nurse 
walked through to check on him.
    The lesson from that is that we are replacing every door 
across our system with weight sensors. Now, is it perfect? No. 
But it is the best that we have in order to correct this issue.
    What else have we learned? We have learned that some of 
these veterans come to our campuses because--and we know this 
from the notes that they have left--that they know they will be 
taken care of, and they know their families will be taken care 
of.
    There are those that would like to indict the VA in this 
process, and I would caution you that this is not as easy as me 
having just a few more policemen to go through the parking lots 
or the parking structures. But this is about a whole-of-society 
approach that reconnects veterans that are intensely lonely and 
with a feeling of hopelessness that results in these acts of 
self-harm.
    Mrs. Radewagen. Does anyone else have any comments? My time 
is running out.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you, Mrs. Radewagen.
    I now would like to recognize Ms. Brownley, who chairs our 
veterans Health Subcommittee.
    Ms. Brownley. Thank you, Mr. Chairman, and I wanted to do a 
quick follow-up to your line of questioning.
    Dr. Stone, you gave some very positive responses to the 
Chairman's questions in terms of what the VA does vis-a-vis 
responding to a veteran in crisis. My question is, how do you 
know that you are 100 percent correct?
    Dr. Stone. We know because we tabulate on our training 
management system the amount of training that has been done.
    Now, we certainly have new employees coming on board that 
need training, but you would think that with the large amount 
of redundancy in our system that there would be the possibility 
that each veteran would be able to be taken into our care 
effectively and without being turned away.
    Ms. Brownley. So training is enough in terms of ensuring 
that we have a 100 percent positive response to a veteran in 
crisis? I understand that people--there is turnover and that 
sort of thing, but it seems to me as though there needs to be 
more of that to know site by site that those things are 
actually being executed. That is my concern.
    Dr. Stone. Congresswoman, thank you, and I appreciate it. 
It is my concern also. And I think that is why I mentioned 
amongst our police officers the ability to actually demonstrate 
empathy, to be able to demonstrate the ability to deescalate a 
crisis situation is absolutely essential.
    Ms. Brownley. Thank you.
    Another question I had. The doctor from NIH laid out a 
program, an evidence-based safety program, I think that you 
called it. But basically to quickly summarize, it is screening 
all patients, then a social worker drilling down a little bit 
more in terms of screening, and then obviously if that 
screening tells the professional that a veteran is in crisis, 
then linking she or he with a crisis center, perhaps within the 
VA, perhaps within the community. I think we all agree it is a 
community effort.
    So evidence-based program, effective, good results, is this 
what we are doing in the VA every single day, screening every 
single patient, having a social worker do the screening, and 
then, if need be, linking that veteran to services?
    Ms. Franklin. Yes, Chairwoman, that is exactly what we are 
doing. We have received those results from NIMH, and we have 
implemented that enterprise-wide, exactly those three 
methodologies, not only screening in mental health but 
screening in every single clinic across the entire VA. If 
somebody gets seen in podiatry, they are getting a screen on 
suicide, make no mistake.
    And the safety plans across the board, this past year we 
implemented a standardized safety plan protocol so that we 
could make sure that every safety plan that was done is done 
the same and is done with a high degree of rigor and evidence 
to the exact model that was briefed by my colleague and follow-
up contact through caring outreach exactly following the 
research model. Yes, ma'am.
    Ms. Brownley. Thank you.
    And the last question I had was on military sexual trauma. 
So it is my understanding, it has been a while since I read the 
report, but there was an OIG report, I think it was in 2018, 
that talked about MST claims. And the report, if I recall it 
correctly, said that 60 percent of the MST claims were 
incorrectly denied so that women and men, perhaps, were not 
receiving the benefits they needed. Obviously, MST is very much 
linked to the topic that we are talking about this evening.
    If you could tell me, can you respond to that and let me 
know what the VA is doing about it?
    Dr. Stone. Congresswoman, certainly. I represent VHA, not 
VVA, and I appreciate the question. And just to make sure that 
I have this right, we will check and get back to your staff to 
make sure that we answer this correctly. But my understanding 
is those denied claims are now all being reviewed to assure 
that they are accurate.
    Ms. Brownley. I would like a follow-up if you can provide 
it. I think it is of your interest. It is of our interest, 
obviously. I understand it is under VBA, but MST and the link 
here I think is very important, and I think we need to actually 
have very firm answers.
    And my time is about to run out, but you mentioned in your 
testimony about a national network of women's health champions, 
which sounds to me like a new program. I don't have time to ask 
the question today. But I haven't heard about it and am very 
interested to understand what it is about.
    I yield back.
    The Chairman. Thank you, Ms. Brownley.
    Now I will recognize Mr. Bilirakis for 5 minutes.
    Mr. Bilirakis. Thank you very much, Mr. Chairman. I 
appreciate it. Thank you for holding this hearing. And I want 
to thank Dr. Roe as well.
    Thank you for your testimony. I appreciate it so very much.
    Dr. Franklin, quickly, what about screening more intensely 
for suicide awareness at DoD? Any comments on that?
    Ms. Franklin. Screening more intensely with DoD?
    Mr. Bilirakis. DoD. Yeah. Yeah.
    Ms. Franklin. Yes. There was an executive order that was 
pushed out in this past year, not the one that Dr. Stone 
mentioned in his testimony but an earlier one, and this 
executive order calls for increased screening from DoD so that 
when troops are leaving the Active Duty side they have eyes on 
by a medical provider and those results are immediately pushed 
over to our mental health teams over on the VA side so that 
there is an accurate view on the servicemember's mental health 
status before they leave Active Duty.
    Mr. Bilirakis. Okay. Very good.
    Dr. Stone. Let me add just a little bit to that. I think 
this is absolutely correct. But in that first executive order, 
the ability for us to interact with a servicemember in the year 
before they leave Active Duty is absolutely essential. And the 
authorities you have granted us in allowing us to see 
servicemembers for that first year after they come off Active 
Duty is an absolute risk reduction.
    I would ask the Committee to take a deep look at the work 
that has been done since the late 1990s in the Air Force that 
has actually integrated a resiliency, relationship-based 
training, and suicide awareness amongst all Active Duty and 
Reserve members of the Air Force. The Air Force has not seen 
the increase in the number of suicides that a number of the 
other uniformed services have. So this interaction and 
potentially modelling after the Air Force training is 
absolutely essential.
    Mr. Bilirakis. Very good. Well, I would like to work with 
you, sir, on some legislation with regard to that because I 
think that would make a big difference. I really do.
    Let me ask another question. I do have some prepared 
questions, too, but I don't know if we will have time. Can you 
tell me, and you may not have some statistics on this, but 
prior wars, prior eras, let's say the Vietnam era, even going 
back to World War II, give me some statistics with regard to 
suicide rates. How would we compare to what is going on today, 
the 20 a day, which is obviously much--one is much too high as 
far as I am concerned?
    Can you give me any stats with regard to that, for instance 
the Vietnam era, as far as the suicide rate is concerned?
    Ms. Franklin. Yes. Absolutely, Chairman.
    The data collection has gotten better over the years, so 
sometimes it is difficult to compare data across war efforts. 
We have only recently gotten a lot more savvy with our data and 
surveillance efforts.
    But what I will tell you is that when we look at our 
current effort, we look, we see our highest rate of suicide 
right now amongst 18- to 34-year-olds when you look at the rate 
per 100,000, and we see our highest raw number amongst men over 
the age of 55, which we suspect comes from that other era, that 
other war effort. And so we also know that we have more 
veterans in that group or in that category.
    And so that is what I offer. And I turn it back. Dr. Stone 
who may have more context.
    Mr. Bilirakis. So with regard to how about percentages? You 
say you have more veterans in that category, but how about 
percentages? I mean, we are spending more money and we have 
more programs, but evidently it is not doing any good.
    Dr. Stone. Twenty-one percent of the suicides that we 
experienced in 2016 were in veterans over 75 years old.
    Mr. Bilirakis. All right.
    Dr. Stone. When I add the 55 to 74 to that first group I 
mentioned, it adds up to over 60 percent of the suicides 
amongst veterans in this Nation.
    Clearly, we need to recognize the fact that of the 20.4 
million veterans in this Nation, 77 percent have experienced 
combat, and the long-term effect on these veterans cannot be 
underestimated.
    Now, I grew up in a generational home. Multiple generations 
had been in that home. Everybody on that street were 
generational homes. I couldn't walk out the front door as a 
young child, but yet I had 20 moms that were up and down that 
street.
    Just think about the neighborhoods that each of us live in 
today and recognize the isolation that many of us feel. I have 
lived in my current neighborhood for 4 years. I know the 
neighbors on either side. I have been in their homes. No one 
else.
    Counter that to on-base housing that I experienced on 
Active Duty. When my family and I moved into a home, every 
single family in the neighborhood came to bring us food, to 
make sure we were all right, did we need anything. And every 
weekend after that for weeks we were welcomed into their homes 
until we became firm members of that community. This is a 
profound difference that we are seeing in all age groups of 
veterans.
    Certainly, the 18 years of combat that we have experienced 
in the current environment has taken a tremendous toll on 
veterans under age 35, but make no mistake that the increased 
suicide rate amongst veterans affects all age groups.
    The Chairman. Thank you, Dr. Stone. Thank you. Let's try to 
keep our comments within the 5. We have a lot of people to get 
through, but I allowed you to go on because it was so 
compelling, what you were saying.
    Let us move on to Miss Rice for 5 minutes.
    Miss Rice. Thank you, Mr. Chairman.
    And thank you all for coming here to testify tonight.
    Sir, I want to talk about an issue that--I don't think we 
can adequately address the issue of suicide amongst veterans 
without talking about guns, firearms. If you look at--there is 
no question that firearms are one of the most common means of 
completing suicide among the general population, and 69 percent 
of veterans have completed suicide via firearm.
    Women veterans are also more likely to utilize firearms in 
the attempt and/or completion of suicide than their civilian 
counterparts.
    It has been proven that restricting access to firearms may 
reduce suicide rates.
    So this is for anyone on the panel. Has the VA studied gun 
violence in the veteran population? What research is currently 
available on gun violence in connection to suicide?
    I am well aware that we as a body, Congress, has not been 
willing to fund a study to look at the overall reason for the 
epidemic of gun violence in this country, but since we are 
talking about the VA, I am specifically asking about the VA.
    Is this an issue that warrants more research to shed light 
on why firearms are the most common means utilized? And what 
resources does VA offer to veterans that may choose to limit 
their access to firearms?
    So anyone who wants to answer that.
    Mr. McKeon. Well, to put it in a national context, let me 
mention a couple of things.
    So 51 percent of all suicides in America utilize a firearm. 
So it is clearly a very important issue. The collaborative 
safety plan that Dr. Avenevoli spoke to includes as part of 
that paying attention to access to lethal means when working 
with an individual who is suicidal. That frequently includes 
firearms. It can also include things like access to large 
amounts of pharmaceuticals or other dangerous substances.
    SAMHSA, through our Suicide Prevention Resource Center, has 
an online course on counseling about access to lethal means. 
Again, this is within the context of someone who is suicidal 
and trying to reduce access to lethal means on a temporary 
basis.
    And then finally I would mention that a number of our 
SAMHSA grantees are doing work with firearm-owning groups and 
things like what is called the Gun Shop Project, working with 
them and with other groups to try to have a collaborative 
effort to educate about suicide warning signs so that people 
know how to respond.
    Ms. Franklin. And the only other thing that I would add 
from the VA side, we are working hand in hand with SAMHSA on 
many of those initiatives that Dr. McKeon spoke about. We also 
train our mental health providers with a special training on 
access to lethal means and how to talk with veterans about this 
issue.
    We do have a partnership with the National Shooting and 
Sports Foundation, and this is a partnership that helps us 
execute trainings in local communities with gun shop owners on 
signs and symptoms of suicide risk. And then we do work on this 
issue around putting time and space between the person at risk 
and any means that is lethal, and certainly firearms are the 
top means in our population as you note, but equally so, 
medication and a host of other issues around this topic.
    Miss Rice. Dr. Stone, you mentioned before, you used the 
word ``ineligibility.'' And to me, I just think it is the most 
insane policy that there is any man or woman who wore the 
uniform of this country and is--I don't care what they did--is 
ineligible for some kind of--for access to health care.
    I wonder, Dr. Stone, if you can tell us what specific risks 
other than honorable discharges represent because of their 
limited access to VA mental health care services, specifically 
women veterans who are more likely to have experienced MST are 
also more likely to have received a bad paper discharge as 
retaliation for reporting MST before the 2-year mark when they 
would be eligible for VA health care. So I think this is an 
issue that we need to talk about in terms of--I just don't 
think that there should be--that veteran and ineligibility 
should never go hand in hand.
    Dr. Stone. I think, Congresswoman, you are exactly correct. 
And one of the big problems that we have, as the Chairman 
identified in his opening statement, is never-activated 
guardsmen and reservists. They have never been called to 
Federal service, so technically they are not a veteran, and I 
am not eligible to welcome them into the system.
    Now, we have tried to overcome that by using our vet 
centers and combining, and we have worked very successfully 
with the Guard Bureau and the Army Reserve to try and move our 
vets center on a mobile basis into drill weekends.
    But many of the suicides we are seeing in never-activated 
guardsmen and reservists are between age 35 and 54. So they are 
long since their service days. And how to reconnect with them 
or to give us the authority to engage them, it seems to me that 
if I can accept veterans with other than honorable paper, we 
ought to be able to accept the never-activated Guard and 
Reserve who account for about 2-1/2 to 3 of the daily suicides 
that we are seeing.
    Miss Rice. Thank you, Dr. Stone. I think it is a 
conversation we should continue to have.
    And thank you, Mr. Chairman.
    The Chairman. Thank you, Miss Rice. Those are really great 
questions.
    Mr. Bost, you are recognized for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman. And thank you for having 
the hearing tonight.
    I just, just real quickly, there is something that I should 
bring up. You know, because it came up during the last 
questioning. You know, losing one veteran to suicide is tragic. 
And I know none of us take it lightly. That being said, the 
veteran's 2nd Amendment right and the ability to take that 
right away from them will not stop one of them from attempting 
suicide and, in fact, may discourage them from seeking help 
through the VA or through other means if they believe that they 
might lose that right. And I think that is a concern. And it 
depends on where you are at in the country. But I know where I 
come from and many of them have expressed that concern to me as 
well.
    We are all committed to preventing suicide, and I am 
dedicated to ensuring that we are appropriately educating at-
risk servicemembers and veterans and their families about 
firearm safety and providing them meaningful support to help 
them overcome the struggles that they face. But as I said, I do 
believe we want to be very, very careful when we go down that 
road.
    But, Dr. Stone, you actually--I think you answered part of 
this, but I would really like to know, because you reference in 
your testimony the President's executive order from last year. 
And I wanted to thank him for signing that but ask you what, if 
any, outcomes and lessons have been learned from the EO since 
it was signed, especially when the veterans are being screened 
from benefits from the VA and going on through the TAP Program 
at DoD. What are we gleaning from that?
    Dr. Stone. What we are learning, and I mentioned a bit 
about the Air Force experience that is incredibly intriguing. 
But what we also learned is that the more veterans and 
servicemembers learn about our services, the more they engage 
us. And it is the absolutely right thing to do for us to be 
engaged with them well before they get out of uniform.
    Now, certainly, when you are sitting at the discharge 
station getting ready to get out, you don't want to hear very 
much. But in that 6 to 12 months before, it is time for us to 
engage. And the active services have all been very gracious in 
giving time for our staff to come in and talk about access as 
well as risk for that servicemember in the year after they 
leave service.
    Now, I discussed earlier the difference in American society 
on the civilian side versus American society in uniform. These 
are dramatic changes for the servicemember who may have 
experienced 10, 15, or 20 years in uniform.
    Mr. Bost. And believe me, I am not criticizing when I go 
down this next path. Okay? I am trying to figure it out as a 
Member of this Committee, and I am sure this whole Committee is 
asking this. You know, the VA is, but once again, back before 
us and telling us that combat veteran suicide is a top priority 
for the VA. But your budget continues to increase. Suicide 
prevention money, we are giving more money towards that.
    But what actual results can be seen from a funding level 
that we are putting out there? We are not changing it. We are 
still at that 20 a day. We have got to come up with the ideas 
that truly change this. We have got to figure out that it 
that--if we are increasing money, we are not changing it, we 
are increasing programs, and we are not changing it, how do we 
become really effective and bring those numbers down?
    Now, I know that you brought up the fact of the age. And 
the concern of the age too is--where are we at when they commit 
suicide? What other things might be going on in their life? Do 
we monitor that? Do we know those statistics? And how do we 
bring it down? Because every year we can come back and talk 
about it. But if we don't change the numbers, and we can raise 
the money every year, but if we don't change the numbers, we 
are not helping them.
    Dr. Stone. Certainly, I can't disagree with your statement, 
Congressman. But I think the message here is that if this was 
10 years ago, this would have been a $4 billion budget, and I 
would have half the number of mental health providers that I 
have today. We have same-day access to mental health services, 
but we haven't changed the numbers.
    Now, there are those that would argue that maybe we have. 
Maybe this would be worse as a crisis if we didn't have 24,000 
mental health professionals ready to see you today as a 
veteran.
    If, in fact, this is not the answer, then we have some hard 
looks at each other and hard looks at ourselves in the mirrors 
about what society has become. And I mentioned that in the 
generational home that I mentioned earlier. These are very 
tough discussions to have. We do know that the incredibly high 
rates, the military sexual trauma, intimate partner violence, 
substance abuse, mental health disorders lead to a dramatic 
escalation in female veterans as was mentioned by some of your 
colleagues earlier.
    We know also, amongst all veterans, that it is--in the 2 
weeks before becoming homeless, the rates of suicide go up 
dramatically. We also know that for veterans that are involved 
with the justice system, the month after they have been 
incarcerated--or after they get out from incarceration, 
dramatic levels of suicide. But this is true across all of 
American society. Frankly, that is a worldwide phenomenon.
    Mr. Bost. Thank you.
    The Chairman. Thank you, Mr. Bost.
    I now recognize Mr. Lamb for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman.
    Dr. Stone, I want to thank you for mentioning the whole 
health programs in your testimony and for being a supporter of 
those. I also have been struck by the potential in the VA's 
whole health program. And I got the chance to visit the program 
at the D.C. VA hospital, I believe it was last summer. And it 
was just--it is just a really promising area. And it is--I just 
commend the VA for pursuing it and being innovative and risk 
taking with that.
    And what struck me about it was not just the value of the 
services themselves. The--it was--I think what we saw was 
acupuncture, meditation, yoga, and a couple other things. But 
you used the term empowering veterans. And what it really did 
was it gives veterans an active role in managing their own 
health care. It basically gives them a bunch of great 
nontraditional somewhat unusual options and says, Pick from 
these yourself. And whichever one you like, or you find 
valuable, keep coming back. And that was how they were running 
it.
    And you could tell that from that a little community arose. 
And some of the same veterans would keep coming back to the 
same classes as they were able to. And they got to know each 
other and were looking out for each other and everything. And I 
think that--you know, when we were there, it was mostly older 
veterans. But I think there is a lot of potential to use a 
program like that to attract some of the younger veterans into 
the system, because military members on Active Duty now are 
being trained in some of the same stuff. DoD has been pretty 
good at getting some of these things out there. So I think 
people are more used to it.
    So I have introduced legislation to try to expand the 
availability of whole health within the VA. And I would love to 
have your support on that. But I was just hoping that either 
you or Dr. Franklin could talk about any connection you believe 
exists between the availability of the whole health programs 
and your suicide prevention efforts, how those can go hand in 
hand.
    Thank you.
    Dr. Stone. As we modernize the VA, Congressman, one of the 
ten lanes of effort is to expand across the entire enterprise 
the whole health model. One of the things our colleagues have 
delivered in knowledge is an understanding of the role of 
physical exercise or the participation in team-based sports at 
any age has a dramatically preventative activity in reducing 
the suicide risk.
    And I will defer to Dr. Franklin if she has other comments.
    Ms. Franklin. I appreciate your thoughts on the whole 
health care. And I am eager for us to execute it across the 
enterprise. It started with the 18 flagship entities, one of 
which you may have visited. And it is well under way for full 
execution across the enterprise. And this notion of focusing on 
the social determinants of health and thinking about veterans 
in the context of biological, sociological, psychological, and 
spiritual and allowing them to drive their care is the future 
of the organization, so I definitely appreciate it.
    Mr. Lamb. Thank you both for your work on that.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. Lamb.
    Mr. Bergman, you are recognized for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman. Thanks to everyone 
for being here. This is a subject that I know all of us take 
very seriously.
    And I am not sure which one of you gave the following 
stats, so I apologize for that. The second leading cause of 
death in the age group 18 to 34.
    What is number one, three, and four? Any ideas?
    Mr. McKeon. Well, in that age group, number one is 
accidents.
    Mr. Bergman. Okay.
    Mr. McKeon. And three is--homicide is either third or 
fourth. But that, I don't remember exactly. We can certainly 
get that for you.
    Mr. Bergman. Okay. Well--and also, in that--regardless of 
what is one, two, three, and four, is there, from a gross 
standpoint, big numbers, not finite data, is there any huge 
percentage difference? Now, accidents are accidents. But any 
significant percentage differences in, like, three and four? 
All of a sudden, just a drop off?
    Mr. McKeon. Well, I think that--one thing to remember, for 
example, is that while accidents may be at times very random, 
they are--
    Mr. Bergman. I don't want to waste time on accidents, if 
that is okay. I just--we try--the bigger point here is a 
relative perspective of where it fits in causes of death as we 
talk to people and talk to other entities and figure out where 
to put, if you will, finite resources towards solving problems. 
An example, isolation we know causes potential suicidal 
ideations.
    Back when some of us with gray hair entered the military, 
there were military barracks. You had the communal living where 
you had your bunk mate, you had that. Now we have private 
rooms, if you will, once you reach maybe E4 or E5. And that 
idea we are not able to have eyes on, on our fellow military 
members regardless.
    So, you know, differences when it comes generationally to--
when it talks about the community, the neighborhoods. You know 
your neighbors, or you don't know your neighbors. Well, you 
know, do you know your platoon mates? Do you know the people 
after you leave either the association? So I think there is 
differences societally here as we look at dealing with mental 
health.
    State-sponsored programs. Do States have different programs 
that you can refer to as examples of how it is being done very 
well? Some States versus others. Not that we need to know, but 
are there best practices being shared when it comes to--you 
know, the one-size-fits-all when it comes out of Washington, 
D.C., may not resonate in--you know, in northern Michigan or 
isolated areas or somewhere where--are more rural than urban. 
But are there any things you do to compare and contrast and 
take best practices?
    Mr. McKeon. I would mention a couple of things. Many States 
are making strong efforts for suicide prevention. An example of 
that is what is called the Colorado National Collaborative, 
which CDC has been very engaged in. The idea there is to try to 
promote suicide prevention in a comprehensive public health way 
and to bring it down to the local level. And, again, it is 
something that is being driven by those States and communities. 
There is Federal funding that is being utilized.
    Mr. Bergman. I guess the question--because my time is 
running short, and I got a couple quick questions. But as long 
as we can see that best practices are being captured and then 
put out so that we gain from it, not just a one-size-fits-all 
perspective. And as far as a requirement for veterans to make 
contact within a year after leaving Active Duty, did I get that 
right? Okay. Any idea what percentage of those veterans are 
still in the individual ready reserve? Because that is--when 
you talk about that 18 to 34 group, a lot of those are still in 
that timeframe where they have a 4-year commitment. Who is 
doing that? How is that contact being made?
    Dr. Stone. So we have talked to both the Army Guard and the 
Army Reserve who have the largest reserve--individual ready 
reserve.
    Mr. Bergman. Yeah. But they are not in. When a young 
soldier, sailor, airman, marine who leaves Active Duty, they 
are under DoD, they are Title 10. But their responsibility is 
not Title 32.
    So the point is who is taking care of those folks in the 
individual ready reserve?
    Dr. Stone. That is very difficult to say.
    Mr. Bergman. Okay. But you can take that for the record. 
And I would suggest, Mr. Chairman--I know my time is up--that 
would be an interesting--maybe for a round table for us to talk 
about that, because there is some significant differences 
there, especially given the age group that we are talking about 
here is the number two leading cause of death.
    And I yield back.
    The Chairman. The point is well taken, General Bergman. And 
it has been noted by my staff. And I take your suggestion.
    Mr. Brindisi, you are recognized for 5 minutes.
    Mr. Brindisi. Thank you, Mr. Chair. Thank you, Dr. Stone, 
and to all our witnesses who are here today.
    I just spent a couple weeks back in the district and had a 
chance to tour some of our VA clinics in anticipation of this 
hearing coming up. I had the opportunity to ask the 
professionals at our VAs what are some of the things that we 
can do collectively to try and reduce suicide? And one of the 
things that was mentioned to me on several occasions was 
focusing more on that transition period out of Department of 
Defense Active Duty life and into the VA. And how we can do a 
better job coordinating. And I know we touched upon this a 
little bit.
    But are there ways--because my understanding--I am not a 
veteran, but as you are coming out of active military, there is 
a lot of information that is thrown at you. It is--one of the 
VA professionals actually likened it to a phrase I am pretty 
familiar with, drinking from a fire hose.
    So what can we do--what kind of coordination efforts are 
taking place between the DoD and the VA? And is the DoD being 
cooperative in assisting the VA reach a veteran in that 6- to 
12-month period prior to getting out of Active Duty?
    Dr. Stone. So the answer is yes, DoD is being great 
partners in this process. We would always like to have more 
time to spend with the veteran, because the more time we spend 
with the veteran, the more likely they are to engage with us 
after they get out of service.
    I think, secondly, are we effectively outreaching in that 
year after they get off of Active Duty? You have funded us very 
graciously, and we will spend about $200 million this year in 
outreach efforts of various types, everything from electronic 
billboards to Web sites in which we are reaching out, to even 
direct mailings. We mailed 500,000 letters to other than 
honorable in December of last year. And we are able to capture 
well over 1,000 veterans to come in and see us. But it all 
depends on the individual. And it all, most importantly, 
depends on when the individual is really open to hearing our 
message.
    There is no doubt that we are the most integrated health 
care system when it comes to mental health. And the ability for 
us to interact with that veteran and provide integrated ongoing 
services is what is essential to their well-being in the 
future.
    Mr. Brindisi. Thank you for that.
    And one of the interesting programs that I heard about from 
the VA region that I represent, I am not sure if you are 
familiar with something called Freeze the Keys? Have you heard 
of this before?
    Dr. Stone. I have not, but Dr. Franklin may have.
    Ms. Franklin. No.
    Mr. Brindisi. Okay. So touching a little bit upon our 
conversation earlier about gun violence. So in the Syracuse VA 
region in upstate New York, they had told me about this program 
that they are implementing called Freeze the Keys where they 
will take the keys of a gun storage cabinet. The veteran may 
own a firearm they keep in a storage cabinet, and they keep 
that storage cabinet locked. And they will take the keys from 
the storage cabinet and put it into a cup and then put water in 
the cup, freeze the cup in a freezer. So when the veteran has 
the impulse that they may want to go get their firearm to 
commit suicide, they actually have to get the key out of that 
frozen cup which creates more time for them to think about the 
act that they may take.
    And on this cup is a picture, perhaps, of a loved one, 
perhaps of a veteran's crisis suicide number. Just something 
that they are doing where they think it may give more time, 
because it is an impulse, it is a quick impulse when you want 
to take your life. This may give a little more time for them to 
think about it before they actually are able to get the key out 
of the ice and go to the storage cabinet, get the firearm, and 
commit suicide.
    Sounds like a good practice.
    Dr. Stone. One the most deeply troubling facts in survivors 
of suicide is that in about 25 percent, the distance between 
the decision to commit an act of self-harm to actually 
committing the act is 5 minutes. And in about half, it is less 
than 60 minutes. Anything that puts distance between that 
decision and attempts to deescalate the crisis has value, 
whether putting keys and freezing them in, putting a picture of 
a loved one, or simply the phone ringing of a loved one saying 
``I have been thinking about you'' is a chance to deescalate.
    Mr. Brindisi. Thank you. I certainly encourage you, because 
it just seemed like a wonderful program that they are utilizing 
up in the area that I represent. Perhaps it is a practice that 
maybe we could use across the country to help give more time to 
make that decision.
    The Chairman. Thank you, Mr. Brindisi.
    Mr. Banks, you are recognized for 5 minutes.
    Mr. Banks. Thank you, Mr. Chairman.
    Dr. Stone, I have a question for you at the outset. What 
are you and the Secretary doing to create a culture of urgency 
at the VA and the VHA to deal with veteran suicides?
    Dr. Stone. Congressman, I think there is a culture of 
urgency. I think this is the Secretary's and my number one 
priority is to do everything we can to reduce or eliminate 
veteran suicide.
    But as I said in my opening comments, we cannot do this 
alone. And we need the entirety of American society to dedicate 
themselves along with us and support us. It is, as I mentioned 
to your colleague, a telephone call to a veteran or somebody 
that you haven't seen, somebody from your faith group to pick 
up the phone.
    One of the things we recognize in your State, your State 
has some of the lowest suicide rates in the Nation both among 
civilians and veterans. There is something unique that goes on 
in your State. It may be the small towns. It may be the faith-
based communities. But there is something unique that the 
suicide rates in your State are dramatically lower than a lot 
of other areas.
    The other thing we recognize is, in highly populous States 
like California and New York, there are reduced suicide rates 
over the more rural States. If I go to Montana or South Dakota, 
the rates are dramatically higher.
    Is this about loneliness? Is this about isolation? Is this 
about being disconnected? The answers to all of those are yes.
    Mr. Banks. Can you point to for our benefit examples of 
ways within the bureaucratic organization that you are creating 
that sense of urgency better than before?
    Dr. Stone. Yeah, I think so. And I am really proud of the 
24,000 mental health providers and their staff. I think the way 
we show that is by absolute accessibility on a same-day basis. 
And even in places that are going to just open access to get 
veterans in. We will see almost 22 million ambulatory visits 
from mental health. And we are very proud of it. We are 
continuing to retain and attract behavioral health providers.
    The increase in our telemedicine work where we will move 
from 13 percent of veterans this year to about 20 percent of 
veterans eligible--or able to participate in telemental health 
is extraordinary. I think all of this demonstrates our 
commitment.
    But as I said earlier, simply hiring more mental health 
providers will make access better, but it won't fundamentally 
change the problems of homelessness or fundamentally change the 
problems of financial challenges or relationship changes.
    You know, in the last 18 years, the Department of Defense 
has done wonderful work showing the problems with dwell time, 
that you can't go out for 15 months to combat, especially 
combat that is intense every single day. You know, you go back 
to the Vietnam era. One of your colleagues earlier asked. You 
go back to the Vietnam era. People went out for a week, and 
then they came back to the rear and they decompressed. These 
wars, you are in combat every single day.
    In the time I spent in Afghanistan, the medical corps gets 
every bad thing that happens in war place. It was a flow of 
casualties every single day. You cannot underestimate the fact 
that the human mind and the human body must decompress from 
that. And when you go out for 15 months and come home for a 
year and then you go out again is an operational pace with an 
all-volunteer force that is unsustainable.
    Mr. Banks. Let me shift gears really quick.
    Last September President Trump signed legislation I 
authored that would require the Secretary to conduct a study of 
5 years of data analytics of the veteran crisis line.
    Can you confirm that that process has begun or tell us 
about any progress of that today?
    Dr. Stone. I can't, but Dr. Franklin may be able to.
    Ms. Franklin. Yes. Absolutely. There was a number of 
recommendations that came from that related to the veteran 
crisis line, and we have successfully closed out those 
recommendations.
    Mr. Banks. The recommendation--this was mandating a study 
of 5 years using data analytics to study the effectiveness of 
the veteran crisis line.
    Ms. Franklin. Okay. Forgive me. I may have crossed your 
question with IG recommendations.
    But, absolutely, we can check on that and get an answer 
back to you for the record.
    Mr. Banks. Thank you.
    My time has expired.
    The Chairman. Thank you, Mr. Banks. I appreciated your 
questions.
    And, Dr. Stone, I have asked my staff to take a look at 
this response that you gave on the nature of the deployments 
and how they differ today.
    I will now recognize Mr. Pappas for 5 minutes.
    Mr. Pappas. Thank you very much, Mr. Chair. And I 
appreciate the panel and your thoughts here today as we 
confront this critical issue for our Nation and for all our 
veterans and their family members.
    I wanted to build off of one thing that Dr. Stone was 
discussing, and that was the VA police force. And you indicated 
a little bit of the training that goes in in terms of 
identifying the signs. And I think that is a really important 
discussion to have ensuring that they have that experience 
under their belt. We should be treating this as any other 
medical issue. So knowing the signs of mental illness should be 
just like knowing the signs for stroke or heart attack or 
anything else that someone might walk into a facility 
experiencing.
    But I am wondering beyond that, as we look at the IG report 
around VA policing, if you have any further comments that you 
would like to offer in terms of implementation of the 
recommendations. There was concern around ensuring that police 
units were appropriately staffed at VA facilities around the 
country. And if you don't have anything further to add on that 
right now, certainly we can follow up and have a further 
discussion following this hearing.
    Dr. Stone. I do. I think there is a number of things that 
are troubling in the way we structure police and police 
management. We are actually going through a process of 
restructuring regional management.
    There is very little career mobility in the VA police 
force. It is pretty much run as a police force out of an 
individual health care facility. Because of that, it is hard 
for us to retain police officers. In addition, we have graded 
police officers at too low a pay scale, and our ability to 
retain very high-quality officers is really challenged. So 
there is a number of areas I would be happy to take offline 
with you that I think we could do a much better job of 
retaining these great officers that we have.
    Mr. Pappas. Thank you. I appreciate that. We will certainly 
be following up.
    As you know, on April 12, the administration's ban on 
transgender servicemembers went into effect. I have concern for 
that group. As you may know, transgender veterans are known to 
experience suicide at higher rates. And I am wondering what 
thoughts have been given to the handoff as these folks leave 
service in terms of making sure that they are getting the care 
that they need.
    Dr. Stone. So there has been no change in the VA's posture. 
And that is that we continue to welcome all servicemembers to 
care. We provide all care regarding transgender work. The only 
thing we don't do is the surgery. But we welcome all 
transgender members, and we will continue to do so.
    And--Dr. Franklin.
    Ms. Franklin. Sure. And I would just add that so much so 
with regard to Dr. Stone's comment, we recently developed a 
tool kit for all of our medical providers. And it is listed on 
our Web site. And it is a--we have disseminated across the 
entire enterprise. It really speaks to how to engage with this 
unique population. And exactly what you note, their increased 
risk for suicide particularly when you look at the nonveteran 
suicide data points to 12 to 19 percent increase risk with this 
population. And so we got out of that--in front of that as 
early as we could, developed the tool kit, and we are training 
our staff with a series of webinars on it as well.
    Mr. Pappas. Thank you very much.
    I am glad you handed out these cards and made sure that we 
all put the number in our phone, this has been an important 
resource to our district office as we get calls from vets in 
the State of New Hampshire. And I am hoping that you will 
continue to look for ways to work elevate this resource as you 
implement the VA's national strategy for preventing veteran 
suicide.
    As you explained, there are well-followed practices and 
procedures that are in place when a veteran calls who is in 
crisis, who is experiencing suicidal thoughts.
    I wondered if you could comment on other situations that 
might come up on the line. Veterans who may be experiencing 
depression or mental illness and how those cases are handled. 
And I am wondering, I guess, what resources are available to 
clinicians on the crisis line, local suicide prevention 
coordinators to help facilitate services for these individuals. 
And I am thinking particularly around transportation.
    Ms. Franklin. Absolutely. It is such a good question, 
because not all the calls that come to the veteran crisis line 
are crisis related. But all the calls are important, and we 
tackle them in the same way. So we assess and triage and get 
folks into care depending on the level of care that they need 
and what they identify when they call the crisis line. In some 
cases, that care might be a warm handoff to a vet center. In 
some cases it might be a handoff into a community-based 
organization or one of our own medical centers in a non-crisis 
capacity.
    When you are thinking about transportation, transportation 
can absolutely be a barrier to care. We have a number of 
entities where we are funding transportation capabilities. We 
are also partnering with a number of agencies. There is a good 
example happening in Massachusetts with Mass General where they 
are partnering with the local police force for off-duty police 
officers. And maybe you are familiar with it. Part of the home 
base capability that is connected to Mass General whereby 
retired police officers and off-duty police officers are 
helping to do that transportation piece of it making sure that 
that doesn't become a barrier for people getting into care when 
they need it most.
    Mr. Pappas. Thank you very much.
    I yield back.
    The Chairman. Thank you, Mr. Pappas.
    Now I recognize Mr. Meuser for 5 minutes.
    Mr. Meuser. Thank you, Mr. Chairman. And thank you, Dr. 
Roe. Thank you very much to our witnesses. I appreciate very 
much your service. Clearly, you are all very, very experienced 
and capable to be handling these important jobs, and I just 
really want to thank you for your service.
    I do represent Pennsylvania's 9th congressional. We have 
over 50,000 veterans. We also maintain Fort Indiantown Gap Army 
training facility as well as the Lebanon VA. Seventy percent of 
the 20 suicide deaths per day among our veterans, which is 
absolutely heart wrenching, have not received VA health care, 
as we have been discussing, for the previous 2 years.
    Conversations that I have with the Lebanon VA have made it 
clear that we need to work on meeting veterans where they are. 
And, for example, the Lebanon VA has partnered with local 
colleges, veteran-oriented campus groups. The VA provides 
instruction for college faculty to identify challenges and have 
VA staff contact points for veteran students, on a volunteer 
basis, who are willing to help.
    So, Dr. Franklin, I will ask you, can you speak about the 
importance of community engagement, the need for such outreach? 
Is this something that is encouraged and is regularly 
practiced?
    Ms. Franklin. Yes. And I think it is something that has 
been practiced even more so in the last year and a half. This 
idea of partnering and outreach with community. And there is a 
number of different ways that we are doing it. On the one hand, 
at the national level, certainly putting the right MOAs and 
MOUs, memorandums of understanding and agreement into place and 
so that we solidify those relationships so that they stand the 
test of time.
    And then also informal relationships. And I appreciate the 
fact that they are doing that right out in Pennsylvania, 
because we are teaching at the national level for them to do 
the same thing locally. And what we are doing is we are asking 
them to use their data and to use their data to define where to 
go for partnerships. And so when we look at the data and we see 
large numbers, our highest rate with 18- to 34-year-olds, we 
are asking them to work with veterans where they work, live, 
and thrive. And in some cases, you know, we believe they may be 
in university settings.
    So the fact that you note that they are developing 
partnerships, trying to get after suicide outside the four 
walls of our VA system and that they are doing it with 
community partnerships like universities tells me that they are 
on track, and that is the future of the organization. We are 
really trying to push for broad partnerships in this focus on 
the fact, as the Chairman said, that we can't do it alone. And 
we need to increase our partnerships and community engagement.
    Mr. Meuser. Thank you.
    The Lebanon VA also makes its grounds very inviting. It is 
lobby inviting. It creates social atmosphere for the veterans, 
and in many cases their families. They have a military museum 
within the facility.
    Is this something that is encouraged in other VAs, Dr. 
Stone?
    Dr. Stone. Yes, sir, it is. It is encouraged across the 
system. Many veterans find this a welcoming place and a place 
of social connection. And that is the big key to what we are 
discussing. It is why, for the veteran that wants it, we have 
chapels on our campuses. We have various veteran-related 
memorials. And these all seek to connect the veteran back to us 
and bring them into the system.
    Mr. Meuser. Yeah. That is very much in line with what you 
were referring to a couple of times today. So I am glad to hear 
that.
    Do you consult with the DAV, the VFW, and the American 
Legion, many of the members are here today, I think, as well, 
on these issues? I mean, get their ideas on what they think 
should be done?
    Dr. Stone. We do. In fact, I just finished a series of 
breakfast meetings with as many VSOs that would be willing to 
meet with us. And I think we met with 18 different 
organizations with--the specific question was how to solve this 
problem.
    And it is my belief, as you figured out already from my 
earlier comments, that belonging, being part of something has 
huge value. Therefore, I believe that membership in the VSOs is 
protective. Now, we can't demonstrate that because nobody keeps 
numbers on that, or very few of the VSOs do. But we believe it 
is protective and has huge value in connecting the veteran to 
the community.
    Mr. Meuser. Thank you.
    And you can clearly see by your words and intonations your 
dedication, all of you. So thank you on behalf of veterans, 
certainly in my district and everywhere, thank you.
    Chairman, I yield back.
    The Chairman. Thank you, Mr. Meuser.
    Mrs. Luria, you are recognized for 5 minutes.
    Mrs. Luria. Thank you.
    Dr. Stone, in the Department of Veterans Affairs fiscal 
year 2019 annual performance plan, strategic objective 2.2 
states that the VA ensures at-risk and underserved veterans 
receive what they need to eliminate veteran suicide and 
includes three recommended interventions and follow-up care.
    Are you familiar with this objective and do you know what 
the percentage metric was for satisfactory performance?
    Dr. Stone. I am not, but Dr. Franklin may be.
    Mrs. Luria. Dr. Franklin, are you familiar with this?
    Ms. Franklin. I am not sure I am familiar with them 
exactly. I know that you might be talking about our REACH VA 
intervention.
    Mrs. Luria. Well, it was the only metric within the 2019 
annual performance plan for the entire VA that I could find 
that related to suicide. And in this objective, it stated that 
you would have recommended interventions, three recommended 
interventions, and follow-up care.
    And so in the performance plan, it said that you would seek 
to achieve this 65 percent of the time. Yet, Dr. Stone, earlier 
in your remarks, you said that this was your number one 
priority and that you were putting all efforts behind, you 
know, being 100 percent effective in this area. So seemingly, 
the 65 percent is a relatively low measure of effectiveness for 
your number one priority. Would you agree?
    Dr. Stone. Congresswoman, I must admit to you, I am not 
familiar with this. And I would be more than happy to take a 
look at it and get back to your staff in the next 48 hours to 
talk about it.
    Mrs. Luria. I appreciate that. I would like to follow up 
about that particular metric, since, like I said, it was the 
only one in the plan that refers to suicide.
    Dr. Stone. Because--if I might just go on for a minute. 
Many of these--so I came back to VA in July, and this may be a 
document that was created before I came back. But we will 
resolve this for the Committee. And I apologize to you for not 
being able to answer the question.
    Mrs. Luria. Understand. And I will look forward to the 
follow-up.
    Dr. Franklin, last week I had the pleasure of meeting with 
a veteran's outreach program specialist and several counselors 
from one of our vet centers in the Hampton Roads area. And they 
were all incredibly dedicated to their mission and specifically 
focused on helping to end veteran suicide.
    And the veterans outreach program specialist explained, you 
know, how he gets at this problem of reaching veterans in the 
community by going through barbershops, faith community, all 
types of different things where he reaches veterans in places 
where they are.
    Do you find this particular role within that centers to be 
effective in helping reach those 14 out of 20 veterans that are 
not receiving care now?
    Ms. Franklin. Yes. Absolutely. This is a critical role. And 
I appreciate the fact That that you are mentioning barbershops, 
because we are pushing them towards what we call nontraditional 
partnerships. And certainly, our partnerships with VSOs, and we 
want them locally to reach out to people that connect that we 
have already mentioned on this panel today.
    But one of the things I have really been pushing the 
workforce towards is to reach out to partners who are non-
traditional and--
    Mrs. Luria. I understand. In the interest of time, I 
understand the effectiveness of that tactic. I am just 
wondering are we requesting enough funding, and do we have 
enough personnel in this role within the system to do this 
effectively across the country?
    Dr. Stone. So we have 300 vet centers, including mobile vet 
centers. And I think we have enough personnel. But I spoke 
earlier today with the Chairman and discussed the fact that we 
must begin to move to much smaller engagement units. And I 
think the vet centers have been that model.
    But please remember, it took the Vietnam veteran about 10 
years to decide that they--they would come in for therapy. They 
didn't want to come in to our--
    Mrs. Luria. Okay. I would like to move on. I only have 1-
minute left, and I wanted to touch on one thing, which was your 
outreach budget.
    And looking at last year, only $1.5 million of the 6.2 
million allocated for paid media, or slightly less than 25 
percent, was spent towards that effort.
    For fiscal year 2019, the budget is 47.5 million in suicide 
prevention. How much of that do you plan to use for paid media?
    Dr. Stone. So if you break down the actual budget, one of 
the problems we had that you reference is that prior to 2019 
budget, we lumped all of this together. And it was very hard to 
track. So when I arrived, we broke this out into six separate 
buckets so that we can track it. There is $206 million in those 
buckets. We expect to spend all of it.
    Mrs. Luria. So we are about halfway through the fiscal 
year. Would you anticipate that we are on track based off of 
the time remaining in the year to expend all of it effectively 
this year?
    Dr. Stone. We are. We are--we expended, as of March 30, 
just under 50 percent. We have some additional obligations, 
especially in our centers of excellence and our demonstration 
projects. Although we have obligated the money, there was about 
$8 million that we pushed out to the field, those obligations 
haven't come back in. But we do expect to obligate all of that 
money.
    Mrs. Luria. Okay. And very quickly, what measures of 
effectiveness do you have for that spending? Are you tracking 
the number of engagements based off of the paid media that you 
are doing? And do you have any way to report back whether that 
spending is effective, and you are using it in the best 
methods?
    Dr. Stone. We are. And, certainly, I am not in advertising 
or in in how they measure this. But as they--the measures that 
are beginning to come back indicate that they have been quite 
effective at recognition. The question is will they change 
behavior. And Dr. Franklin may have additional comments.
    Mrs. Luria. Okay. And specifically, like, can you tie that 
to increase calls to the crisis hotline or any other tangible 
metrics that you will be able to report and track over time and 
provide back to us based off of that spending?
    Ms. Franklin. Yes. Absolutely, we can. We are doing it 
through two primary metrics.
    The Chairman. Dr. Franklin, I am going to have to ask you 
to get that back in writing, because we have got to move this 
along. It is a good question, but could you respond--
    Ms. Franklin. I can take it for the record and get back to 
her. Sure. Certainly. Yes, sir. Yes, sir. Yes, Chairman.
    The Chairman. Thank you.
    I would now like to recognize Mr. Barr for 5 minutes.
    Mr. Barr. Thank you, Mr. Chairman. And thanks to Dr. Roe as 
well for holding this very important hearing. And thanks to our 
witnesses for your dedication and focus on this national 
crisis.
    I did want to ask Dr. Stone about the topic that Mr. Bost 
was asking about in terms of the increase in overall commitment 
to the VA since 2005. Approximately a 258 percent increase in 
funding dedicated to VA mental health care, and yet we do 
continue to see, unfortunately, a rate of suicide at over 20 a 
day.
    You mentioned a couple of things that I wanted to kind of 
explore and kind of unpack what is going on, why we haven't 
seen a decline in the total numbers. Is that--and you noted 
that there were a total number of deaths by suicide among 
middle aged and older adult veterans as the highest category. 
But we do also see, from your suicide data report, that the 
rates of suicide are highest among the youngest veterans.
    So the rates are higher among the youngest veterans. And I 
did note, from the Iraq and Afghanistan Veterans of America 
testimony, that veterans aged 18 to 34, the post 9/11 
generation, has the highest rate of suicide. Is that the 
explanation for why the numbers are still elevated even though 
we have made an additional financial commitment to addressing 
this national crisis? And if not, what is the cause of that.
    Dr. Stone. Maybe some of my colleagues can, but I don't 
think I have a full answer to that question except I absolutely 
believe that not all of this is about mental health. I think 
significant amounts of this relate to personal, financial, and 
relationship-based problems and loneliness and isolation.
    Secondly, you and I both know that the post 9/11 generation 
of veteran joined the military knowing they were going to 
combat. That is a unique individual in America that has not 
only joined but understands they were absolutely going to war. 
And the effect of that, I have already discussed. And the 
effect of recurrent deployments and what it does to ongoing 
relationships.
    Mr. Barr. Thank you.
    Recently my hometown of Lexington, Kentucky reached an 
important milestone in ending veteran homelessness. After a 
multiyear collaborative effort, it was certified that no 
veteran was living outdoors or unsheltered, meaning that the VA 
certified an effective, quote, end to veteran homelessness in 
our community. This milestone is particularly important 
because, as many of us are aware, homeless veterans are at a 
significantly higher risk of suicide than non-homeless 
veterans.
    Dr. Stone, Dr. Franklin, I notice that many suicide 
prevention resources that the VA provides are available only 
online or by phone, or information about mental health services 
are sent via mail.
    Given the higher suicide homeless--the higher rate of 
suicide homeless veterans face, how is the VA reaching homeless 
veterans who obviously don't have access to those resources?
    Ms. Franklin. Yes. We have 444 suicide prevention 
coordinators with a surge underway to plus that up by another--
a number of 246 more. And they actually do in-person outreach 
engagements where they are out in communities. We have a metric 
for them to do at least five face-to-face outward engagements 
to tap into people just like you mentioned. And many times, 
when I do my checks and I go out and do visits at the VA, they 
talk with me about these--that they do many more than five. 
Five is the requirement. But they are out. They are tapping 
into veterans where they are out in these communities. And they 
are familiar with shelters and local entities where the 
veterans are. And they are doing face-to-face outreach 
engagements.
    Mr. Barr. Another quick question about the National Guard. 
Obviously, certain National Guard members who were never 
Federally activated are not eligible for VHA mental health 
services, yet they may go to the VA for help in a time of 
crisis. How does the VA handle these guard members who seek 
help?
    Ms. Franklin. We do not turn them away. We treat them. We 
bring them in into the fold. We give them care immediately, 
right away, barrier free, access free. Furthermore, Dr. Stone 
signed a MOA this year with the National Guard and the Reserve 
Leadership to have our mobile vet centers out at every drill 
weekend. And we did a one-for-one match with every drill 
weekend to assign it to a mobile vet center so that they are 
getting care early and consistently over time.
    Mr. Barr. And in my remaining time, briefly, equine-
assisted therapy, we see this in Central Kentucky, the horse 
capital of the world.
    Dr. Franklin and SAMHSA, any of the witnesses here, what is 
the evidence in support of these adaptive sports therapies?
    Ms. Avenevoli. So we have a whole center at the NIH that 
focuses on alternative therapies, or nonpharmacological 
therapies. What we find from most of this work is that they 
share components that are relevant to treating mental illness 
or suicide risk. I am not as familiar with equine-assisted 
therapy, but it does have key components of things like 
mindfulness and connection and attachment that are key 
components of a lot of our evidence-based therapies like 
cognitive behavioral therapy.
    Mr. Barr. Thank you.
    My time has expired.
    The Chairman. Thank you. Mr. Barr.
    I now recognize we can Mrs. Lee for 5 minutes.
    Mrs. Lee. Thank you. And thank you all for being here and 
sticking through this.
    First of all, I appreciate the approach, the whole health 
approach, that you are taking. And I wanted to address what you 
said, Mr. Stone, that it is not all about mental health. And in 
the CDC report that was included in our packet, it reported 
that more than half the people who died by suicide did not have 
a known mental health condition. It went on to say that many of 
these deaths were preceded by economic losses, physical health 
problems, and housing stress. And it further said that--it went 
on to identify seven strategies for helping deal with those 
individuals who are identified as high risk. The number one 
strategy was economic support.
    Given that the highest--we are seeing the biggest increase 
in our younger veterans, and we are seeing a big increase in 
suicides across the country in young--our young members of our 
society, my question is, have you done any tracking on access 
to economic benefits to the veteran's benefits? You know, has 
there been any tracking in terms of risk in terms of who has 
committed these suicides? Have they had trouble accessing the 
VA benefits, et cetera?
    Dr. Stone. So we do know anecdotally that there is 
financial problems related to a number of the recent on-campus 
suicides. But I cannot create a pattern for you that this 
relates to what I believe is anecdotal.
    We do know, however, that at the point of impending 
homelessness, the incidence of suicide rate, which in veterans 
is just over 30 per 100,000, dramatically goes up to about 80 
per 100,000 population.
    So financial instability is an absolute risk factor.
    Mrs. Lee. So I want to get into tracking and what you are 
doing also with respect to the Department of Defense and the 
executive order and the electronic health records, as the chair 
of the Subcommittee. I understand that you are collaborating on 
the screening tool for the new electronic health record system. 
What is the status of that collaboration?
    Dr. Stone. It is an active collaboration at this time as we 
try to create a common platform that will allow not only access 
to data but common clinical pathways that allows us to capture 
information in the same way.
    Mrs. Lee. Are there specific aspects of DoD policy and 
practice that you are incorporating, and vice versa?
    Dr. Stone. Yes. Yes. There is active collaboration and the 
IPO that works with us to collaborate is actively engaged in 
this as are the work committees. We have 18 different 
committees that are working to collaborate.
    Mrs. Lee. Well, seeing that the IPO is not fully formed, 
that is sort of a problem. And the fact that the--you know, the 
Department of Defense has not agreed to come to a round table 
that we had to discuss about this, I mean, we are not--I don't 
see evidence of the IPO.
    Dr. Stone. So the IPO has been in existence for a fair 
length of time, and we have been working together for years as 
we have worked through this. Both secretaries committed to 
enhancing the IPO, and we are still working our way through 
those processes.
    But as I stated earlier, I have found DoD a wonderful 
partner in this.
    Mrs. Lee. So when the electronic health record goes live 
next spring, will suicide risk be a flag that is immediately 
available?
    Dr. Stone. Yes.
    Mrs. Lee. And are there any flags that will not be 
available by go live?
    Dr. Stone. I would have to bring the work group leads that 
are actually working this. I will be attending in Kansas City 
next month, one of the work groups myself, to actually work 
through this process and observe it.
    We have had four separate meetings that have brought 
clinicians and leaders together in order to make these 
decisions. The fifth will occur in the next couple of weeks, 
and then I will be out at work group six in order to work our 
way through this.
    Mrs. Lee. Okay. Great.
    One final question. What data will be collected from the 
health telenet platform? And how will it be used for further 
development of effective interventions?
    Ms. Franklin. We will have to take that for the record in 
terms of the specific data for telemental health--
    Okay?
    Mrs. Lee. All right. Thanks.
    I yield.
    The Chairman. Yeah. Thank you, Mrs. Lee.
    Mr. Cunningham, you are recognized for 5 minutes.
    Mr. Cunningham. Thank you, Mr. Chair. And thank you to 
every one of you for attending tonight.
    Suicide prevention coordinators are critical to VA's 
efforts to prevent veteran suicides. I wanted to see if you all 
could speak to, in your opinion, as to what shortcomings the VA 
has with suicide prevention coordinators as far as mistakes 
they may make, or any issues or weaknesses found within that 
particular employment.
    Ms. Franklin. Sure. I can take that.
    We have, I said earlier, 444 suicide prevention 
coordinators around the Nation. I would note that we are the 
only hospital system that has employed full-time suicide 
prevention coordinators to get after this issue. We are in the 
process of hiring up another 246. This is based on an analysis 
that was done over the past year that recognized the fact that 
we plussed up our veteran crisis centers. As you well know, 
this has been briefed to this Committee.
    And then we also created a new capability called REACH VET, 
which is a predictive algorithm that produces a red flag and 
looks at a number of variables and provides a force function 
for our SPCs and others inside the hospital system to do caring 
outreach to veterans that present with high risk. And so that 
has created an additional workload and burden on this 
capability that was stood up over 11 years ago. And as well it 
is a time to just continue to reset and refresh the community. 
We offer a training for them every other year in collaboration 
with DoD called a DoD VA suicide prevention conference where we 
do an ongoing assessment of their needs, and we make sure that 
we are training them with the latest evidence-based practices 
and that we are supporting them. They are taking care of our 
Nation's veterans who are at most high risk, and we care for 
them as well. And we want to make sure that we are providing 
them the best care possible.
    We recently also conducted an analysis to further advance 
public health entities other than just suicide prevention 
coordinators that are doing straight clinical work. We want to 
make sure we are doing additional work outside the community 
with outreach so that it is a holistic approach.
    Mr. Cunningham. Right.
    And of those 246 additional hires, how many vacancies 
waiting to be filled, if any?
    Ms. Franklin. So those are not vacancies. Those are 
additional plus ups above and beyond.
    Mr. Cunningham. Are there any current vacancies waiting to 
be filled?
    Ms. Franklin. We don't have the vacancy rate with just 
SPCs, but we have it with our mental health writ large which 
includes all of our social workers and psychologists and 
others. And the vacancy rate hovers around 10 percent. I know 
Dr. Stone might want to add to that.
    Dr. Stone. Yeah, I do. Because we are working with a 
segment of health care delivery that no one else has ever done 
before, we are still figuring this one out. And when I say 
that, the average of suicide prevention coordinator will have a 
cohort of about 90 patients. But yet, not all of them are they 
contacting every day. In some instances, especially in those 
people coming out of our emergency rooms that are at risk, they 
are being contacted by the nurses or, actually, even the 
provider.
    We implemented, as was mentioned by my colleagues, a post-
suicide attempt suicide prevention contract that I have spoken 
about previously, not here today but in previous testimony, 
that has been pretty dramatic at reducing future suicide rates. 
But the individuals that are actually interacting with that at-
risk veteran are either the nurses or the actual provider that 
cared for them in the emergency room.
    So adding the additional personnel is a recognition that we 
continue to grow in our engagements, in our veteran crisis 
line, as well as identifying at-risk veterans by going through 
what we call our REACH VET Program. We have now identified over 
30,000 veterans that we considerate at substantial risk of 
future suicide, and making positive contact with them is 
essential.
    Mr. Cunningham. I appreciate that, Dr. Stone.
    And one final question for you, as I am trying to, you 
know, understand what you testified to here today.
    Let's say you are king for the day. And for every extra 
dollar of funding that you received, how much of that would you 
put into addressing mental health within the VA hospital and, 
you know, suicide prevention coordinators addressing the issue 
head on. And then what percentage of that dollar would you 
allocate towards the issues you previously identify, whether it 
be homelessness or economic, basically those underlying 
factors.
    Dr. Stone. I think having sat through the last couple hours 
here with me, you understand--well understand very well my 
answer. This is not a financial problem. This is a problem of 
the society that we live in. And this is about the 
interpersonal connections that we each have to each other as a 
society.
    I can hire another 20,000 mental health providers. And what 
I can say to you is that people in crisis will get great care. 
And they will come in or be seen in the same day as they are 
today. I can hire additional people for at-risk.
    But this is about moving to the left. Moving towards the 
fact that we need to reduce risk. And it goes back to your 
colleague's comments earlier about whole health and identifying 
what connects us as humans to other humans and finding 
stabilization as a society that is much different than it was 
for those veterans that came home 30, 40, and 50 years ago.
    Mr. Cunningham. I appreciate your time. And I appreciate 
the service each of you all provide.
    I yield back.
    The Chairman. Thank you, Mr. Cunningham.
    Mr. Cisneros, you are recognized for 5 minutes.
    Mr. Cisneros. Thank you, Mr. Chairman, and I just want to 
thank all the witnesses for being here this evening.
    Dr. Stone and Dr. Franklin, I sat down and had a 
conversation with the director of the VA Long Beach Medical 
Center, and he mentioned a pilot program that they are running 
called the Veterans Medical Evaluation Team or VMET. Have you 
heard of it? Yeah.
    So for those of you who don't know, this program is a 
partnership between the Department of Veterans Affairs in Long 
Beach and also law enforcement, local law enforcement to 
actively reach military veterans in trouble even if they are 
not connected with the VA system. They train local police 
officers. Even a VA clinical technician will even often go with 
the law enforcement officer on calls when it is regarding a 
veteran. He touted this as a very successful pilot program that 
they are running, and we heard about several other examples of 
successful pilot programs that local VA hospitals are running 
as well just here this evening.
    How is the VA kind of collecting this data from these? I 
mean, obviously you are encouraging local VA hospitals to go 
out and to run community programs, but how is the VA overall 
collecting this data and then deciding if these pilot programs 
are successful and then trying to implement them out on a 
larger scale?
    Ms. Franklin. It is a very good question, and I appreciate 
this example that is happening in your area because we have 24 
cities that are working with us and 7 States. We call them 
mayors and governors challenge, and they are implementing, just 
as you described, creative evidence-based approaches that 
involve training community members and accessing care and 
reaching veterans where they work, live, and thrive.
    We bring them in in collaboration with our colleagues here 
from SAMSA to train them on these approaches so that they can 
execute these, and we monitor them over time through a 
technical assistance arm that is offered through my colleague, 
Richard McKeon, who is here today. And we do it together. We 
host a series of monthly calls with local mayors and governors, 
county teams to learn the best practices.
    And we have created an online IT platform where we call it 
a community of practice where they can also input their best 
practices and the data into this platform where anybody across 
the VA can go in, look, share, and learn. And so that is a 
little bit of how we are doing it. I want to have Dr. McKeon 
also share because he is helping us on this effort.
    Mr. McKeon. Yes. I think it is a very important initiative 
because it is really trying to promote comprehensive approaches 
to suicide prevention at the local level which is what we think 
is really needed. And so we look forward to our continued 
partnership with the Veterans Administration around this work 
both in the cities and the rural areas and among States.
    Mr. Cisneros. So we are sharing best practices which is 
great, but has there been any example of a program where you 
have taken a program and said okay, we need to implement this 
nationwide because it is working?
    Ms. Franklin. Yes. I will give you one example that was 
actually done under the leadership of Dr. Stone, and that 
involves our ER work. So there was an initial early study that 
spoke to the importance of aftercare when people leave our ERs 
where they are getting a simple intervention, also mentioned by 
my NIMH colleague, around caring outreach with a phone call to 
veterans when they leave the emergency room. And it pointed 
towards significant reductions in suicide when they have this 
caring outreach, and we had done it in a pocket, I believe it 
was seven of our facilities, and we had tracked the data over 
time in a small pilot.
    And when Dr. Stone got in the seat of the executive 
director, we had a series of meetings that put it on a fast 
track for full implementation across the entire VA system, 
every ER. I don't know if that sounds like--
    Dr. Stone. And this is specifically directed at survivors 
of a suicide attempt. And as was mentioned earlier by our 
colleagues, they had seen a 30 percent reduction. We are 
actually seeing a 50 percent reduction in future suicide 
attempts.
    Mr. Cisneros. You know, we have heard numerous times today 
this is basically going to take a village. The VA can't do it 
by itself. Everybody is going to need to get involved working 
with local law enforcement and local officials as well to make 
this all happen.
    The last thing I have, you had mentioned the program that 
you have been working with, with the Air Force, and you have 
been able to work with the Air Force to kind of help minimize 
the numbers. That is the first I heard of this program. I would 
love to see more information about that, and I would really--if 
it is being so successful with the Air Force, why haven't we 
been able to implement it with the other services?
    Dr. Stone. I would not speculate, sir, on what the other 
services have done or not done. I have been out of uniform 
since 2014. I can tell you that we in VA are incredibly 
intrigued with the fact that the Air Force has taken as far 
back as 1996 the integration of suicide prevention strategies 
and integrated them into virtually every level of officer and 
enlisted training.
    And in response to 18 years of warfare, they have seen 
almost no increase in Air Force veterans or Air Force active 
servicemembers of suicide rates.
    Mr. Cisneros. Well, my time has expired, but if you can 
make that program, the information about it available to us, I 
would appreciate that. Thank you.
    Thank you, Mr. Chair.
    The Chairman. Thank you, Mr. Cisneros.
    Ms. Underwood, you are recognized for 5 minutes.
    Ms. Underwood. Thank you, Mr. Chairman.
    Dr. Franklin, annual reviews of VA's suicide prevention and 
mental health services have found that most veterans receive 
good mental health care from the VA. Despite that, though, the 
suicide rates for veterans in my home State of Illinois is 
almost double the rate of the general population. I am a public 
health nurse. I prepared for this hearing tonight by reviewing 
the medical research on the subject, and I would like to walk 
through some of that research briefly with you today.
    Suicide attempts for servicemembers are more likely to 
result in death than they are for civilians. Is that correct?
    Ms. Franklin. Yes, ma'am, it is.
    Ms. Underwood. So let's talk about what the research says 
might contribute to that so we can make sure implementing 
evidence-based policies to prevent it. You are aware that both 
men and women veterans have much higher rates of firearm 
ownership and easier access to firearms than the general 
population. Is that correct?
    Ms. Franklin. Yes. Yes Chairwoman.
    Ms. Underwood. Okay and so veterans, of course, already are 
familiar and comfortable with firearms than the general 
population. Is that correct?
    Ms. Franklin. Yes.
    Ms. Underwood. Okay. So we know that both men and women 
veterans are more likely than civilians to use firearms for 
suicide. Is that correct?
    Ms. Franklin. Seventy percent more, yes.
    Ms. Underwood. Okay. And so this is especially more 
dangerous because attempting suicide with a firearm is more 
deadly than with any other method?
    Ms. Franklin. Absolutely.
    Ms. Underwood. Okay. So I really do commend the VA for 
calling attention to firearm suicide among veterans, and 
currently the VA's national suicide data report found that 
intervention focused on preventing self-harm by firearm are 
integral to preventing veteran suicide. Since 2008, the VA has 
offered free gun locks to veterans in an effort to reduce 
suicide. Is that correct?
    Ms. Franklin. Yes, we have.
    Ms. Underwood. Okay. And so the VA has an educational 
campaign as well. I saw fliers myself during my visit to the 
Level Healthcare Center back home last week, but obviously 
veteran suicide remains at a critical level. VA health 
professionals receive training on providing lethal means 
counseling to veterans. Is that correct?
    Ms. Franklin. Yes, we do.
    Ms. Underwood. Okay. Can you tell us what that training 
looks like?
    Ms. Franklin. The training is focused on how to talk with 
veterans in a firearm friendly way that is culturally relevant. 
We don't want our clinicians to lose veterans or to turn them 
off by using the wrong term or to have them begin to talk about 
this issue in a way that brings it into the public square and 
is a potential political issue.
    We teach our clinicians that it is about safety, and the 
training is focused on protecting the environment as is the 
last question in the safety plan that both of my colleagues 
here from SAMSA and NIMH mentioned. It is about assessing the 
environment for all causes and manner of safety issues, and we 
focus the training on putting time and space between the person 
at risk and the identified means with many of the things that 
were talked about at this hearing this evening like whether it 
is the freeze method or storage of firearms or even having a 
peer involved and having a peer hold a weapon while--a firearm 
while a veteran is at imminent risk.
    Ms. Underwood. And so who receives the training? So, you 
know, you mentioned that the professionals do get it, but which 
categories of professionals?
    Ms. Franklin. Mental health professionals.
    Ms. Underwood. Okay. In the written testimony, it talked a 
lot about how many veterans received primary care, and most or 
many of these screenings are done by the primary care 
providers. Do you see any utility in training your VA primary 
care providers in these methods?
    Ms. Franklin. Yes. If it were up to me, we would train the 
entire VA on how to talk about lethal means. It is a short 
training. It is available online. It is easy to take, and we 
would monitor and assess it over time and continue to make it 
better, absolutely yes, ma'am.
    Ms. Underwood. Is that a resource constraint that prevents 
the primary care providers and others being mandated or 
required to undergo this training?
    Ms. Franklin. Quite honestly, I don't think it is about 
resources. I think it is about getting their commitment and 
getting them on board to do it. We certainly have work to do in 
this space to make sure the primary care docs prioritize that 
in their training rotation and platform, if you will.
    Ms. Underwood. Okay. Well, I think that this Committee 
would certainly support elevating that among the priority 
measures for the primary care providers. And if there is 
anything that we can do to accelerate that, I think it would be 
useful. We want to make sure that all health care professionals 
are armed with the resources that they need in order to 
properly service our veterans.
    Has the VA engaged at all with firearm dealers and 
ownership groups to find ways to increase their involvement 
with veteran suicide prevention?
    Ms. Franklin. Yes, absolutely. That is why we have a 
participate with the National Shooting and Sports Rifle 
Foundation which I mentioned earlier. It is an MOA, so it is an 
official partnership. It involves the whole leadership chain. 
It is not just with my single program. It is between the whole 
VA and the whole National Shooting and Sports Foundation.
    And it also involves the American Foundation for Suicide 
Prevention which is another non-profit that is heavily engaged 
in the research in this space. And it calls for the three 
agencies to work together to bring firearms owners, dealers, 
and even trade organizations to the table and teach them about 
signs and symptoms of risk.
    Actually, the State of New Hampshire has had quite a bit of 
success in this as has the State of Colorado, and so we are 
doing quite a bit of work in this space.
    Ms. Underwood. And when you say bring together, are you 
actually hosting these meetings?
    Ms. Franklin. We are not hosting them at the national 
level, but they sure are hosting them locally, and they are 
even going door to door to firearm dealers and people that 
sell, and they are talking with them about suicide risk. 
Richard McKeon may have some additional information.
    Mr. McKeon. So in numerous States, this kind of work is 
going on with SAMSA funding, so SAMSA is not convening those 
meetings directly, but our funding that goes to States has been 
used in a number of different States to fund this kind of 
activity.
    Ms. Underwood. Well, thank you so much for sharing this 
information. I do think that there might be some utility as we 
explore evaluating these types of partnerships and seeing if 
there is more of a direct role that these agencies can play. 
And certainly if our Committee can be helpful in accelerating 
that, we stand by to do so. Thank you.
    Ms. Franklin. Thank you, Chairwoman.
    The Chairman. Mr. Rose, you are recognized for 5 minutes.
    Mr. Rose. Thank you, Mr. Chairman. To the witnesses, thank 
you so much for being here today. Dr. Stone, Dr. Franklin, I 
can see that you are deeply committed to this issue. My fear is 
that there are some things, as you mentioned, that are out of 
our control. And I am saying this as someone that was an 
infantry platoon leader in Afghanistan 6 years ago, and one 
thing is our operational tempo and the intensity of our 
deployments. So my questions today center around the effects of 
these issues on suicides. I am going to read off a few 
statistics to you, and then I have a few questions.
    In a report published in 2018 by the Uniformed Services 
University, it shows that those who served 12 or fewer months 
before their first deployment were approximately twice as 
likely to attempt suicide during or after their second 
deployment. Also, in additional studies, those redeployed 
within 6 months or less were 60 percent more likely to attempt 
suicide. Were you aware of these statistics?
    Dr. Stone. I am.
    Mr. Rose. Have you seen any further causal relationship 
between the number of deployments and the intensity of 
deployments as it relates to suicide between the 18 to 34 
demographic, particularly the post 9/11 combat veterans?
    Dr. Stone. Certainly there are some deeply troubling issues 
regarding operational pace that you bring up and I referenced 
earlier in testimony. And that is not only the intensity of 
ongoing combat in a 12- to 15-month deployment as well as the 
dwell time when we bring servicemembers back. That was 
extensively studied in the Army STARS Program. It was also a 
point of interest for General Chiarelli as the Vice Chief of 
Staff of the Army who spearheaded a number of studies on dwell 
time and relationship-based effects related to the amount of 
suicides in ground troops in both the Army and the Marine 
Corps, and all of that work was done in cooperation with the 
Marine Corps.
    Mr. Rose. So my question, though, is as you see further 
evidence relating deployments and op tempo to suicides, amongst 
young men and women, do you think it is within your purview to 
make recommendations to the Active Duty Army as to what they 
should change, and note that if they do not change those 
things, they are creating an avoidable, and what I would argue, 
incredibly wrong risk of suicide amongst our veteran 
populations. Do you think that is within your purview to make 
those recommendations to the Active Duty Army?
    Dr. Stone. I think that identifying data and sharing that 
data with our uniformed colleagues is entirely appropriate. I 
am not the decisionmaker.
    Mr. Rose. And so--no, of course not. But I am talking about 
recommendations. And so would you recommend to the Active Duty 
Army, would you say that it is responsible to redeploy soldiers 
with less than 6 months of dwell?
    Dr. Stone. Those are decisions that the active component 
must make.
    Mr. Rose. I am asking as a health care professional if you 
would say it is responsible.
    Dr. Stone. And I am saying to you, Congressman, that those 
are decisions that the active component must make. We can 
provide data. We can share that data. We have a cooperative 
environment in which we as health care professionals are 
discussing this, but you can go back through the 20 years of 
this war and really look at the push and pull between the size 
of the ground force and the relationship between the medical 
professionals that were advising senior leaders and decide for 
yourself how that has been handled.
    I was in uniform for 23 years. I served on the Army staff. 
I had my chance to say what I needed to say and was welcomed by 
senior leaders and was proud to work alongside the ground 
combat forces. That said, my job at this point is to take care 
of 20 million veterans that want to see us and to take care of 
their problems. The decisions on dwell time, combat time are 
certainly in a discussion between you and those active leaders.
    Mr. Rose. Okay. I understand.
    Now, moving on to National Guard soldiers presently serving 
in the National Guard, how do you explain, what is your 
understanding of this crisis with suicides amongst National 
Guard soldiers who have not deployed, and do you think that the 
training op tempo has any connection to this and the fact that 
it has increased dramatically in the last 20 years?
    Dr. Stone. I think there is some deeply troubling parts of 
the National Guard, and I referenced this earlier in testimony 
when I said that every one of these servicemembers joined 
knowing that they were probably going to combat. This is a 
different National Guard than simply a guard that takes care of 
the national or the State-related problems of floods, 
hurricanes, and tornadoes.
    This combat force is an area of debate that has been 
highlighted recently in a book called Signature Wounds. Is the 
pace too much for the ground combat forces of the guard? These 
are individuals that have served tremendously well in combat, 
but the force--the stress on that force is significant and one 
that I think we all need to consider.
    Mr. Rose. Do you think it is within your purview to make 
recommendations to the National Guard?
    Dr. Stone. And we have entered into an MOU with the 
National Guard, and the National Guard has been a wonderful 
partner. General Catavee has been great in our meetings about 
discussing and trying to do everything he possibly can to 
reconnect.
    One of the things that we see is that there is a lower rate 
of suicide in guard members than there is in reserve members in 
spite of the fact that the guard is much larger. There is 
something protective about the connection within States.
    Remember that the Army Reserve is a force that you might 
travel 400, 500, or 600 miles in order to do your reserve 
service. The guard has something protective about it that we 
need to study more, and I can tell you that the leadership of 
the guard and the Army Reserve has been great about entering in 
these conversations openly and with a sense of self 
examination.
    Mr. Rose. Thank you very much again for your time and for 
your service.
    The Chairman. Thank you, Mr. Rose, for your questions.
    Mr. Levin. Oh. Actually, not Mr. Levin. I am sorry Mr. 
Levin. Mr. Watkins, you are recognized for 5 minutes.
    Mr. Watkins. Thank you, Mr. Chairman. Thank you to the 
panel for being here. These questions will go to anybody who 
would like to answer.
    So having served or lived and worked both in service and as 
a paramilitary contractor for 8 years in Iraq and Afghanistan, 
I know firsthand some of the challenges servicemembers face 
when they come back home, and my question is how do you--the 
metric of 22 suicides a day. I want to take a closer look at 
that for a deeper understanding.
    That metric kind of hints and suggests this narrative that 
it is Gulf War veterans, but am I learning right that it is--a 
lot of those suicides are Vietnam era veterans?
    Dr. Stone. 21 percent of the national veteran suicide 
number is over age 75, percent is between age 55 and 74, 27 
percent is between age 35 and 54. And 15 percent is 18 to 34.
    Mr. Watkins. All right. Thanks. Is the VA open to--
alternative is a very loaded phrase, but other means of therapy 
aside from psychotherapy, for example, transcendental 
meditation?
    Ms. Franklin. I think you might be talking about 
complementary care, and absolutely. It is part of our whole 
health model, and there are a number of treatments. I don't 
know that the ones that you specifically mentioned are on that 
list. I can get back to you on that, but we are open to any and 
all forms of complementary or adjunct care to treatment plans, 
yes.
    Mr. Watkins. And do you have data that could measure the 
efficacy of those as compared to the more traditional 
psychotherapy?
    Ms. Franklin. We don't have data specifically when those 
are implemented alone. What happens is they are traditionally 
implemented as part of a broader care system. So for example, a 
client might get cognitive behavioral therapy with additional 
complementary care and thus and such, and it is typically 
evaluated as part of the full system of care, a full treatment 
plan, if you will, for a veteran.
    Mr. Watkins. Are the veterans open to those approaches?
    Ms. Franklin. It appears as though they are. I have read 
quite a bit in the literature about them being open to things 
like yoga and other forms of that type of therapy.
    Mr. Watkins. Are Active Guard and Reserve commanders open 
to those approaches as well? I know it is tough for you to say.
    Dr. Stone. I think there has been tremendous progress in 
the openness of active leaders to these because it can keep 
soldiers in the fight, and soldiers do very well with these 
types of training.
    I think the early intervention and the embedding of both 
behavioral health providers with the active component 
formations has shown tremendous value in both special 
operations as well as traditional ground forces.
    Mr. Watkins. Should those take a bigger role in soldiers' 
basic trainings?
    Dr. Stone. I think that making servicemembers aware of the 
role of complementary medicine is tremendously valuable. 
Probably the hardest data we have really relates to organized 
sports activities and the protective effect of organized sports 
activities. And the fact that I think in our latest--the last 
year's report, it identified that about 150 minutes of 
organized exercise had really demonstrable protective effect in 
veterans.
    Mr. Watkins. Great. Thank you so much. I have no doubt 
there would be many more suicides if it weren't for your 
efforts, so thank you for your service.
    I yield my time.
    The Chairman. Thank you, Mr. Watkins.
    And now, Mr. Levin, you are recognized for 5 minutes.
    Mr. Levin. Well, thank you, Mr. Chairman, for holding this 
hearing on what is a critically important issue to all of us 
around the country. Particularly in my district in San Diego 
and Orange County, there is a very large veteran population, 
home to Marine Corps Base Camp Pendleton. I had an opportunity 
during the district work period to visit with the leader of the 
San Diego VA as well as have several meetings with many of the 
veteran service organizations and other non-profits that are 
leading in this and related issues.
    I wanted to ask another question about the intersection of 
guns and suicide as it pertains to veterans. In its national 
suicide data report, the Department of Veterans Affairs calls 
for, and I quote, ``a continued focus on innovative crisis 
intervention services.''
    One crisis intervention tool that 15 states have now 
adopted and that is shown to reduce suicides is called an 
extreme risk law. When someone is showing warning signs of 
being in crisis and a risk to themselves or others, these laws 
allow their family members or law enforcement to ask a judge to 
temporarily restrict their access to firearms.
    When Connecticut stepped up enforcement of its extreme risk 
law, it saw a 14 percent reduction in the State's firearm 
suicide rate, and in the 10 years after its extreme risk law 
went into effect, Indiana saw a 7.5 percent reduction in its 
firearm suicide rate. The impact of an intervention tool like 
this could be magnified for the veteran population because not 
only do veterans have a higher rate of suicide than the general 
public, but they are more likely to use a firearm compared to 
both the general public and to any other method.
    To each of our panelists, do you think Congress passing 
extreme risk legislation is one thing we could do right now to 
help address the veterans suicide crisis?
    Mr. McKeon. Well, Congressman, I think that we are very 
aware of the extreme risk protective orders, and the data from 
places like Connecticut and Indiana are very encouraging. I was 
at a presentation just last week around this very issue in 
States that have passed this. I think we want to work closely 
to make sure that family members and others are aware of the 
availability of this. I am not really able to take a stance on 
whether national legislation, but I think that in those States 
that have taken this, we want to make sure that those who 
surround veterans and others who are at risk for suicide are 
aware of it as a potential.
    Mr. Levin. Thank you, Doctor. Anyone else care to comment?
    Well, another area that I wanted to address is 
collaboration between the Department of Defense and the 
Veterans Affairs Administration. For me, and for those that I 
have spoken with, it appears to be a critical aspect for an 
effective veterans' suicide prevention relationship between 
private and defense and the VA. And this means ensuring a warm 
handoff as servicemembers leave the military but also sharing 
relevant information that can inform VA's intervention 
strategies.
    Now, I understand that the military keeps track of which 
servicemembers are at higher risk for suicide. Dr. Stone, my 
question for you is does the DoD share this information with 
the VA, and if not, have you requested, or will you request 
they do so?
    Dr. Stone. I think sharing of the medical records is a lot 
different than a commander calling another commander when you 
move a servicemember or PCS a servicemember. One of the things 
we implemented when I was still in uniform was warm handoffs 
between line commanders, not just the mental health 
professionals. I think we have had an excellent discussion and 
earlier we discussed about our combined use of clinical 
practice guidelines of how we do transitions and handoffs.
    I think you have identified an area that we could do 
better, but I will tell you there is good discussion going on, 
and I am absolutely optimistic that as we implement the 
electronic medical record on a common platform, the ability to 
instantly see what is going on from the time the servicemember 
joined the military will go a long way from the longitudinal 
viewer that we have today where we have to toggle in and out of 
our current Vista system to an electronic record viewer from 
DoD. So a common platform is essential.
    Mr. Levin. Thank you. I really appreciate all of your work 
on behalf of veterans, and thank you for taking the time with 
us tonight.
    And I yield back the balance of my time.
    The Chairman. Thank you, Mr. Levin.
    I want to thank all of the witnesses for appearing before 
this Committee today. It certainly has been a long and 
strenuous evening, and I appreciate your willingness to work 
with this Committee in combating this tragic crisis.
    This is a first of, I think, many hearings that we will be 
conducting as well as round tables on this topic of veteran 
suicide, and we will, as I said in my opening remarks, continue 
to hear from all the stakeholders including the families of 
those veterans that have committed suicide, those veterans that 
have survived suicide, and the many other professionals and 
stakeholders and VSOs that have insights to help this Committee 
take action and to really make a difference in reversing this 
trend that we see in veteran suicide.
    I understand that the minority does not wish to make a 
closing statement. I will conclude with these words. To the 
veterans who are watching this hearing and to those struggling 
with the thoughts of suicide, a grateful Nation cares for you. 
Both your service and life are valued, and your continued 
existence is necessary to advancing the causes for which you so 
selflessly served. You sacrificed everything to preserve our 
freedoms. We, as a Nation, are committed to preserving your 
life.
    If you or someone you know is contemplating suicide or in 
need of additional assistance, please call the suicide 
prevention lifeline at 1-800-273-8255. That number again is 1-
800-273-8255. And when you call that number, press 1 to get in 
touch with a professional that is waiting to assist you.
    All Members will have five legislative days to revise and 
extend their remarks and include extraneous material.
    Again, thanks for all of the witnesses for appearing today 
before this Committee, and this hearing is now adjourned.

    [Whereupon, at 9:48 p.m., the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              

               Prepared Statement of Chairman Mark Takano
    Good evening. I call this hearing to order.
    First I would like to welcome our witnesses this evening: Dr. 
Stone, from the Veterans Health Administration, Dr. Avenevoli from the 
National Institutes of Health, and Dr. McKeon from the Substance Abuse 
and Mental Health Services Administration.
    Today's hearing will be the first of many this Committee will hold 
as it begins the critical work to address veteran suicide. I think we 
can all agree how important it is to take care of our veterans which is 
why I have made ending veteran suicide my number one priority.
    Sadly, America is facing a national public health crisis that 
demands urgency from Congress, the administration, medical and clinical 
professionals, veteran service organizations and veterans themselves.
    This morning, we lost another veteran to suicide at a VA hospital. 
Two weeks ago, three veterans committed suicide on VA property in just 
five days. Seven veterans have ended their lives on VA campuses this 
year.
    It's clear we are not doing enough to support veterans in crisis. 
While these incidents may be alarming, they do not tell the full story 
of veteran suicide in our country. It is harmful to veterans and overly 
simplistic to solely blame VA for these tragedies. We must come 
together as a nation to address this crisis.
    Too many Americans have been personally touched by this troubling 
trend-for me, it was my own uncle, a Vietnam veteran, who died by 
suicide. EXPOUND ON STORY.
    Each day 20 veterans, servicemembers, reservists, and members of 
the National Guard die by suicide.
    One veteran lost to suicide is one too many. But 20 deaths a day -- 
totaling more than 7,300 deaths per year is unacceptable. That's 1,800 
more deaths per year than the 5,429 servicemembers who have been killed 
in action since 2001.
    Both numbers are surprising and further evidence of a frustrating 
and persistent problem that we've failed to adequately address.
    When you examine the statistics, the barriers to access many 
veterans face become very clear. Only 6.1 of those deaths are veterans 
accessing services at VA. 10.6 deaths a day are veterans not using VA 
at all, and 3.8 current active duty or members of the National Guard.
    We all have a responsibility to act because there's no excuse for 
failing these veterans here at home.
    My Republican colleague, Ranking Member Roe, often says we haven't 
"moved the needle" far enough to reduce veteran suicide. He's right. 
That number has held steady at 20 deaths a day since 2014-- far too 
long. It's time for Congress to look at this crisis with fresh eyes.
    In 2015, Congress passed the Clay Hunt Suicide Prevention for 
American Veterans (SAV) Act, but this well intentioned effort hasn't 
done enough. Recently, I met with several members of Clay Hunt's unit, 
who identified the specific challenges they faced as they transitioned 
out of the military.
    We need to understand why this legislation hasn't done more to 
prevent suicides. We need to expand our understanding of mental health 
among veterans. We need to commit to providing the resources needed to 
implement a comprehensive plan.
    Most importantly, Americans must hear from and listen to our 
veterans. We need to hear from veterans who have attempted suicide, 
understand their circumstances, and find out what they believe worked 
and what failed.
    These veterans have a story to share that can tell us something 
about our attempt to address suicide and how responsive government can 
be to their situation.
    This committee will not be indifferent to the problems veterans 
face nor will we turn a blind eye to the many causes that lead to 
veterans committing suicide. And I'm glad we could all come together 
today to begin to tackle this important issue.
    Ultimately, it's up to all of us to reduce and prevent veteran 
suicide because this is not a problem VA can solve alone. We know that 
dedicated doctors, nurses, and VA employees have saved over 240 
veterans from committing suicide on VA campuses in recent years. VA 
briefs me on each suicide at a VA facility, and there's still so much 
we don't know. We must involve partners at the federal, state, and 
local levels and do a better job of supporting veterans in need 
regardless of whether that need is clinical or social.
    By supporting clinically effective programs and increasing access 
to programs that mitigate the impact of concerns -- be they financial, 
marital, substance abuse related, or physical health -- veterans will 
feel the support they seek.
    VA must also ensure every interaction it has, not just in a 
clinical setting, makes veterans feel supported. One example from VFW 
struck me when I was reading the statements for the record from the 
VSOs:
    And I quote: "The VFW is working with a veteran who was rushed to a 
VA hospital during a mental health crisis caused by untreated bipolar 
disorder and depression. The veteran was admitted to the medical 
center's inpatient mental health care clinic for two weeks, despite not 
being eligible for VA health care. VA saved his life, but now he has a 
$20,000 bill.
    His mental health crisis was exacerbated by unemployment and his 
inability to provide for his family.
    With proper treatment he has been able to return to work, but still 
lacks the resources to pay the VA bill. The VFW is working on having 
his bill waived, but he will never return to VA if he has another 
mental health crisis."
    This is just one more testament to what we already know-when a 
veteran is faced with the sky-high cost of medical care, it can be a 
significant barrier to getting the help they need.
    To really combat this crisis we will have to change our mission. We 
must reexamine our approach to suicide prevention, exhaust our research 
possibilities, break the stigma faced by those seeking mental health 
services, and expand the healthcare and support we offer veterans. Like 
all of those in this room, I believe Americans are ready to meet this 
challenge.
    Countering this crisis will require us to shine a national 
spotlight on veteran suicide. There is still so much we do not know. We 
need to better understand the root causes driving veteran suicide, hear 
from the families who have lost loved ones, and listen to the 
clinicians and social workers who are on the front lines battling to 
end veteran suicide.
    As Americans, we are proud of the service and sacrifice veterans 
have made for our country, but a polite "Thank You for Your Service" 
isn't enough for our veterans in crisis. Instead, we must thank and 
honor our veterans with action, work together to deliver top quality 
healthcare, provide community support, and ensure we offer a stable 
transition out of military service and into quality, sustainable 
employment.
    Truly thanking veterans for their service means helping them when 
they need it most and rise above political opportunism to support 
veterans in crisis. It is my hope that together, we can curb this 
crisis.
    Before I recognize Ranking Member Roe I'd like to point out that 
May is Mental Health Awareness Month and we all have to do our part. I 
encourage every member of this Committee to record a suicide prevention 
PSA to highlight VA's Be There campaign.
    As Wounded Warrior Project pointed out, ". if a treatment program 
does not offer a family or caregiver component, and warriors go through 
clinical processes then return home, it may leave the family or 
caregiver to feel left in the dark about what occurred."
    We should be doing all we can to ensure family members and 
caregivers not only feel supported but have access to much needed 
resources as they help their loved one recover.
    In addition, I would encourage all of you to meet with both 
veterans who are suicide survivors and speak with families who have 
lost loved ones to suicide to better understand how we can work to end 
this crisis.
    To the veterans watching this hearing, and to those struggling with 
thoughts of suicide: A grateful nation cares for you. Both your service 
and life are valued, and your continued existence is necessary to 
advancing the causes for which you so selfless served - You sacrificed 
everything to preserve our freedoms. We, as a nation, are committed to 
preserving your life.
    If you, or someone you know, is contemplating suicide or in need of 
additional assistance please call the suicide prevention lifeline at 1-
800-273-8255 and press 1 to get in touch with a professional that is 
waiting to assist you.partnerships, build new ones, and improve suicide 
prevention strategies through scientific research.

                                 
             Prepared Statement of Shelli Avenevoli, Ph.D.
    Good evening, Chairman Takano, Ranking Member Roe, and 
distinguished Members of the Committee. I am Shelli Avenevoli, Ph.D., 
Deputy Director of the National Institute of Mental Health (NIMH) 
within the National Institutes of Health (NIH). It is an honor to 
appear before you today alongside my colleagues, Richard A. Stone, 
M.D., Executive in Charge, Veterans Health Administration (VHA); Keita 
Franklin, LCSW, Ph.D., Executive Director, Suicide Prevention, U.S. 
Department of Veterans Affairs (VA), Office of Mental Health and 
Suicide Prevention; and Richard T. McKeon, Ph.D., M.P.H, Chief, Suicide 
Prevention Branch, Center for Mental Health, Substance Abuse and Mental 
Health Services Administration (SAMHSA).
    I want to thank this Committee for your sustained interest in the 
NIH, where we work to ensure that our nation remains the global leader 
in biomedical research and advances in human health. I also want to 
thank the Committee for bringing us together to address the challenges 
of suicide prevention in this country, for veterans and all Americans.
    The Centers for Disease Control and Prevention (CDC) reported that 
47,173 Americans took their own lives in 2017. \1\ This is a part of a 
two-decade trend that has resulted in a 33 percent rise in the national 
suicide rate. \2\ As the national lead for research on suicide risk and 
prevention, and as part of the National Action Alliance for Suicide 
Prevention, NIMH works with the CDC, SAMHSA, VA, and other federal 
agencies and private partners to better understand - and help reduce - 
suicide risk. \3\
---------------------------------------------------------------------------
    \1\ https://webappa.cdc.gov/sasweb/ncipc/mortrate.html
    \2\ https://www.cdc.gov/nchs/products/databriefs/db330.htm
    \3\ https://theactionalliance.org/
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    Suicide prevention research is a top priority for NIH. \4\ Over the 
past five years, NIH has steadily increased its support for suicide 
research across the spectrum, from basic to applied research. NIH spent 
approximately $52 million on suicide research in fiscal year (FY) 2016, 
$68 million in FY 2017, and $96 million in FY 2018. NIMH continues to 
support research aimed at understanding the complex mechanisms 
underlying suicide risk to inform the development of transformative 
prevention and treatment interventions of tomorrow. We also support 
research to test the effectiveness of treatments, as well as identify 
promising new clinical interventions to prevent suicide and treat 
suicide risk. Together with our federal and private partners, we work 
to translate research findings into practice by facilitating wider use 
of evidence-based prevention and treatment interventions.
---------------------------------------------------------------------------
    \4\ https://www.nimh.nih.gov/about/director/messages/suicide-
prevention.shtml
---------------------------------------------------------------------------
    Comprehensive suicide prevention efforts require multiple 
approaches, within and beyond the healthcare system. I want to begin by 
focusing on opportunities within the healthcare system related to 
access and clinical innovations. It is estimated that nearly half of 
individuals who die by suicide see a healthcare practitioner in the 30 
days prior to death, and around 80 percent do so in the year before 
\5\death \6\. In addition, estimates indicate that approximately half 
of suicide decedents have at least one emergency department (ED) visit 
in the year before death. Recent research has identified several 
specific interventions that healthcare systems can implement to 
identify individuals with suicide risk more quickly, and help treat and 
reduce suicide risk to save lives.
---------------------------------------------------------------------------
    \5\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4026491/
    \6\ https://www.ncbi.nlm.nih.gov/pubmed/12042175
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    A key step to helping someone with elevated suicide risk is timely 
identification. One way to do this is to ask people directly about 
suicide risk, especially in healthcare settings. The NIMH-funded 
Emergency Department Safety Assessment and Follow-up Evaluation study 
(ED-SAFE) demonstrated that a 3-item screening tool improved providers' 
ability to identify individuals at risk for suicide. This study showed 
that when screening was conducted on all patients - regardless of the 
reason for their ED visit - the number of patients identified as being 
at risk for suicide was double the number identified under usual care. 
\7\ If used universally, the ED-SAFE researchers estimated that suicide 
risk screening tools could identify more than three million additional 
adults at risk for suicide each year. Use of enhanced suicide risk 
screening is expanding - including in the VA, which began a new 
screening initiative in 2018. \8\
---------------------------------------------------------------------------
    \7\ https://www.ncbi.nlm.nih.gov/pubmed/26654691
    \8\ https://www.blogs.va.gov/VAntage/55281/va-sets-standards-in-
suicide-risk-assessment-offers-support-to-community-providers/
---------------------------------------------------------------------------
    In addition to screening people for suicide risk during healthcare 
visits, we now know that it is possible for healthcare systems to use 
data from electronic health records in novel ways to help identify 
people with suicide risk. The first application of these methods to 
identify suicide risk occurred as part of NIMH's partnership with the 
Department of the Army in conducting the Army Study to Assess Risk and 
Resilience in Servicemembers (Army STARRS; the largest U.S. study of 
mental health risk and resilience ever conducted among military 
personnel). \9\ Researchers from NIMH and Army STARRS then partnered 
with the VA to develop predictive models of suicide risk among veterans 
receiving VA health care. This research demonstrated the feasibility of 
developing algorithms to identify patients within the VA system whose 
predicted suicide risk was 20-30 times higher than average. While these 
patients with very high predicted risk were already receiving a lot of 
health care, most of them had not been flagged as having elevated 
suicide risk using existing identification methods. \10\
---------------------------------------------------------------------------
    \9\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286426/
    \10\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539821/
---------------------------------------------------------------------------
    Using analyses of VA electronic health records, the research led 
directly to the VA's Recovery Engagement and Coordination for Health - 
Veterans Enhanced Treatment (REACH-VET) program, which currently 
applies an algorithm each month to the VA patient care population to 
identify a small fraction (0.1 percent) of patients with the highest 
predicted suicide risk. Suicide prevention coordinators at each VA 
facility work with these patients and their clinicians on suicide-
focused clinical assessment and ways to enhance treatment. The VA was 
the first healthcare system in the United States to utilize these 
methods in their suicide prevention programs. Other systems are 
beginning to follow the VA, including some of the 13 healthcare systems 
across the United States that are part of NIMH's Mental Health Research 
Network. \11\
---------------------------------------------------------------------------
    \11\ https://www.ncbi.nlm.nih.gov/pubmed/29792051
---------------------------------------------------------------------------
    Identifying people who need help is a key first step, but screening 
alone is not sufficient. Improving patient outcomes requires that 
effective interventions be initiated during the health care encounter 
when someone is identified with suicide risk. Moreover, to enhance 
continuity of care, follow-up with the patient should be made when the 
patient is discharged back into the community. During the initial 
encounter, one promising approach is the Safety Planning Intervention 
adapted by the VA, \12\ in which a clinician collaborates with the 
patient to identify specific strategies to decrease the risk of 
suicidal behavior, such as ways to reduce the patients' access to 
lethal means during a time of crisis, and to identify personalized 
coping strategies. \13\ Safety planning can be combined with proactive 
follow-up with the patient, by telephone and/or in writing, to provide 
psychosocial support and encourage engagement in follow-up care. NIMH's 
ED-SAFE study, which focused on ED patients at risk for suicide, found 
that brief interventions in the ED, plus up to seven follow-up phone 
calls to the patient by a clinician, reduced suicide attempts by about 
30 percent during a 12-month period. \14\ Consistent with this finding, 
a recent study conducted in VA EDs found that a Safety Planning 
Intervention with follow-up phone calls reduced suicidal behavior by 
nearly 50 percent over 6 months, and doubled the likelihood of 
individuals receiving follow-up mental health treatment. \15\
---------------------------------------------------------------------------
    \12\ https://amhcajournal.org/doi/abs/10.17744/
mehc.34.2.a77036631424nmq7
    \13\ https://www.mentalhealth.va.gov/docs/VA--SafetyPlan--
quickguide.pdf
    \14\ https://www.ncbi.nlm.nih.gov/pubmed/28456130
    \15\ https://jamanetwork.com/journals/jamapsychiatry/fullarticle/
2687370
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    Multiple agencies, including NIMH and VA, are supporting several 
research studies that have uncovered benefits from an intervention 
called ``caring communications,'' in which patients are sent follow-up 
written communication - by postcard or letter, or now also by text 
message - in the weeks and months after they are identified with 
suicide risk. Such communications, which convey general support to the 
patient, have been found to reduce suicidal behaviors up to a half in 
the subsequent year. \16\ While we do not yet know the exact ``how and 
why'' these follow-up interventions work, the common element is regular 
and supportive contact with the patient during a critical period when 
they transition between structured healthcare settings and the 
community. Research shows that caring communications is a very high-
value intervention; that is, it is a relatively low-cost intervention 
compared to its benefits. \17\ Telephone or written follow-up 
communications can be provided by the hospital where the patient was 
identified, from a centralized facility coordinated by the health 
system, or by staff from Crisis Line programs such as the National 
Suicide Prevention Lifeline or the Veterans Crisis Line. This type of 
proactive follow-up is, unfortunately, not yet part of standard 
practice.
---------------------------------------------------------------------------
    \16\ https://jamanetwork.com/journals/jamapsychiatry/fullarticle/
2723658
    \17\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750130/
---------------------------------------------------------------------------
    For individuals who cannot be safely discharged to outpatient care 
because of severe suicide risk, there is an urgent need for fast-acting 
interventions. These individuals could receive rapid acting treatment 
in EDs and inpatient psychiatric units. Several potential fast acting 
medications have received recent Food and Drug Administration (FDA) 
approval: brexanolone infusion for severe postpartum depression, and 
esketamine nasal spray for rapid resolution of treatment resistant 
depression. Both of these medications must be delivered under an FDA 
approved Risk Evaluation and Mitigation Strategy. Other promising rapid 
acting interventions have been available for some time but have not 
been tested as a first-line intervention for acute suicide risk. We 
need studies that can determine safety, dosing, duration and 
combinations of treatments, \18\ so that we avoid risk of addiction for 
some of these treatments (e.g., ketamine and/or related compounds), and 
find combinations of treatment that result in longer recovery periods. 
The VA has had National Protocol Guidance on Ketamine Infusion for 
Treatment Resistant Depression and Severe Suicidal Ideation since 2017, 
and there are VA studies, for example, testing ketamine for PTSD and 
treatment-resistant depression, and esketamine for suicide \19\risk 
\20\.
---------------------------------------------------------------------------
    \18\ https://www.ncbi.nlm.nih.gov/pubmed/28249076
    \19\ https://www.ncbi.nlm.nih.gov/pubmed/29727073
    \20\ https://clinicaltrials.gov/ct2/show/NCT03788694-
term=Marianne+Goodman&rank=2
---------------------------------------------------------------------------
    Earlier I mentioned that comprehensive suicide prevention efforts 
require multiple approaches, within and beyond the healthcare system. 
The National Action Alliance for Suicide Prevention identified a range 
of best healthcare practices, collectively called Zero Suicide, \21\ 
for improving outcomes among individuals at risk for suicide, and NIMH 
is investing in research to evaluate the real-world experiences of 
health systems that implement Zero Suicide programs. Zero Suicide 
practices include suicide risk screening, safety planning, treatments 
that target suicide risk (e.g. cognitive behavior therapy; dialectical 
behavior therapy), follow-up phone calls, and caring communication 
interventions I just described. To estimate the effects of such 
practices on suicide attempts and deaths, and to inform ongoing quality 
improvement, it is necessary to monitor the outcomes of patients who 
are identified as being at risk and treated. The 21st Century Cures Act 
(Pub. L. 114-255) called for the development of the federal 
Interdepartmental Serious Mental Illness Coordinating Committee, \22\ 
which has specifically recommended that health systems track patient 
survival after events like an ED visit during which suicide risk is 
identified. The VA already tracks the mortality of all veterans, and 
links mortality data to healthcare data for veterans receiving VHA 
care. Some other U.S. health systems do so as well, including Medicare, 
Medicaid, and many of the systems that are part of the NIMH Mental 
Health Research Network. But most U.S. healthcare systems and health 
insurers currently do not link their populations to information on 
mortality, which has significantly limited the ability to both study 
and improve healthcare practices that could prevent suicide.
---------------------------------------------------------------------------
    \21\ https://theactionalliance.org/healthcare/zero-suicide
    \22\ https://www.samhsa.gov/ismicc
---------------------------------------------------------------------------
    For many people, suicide risk is associated with comorbid mental 
illness. Early identification and effective treatment of such illnesses 
is important for many reasons, including the potential to prevent 
people from becoming suicidal in the first place. There are too few 
mental health service providers in the United States, and individuals 
who go on to die by suicide are most commonly seen by a primary care 
provider. Therefore, I want to highlight an evidence-based approach for 
treating mental illnesses in primary care settings called the 
Collaborative Care model. Collaborative Care is a specific approach 
that enhances ``usual'' primary care by adding two key services: care 
management support for patients receiving mental health treatment; and 
regular consultation between a mental health service provider and the 
primary care team, particularly for patients who are not improving. 
Numerous studies - including some conducted in the VA - have shown that 
Collaborative Care improves the quality of care and patients' 
satisfaction of their care, mental and physical health outcomes 
including faster recovery, and improved functioning in people with 
common mental illnesses. \23\ Importantly, several studies have also 
found that Collaborative Care reduces suicidal \24\ideation. \25\ 
Medicare added payment for Collaborative Care in 2017, and some other 
healthcare systems and insurers are now also doing \26\ so \27\.
---------------------------------------------------------------------------
    \23\ https://www.ncbi.nlm.nih.gov/pubmed/22516495
    \24\ https://www.ncbi.nlm.nih.gov/pubmed/14996777
    \25\ https://www.ncbi.nlm.nih.gov/pubmed/17038073
    \26\ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf
    \27\ https://www.ncbi.nlm.nih.gov/pubmed/27973984
---------------------------------------------------------------------------
    In addition, I would like to highlight two other areas of research 
relevant to this hearing. First, access to 24/7 suicide crisis support 
anywhere in the United States is available through the toll-free 
National Suicide Prevention Lifeline. \28\ The Lifeline is a critical 
component to U.S. suicide prevention, and offers access to the 
Veteran's Crisis Line. \29\ NIMH includes the Lifeline as a crisis 
resource in all suicide prevention materials; media recommendations 
\30\ for safe messaging on suicide state that providing ways to access 
crisis support is key. In addition, many NIMH suicide prevention 
research protocols use the Lifeline as part of their safety assurance. 
NIMH research has shown that it is worth investing in quality 
improvements in telephone crisis services because these services can 
decrease distress and suicidal behavior, and improve linkage to care. 
\31\ Utilization of these services is increasing, in general and 
especially after media coverage of the suicide deaths of celebrities. 
It is critical that we find ways to support increased capacity for 
national crisis lines during surges in call volumes after such widely-
reported events. Second, researchers estimate that approximately 1,800 
additional suicide deaths occurred after extensive media coverage of 
actor and comedian Robin Williams' death. \32\ This points to the 
opportunity for public and private partners to work with the media to 
implement safer reporting and messaging about suicide, including 
information on how to get help. We can, and should, work together with 
the media to minimize ``contagion'' or ``imitation'' of suicides, 
including veteran suicides on VHA campuses.
---------------------------------------------------------------------------
    \28\ https://suicidepreventionlifeline.org/
    \29\ https://www.veteranscrisisline.net/
    \30\ http://reportingonsuicide.org/
    \31\ https://onlinelibrary.wiley.com/doi/full/10.1111/sltb.12339
    \32\ https://www.ncbi.nlm.nih.gov/pubmed/29415016
---------------------------------------------------------------------------
    In sum, there exist evidence-based approaches to reducing suicide 
risk. However, translating research into real world settings requires 
strong collaborations in order to facilitate and expand the use of 
effective suicide prevention practices to all communities, to change 
the ``tragic trend.'' Our partnerships with the Army, VA, CDC, SAMHSA, 
and other agencies have led to important findings on suicide risk 
identification, interventions, follow-up care, and overall healthcare 
system improvements. As partnered Agencies, we are beginning to see how 
a growing number of healthcare systems - VA and elsewhere - are 
implementing evidence-based suicide prevention practices. Through the 
National Action Alliance for Suicide Prevention, federal and private 
healthcare partners are sharing information about lessons learned as 
they work to include suicide prevention efforts as a standard practice. 
To increase our potential to save lives, we must continue to leverage 
existing partnerships, build new ones, and improve suicide prevention 
strategies through scientific research.

                                 
         Prepared Statement of Richard T. McKeon, Ph.D., M.P.H.
    Chairman Takano, Ranking Member Roe, Members of the Committee - 
thank you for inviting the Substance Abuse and Mental Health Services 
Administration (SAMHSA) to participate in this extremely important 
hearing on suicide prevention for America's veterans. I am Richard 
McKeon, Chief of the Suicide Prevention Branch in the Center for Mental 
Health Services, SAMHSA.
    An American dies by suicide every 11.1 minutes, and as the recent 
Centers for Disease Control and Prevention (CDC) Vital Signs analysis 
shows, this tragic toll has been increasing all across the country. 
Suicide is the 10th leading cause of death in the United States, the 
second leading cause of death between ages 10 and 34. We lost over 
47,000 Americans to suicide in 2017, almost the same number we lost to 
opioid overdoses. For each of these tragic deaths, there are grief 
stricken families and friends, impacted workplaces and schools, and a 
diminishment of our communities. When one of these deaths involves an 
American who has served his country in the military, as happens on 
average 20 times each day, we as a nation suffer additionally. SAMHSA's 
National Survey on Drug Use and Health has also shown that 
approximately 1.4 million American adults report attempting suicide 
each year, and over 10 million adults report seriously considering 
suicide. This leads to huge direct medical costs, and more importantly, 
tremendous human misery.
    As painful as these numbers are, our concern is intensified by the 
CDC's report that suicide has been increasing in 49 of the 50 states, 
with 25 of the states experiencing increases of more than 30 percent. 
These increases have been taking place among both men and women, and 
across the lifespan. While Federal efforts to prevent suicide have been 
steadily increasing over time, thus far, they have been insufficient to 
halt this tragic rise. We can only halt this rise nationally if we are 
also reducing suicide among the estimated 20 veterans a day who die by 
suicide including those not in the care of the U.S. Department of 
Veterans Affairs (VA). All of us must be engaged in this effort, and 
for this reason SAMHSA includes language in all our suicide prevention 
funding opportunities prioritizing veterans and has worked actively 
with VA on suicide prevention since 2007. While we have not as of yet 
been able to halt this tragic rise, we have seen that concerted, 
sustained, and coordinated efforts can save lives.
    One area where we have made a concerted national effort, namely 
youth suicide prevention, has produced evidence that lives have been 
saved. Cross-site evaluation of our Garrett Lee Smith State/tribal 
youth suicide prevention grants has shown that counties that were 
implementing grant-supported suicide prevention activities had fewer 
youth suicides and suicide attempts than matched counties that were 
not. However, this life-saving impact fades two years after the 
activities have ended when there is no longer a difference in suicide 
rates between counties who implemented youth suicide activities and 
counties that did not.. withThe greatest impact was seen in counties 
that have had the longest period of sustained funding for their 
efforts. This underscores the need to embed suicide prevention in the 
infrastructure of states, local, and tribal and communities. While all 
50 states have received a Garrett Lee Smith (GLS) state grant, 
sometimes the suicide prevention activities end when the grant ends. An 
example of the successful implementation of a GLS grant is the White 
Mountain Apache tribe in Arizona, which received three consecutive GLS 
grants and has shown a reduction of almost 40 percent in youth 
suicides. In that community, a suicidal youth, wherever they may be on 
the reservation, will be seen by a trained Apache community worker 
rapidly after their suicide risk has been identified and the individual 
will be linked to needed treatment and supports. This example 
demonstrates the value of the GLS grants at the county level and also 
the value of timely access to effective suicide prevention and 
intervention services. In addition to decreasing suicide rates, an 
economic evaluation of the GLS program estimated $4.50 in cost savings 
per dollar invested in the GLS program \1\.
---------------------------------------------------------------------------
    \1\ Garraza et al An Economic Evaluation of the Garrett Lee Smith 
Memorial Suicide Prevention Program'' Suicide and Life Threatening 
Behavior , December 2016
---------------------------------------------------------------------------
    In Fiscal Years (FY) 2017 and 2018, Congress provided SAMHSA, for 
the first time, $11 million dollars to focus on adult suicide 
prevention, with $9 million appropriated to the Zero Suicide 
initiative. Zero Suicide is an effort to promote a systematic evidence-
based approach to suicide prevention in healthcare systems using the 
most recent findings from controlled scientific studies as part of a 
package of interventions that moves suicide prevention from being a 
highly variable and inconsistently implemented individual clinical 
activity to a systematized and prioritized effort. The Zero Suicide 
initiative uses the most recent science on screening, risk assessment, 
collaborative safety planning, care protocols, evidence-based 
treatments and care transitions (providing rapid follow up after 
discharge from inpatients units and Emergency rooms), as well as 
ongoing continuous quality improvement. The Zero Suicide initiative was 
inspired by the success of the Henry Ford Healthcare system in reducing 
suicide by more than 60 percent among those receiving care, and other 
early adopters such as Centerstone in Tennessee, one of the Nation's 
largest community mental health systems, have shown similar results. 
More recently the state of Missouri has shown that it is possible to 
reduce suicide among those receiving care in the state's community 
mental health system. As an example of this approach, Centerstone's 
protocol for treating those identified at high risk requires that an 
outreach phone call be made promptly if the person at risk misses a 
scheduled appointment. In one instance, a person on the Centerstone 
high risk protocol missed his appointment and when the follow up phone 
call was made the person was on a bridge about to jump. Instead, he 
came to Centerstone and agreed to be hospitalized. SAMHSA has funded 19 
states, tribes and health care systems to incorporate Zero Suicide and 
technical assistance in implementing this approach, and this has been 
provided to many more through the Suicide Prevention Resource Center. 
SAMHSA has also been working through all of its suicide prevention 
grant programs to improve post discharge follow up since multiple 
studies have shown that rapid contact after discharge and prompt link 
to outpatient services can prevent suicide attempts. SAMSHA's efforts 
can and do make a difference in communities.
    The SAMHSA suicide prevention program that touches the greatest 
number of suicidal people is the National Suicide Prevention Lifeline 
(the Lifeline). The Lifeline is a network of 165 crisis centers across 
the country that answer calls to the toll-free number 800-273-TALK 
(8255). The National Suicide Prevention Lifeline includes a special 
link to the Veterans Crisis Line, which is accessed by pressing 
``one''. The Lifeline is available 24 hours a day, 7 days a week, and 
in many communities in America it is the only feasible option for a 
suicidal person to reach out for help. The Lifeline is available late 
at night or on a Sunday afternoon and for some can be more helpful than 
a costly visit to an Emergency Department. Last year, more than 2.2 
million calls were answered through the Lifeline, and that number has 
continued to grow at a rate of about 15 percent per year. About 25 
percent of Lifeline callers are actively suicidal at the time of the 
call and some of them need emergency rescue services. The Lifeline also 
provides a chat service through the website, and the percentage of 
those using the crisis chat service who are actively suicidal is even 
higher. We believe this is reflective of the rising rates of suicide in 
youth, who may be more likely to use a chat service. Evaluation studies 
have shown that callers to the Lifeline experience decreased suicidal 
thoughts and hopelessness by the end of the call. Follow-up calls from 
Lifeline centers are frequently experienced as lifesaving. However, the 
increasing call volume is also straining the Lifeline system of 
community crisis centers which are responsible for responding to calls 
and chats. These crisis centers are not directly operated or funded by 
SAMHSA. The Veterans Crisis Line and their three centers are directly 
operated by VA, and other Lifeline community crisis centers depend on 
local or state funding. When local crisis centers are unable to answer 
Lifeline calls, the calls must be answered by designated regional back 
up centers. When calls go to regional back up centers, the amount of 
time it may take to answer the call can increase. SAMHSA has summarized 
these issues in its report to the Federal Communications Commission 
(FCC) as required under the National Suicide Hotline Improvement Act. 
SAMHSA's report calls attention to the fact that if the FCC and 
Congress were to designate a 3 digit N11 number for suicide prevention 
this would likely lead to a substantial increase in Lifeline calls. 
While such an increase in Lifeline calls and in seeking help is vitally 
important, it depends on the availability of centers to promptly answer 
the calls to be lifesaving.
    SAMHSA and the VA have been working together to prevent suicide 
since 2007, when the Veterans Crisis Line was first established and the 
``press one option'' was introduced into the National Suicide 
Prevention lifeline message. More recently, SAMHSA and VA have worked 
together to fund a series of Mayor's Challenges and Governor's 
Challenges to prevent suicide among all veterans, service members, and 
their families, regardless of whether they are receiving care though 
VA. Supported through an Interagency Agreement with VA, SAMHSA's 
Service Members, Veterans and their Families Technical Assistance 
Center, has convened cities and states in what are called policy 
academies and implementation academies to promote comprehensive suicide 
prevention for veterans. Multiple public and private partners are 
engaged in this coordinated effort for which onsite technical 
assistance is also provided. As an example, in the Richmond Mayor's 
Challenge, the McGuire VA Medical Center and the public mental health 
center, Richmond Behavioral Health Authority, have developed a 
coordination and referral process to assure that veterans at risk don't 
fall through the cracks between VHA and community systems. A caring 
contact letter from the McGuire VA Medical Center is to be included in 
the discharge packet for veterans leaving community hospitals. The work 
in Richmond is now being implemented elsewhere in Virginia as part of 
the Governor's Challenge. We believe that this type of strong, 
continuing, interdepartmental effort that incorporates states and 
communities as partners is necessary to reduce veteran suicide. SAMHSA 
and VA also work together through the Federal Working Group on Suicide 
Prevention, which includes VA, Department of Defense, Department of 
Justice, Department of Homeland Security, CDC, National Institute of 
Mental Health, Indian Health Service, Administration for Community 
Living, and the Health Resources and Services Administration. SAMHSA 
and VA also work with other public and private organizations through 
the Nation Action Alliance for Suicide Prevention, which was stood up 
with SAMHSA funding in 2010 and has engaged over 250 organizations 
since its inception. The Action Alliance worked with the Office of the 
Surgeon General, SAMHSA, and others to revise the National Strategy for 
Suicide Prevention and continues to engage partners from multiple 
sectors to promote comprehensive suicide prevention efforts.
    SAMHSA also worked with the National Academy of Sciences on a 
workshop on suicide and serious mental illness and serious emotional 
disturbance to improve prevention and intervention strategies. This 
workshop included a focus on veterans. SAMHSA is also developing a 
toolkit to assist families when a loved one is suicidal.
    In summary, SAMHSA is engaged in an unprecedented amount of suicide 
prevention activities, but we know we need to do more to play our role 
in halting the tragic rise in loss of life we are experiencing across 
the country. In particular, we know we need to be engaged in a strong 
continuing, collaborative effort with VA to reduce suicide among 
veterans. We know we must constantly be looking to improve our efforts 
and to learn from both our successes and our failures. We owe it to 
those who have served this Nation and to all those we have lost, as 
well as to those that loved them, to continually strive to improve 
until suicide among veterans, and among all Americans is dramatically 
reduced.

                                 
              Prepared Statement of Richard A. Stone, M.D.
    Good evening, Chairman Takano, Ranking Member Roe, and Members of 
the Committee. I appreciate the opportunity to discuss the critical 
work VA is undertaking to prevent suicide among our Nation's Veterans. 
I am accompanied today by Dr. Keita Franklin, Executive Director, 
Suicide Prevention Program.

Introduction

    Suicide is a serious public health crisis that affects communities 
across the country, and recently, this terrible tragedy occurred on the 
grounds of our VA health care facilities when three Veterans ended 
their lives in a single week. VA health care facilities are designed to 
be safe havens for the women and men who defended our Nation, and a 
suicide among fellow Veterans and those who have given their lives to 
care for them is heartbreaking. We are deeply saddened by this loss.
    Our promise to Veterans remains the same: to promote, preserve, and 
restore Veterans' health and well-being; to empower and equip them to 
achieve their life goals; and to provide state-of-the-art treatments. 
Veterans possess unique characteristics and experiences related to 
their military service that may increase their risk of suicide. They 
also tend to possess skills and protective factors, such as resilience 
or a strong sense of belonging to a group. Our Nation's Veterans are 
strong, capable, valuable members of society, and it is imperative that 
we connect with them early as they transition into civilian life, 
facilitate that transition, and support them over their lifetime.
    The health and well-being of the Nation's men and women who have 
served in uniform is the highest priority for VA. VA is committed to 
providing timely access to high-quality, recovery-oriented, evidence-
based health care that anticipates and responds to Veterans' needs and 
supports the reintegration of returning Servicemembers wherever they 
live, work, and thrive.
    These efforts are guided by the National Strategy for Preventing 
Veteran Suicide. Published in June 2018, this 10-year strategy provides 
a framework for identifying priorities, organizing efforts, and 
focusing national attention and community resources to prevent suicide 
among Veterans through a broad public health approach with an emphasis 
on comprehensive, community-based engagement. This approach is grounded 
in four key focus areas as follows:

      Primary prevention that focuses on preventing suicidal 
behavior before it occurs;
      Whole Health that considers factors beyond mental health, 
such as physical health, social connectedness, and life events;
      Application of data and research that emphasizes 
evidence-based approaches that can be tailored to fit the needs of 
Veterans in local communities; and
      Collaboration that educates and empowers diverse 
communities to participate in suicide prevention efforts through 
coordination.

Mental Health and Suicide Prevention

    We know that an average of approximately 20 Veterans die by suicide 
each day; this number has remained relatively stable over the last 
several years. Of those 20, only 6 have used VA health care in the 2 
years prior to their deaths, while the majority - 14 - have not. In 
addition, we know from national data that more than half of Americans 
who died by suicide in 2016 had no mental health diagnosis at the time 
of their deaths.
    Through the National Strategy, we are implementing broad, 
community-based prevention initiatives, driven by data, to connect 
Veterans outside our system with care and support on national and local 
facility levels targeted to the 14 Veterans outside VA care.
    When we look at our data from the years 2015 to 2016, we see a 
small decrease in the number of suicides; there were 365 fewer deaths 
by suicide in 2016 compared to 2015. This means we are moving in the 
right direction, but if there is still one suicide, we know there is 
significantly more work to be done. We are also concerned about the 
fact that we are seeing a rise in the rates of Veteran suicides among 
those aged 18 - 34 in the past 2 years. Efforts are already underway to 
better understand this population and other groups that are at elevated 
risk, such as women Veterans, never Federally-activated Guardsmen and 
Reservists, recently separated Veterans, and former Servicemembers with 
Other Than Honorable (OTH) discharges.
    We have seen a notable increase in women Veterans coming to us for 
care. Women are the fastest-growing Veteran group, comprising about 9 
percent of the U.S. Veteran population, and that number is expected to 
rise to 15 percent by 2035.
    Although women Veteran suicide counts and rates decreased from 2015 
to 2016, women Veterans are still more likely to die by suicide than 
non-Veteran women. In 2016, the suicide rate of women Veterans, with 
257 women Veterans dying by suicide, was nearly twice the suicide rate 
of non-Veteran women after accounting for age differences.
    These data underscore the importance of our programs for this 
population. VA is working to tailor services to meet their unique needs 
and have put a national network of Women's Mental Health Champions in 
place to disseminate information, facilitate consultations, and develop 
local resources in support of gender-sensitive mental health care.
    For all groups experiencing a higher risk of suicide, including 
women, VA also offers a variety of mental health programs such as 
outpatient services, residential treatment programs, inpatient mental 
health care, telemental health, and specialty mental health services 
that include evidence-based therapies for conditions such as 
posttraumatic stress disorder (PTSD), depression, and substance use 
disorders.
    While there is still much to learn, there are some things that we 
know for sure. Suicide is preventable, treatment works, and there is 
hope.
    Established in 2007, the Veterans Crisis Line provides confidential 
support to Veterans in crisis. Veterans, as well as their family and 
friends, can call, text, or chat online with a caring, qualified 
responder, regardless of eligibility or enrollment for VA. VA is 
dedicated to providing free and confidential crisis support to Veterans 
24 hours a day, 7 days a week, 365 days a year. However, we must do 
more to support Veterans before they reach a crisis point, which is why 
we are working with internal partners like VA's Homeless Program Office 
and Office of Patient Centered Care and Cultural Transformation in 
their deployment of Whole Health and with multiple external partners 
and organizations. In an effort to increase resiliency, VA must empower 
and equip Veterans, through internal partners like these, to take 
charge of their health and well-being and to live their life to the 
fullest.
    VA's premier and award-winning digital mental health literacy and 
anti-stigma resource, Make the Connection (at 
www.MakeTheConnection.net), highlights Veterans' true and inspiring 
stories of mental health recovery and connects Veterans and their 
family members with local VA and community mental health resources. 
Over 600 videos from Veterans of all eras, genders, and backgrounds are 
at the heart of the Make the Connection resource. The resource was 
founded to encourage Veterans and their families to seek mental health 
services (if necessary), educate Veterans and their families about the 
signs and symptoms of mental health issues, and promote help-seeking 
behavior in Veterans and the general public.
    With more than 593,000 visits to more than 180,000 Veterans in 
Fiscal Year (FY) 2018, VA is a national leader in providing telemental 
health services -defined as the use of video teleconferencing or 
telecommunications technology to provide mental health services. This 
is a critical strategy to ensure all Veterans, especially rural 
Veterans, can access mental health care when and where they need it. VA 
offers evidence-based telemental health care to rural and underserved 
areas via 11 regional hubs, expert consultation for patients via the 
National Telemental Health Center, and telemental health services 
between any U.S. location - into clinics, homes, mobile devices, and 
non-VA sites via VA Video Connect, an application (app) that promotes 
`Anywhere to Anywhere' care. VA also offers tablets for Veterans 
without the necessary technology to promote engagement in care. VA's 
goal is that all VA outpatient mental health providers will be capable 
of delivering telemental health care to Veterans in their homes or 
other preferred non-VA locations by the end of FY 2020.
    VA has deployed a suite of 16 award-winning mobile apps supporting 
Veterans and their families by providing tools to help them manage 
emotional and behavioral concerns. These apps are divided into two 
primary categories - those for use by Veterans to support personal work 
on issues such as coping with PTSD symptoms or smoking cessation and 
those used with a mental health provider to support Veterans' use of 
skills learned in psychotherapy. Enabling Veterans to engage in on-
demand, self help before their problems reach a level of needing 
professional assistance can be empowering to Veterans and their 
families. It also supports VA's commitment to be there whenever 
Veterans need us. In FY 2018, VA's apps were downloaded 700,000 times.

A Public Health Approach to Suicide Prevention

    Maintaining the integrity of VA's mental health care system is 
vitally important, but it is not enough. VA alone cannot end Veteran 
suicide. We know that some Veterans may not receive any or all of their 
health care services from VA, for various reasons, and we want to be 
respectful and cognizant of those choices.
    As VA expands its suicide prevention efforts into a public health 
approach while maintaining its crisis intervention services, it is 
important that VA revisit its own infrastructure and adapt to ensure it 
can lead and support this effort. VA has examined every aspect of the 
problem, looking at it through the lens of each subgroup, level, and 
model, and VA is putting changes into place that leverage thoughtful 
investments of new practices, approaches, and additional staffing 
models. It is only through this multi-pronged strategy that VA can lead 
the Nation in truly deploying a well-rounded, public health approach to 
preventing suicide among Veterans. Preventing suicide among all of the 
Nation's 20 million Veterans cannot be the sole responsibility of VA; 
it requires a nationwide effort. Just as there is no single cause of 
suicide, no single organization can tackle suicide prevention alone. VA 
developed the National Strategy with the intention of it becoming a 
document that could guide the entire Nation. It is a plan for how 
EVERYONE can work together to prevent Veteran suicide.
    Suicide prevention requires a combination of programming that hits 
many levels, including universal, selective, and indicated strategies. 
This ``All-Some-Few'' strategic framework allows VA to design effective 
programs and interventions appropriate for each group's level of risk. 
Not all Veterans at risk for suicide will present with a mental health 
diagnosis, and the strategies below employ a variety of tactics to 
reach all Veterans.

      Universal strategies aim to reach all Veterans in the 
U.S. These include public awareness and education campaigns about the 
availability of mental health and suicide prevention resources for 
Veterans, promoting responsible coverage of suicide by the news media, 
and creating barriers or limiting access to hotspots for suicide, such 
as bridges and train tracks.
      Selective strategies are intended for some Veterans who 
fall into subgroups that may be at increased risk for suicidal 
behaviors. These include outreach targeted to women Veterans or 
Veterans with substance use challenges, gatekeeper training for 
intermediaries who may be able to identify Veterans at high-risk, and 
programs for Veterans who have recently transitioned from military 
service.
      Indicated strategies are designed for the relatively few 
individual Veterans identified as having a high risk for suicidal 
behaviors, including some who have made a suicide attempt.

    Current VA efforts regarding lethal means safety highlight this 
model. From education on making the environment safer for all present, 
to training on how to increase effective messaging around firearms in 
rural communities, to creation of thoughtful interventions around 
lethal means safety by clinicians when someone is in crisis, the ``All-
Some-Few'' framework permeates the work we do.
    Guided by this framework and the National Strategy, VA is creating 
and executing a targeted communications strategy to reach a wide 
variety of internal and external audiences. Our goals include the 
following:

      Implementing research-informed communication efforts 
designed to prevent Veteran suicide by changing knowledge, attitudes, 
and behaviors;
      Increasing awareness about the suicide prevention 
resources available to Veterans facing mental health challenges, as 
well as their families, friends, community partners, and clinicians;
      Educating partners, the community, and other key 
stakeholders (e.g., media and entertainment industries, other 
Government organizations) about the issue of Veteran suicide and the 
simple acts we can all take to prevent it;
      Promoting responsible media reporting of Veteran suicide, 
accurate portrayals of Veteran suicide and mental illnesses in the 
entertainment industry, and the safety of online content related to 
Veteran suicide;
      Explaining VA's public health approach to suicide 
prevention and how to implement it at both the national and local 
level;
      Increasing the timeliness and usefulness of data relevant 
to preventing Veteran suicide and getting it into the hands of 
intermediaries who can save Veterans' lives.

Promoting VA Suicide Prevention, Whole Health, and Mental Health 
    Services

    Suicide prevention requires a holistic view - not just at the 
systems level but at the personal care level as well. VA is expanding 
our understanding of what defines health care, developing a Whole 
Health approach that engages, empowers, and equips Veterans for life-
long health and well-being. VA is uniquely positioned to make this a 
reality for our Veterans and for our Nation. The Whole Health delivery 
system includes the following three components: empowering Veterans 
through a partnership with peers to explore their mission, aspiration, 
and purpose and begin their overarching personal health plan; equipping 
Veterans with proactive, complementary, and integrative health 
approaches (e.g., stress reduction, yoga, nutrition, acupuncture, and 
health coaching); and aligning the Veteran's clinical care with their 
mission and personal health plan.
    By focusing on approaches that serve the Veteran as a whole person, 
Whole Health allows Veterans to connect to different types of care, new 
tools, and teams of professionals who can help Veterans better self-
manage chronic issues such as PTSD, pain, and depression.
    VA is dedicated to designing environments and resources that work 
for Veterans so that people find the right care at the right time 
before they reach a point of crisis. However, Veterans must also know 
how and where they can reach out and feel comfortable asking for help.
    VA relies on proven tactics to achieve broad exposure and outreach 
while also connecting with hard-to-reach targeted populations. Our 
target audiences include, but are not limited to women Veterans; male 
Veterans age 18-34; former Servicemembers; men age 55 and older; 
Veterans' loved ones, friends, and family; organizations that regularly 
interact with Veterans where they live and thrive; and the media and 
entertainment industry, who have the ability to shape the public's 
understanding of suicide, promote help-seeking behaviors, and reduce 
the risk of copycat suicides among vulnerable individuals.
    VA uses an integrated mix of outreach and communications strategies 
to reach audiences. We proactively engage partners to help share our 
messages and content, including Public Service Announcements (PSA) and 
educational videos and also use paid media and advertising to increase 
our reach.
    Outreach efforts included the Mayor's Challenge program, care 
enhancements for at-risk Veterans, the #BeThere campaign, and 
development of the National Strategy for Preventing Veteran Suicide. 
This also included, in partnership with Johnson & Johnson, releasing a 
PSA titled ``No Veteran Left Behind,'' featuring Tom Hanks via social 
media. VA continues to use the #BeThere Campaign to raise awareness 
about mental health and suicide prevention and educate Veterans, their 
families, and communities about the suicide prevention resources 
available to them. During Suicide Prevention Month (September), the 
suicide prevention program implemented a dedicated outreach effort for 
the #BeThere Campaign, including several Facebook Live events that 
reached more than 160,000 people, a satellite media tour promoting the 
campaign that reached more than 8.9 million on television and 33.9 
million on radio, partner outreach, and more. Through this outreach, we 
generated more than 347,000 visits to the Veterans Crisis Line Web site 
during Suicide Prevention Month.
    Data is also an integral piece of our outreach approach, driving 
how we define the problem, target our programs, and deliver and 
implement interventions. Each element of our strategy is designed to 
drive action; these elements are intended to be collectively and 
wherever possible, individually measurable so that VA can continually 
assess results and modify approaches for optimum effect.
    All these efforts are with the intent to serve Veterans at risk of 
suicide whether or not they receive services at VA. We continue to work 
to better understand and target prevention efforts towards the 14 
Veterans who die by suicide every day who were not recent users of VA 
health services. These groups comprise many of our target audiences. 
For example, in 18-34 year-olds, suicide rates among this age group are 
increasing, and we are focusing on channels and strategies to get in 
front of this audience.
    We are leveraging new technologies and working with partners on 
live social media events and continuing our digital outreach through 
online advertising. However, VA also continues to rely on our 
traditional partners like Veterans Service Organizations (VSO), non-
profits organizations, and private companies to help us with their 
person-to-person networks and to help spread the word.
    VA is also working with Federal partners, as well as state and 
local governments, to implement the National Strategy. In March 2018, 
VA, in collaboration with the Department of Health and Human Services, 
introduced the Mayor's Challenge with a community-level focus, and just 
last month, debuted the Governor's Challenge to take those efforts to 
the state level. The Mayor's and Governor's Challenges allow VA to work 
with 7 governors (from Arizona, Colorado, Kansas, Montana, New 
Hampshire, Texas, and Virginia) and 24 local governments, chosen based 
on Veteran population data, suicide prevalence rates and capacity of 
the city or state, to develop plans to prevent Veteran suicide, again 
with a focus on all Veterans at risk of suicide, not just those who 
engage with VA.
    Our partnership with the Department of Defense (DoD) and Department 
of Homeland Security (DHS) is exemplified by the successful 
implementation of Executive Order (EO) 13822, Supporting Our Veterans 
During Their Transition from Uniformed Service to Civilian Life. EO 
13822 was signed by President Trump on January 9, 2018. The EO focused 
on transitioning Servicemembers (TSM) and Veterans in the first 12 
months after separation from service, a critical period marked by a 
high risk for suicide.
    The EO mandated the creation of a Joint Action Plan by DoD, DHS, 
and VA for providing TSMs and Veterans with seamless access to mental 
health treatment and suicide prevention resources in the year following 
discharge, separation, or retirement. The Joint Action Plan was 
accepted by the White House and published in May 2018 and has been 
under implementation since that time. All 16 tasks outlined in the 
Joint Action Plan are on target for full implementation by their 
projected completion dates, and 7 out of the 16 items are completed and 
in data collection mode. Some of our early data collection efforts 
point towards an increase in TSM and Veteran awareness and knowledge 
about mental health resources, increased facilitated health care 
registration, and increased engagement with peers and community 
resources through the Transition Assistance Program (TAP) and Whole 
Health offerings.
    TAP curriculum additions and facilitated registration have shown 
that in the first quarter of FY 2019, 81 percent of 7,562 TSM 
respondents on the TAP exit survey reported being informed about mental 
health services. In addition, data from the previous quarter 
demonstrated that 35.6 percent of the 36,801 TSMs listed in the TAP 
Data Retrieval Web Service registered/enrolled in VA health care 
before, during, or within 60 days of their VA TAP Course. Whole Health 
data is demonstrating that between March and December 2018, 96 percent 
of VA medical centers (VAMC) reported offering Introduction to Whole 
Health. Introduction to Whole Health is open to all Veterans and 
employees. Nationally, the total number of reported participants in 
Introduction to Whole Health is over 10,000 since March 2018. Of these, 
over 990 TSMs have attended Introduction to Whole Health. In the first 
quarter of FY 2019, over 425 TSMs attended Introduction to Whole Health 
in the first quarter of FY 2019, with 6 percent of these referred to 
mental health services.

    Through the coordinated efforts of VA, DoD, and DHS, the following 
actions took place:

      Any newly-transitioned Veteran who is eligible can go to 
a VAMC, Vet Center, or community provider, and VA will connect them 
with mental health care if they need it.
      In December 2018, VA mailed approximately 400,000 
outreach letters to former Servicemembers with OTH discharges to inform 
them that they may receive emergent mental health care from VA, and 
certain former Servicemembers with OTH discharges are eligible for 
mental health care for conditions incurred or aggravated during active 
duty service.
      Some DoD resources available to Servicemembers, such as 
Military OneSource, will now be available to Veterans for 1 year 
following separation.
      After the first year, eligible Veterans may still receive 
mental health care support through VA, Vet Centers, the Veterans Crisis 
Line, or from a referred community resource.
      Veterans will also be able to receive support through VA 
partners and community resources outside of VA, like VSOs.

    EO 13822 was established to assist in preventing suicide in the 
first year post transition from service; however, the completed and 
ongoing work of the EO will likely impact suicide prevention efforts 
far beyond the first year through increasing coordinated outreach, 
improving monitoring, increasing access, and focusing beyond just the 
first year post transition and into the years following transition. VA 
is working diligently to promote wellness, increase protection, reduce 
mental health risks, and promote effective treatment and recovery as 
part of a holistic approach to suicide prevention.
    On March 5, 2019, EO 13861, National Roadmap to Empower Veterans 
and End Suicide, was signed to improve the quality of life of our 
Nation's Veterans and develop a national public health roadmap to lower 
the Veteran suicide rate. EO 13861 mandated the establishment of the 
Veterans Wellness, Empowerment, and Suicide Prevention Task Force to 
develop the President's Roadmap to Empower Veterans and End a National 
Tragedy of Suicide (PREVENTS) and the development of a legislative 
proposal to establish a program for making grants to local communities 
to enable them to increase their capacity to collaborate with each 
other to integrate service delivery to Veterans and to coordinate 
resources for Veterans. The focus of these efforts is to provide 
Veterans at risk of suicide support services, such as employment, 
health, housing, education, social connection, and to develop a 
national research strategy for the prevention of Veteran suicide.
    This EO implementation will further VA's efforts to collaborate 
with partners and communities nationwide to use the best available 
information and practices to support all Veterans, whether or not they 
are engaging with VA. This EO, in addition to VA's National Strategy, 
further advances the public health approach to suicide prevention by 
leveraging synergies and clearly identifying best practices across the 
Federal Government that can be used to save Veterans' lives.
    The National Strategy is a call to action to every community, 
organization, and system interested in preventing Veteran suicide to 
help do this work where we cannot. For this reason, VA is leveraging a 
network of more than 60 partners in the public, private, and non-profit 
sectors to help us reach Veterans where they live, work, and thrive, 
and our network is growing weekly. For example, VA and PsychArmor 
Institute have a non-monetary partnership focused on creating online 
educational content that advances health initiatives to better serve 
Veterans. Our partnership with PsychArmor Institute resulted in the 
development of the free, online S.A.V.E. (Signs, Ask, Validate, and 
Encourage and Expedite) training course that enables those who interact 
with Veterans to identify signs that might indicate a Veteran is in 
crisis and how to safely respond to and support a Veteran to facilitate 
care and intervention. Since its launch in May 2018, the S.A.V.E. 
training has been viewed more than 18,000 times through PsychArmor's 
internal and social media system and 385 times on PsychArmor's YouTube 
channel. S.A.V.E. training is also mandatory for VA clinical and non-
clinical employees. Ninety-three percent of VA staff are compliant with 
their assigned S.A.V.E. or refresher S.A.V.E. trainings since December 
2018. This training continues to be used by VA's Suicide Prevention 
Coordinators (SPC) at VA facilities nationwide, as well as by many of 
our VSOs.
    Our partnership with Caring Bridge, a global, non-profit social 
media network that allows people with health issues to stay connected 
to their families and loved ones during a health journey, has resulted 
in Caring Bridge's launch of a military-specific forum. The forum 
focuses directly on the needs of Servicemembers, Veterans, and their 
families. This interactive site is also helping us reach those Veterans 
who are not currently in VA's health care system.

Conclusion

    VA's goal is to meet Veterans where they live, work, and thrive and 
walk with them to ensure they can achieve their goals, teaching them 
skills, connecting them to resources, and providing the care needed 
along the way. Through open access scheduling, community-based and 
mobile Vet Centers, app-based care, telemental health, more than 400 
SPCs, and more, VA is providing care to Veterans when and how they need 
it. We want to empower and energize communities to do the same for 
Veterans who do not use VA services. We are committed to advancing our 
outreach, prevention, empowerment, and treatment efforts, to further 
restore the trust of our Veterans every day and continue to improve 
access to care. Our objective is to give our Nation's Veterans the top-
quality experience and care they have earned and deserve. We appreciate 
this Committee's continued support and encouragement as we identify 
challenges and find new ways to care for Veterans.
    This concludes my testimony. My colleague and I are prepared to 
respond to any questions you may have.

                                 
                       Statements For The Record

                       American Veterans (AMVETS)
    Joseph Chenelly
    Executive Director
    AMVETS

    Chairman Takano, Ranking Member Roe, and honorable members of the 
House Committee on Veterans' Affairs, I appreciate the opportunity to 
present you with our views on the mental health and suicide epidemic 
plaguing our Nation's veterans' community.
    As the largest veteran nonprofit to represent all of our Nation's 
veterans, we are dedicated to pursuing those issues that are most 
negatively affecting our veterans or that stand to provide the greatest 
positive benefit to them. As such, the three most pressing issues 
AMVETS is working to address this Congress are: addressing our mental 
healthcare crisis and suicide epidemic, addressing the critical needs 
of women veterans, and providing timely access to high-quality 
healthcare.
    In the past year, AMVETS has made significant investments to 
perform a second to none advocacy role for our Nation's veterans. We 
have assembled a world-class team of veterans' advocates with 
significant Capitol Hill experience. We have asked that team to 
prioritize the mental health and suicide epidemic. In our opinion, 
there is clearly no bigger issue affecting our Nation's veterans and 
Servicemembers than the more than 6,000 veterans and Servicemembers 
taking their lives each year. For far too long this issue has been 
quietly placed on the backburner.
    As we stated in our joint testimony before the House and Senate 
committees on veterans' affairs on March 7, our Nation's veterans could 
not be sending a clearer message that VA mental healthcare is not 
working than by killing themselves in VA parking lots. According to the 
Washington Post, from October 2017 through November 2018, 19 veterans 
have died by suicide on VA campuses. Marine Col. Jim Turner killed 
himself in the Bay Pines VA Medical Center parking lot weeks before 
Christmas. Dressed in his dress blues uniform, bearing his medals, he 
left us with this message: ``I bet if you look at the 22 suicides a day 
you will see VA screwed up in 90%.''
    Our National Commander provided emotional oral testimony as he 
recalled the story of an AMVETS Post Commander who took his life in the 
parking lot of his post. The issue is raw and real for our AMVETS 
family.
    From October 2017 through November 2018, more than 6,000 veterans 
died as a result of suicide. In that same time period, the Senate held 
one hearing on veterans' mental health, the House held two, and more 
than $8 billion was spent in an effort to address the issue. Despite 
veterans killing themselves on VA campuses, and record expenditures by 
VA to address mental health, VA continues to insinuate that veterans 
killing themselves have not participated in VA care (recently).
    The narrative on Capitol Hill has been relatively mundane with 
lawmakers highlighting the disturbing number of deaths, suggesting more 
needs to be done, providing increases to the mental healthcare budget, 
and then moving along to other priorities. VA highlights a need for 
additional funding to pay for more practitioners and clinical space, 
while providing scant information on the effectiveness of its programs. 
The majority of VSO's, including AMVETS, have supported these efforts 
hoping that more clinicians, more space, and pay raises for mental 
health practitioners would lead to better outcomes: none of this has 
substantively moved the needle.
    In short, we must confront an uncomfortable and deeply troubling 
truth: VA's current efforts and approaches to suicide prevention and 
mental health are not working.
    How do we know this- In the simplest of terms, the suicide numbers 
aren't decreasing. After a statistical correction led to the drop from 
22 to 20 suicide per day, the numbers of veteran suicides per day has 
barely budged. This is in spite of billions of dollars, new 
legislation, and a considerable amount of activity in the form of 
speeches, executive orders, and other initiatives.
    The VA's efforts related to mental health simply are not working. 
The independent evaluation that was completed as part of The Clay Hunt 
SAV Act found scarce evidence of improvements to veterans lives despite 
tens of billions of dollars being spent over the past decade, and a 
generally unaffected rate of suicide. This evaluation explored VA 
effectiveness across the broad spectrum of mental health programming, 
and perhaps more damning than what the data show is what they don't - 
most of what the VA is doing relative to mental health is not being 
tracked.

    "new innovative and engaging approaches for the treatment of PTSD 
are needed." The Journal of American Medical Association (JAMA) 2015

    The failures detailed in the Clay Hunt report validates what is 
clear across PTSD treatments more generally - they are not working. 
Half of those who might benefit from mental health treatment will not 
seek it due to access challenges and stigma; of those who do, we see 
dropout rates ranging from 40-90 percent; and of those who complete 
treatment, up to two-thirds of successfully treated individuals retain 
the PTSD diagnosis (Schnurr, 2007; Steenkamp 2015).
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    "These findings point to the ongoing crisis in PTSD care for 
service members and veterans. Despite the large increase in 
availability of evidence-based treatments, considerable room exists for 
improvement in treatment efficacy, and satisfaction appears bleak based 
on low treatment retention.we have probably come as far as we can with 
current dominant clinical approaches." The Journal of American Medical 
Association (JAMA) 2017

    Trauma-focused therapies appear to be only marginally more 
effective than non- trauma-focused psychotherapies (e.g. interpersonal 
psychotherapy, acceptance and commitment therapy), questioning the use 
of these interventions as ``first-line'' treatments considering their 
high dropout rates (via Tedeschi and Moore 2018).
    ``If a veteran is not interested in a trauma-focused psychotherapy, 
or if the therapy is not available, the VA/DoD guidelines (2017) 
recommend the use of four specific medications to include three 
selective serotonin reuptake inhibitors (paroxetine [Paxil], sertraline 
[Zoloft], fluoxetine [Prozac], and one serotonin norepinephrine 
reuptake inhibitor (venlafaxine [Effexor]). Even though many more 
medications are used with veterans battling PTSD and related disorders, 
the guidelines do not support their use due to a lack of research 
supporting their efficacy or because the risks of these medications 
outweigh the benefits.'' (Tedeschi and Moore, 2018)
    As we have already highlighted, we are concerned by the limited 
research available to show these pharmacological approaches are having 
significant positive outcomes for veterans over a significant period of 
time. Additionally, extended use of these psychotropics has been linked 
to suicide and depression, the exact outcome VA is working to combat.

    "Are we somehow causing increased morbidity and mortality with our 
interventions?" Dr. Thomas Insel, former Director, of the National 
Institute of Mental Health

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Explanations or Excuses-

    When the VA is queried about the efficacy - or lack thereof - of 
current approaches, they resort to a couple of fallbacks. One is to 
point to their use of evidence-based treatments, which passes the buck 
back to the mental health authorities and associations. A second, and 
far more troubling, is their effort to consistently ``blame the 
patient.''
    The VA consistently references the fact that out of the 20 suicides 
that occur each day amongst veterans, 14 have had little to no access 
to the system over the prior two years. The implication - 
notwithstanding the fact that six veterans in active treatment also 
took their lives - is that if had they been engaged in VA care, they 
might have had a different fate. The fundamental question that the 14 
of 20 statistic raises is what we know about the veterans who have 
fallen through the cracks. Are they receiving VA benefits- What 
happened that led them to not access VA care- Has the VA called or 
communicated with them in the past two years- Had they ever received 
mental health treatment from VA- In a world where dropout rates are 
extravagant, it would be reasonable to posit that at least some of 
these men and women might have sought help and found it lacking. These 
are just some of the questions that this soundbite raises - and yet, we 
have no answers. Answers that would allow us to attack this issue 
effectively, and would be far more consistent with the public health 
approach that VA has supported with respect to suicide.

A Vicious Loop

    We have yet to see anything that VA or civilian authorities are 
doing that would inspire confidence that they have a clue about what to 
do to address the suicide epidemic. With treatments adopted from the 
civilian world - which is experiencing a horrific suicide crisis of its 
own - the question is this: on what basis can VA tell us that more 
resources, more providers, and more treatments is the answer- If we do 
the same thing over and over again and still expect a different result, 
that is the definition of insanity.
    While the VA claims to hold suicide prevention as its top priority, 
in truth, VA's top priority is self-preservation. They will blame 
veterans, Congress, VSOs - anything but accept accountability for their 
failures. The truth is that VA does not know what works for suicide 
prevention nor what effective mental health approaches might look like. 
The one thing that veterans need and deserve from VA is what one would 
expect from a great military leader - humility. The humility to 
acknowledge that the current approach isn't working, that we must be 
open to new and innovative approaches, and that veterans deserve 
better. Humility to acknowledge that the VA system - from bad service 
to long wait times - might in fact prevent those who would have 
benefited from seeking help. Humility to recognize that most veterans 
don't want to talk to someone they don't know about things they can't 
understand; they certainly don't want a fistful of pills that numb and 
offer a plethora of terrible side effects.
    Humility - the recognition that we don't have all the answers but 
we damn sure better start looking in new places - is what AMVETS is 
asking for. We don't expect VA to solve the problem on their own. And 
at the same time, we know that you can't start solving a problem until 
you recognize you have one. And VA - let us state unequivocally since 
you won't - we have a suicide problem and we don't have the answers of 
what to do about it yet.

Recommendations

    If our words come across as harsh or intense, they are. They come 
from a place of pain, loss, anger, frustration, disappointment, and 
devastation. Our members have all directly experienced the cost of the 
suicide epidemic in the losses of our brothers and sisters, friends and 
mentors, guides and teachers.
    So what needs to happen next- Beyond the recognition that we must 
stop pretending that more resources and more treatments will do trick, 
we believe we need to take action in the following areas:

Follow The Data

    We need to dive deeply into the 14 out of 20 suicides per day and 
understand VA touchpoints, VBA benefits being received, prior VHA 
engagements, and so forth.
    While the VA sought to sugar coat the report required by the Clay 
Hunt SAV Act, the independent evaluation discussed earlier is damning. 
It indicates that the average veteran did not experience any clinically 
significant change in their symptoms - whether they were in outpatient 
care or residential treatment. The report also revealed that the VA is 
not collecting basic metrics for mental health in the large majority of 
instances.
    This report truly is a ``smoking gun'' for it reveals that for all 
the billions spent, we have seen little to no progress.
    The vast majority of veterans with mental health struggles will 
either never seek care or dropout before completion. Exploring options 
that address these two challenges - by expanding the mental health 
continuum beyond just clinical options and leveraging the role of peers 
- must be high on the to-do list.

Fix Transition

    Considerable efforts have been undertaken to revise the transition 
process so it accommodates a longer timeframe and is more supportive of 
transitioning service members. However, we know that many veterans 
struggle with the loss of identity, purpose, and connection upon 
departing the military - a theme best captured in Sebastian Junger's 
book Tribe. These challenges extend far beyond employment and the mind, 
into subjects of the heart and soul. It is essential to extend 
transition beyond its current myopic focus on employment, to account 
for the loss of all that is great and good about military service. This 
loss contributes to considerable challenges and was the subject of an 
outstanding piece on transition stress by Dr. George Bonanno and 
Meaghan Mobbs in the Clinical Psychology Review. The psycho-social 
aspects of the transition - much ignored by the current process - were 
also the subject of a remarkable paper from the VA Center of 
Innovation. When we disregard these challenges as part of the 
transition process, we set veterans up for failure and lead them to 
conflate struggle in post-military life with PTSD from deployments.

Get Left of Boom

    The phrase ``left of boom'' is a military idiom that refers to the 
U.S. military's effort to disrupt insurgent cells before they can build 
and plant bombs. We believe a lot can be learned from the military's 
efforts to thwart IED attacks as we look to tackle veteran and 
servicemember suicide and look toward building solutions moving 
forward. A critical component of this prevention-focused approach calls 
for far greater alignment and collaboration between DoD and VA - and 
the recognition by DoD that they bear great responsibility for the 
plight of so many veterans who struggle in post-military life. With the 
suicide crisis now affecting active duty service members at numbers not 
seen in at least a decade, there is great reason to believe that 
changes within DoD would effect not only veterans but help to address 
the current mental health epidemic across the active duty force. To 
this end, we believe that exploring the Leadership Continuum within all 
services is critical. While there are myriad definitions of leadership, 
we subscribe to the view that leadership requires three critical 
components - as noted by the Harvard Business Review - intelligence 
(IQ), technical expertise, and emotional intelligence (EQ). It is in 
the latter area that service members and veterans - and large swaths of 
the general public - struggle. We believe that integrating notions 
around EQ into the Leadership Continuum could meaningfully address 
mental health challenges within the active duty force and, more 
importantly, as it relates to the current subject, set up veterans for 
success in post-military life.
    As stated above, we believe that a large component of the suicide 
epidemic ties back to leadership. Well led units suffer from far lower 
rates of PTSD and suicide than poorly led ones. To that end, we believe 
that the pathologization of struggle - and the resulting medical 
approach that is applied - is a large part of the challenge. If you 
cannot define a problem accurately, you certainly aren't capable of 
solving it. To that end, recognizing that much of the veterans' suicide 
epidemic ties back to active duty and transition leadership - and a 
lack of effective training - helps to recontextualize how we will solve 
this problem meaningfully and sustainably.
    As a result of this lack of training and leadership, most veterans 
approach the VA, if they ever do, following transitions from the 
military that have gone poorly for a latitude of reasons. This may be 
in the form of financial challenges, substance abuse, marital problems, 
a lack of social support, nutrition and physical activity, employment, 
and a host of other issues.
    The crux of the point here is, we need to find ways to train our 
service members and veterans as left of boom as possible. By working 
with them as early as possible, and building the capacity to struggle 
on the front end, we can ensure that veterans can navigate the ups and 
downs that are part of life - and certainly post-military life - in a 
constructive manner.

A Proposed Roadmap Forward

    AMVETS is asking Congress to work with us to end the status quo. We 
are asking for Congress and VA to take accountability, measure outcomes 
and results, and invest in helping veterans become their best selves. 
Let's help them become our Nation's best citizens.
    As such, AMVETS would greatly appreciate Congress's consideration 
to create a bicameral taskforce that combined would hold an event at 
least once every month. Specifically, we are hopeful that Congress will 
closely evaluate the programs and methods currently funded at VA, their 
long-term effects and outcomes in helping veterans live high quality 
lives, while also considering any alternative approaches that are 
leading to positive outcomes by mitigating negative symptoms, creating 
notable improvements in quality of life and, ultimately, stemming the 
suicide epidemic.
    Additionally, we propose a quarterly hearing to attack our 
veterans' mental health epidemic, and by extension, possibly, our 
Nation's mental health problems. The Veterans Affairs and Armed 
Services committees have a real opportunity to change our Nation for 
the better. There is nothing inherent about veterans and mental health.
    Mental healthcare challenges are human issues and are not specific 
to veterans or service members.
    We appreciate Chairman Takano and Ranking Member Roe's leadership 
in hosting this first hearing to address this issue. We would greatly 
appreciate your consideration to hold another no later than July of 
this year. We recommend that the topic of the hearing focuses on the 
findings of the report required by the Clay Hunt SAV Act: the 2018 
Annual Report: VA Mental Health Program and Suicide Prevention Services 
Independent Evaluation. If we don't better understand the outcomes of 
the crux of our existing supported programs, then we cannot reasonably 
start to chart a more effective path forward. Such a hearing should 
consist of individuals who have significant research backgrounds in 
this field who can provide their own independent assessment of the data 
that was provided to VA.
    We also would encourage the committee to assign senior staff, and/
or additional staff, to this issue. Our experience has largely been 
with junior staff, with few senior staff seeming actively engaged on 
the issue, likely as a result of the committee's prioritization of 
Choice/Mission, versus this epidemic. We would also encourage the 
Committee to provide these staff with a significant oversight budget. 
We are aware of few trips made by the committee staff or personal staff 
of HVAC Members to various nonprofits, VA mental health facilities, and 
other non-VA facilities working to tackle suicide and mental health. 
The bottom line is if this issue is going to be a priority, then 
Members of Congress, senior staff, and personal office Veteran 
Legislative Assistants, should be present at key events regarding 
suicide and mental health, while also conducting significant oversight 
off of Capitol Hill, and should be supported and funded to do so.
    As we have mentioned, DoD also owns this epidemic. For many of our 
veterans, their downward spiral starts at their transition from the 
military. That moment when they leave behind their band of brothers, 
lose their mission and purpose, and often find themselves isolated. 
This is a critical final touch point, one in which crucial training can 
be provided prior to their geographic dispersion. Finding meaningful 
ways to engage the House Armed Services Subcommittee on Personnel is 
critical if we are going to truly move this issue Left of Boom. Doing 
so will save money on expensive ineffective treatments down the road, 
and more important, it will save lives.

Conclusion

    Chairman Takano, Ranking Member Roe, and members of the committees, 
I would like to thank you once again for the opportunity to present the 
issues that impact AMVETS' membership, active duty service members, as 
well as all American veterans. As the VA continues to evolve in a 
manner that can improve access to benefits and healthcare, it will be 
imperative to remember the impact that any changes to those systems 
have on millions of individuals who defended our country. We cannot 
stress enough the need to preserve and strengthen the VA as a whole, 
across all administrations, in order to ensure the agency can deliver 
on President Lincoln's sacred promise now and in the future. Working to 
fix our broken mental healthcare system is part of that commitment.

Executive Director Joseph Chenelly

    Joseph R. Chenelly was appointed national executive director of the 
nation's fourth largest veterans service organization in May 2016. In 
this capacity, he administers the policies of AMVETS, supervises its 
national headquarters operations and provides direction, as needed, to 
state and local components. Joe previously served as AMVETS' national 
communications director.
    Joe Chenelly is the first veteran of combat operations in 
Afghanistan and Iraq to lead one of the nation's four largest veterans 
service organizations' staffs.
    A native of Rochester, N.Y., Joe enlisted in the U.S. Marine Corps 
in 1998, serving with the 1st Marine Division, and was honorably 
discharged as a Staff Sergeant in April 2006. He is a combat veteran of 
Operation Enduring Freedom and Operation Iraqi Freedom, having served 
in Afghanistan, Pakistan, Iraq, Kuwait, East Timor and the Horn of 
Africa.
    Joe became a veterans' advocate, a journalist, and a political 
adviser after his time in uniform. He covered military and veterans 
matters on staff with Leatherneck magazine, the Military Times 
newspapers, USA TODAY and Gannet News, reporting on operations in the 
Middle East, Southwest Asia, Africa, as well as disaster relief in the 
United States.
    Joe was named one of the 100 ``most influential journalists 
covering armed violence'' by Action on Armed Violence in 2013. He was 
the first U.S. Marine combat correspondent to step into enemy territory 
after September 11, 2001, as a military reporter in Pakistan and 
Afghanistan. He also reported from the front-lines with American and 
allied forces in Kuwait and Iraq as that war began. He was on the 
ground for the start of both Operation Enduring Freedom and Operation 
Iraqi Freedom.
    Joe served as AMVETS' national communications director in 2005, and 
for the past eight years as assistant national director for 
communications for the Disabled American Veterans (DAV) in Washington, 
D.C. leading grassroots efforts through social networking and new 
media.
    He has also served as president of Social Communications, LLC, and 
as a public affairs officer director for the Department of Navy. Joe is 
an alumni of Syracuse University and Central Texas College. He resides 
in Fairport, N.Y., with his wife Dawn, a service- connected disabled 
Air Force veteran, and their five children.

ABOUT AMVETS

    Today, AMVETS is America's most inclusive congressionally-chartered 
veterans service organization. Our membership is open to both active-
duty, reservists, guardsmen and honorably discharged veterans. 
Accordingly, the men and women of AMVETS have contributed to the 
defense our nation in every conflict since World War II.
    Our commitment to these men and women can also be traced to the 
aftermath of the last World War, when waves of former service members 
began returning stateside in search of the health, education and 
employment benefits they earned. Because obtaining these benefits 
proved difficult for many, veterans savvy at navigating the government 
bureaucracy began forming local groups to help their peers. As the 
ranks of our nation's veterans swelled into the millions, it became 
clear a national organization would be needed. Groups established to 
serve the veterans of previous wars wouldn't do either; the leaders of 
this new generation wanted an organization of their own.
    With that in mind, 18 delegates, representing nine veterans' clubs, 
gathered in Kansas City, Missouri and founded The American Veterans of 
World War II on Dec. 10, 1944. Less than three years later, on July 23, 
1947, President Harry S. Truman signed Public Law 216, making AMVETS, 
the first post-World War II organization to be chartered by Congress.
    Since then, our congressional charter was amended to admit members 
from subsequent eras of service. Our organization has also changed over 
the years, evolving to better serve these more recent generations of 
veterans and their families. In furtherance of this goal, AMVETS 
maintains partnerships with other Congressionally chartered veterans' 
service organizations that round out what's called the ``Big Six'' 
coalition. We're also working with newer groups, including Iraq and 
Afghanistan Veterans of America and The Independence Fund. Moreover, 
AMVETS recently teamed up with the VA's Office of Suicide Prevention 
and Mental Health to help stem the epidemic of veterans' suicide. As 
our organization looks to the future, we do so hand in hand with those 
who share our commitment to serving the defenders of this nation. We 
hope the 116th Session of Congress will join in our conviction by 
casting votes and making policy decisions that protect our veterans.

                                 
                    Disabled American Veterans (DAV)
    JOY J. ILEM
    NATIONAL LEGISLATIVE DIRECTOR

    Mr. Chairman and Members of the Committee:
    Thank you for inviting DAV (Disabled American Veterans) to submit 
testimony for this important hearing regarding our views on the 
Department of Veterans Affairs (VA) suicide prevention efforts and use 
of a public health model for reducing suicide in the veteran 
population. We have also been asked to identify any steps DAV is taking 
as an organization to counter trends in veterans' suicide. Finally, we 
offer our views on the effectiveness of VA's current mental health 
programs and suicide prevention efforts and recommendations on what 
more can be done to ensure veterans have access to critical mental 
health services when they need them.
    As you know, DAV is a non-profit veterans service organization 
comprised of more than 1 million wartime service-disabled veterans that 
is dedicated to a single purpose: empowering veterans to lead high-
quality lives with respect and dignity. Many DAV members use VA's 
specialized mental health services and approved DAV Resolution No. 293 
at our last National Convention, which supports mental health program 
improvements, including: data collection and reporting on suicide rates 
among service members and veterans; improved outreach through general 
media for stigma reduction and suicide prevention; sufficient staffing 
to meet demand for mental health services and enhanced resources for VA 
mental health programs, including Vet Centers, to achieve readjustment 
of new war veterans and continued effective mental health care for all 
enrolled veterans needing such services.

DAV Efforts to Counter Suicide in the Veteran Population

    As an organization, we subscribe to VA's perspective-suicide is 
preventable and that suicide prevention is everyone's business. We 
believe that membership and participation in a veterans service 
organization such as DAV, can be a protective factor for vulnerable 
veterans who may be struggling with serious physical injuries, post-
deployment mental health issues, homelessness, or substance use. DAV 
provides opportunities for comradery, volunteering, serving others, 
engagement in meaningful activities to include adaptive sports and 
recreational events, and connecting with other veterans who may be 
confronting similar challenges.
    As an organization, DAV is committed to doing our part in helping 
to reduce suicide among those who have served. Recently, our entire 
national service and legislative Washington headquarters staff 
participated in S.A.V.E training (Signs. Ask. Validate. Encourage/
Expedite.) conducted by the local VA Suicide Prevention Coordinator 
using the same curricula used for non-clinical VHA staff. Our national 
headquarters office in Cold Spring, Kentucky, also received this 
training.
    DAV has approximately 261 national service officers (NSOs) in 100 
offices across the United States and in Puerto Rico and 32 transition 
service officers that assist service members in filing claims for 
service-connected disabilities. These are frontline staff that interact 
with many veterans seeking assistance each day. Within the next couple 
of weeks, our NSOs will have access to a specific module in DAVs 
training system-iTRAK on suicide prevention and creating warm handoffs 
for those in crisis. This will be required training for all NSOs and 
support staff in each of our field offices.
    DAV's communications team works closely with the VA's public 
affairs office to support the Department's suicide awareness and 
prevention campaign, #BeThere, on a number of social media sites such 
as Facebook, Twitter, Instagram and LinkedIn. We promote the Veterans 
Crisis Line phone number at every opportunity, including it in DAV 
Magazine articles, web posts, awareness campaigns and collaborative 
events. We have worked alongside other organizations aimed to prevent 
veteran suicide such as Vets4Warriors and the Gallant Few. DAV also 
runs our own suicide prevention and awareness social media campaigns 
during Suicide Prevention Awareness Month every September. In addition, 
we recently revised our PTSD booklet, Living With Traumatic Stress, 
which includes information on VA mental health resources and suicide 
prevention.

Use of Public Health Model for Suicide Prevention

    Suicide is a national tragedy and a complex issue that requires a 
public-private approach to improve evidence-based prevention and 
intervention efforts. In its 2018-2022 strategic plan, VA stated that 
suicide prevention is its highest strategic clinical priority. In fact, 
VA has worked diligently with other government partners to gain a 
greater understanding of the epidemiology of veteran suicide and for 
the first time can more reliably track suicide among veterans and 
civilians. This required an interagency collaborative effort with the 
Department of Defense (DoD) and the Centers for Disease Control and 
Prevention, as well as state governments, to ensure that veteran status 
was accurately and consistently captured in national statistics.
    VA's National Strategy for Preventing Veterans Suicide defines the 
``public health model'' it will use to reduce the rates of suicide for 
veterans. The four strategic directions identified include:

    1. Healthy and Empowered Veterans, Families and Communities;
    2. Clinical and Community Preventive Services;
    3. Treatment and Support Services; and
    4. Surveillance, Research and Evaluation.

    Over the past several years, despite intensive efforts to reduce 
suicide among veterans, rates have not significantly declined even 
after the Department identified this issue as the top clinical priority 
of the Administration. VA identified that 14 of the 20 veterans who 
committed suicide each day were not using VA health care services 
presenting a number of challenges for understanding and addressing the 
needs of all potential at risk veterans. \1\ Surveillance has been 
hampered by differing definitions of ``veteran'' and ``death by 
suicide'' (which may or may not include suspicious accidental or 
violent deaths). In addition, some states' reporting data on suicides, 
did not require veteran status be reported. We believe future studies 
should work to standardize definitions and methodologies to help VA 
understand whether its interventions are having an effect at the 
population level.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs. Office of Mental Health and 
Suicide Prevention. VA National Suicide Data Report 2005-2016. 
September 2018. P. 7
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    DAV believes the public health approach adopted by VA can be 
particularly effective in addressing the needs of veterans who do not 
use VA health care (approximately two thirds of all veterans and 70 
percent of those who commit suicide). \2\ It can also be used to 
increase awareness about suicide prevention among members of the 
public, to include veterans' family members, friends and co-workers-as 
well as community health care providers with a goal of educating them 
to recognize the potential risk factors and signs among veterans and 
accept personal responsibility for getting them help when needed. 
Effective communication strategies can help to change stereotypes 
associated with veterans and identify and promote protective factors 
that may help prevent suicidal ideation such as giving veterans a sense 
of purpose and connectedness with family and community.
---------------------------------------------------------------------------
    \2\ U.S. Department of Veterans Affairs Office of Mental Health and 
Suicide Prevention (OMHSP) Facts About Veteran Suicide: June 2018
---------------------------------------------------------------------------
    As VHA allows more community care options for veterans under the 
new MISSION Act, Network community care partners should also receive 
training and be provided with information about warning signs for 
suicide, effective screening, and early interventions for veterans. 
Likewise, as part of its public health model VA must also offer 
training to its community partners who are more likely to treat the 
veteran population not using VA health care services. RAND found that 
community providers are less likely to ask about military service, to 
screen for conditions such as suicidal ideation common among veterans, 
and to understand how to manage the care of veterans with these 
conditions effectively. \3\
---------------------------------------------------------------------------
    \3\ Tanielian, Terri, Carrie M. Farmer, Rachel M. Burns, Erin L. 
Duffy, and Claude Messan Setodji, Ready or Not- Assessing the Capacity 
of New York State Health Care Providers to Meet the Needs of Veterans. 
Santa Monica, CA: RAND Corporation, 2018. https://www.rand.org/pubs/
research--reports/RR2298.html. Also available in print form.
---------------------------------------------------------------------------
    VA has developed training tools and modules for both non-clinical 
and clinical staff and this training is mandatory for all VHA 
employees. The goal of the training is to assist employees in 
identifying veterans at risk of suicide and help them intervene when a 
veteran is in crisis.
    We have also urged VA to ensure community network providers are 
properly trained in effective evidence-based mental health treatments 
and supportive services that are typically not available in the private 
sector so appropriate referrals can be made back to VA for these 
services. VA could, in developing training modules for community 
partners improve and build awareness within the broader health care 
industry. Unfortunately, the Government Accountability Office (GAO) 
recently found that VA's awareness efforts-promotion of campaigns such 
as #BeThere and contact information for veterans and those who care 
about them-dropped off in 2017 and 2018 and that it had not identified 
appropriate ways of measuring the success of these efforts. \4\
---------------------------------------------------------------------------
    \4\ VA HEALTH CARE: Improvements Needed in Suicide Prevention Media 
Outreach Campaign Oversight and Evaluation GAO-19-66: Published: Nov 
15, 2018. Publicly Released: Dec 17, 2018.
---------------------------------------------------------------------------
    To deploy an effective public health model, Congress and VA must 
resource it appropriately with additional funding not those originally 
programmed for delivery of current mental health services. Likewise, 
goals for campaigns and strategies must be clearly identified and 
measured before, during and after the intervention. This continuous 
measurement and improvement cycle is the key to creating effective 
public health initiatives and better health outcomes for veterans.

Effectiveness of VA's Mental Health Programs and Suicide Prevention 
    Efforts

    We applaud VHA's ongoing implementation of universal screening for 
suicidality. Recognizing the problem is the first step of successful 
intervention. As we understand it, almost 2 million veterans have 
already been screened. \5\
---------------------------------------------------------------------------
    \5\ Department of Veterans Affairs. VA Suicide Risk Identification 
Strategy: Overview. June 2018/
---------------------------------------------------------------------------
    VA also deserves recognition for expanding its Veterans Crisis 
Line, implementing a predictive analytics model to create a clinical 
``flag'' for those veterans at greatest risk of suicide (REACH-VET), 
and requiring mandatory training on suicide for both non-clinical and 
clinical staff in the veterans health care system. The Department has 
also allowed veterans with other than honorable discharges to seek 
emergency mental health care and recently announced that all 
transitioning service members could seek VA health care within the 
first year of separation from military service-a time frame at which 
many veterans have been found to be vulnerable to suicide or suicidal 
ideation. \6\ As evidenced by the persistently higher suicide rate 
among veterans (as compared to civilians) and the recent suicides 
taking place on VA grounds, however, it is clear much more work must be 
done.
---------------------------------------------------------------------------
    \6\ Department of Veterans Affairs. Office of Mental Health and 
Suicide Prevention. VA National Suicide Data Report 2005-2016. 
September 2018. P. 7
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    We are pleased to see that VHA has also deployed an evidence-based 
practice of early and structured intervention for veterans who have 
attempted suicide, which promotes safe storage of lethal means 
strategies to address firearm safety. This includes counseling on safe 
storage and reducing access to lethal means that could be used as 
methods of suicide, in addition to employing other coping strategies. 
When followed by phone calls to assess risk, review safety plans, and 
encourage treatment engagement, this safety planning intervention 
almost halved follow-up suicidal behaviors within the first six months 
after intervention. \7\
---------------------------------------------------------------------------
    \7\ Stanley, Barbara, et al. ``Association of Safety Planning 
Intervention with Subsequent Suicidal Behavior Among ER-Treated 
Suicidal Patients.'' JAMA Psychiatry: Original Investigation, Vol. 75, 
Number 9. September 2018. P. 895.
---------------------------------------------------------------------------
    We understand this is a very sensitive and controversial topic-but 
one that cannot be ignored, given that almost 70 percent of veterans' 
suicides are completed using firearms. \8\ As a leading mental health 
advocate in VA stated, ``limiting immediate access to firearms for 
veterans in crisis can save lives. Safe gun storage is one of the most 
important ways to prevent suicide.'' \9\ Despite the challenges in 
addressing this topic, it is clear VA is striving to be a national 
leader in suicide prevention and pressing forward, creating important 
community partnerships in an attempt to find new and effective ways to 
talk about this issue with their veteran patients to ensure they stay 
safe.
---------------------------------------------------------------------------
    \8\ VA National Suicide Data Report: 2005-2016. Department of 
Veterans Affairs. Office of Mental Health and Suicide Prevention. 
September 2018, p. 6.
    \9\ Russell Lemle, PhD, Chief Psychologist at San Francisco VA 
Health Care System as cited in Women Veterans: The Journey Ahead. P. 
30.
---------------------------------------------------------------------------
    The Rocky Mountain Mental Illness Research Education and Clinical 
Center is working to identify the effect of provider counseling on safe 
storage on suicidal behaviors in veterans and VA has forged a historic 
partnership with the National Sports Shooting Foundation and the 
American Foundation for Suicide Prevention. The collaboration is aimed 
at developing a program that empowers communities to engage in safe 
firearm storage practices with an emphasis on reaching service members, 
veterans and their families. Additionally, VA has a planning tool kit 
that will be accessible to all veterans-including a workbook, ``Your 
Personal Safety Plan'' which provides examples and asks veterans to 
identify stressors and triggers and warning signs of serious emotional 
turmoil, in addition to suggesting coping strategies and ideas for 
staying safe in times of emotional crisis. Veterans are urged to 
establish a plan that includes a list of safe people and safe places, 
crisis support and resource contact numbers, who they can talk to if in 
crisis, and how to ensure a safe environment during a stressful period.
    As women veterans' rates of self-directed violence by firearm 
increase, \10\ we want to ensure VA providers are also asking women 
veterans the same questions about gun storage safety-particularly those 
who have been identified for being at-higher risk for suicide. What 
previously might have been an ``attempt'' using poisoning or 
asphyxiation can result in an accomplished suicide due to women 
veterans' increased familiarity with more lethal means. Experts note 
that civilian women are less likely to use firearms and thus their 
attempts are often less \11\lethal \12\.
---------------------------------------------------------------------------
    \10\ VA National Suicide Data Report: 2005-2016. Department of 
Veterans Affairs. Office of Mental Health and Suicide Prevention. 
September 2018, p. 6.
    \11\ VA National Suicide Data Report: 2005-2016. Department of 
Veterans Affairs. Office of Mental Health and Suicide Prevention. 
September 2018, p. 6.
    \12\ National Strategy for Preventing Veteran Suicide: 2018-2028. 
Department of Veterans Affairs. Office of Mental Health and Suicide 
Prevention. p. 22.
---------------------------------------------------------------------------
    Web-based health initiatives have also been proven valuable to 
younger tech-savvy veterans. Apps and website modules are available to 
all veterans and service members, as well as family members and 
friends, managing complex mental health conditions such as PTSD, 
traumatic brain injury (TBI), MST, or dealing with anger issues and 
executive function challenges. Veterans report that these web-based 
initiatives are valuable and help them navigate the challenges of 
readjustment after military deployment and provide guidance in 
reconnecting as a friend, parent or spouse.

General Recommendations for VA's Suicide Prevention Efforts

    While VA has policy guidance (VHA Directive 1071) creating 
mandatory suicide risk and intervention training for all VHA employees, 
there may not be adequate staff or coverage for mental health services 
at VA facilities to ensure veterans are able to access services when 
they are most needed-when a veteran is in crisis. According to VA, 
since 2007, VA's crisis line has handled 3.5 million calls, and 
responded to almost a million more texts and chat messages. It has 
dispatched emergency services 93,000 times and referred veterans to 
suicide prevention coordinators more than 582,000 times. \13\ This is 
strong evidence of veterans' need for immediate crisis intervention.
---------------------------------------------------------------------------
    \13\ Department of Veterans Affairs. Press Release: VA's Veterans 
Crisis Line Improves Service with Third Call Center Opening in Topeka, 
Kansas tps://www.va.gov/opa/pressrel/pressrelease.cfm-id=4070, accessed 
4/25/19.
---------------------------------------------------------------------------
    In addition, many VA primary care clinics have integrated mental 
health services (PC-MHI) to ensure that veterans identified through 
primary care screening can receive a warm handoff to a mental health 
professional and receive immediate attention for any emergent mental 
health problems. VA indicated that in 2018, about half of veterans 
using this service had their initial encounter with a mental health 
professional the same day as their primary care visit. \14\ Given the 
recent tragedies on its own grounds, VA recently sent a reminder to 
veterans that they can obtain same-day emergency mental health 
treatment. However, to ensure the timeliness of care and services, VA 
facilities must have appropriate staffing levels and patient aligned 
care teams in place to meet demand. For these reasons we recommend that 
all VA Mental Health Services meet suggested minimum staffing 
guidelines of 7.72 FTEE per 1000 veteran patients.
---------------------------------------------------------------------------
    \14\ Department of Veterans Affairs. News Release: VA Ensures 
Veterans Have Same-Day Access to Mental Health. April 16, 2019
---------------------------------------------------------------------------
    One way to increase support for mental health providers is to 
utilize and train more peer support specialists to work in mental 
health programs. Properly trained peers embedded with clinical patient 
aligned care teams can help veterans better understand and manage their 
mental health and post-deployment health challenges such as substance 
use, which may put them at higher risk for self-directed suicide. They 
can also help veteran peers focus on goals for recovery and become more 
engaged in treatment.
    Vet Center facilities offering specialized individual and group 
counseling for post- traumatic stress disorder (PTSD) and the after 
effects of military sexual trauma (MST), have also proven to be helpful 
to many at risk veterans. Ensuring that these veterans are connected 
and engaged in treatment and developing new strategies for coping and 
reducing exposures to substance use or other behaviors may help to 
reduce vulnerability to self-directed harm. Nature retreats are another 
therapeutic option that that allow groups of similar veterans (such as 
women or veterans returning from recent deployments) to engage with and 
learn from each other in creating new coping strategies and life goals.
    Further reductions in the number of veterans' suicides may also 
require VA to identify, develop and assess tailored interventions for 
certain at-risk populations such as veterans recently discharged from 
military service, LGBTQ veterans and women veterans. Understanding 
unique differences in their risk factors, protective factors and the 
effectiveness of different treatments for them could help reduce 
suicides among these subpopulations of veterans using VHA. Again, data 
collection, research and analysis must continue to assure that VA is on 
the right track.
    In addition, VA must have the space and facility design to ensure 
veterans who are in immediate crisis receive treatment in safe 
environments. Policy guidance (VHA Directive 1167) is available in 
making mental health environments safe for veterans with suicidal 
ideation, but we note that GAO has found that environment of care 
surveys are often incomplete and inaccurate when facilities submit them 
and recommended VA take concrete steps toward improving its environment 
of care program. \15\ The Committee may want to ask VA to discuss how 
it intends to make such improvements and how to determine whether the 
mental health environment of care checklist is being implemented at all 
of VA's health care facilities with fidelity.
---------------------------------------------------------------------------
    \15\ VA Should Establish Goals and Measures to Enable Improved 
Oversight of Facilities' Conditions GAO-19-21: Published: Nov 13, 2018. 
Publicly Released: Nov 13, 2018.
---------------------------------------------------------------------------
    Finally, we understand that VA and DoD are in the final stages of 
updating their 2013 joint clinical practice guideline on suicide 
prevention and look forward to reviewing this important document. We 
are pleased that VA is also building bridges to other federal agencies 
and working on building coalitions that are better able to connect with 
veterans who use non-VHA providers for health care.
    Overall, VA has done notable work in trying to reduce suicide in 
the veteran population, but they cannot do it alone, especially when 
they lack contact with and information about the majority of veterans 
who do not use VHA services. It will require a large scale strategic 
plan along with sufficient resources (dedicated funding and staff) to 
carry out a successful public health/suicide prevention initiative.
    In closing, DAV believes effective use of the public health model 
and implementation of initiatives within its strategy will allow VA to 
reach beyond its patient population and effect changes in behavior 
within the greater veteran population and other stakeholder groups. 
However, we do have concerns about resources and appropriate staffing 
levels that are necessary to carry out such an expansive effort. 
Without appropriate resources, skilled professionals to monitor 
progress through defined and measureable goals and ongoing data 
collection and analysis, public health initiatives will not be 
effective. We also note that loss of resources siphoned from VA's 
existing mental health program could threaten the integrity of the 
effective programs, services and supportive tools VA has already 
implemented for suicide prevention and mental health treatment of 
veterans using VHA.
    Mr. Chairman, I appreciate the opportunity to provide DAV's views 
to the Committee on this important topic, and recommendations for what 
more can be done to prevent suicide in the veteran population.

                                 
            Iraq and Afghanistan Veterans of America (IAVA)
    Statement of Stephanie Mullen
    Research Director

    Chairman Takano, Ranking Member Roe, and Members of the Committee, 
on behalf of Iraq and Afghanistan Veterans of America (IAVA) and our 
more than 425,000 members worldwide, thank you for the opportunity to 
share our views, data, and experiences on the matter of suicide 
prevention among veterans.
    Suicide prevention is an incredibly important part of our work; it 
is why it is at the top of our Big Six Priorities for 2019 which are 
the Campaign to Combat Suicide, Defend Education Benefits, Support and 
Recognition of Women Veterans, Advocate for Government Reform, Support 
for Injuries from Burn Pits and Toxic Exposures, and Support for 
Veteran Cannabis Utilization.
    Suicide rates over the past 10 years have been rising at a shocking 
rate; in 2016, the Center for Disease Control reports that 45,000 
Americans died by suicide. And while suicide is an American epidemic 
and public health crisis, it is severely impacting the veteran 
population in particular. According to the most recent Department of 
Veterans Affairs data, 20 veterans and servicemembers die by suicide 
every day which is over 7,000 veteran and military lives lost to 
suicide every year. At risk populations include women veterans who are 
almost twice as likely to die by suicide than their civilian 
counterparts. And veterans aged 18 to 34, the post-9/11 generation, 
which has the highest rate of suicide among any generation of veteran.
    We've been watching this trendline for years. In our latest member 
survey, 59 percent of IAVA members reported knowing a post-9/11 veteran 
who died by suicide; 65 percent know a Post-9/11 veteran who has 
attempted suicide. In 2014, these numbers were 40 percent and 47 
percent respectively.
    More alarmingly, our newest data shows that 43 percent of IAVA 
members report having suicidal ideation since leaving the military, a 
12 percent increase since 2014; showing that more and more veterans and 
servicemembers in IAVA's community are experiencing suicidal ideation--
a risk factor for suicide. This information tracks with the final 
report under the Clay Hunt SAV Act: The VA Mental Health Program and 
Suicide Prevention Services Independent Evaluation from 2018. The 
report shows that veterans ages 18 to 45, the post-9/11 generation, had 
the greatest proportion of suicidal behaviors, including suicidal 
attempts and ideation, among any age and made up almost 40 percent of 
the overall suicidal behavior totals.
    Our members intimately know the devastation of this loss and 
despite recent efforts around suicide prevention, an increasing number 
of our members have a personal connection to this public health crisis. 
When IAVA planted 5,520 flags on the National Mall on October 3rd, 2018 
to represent the 20 military and veteran souls lost to suicide that 
year to date, many silently wept remembering either those who were 
lost, or their own personal struggles.
    Every day, entire communities are impacted by veteran suicide. Each 
life lost impacts an entire community: a family, friends, a military 
unit, and the lives of each and every person that veteran or 
servicemember touched. We often say one death by suicide is too many, 
and it is so true, because every life has value and every death has 
impact far beyond just one moment of crisis.
    IAVA is on the front line of this fight. Our groundbreaking Rapid 
Response Referral Program (RRRP) staffed by masters-level case 
managers, known as Veteran Transition Managers (VTMs), continues to 
serve as a safety net for thousands. In 2018, we provided nearly 130 
connections to mental health support for veterans and family members 
around the country, ensuring that those in need of help can easily 
access the quality support they need.
    Importantly, we have a memorandum of understanding (MOU) with VA's 
Veterans Crisis Line (VCL) which allows us to provide a warm handoff 
with a trained responder at the VCL, where the at-risk veteran is never 
left alone or hung up on, literally preventing veteran suicide. In 
2018, RRRP connected 39 veterans to the VCL, which means that about 
every week and a half, VTMs connected a veteran that was either 
currently suicidal or at--risk of suicide with life-saving support. 
IAVA's RRRP and the VCL have been in partnership since RRRP launched in 
2012, and has connected nearly 260 veterans to this life-saving 
resource.
    Unfortunately, RRRP has seen an alarming increase of more than 50% 
in referrals to the VCL from 2018 to 2019 to date. RRRP VTMs are highly 
trained professionals and are pushing hard to detect those at risk of 
suicide. This sensitive surveillance is one of the factors driving this 
uptick but these numbers also indicate the ongoing unmet need for 
mental health care and the urgency in which veteran suicide must be 
addressed.
    While we recognize and appreciate the intent behind today's 
hearing, we believe that a focus should be on the larger veteran 
suicide crisis. When a veteran dies by suicide on VA property, it 
further erodes the foundation of trust between the public and VA; VA is 
supposed to be where veterans go to get healthy and seek treatment. 
When this moment of crisis happens at a VA facility, it is 
heartbreaking and feels preventable. But it is important that we 
recognize that every death by suicide is different. There are different 
risk factors, triggers, and moments of crisis in each case, and a death 
by suicide on VA property is just as tragic and just as great a loss as 
a death by suicide in a veterans' own home, car or workplace. 
Regardless, these tragic events should be a call to action; to ensure 
that all VA policies and procedures surrounding VA emergency mental 
health care, facility security, and personnel training are up to date, 
acceptable, and being implemented correctly. A failure in the system 
should and must be addressed. IAVA recommends that any proposed 
legislation focus on these procedures and policies at VA facilities 
that may be able to intervene in a moment of crisis rather than the 
individual factors surrounding the tragic event itself.
    Suicide is a multidimensional problem that demands a range of 
solutions. In 2014, IAVA launched the Campaign to Combat Suicide. This 
was a result of our members continually identifying mental health and 
suicide as the number one issue facing post-9/11 veterans in our annual 
membership survey. This campaign centers around the principle that 
timely access to high-quality mental health care is critical in the 
fight to combat veteran suicides.
    The Clay Hunt SAV Act, signed into law in 2015, was a critical 
piece of legislation to target mental health and suicide prevention, 
and to bring attention to the growing need for resources in this area. 
And while the aforementioned final report from the Clay Hunt SAV Act 
peer support program overall showed that the peer support pilot 
programs were effective, it highlighted the need for sustained funding 
and increased dedicated staffing to ensure programmatic success. Since 
then, we've seen a number of advancements and many pieces of 
legislation passed addressing the issue. The final third party 
evaluation of mental health services at VA under the Clay Hunt SAV Act 
showed that overall, VA's mental health services had a positive impact 
on the veterans that used them and decreased suicidal ideation and 
suicide attempts among those using certain services. This is a great 
indicator that mental health care at VA is effective for those veterans 
that are able to access it. Expansion of mental health and suicide 
prevention services have continued since 2015: the Veterans Crisis Line 
has expanded, community partnerships have expanded, VA has opened up 
emergency mental health care to those with Other Than Honorable 
discharges, and VA has started using predictive analytics to reach out 
to veterans who show risk factors for suicide.
    However, we are far from a long term sustainable solution to 
address veteran suicide. It is critical that VA, Congress, and veterans 
organizations look to new and innovative solutions to reach every 
veteran and engage the American public in the veteran suicide crisis. 
Most veterans do not receive care at VA, and even more receive at least 
some care in the community. Among IAVA members, only 27 percent receive 
VA health care exclusively and 25 percent receive private health care 
exclusively. This means that to effectively address the issue of 
veteran suicide we must engage with private health care clinicians and 
insurance companies in the discussion. We must meet veterans where they 
are - and that is often not inside a VA facility.
    We applaud VA for taking a public health approach to the veteran 
suicide crisis. It will take mobilizing every sector of society to 
effectively address this crisis. In IAVA's Policy Agenda for the 116th 
Congress, we lay out a series of recommendations on this issue in 
particular. To highlight just some of the recommendations, IAVA 
believes VA should apply existing data at their disposal to implement 
effective and evidence-based programs for suicide prevention, require 
all clinicians to have comprehensive mental health care and suicide 
prevention training including all Primary Care Providers both within VA 
and the community care program, expand and improve predictive analytics 
programs that aim to engage a veteran before a moment of crisis, invest 
in postvention programs targeting veterans impacted by suicide to 
prevent the risk of suicide contagion, and implement a public awareness 
campaign around firearms and suicide.
    While these may seem like broad and sweeping recommendations, we 
believe the best next step in addressing this crisis is passage of the 
Commander John Scott Hannon Veterans Mental
    Health Care Improvement Act (S.785) introduced by Sens. Jon Tester 
and Jerry Moran, which will bring even greater attention and resources 
to VA to combat the veteran suicide crisis. IAVA is very pleased with 
the provisions in the bill to provide grants to organizations that 
provide mental health care services for veterans not receiving VA care, 
as well to organizations that provide transition assistance to veterans 
and spouses. S. 785 also invests in a number of studies, including the 
link between elevation and suicide and an evaluation of Vet Centers' 
Readjustment Counselors efficacy; it also provides for an increased 
number of tracking metrics to ensure that VA is providing the best 
possible mental health care possible. IAVA looks forward to supporting 
a House companion bill as soon as it is introduced. Thank you for 
allowing IAVA to share our views.

                                 
                       The American Legion (TAL)
    VETERANS AFFAIRS AND REHABILITATION DIVISION
    Chairman Takano, Ranking Member Roe, and distinguished members of 
the Committee on Veterans' Affairs, on behalf of National Commander 
Brett Reistad and the nearly two million members of The American 
Legion, we thank you for the opportunity to testify on this deeply 
troubling issue of the growing number of suicides amongst the veteran 
community, and on how to prevent such tragedies. As the largest 
patriotic service organization in the United States with a myriad of 
programs supporting veterans, The American Legion appreciates the 
leadership of this committee in focusing on this critical issue.

Background

    The latest data on veteran suicide shows more than 6,000 veterans 
have died by suicide every year from 2008 to 2016, and in 2016, the 
suicide rate was 1.5 times greater for veterans than non-veteran 
adults. \1\ Veteran Suicide is a national issue and far exceeds the 
ability of any one organization to handle alone. The American Legion 
stands behind the Department of Veterans Affairs (VA) in its efforts to 
collaborate with partners and communities nationwide.
---------------------------------------------------------------------------
    \1\ The 2016 VA National Suicide Data Report
---------------------------------------------------------------------------
    On April 24, 2019, National Commander Brett Reistad teamed up with 
Dr. Keita Franklin, VA's Executive Director of Suicide Prevention, and 
penned a letter \2\ emailed to nearly 850,000 American Legion members, 
family, and friends, to let them know that we are working together to 
adopt a public health approach to suicide prevention. The public health 
approach looks beyond the individual to involve peers, family members 
and the community in preventing suicide. Preventing veteran suicide is 
a top priority for VA, but they need help from dedicated partners to 
reach veterans outside the VA health-care system. The letter provided 
links to VA's National Strategy for Preventing Veteran Suicide, a 
toolkit that includes a guide to online suicide prevention resources, 
and a resource locator for contacting local VA Suicide Prevention 
Coordinators.
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    \2\ https://www.legion.org/commander/245458/legion-va-team-
approach-suicide-prevention
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    The best available information and practices should be used to 
support all veterans, whether or not they are engaging with VA. \3\ 
According to the VA National Suicide Data Report 2005-2016, there are 
approximately 20 million veterans in the United States. Of these 20 
million, only 30 percent receive services from the Veteran Health 
Administration (VHA).
---------------------------------------------------------------------------
    \3\ National Strategy for Preventing Veteran Suicide 2018-2028
---------------------------------------------------------------------------
    In April of 2019, three suicides were reported at VA facilities 
within the span of five days. In February, the Washington Post reported 
that 19 suicides took place on VA campuses from October 2017 to 
November 2018, seven of them in parking lots. The American Legion 
remains deeply concerned by the substantial number of servicemembers 
and veterans who die by suicide, and is committed to finding solutions 
to help end this crisis.
    One contributing factor to the increase in suicide on VA campuses 
may be traced to staffing shortages experienced by VA hospitals and 
clinics. Data released in February 15, 2019, as mandated by the VA 
Mission Act, reported 48,985 employment vacancies in VA. This number 
increased by nearly 4,000 since last reported in August 2018. \4\ The 
high rate of employee turnover, insufficient recruitment, retention, 
and relocation budget, and a drawn-out hiring processes attributes to 
shortages in VA personnel. These factors inherently lend themselves to 
overworked staff, poor patient experiences, and lower quality of care.
---------------------------------------------------------------------------
    \4\ VA Mission Act Section 505 Data released February 15, 2019
---------------------------------------------------------------------------
    Another area of concern is the number of potentially harmful 
medications like benzodiazepines and opioids currently prescribed to 
veterans. VA has made progress in improving opioid safety through its 
Opioid Safety Initiative (OIS) and state prescription drug monitoring 
programs (PDMP); however, room for improvement exists. A study 
conducted by the VA's Office of Inspector General found several factors 
that may have contributed to inconsistent adherence to key opioid risk 
mitigation strategies. These inconsistencies include: the absence of a 
pain champion (a primary care position required by VHA that can help 
providers adhere to opioid risk mitigation strategies), limited access 
to academic detailing, and inconsistent reviews of veteran medical 
records to ensure provider adherence to these strategies. \5\
---------------------------------------------------------------------------
    \5\ Department of Veterans Affairs Office of Inspector General 
Report No. 17-01846-316
---------------------------------------------------------------------------
    Monitoring opioid prescriptions given to veterans using programs 
outside VA is critical to reducing the risk of veteran overdoses. The 
Government Accountability Office also found patients who receive opioid 
prescriptions from non-VA clinical settings are especially at risk. 
This is due to conflicting guidelines of VA facilities and non-VA 
facilities as it relates to opioid prescribing and monitoring. 
Moreover, that risk is exacerbated when information about opioid 
prescriptions is not shared between VA and non-VA providers. \6\
---------------------------------------------------------------------------
    \6\ GAO report 18-380
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    We must consider these facts as we try and understand the tragic 
trend of veteran suicides on the VA facilities, and work to increase 
the quality of mental health services provided by VA.

Efforts of The American Legion to Reduce Veteran Suicide

    In a national effort to reduce veteran suicide, The American Legion 
established a Suicide Prevention Program (SPP) on May 9, 2018. The 
program is charged with examining trends of veteran suicide as it 
relates to traumatic brain injury, posttraumatic stress disorder 
(PTSD), military sexual trauma (MST), and analyzing the best practices 
in veteran suicide prevention not currently used by the Department of 
Defense (DoD) or Department of Veterans Affairs (VA). The objective of 
the SPP is to then encourage the aforementioned government agencies to 
adopt best practices not already utilized. \7\
---------------------------------------------------------------------------
    \7\ Legion Resolution #20, 2018 Spring NEC
---------------------------------------------------------------------------
    The American Legion's TBI/PTSD Committee met on January 24, 2019, 
during our annual Washington Conference, and in an effort to increase 
collaboration with partners and communities nationwide, the committee 
developed a Mental Health Survey. The survey is designed to collect 
data that will help The American Legion bring local resources related 
to TBI, PTSD, and Suicide Prevention to veterans and their families. 
The survey is scheduled for release in May during Mental Health 
Awareness Month. Information collected will include current suicide 
prevention training taken by participants and their perceived 
effectiveness of that training. This data will help The American Legion 
determine its current suicide prevention readiness and areas of 
potential improvement. Data will also be collected on treatment 
programs for TBI and PTSD, both inside and outside of VA. The 
information gathered on various forms of treatment experienced by 
participants will aid in the development of a consolidated list of 
available resources for veterans. Resources will be categorized by 
location and vetted to ensure the treatments are evidence based and 
beneficial for veterans.
    Within the American Legion National Headquarters in Washington, 
D.C., our Executive Director of Government and Veterans Affairs, 
created a community service policy encouraging employees to get 
involved with their local communities and work together to save 
veterans' lives. The policy allows employees additional paid time off 
to volunteer (40 hours per year) with a suicide prevention program of 
their choice. This policy encourages good citizenship by supporting 
local organizations that offer meaningful opportunities for civic 
engagement in effort to prevent veteran suicide.
    In an effort to raise awareness of veteran suicide, The American 
Legion's Veterans Affairs & Rehabilitation Headquarters Division 
published a white paper report titled, ``Veteran Suicide.'' This report 
describes causes, risk factors, and protective factors of veteran 
suicide, as well as the American Legion's concerns and recommendations 
regarding this tragic national issue. Publications from The American 
Legion's TBI/PTSD Committee titled, ``The War Within,'' and ``The Road 
Home,'' highlight the Legion's research of Post-Traumatic Stress and 
Traumatic Brain Injury. TBI and PTSD are serious risk factors that put 
veterans at an increased risk of suicide. The information covered in 
these publications includes: the symptoms and risk factors of 
individuals dealing with PTSD and TBI; the treatments and testimonials 
of those on the road to recovery, and the Resolutions passed by The 
American Legion in an effort to ease the suffering of these veterans. 
The Suicide Prevention and Crisis Response Protocol is a toolkit 
developed by TBI/PTSD Committee to relay the recommendations of the 
Committee pertaining the veteran suicide and suicide prevention. 
Information on suicide prevention training, suicide prevention 
resources, and how to market information pertaining to suicide safely, 
can all be found in this toolkit.
    The American Legion's efforts are also evident at our local posts. 
Legion Post 102 in Erie, Kansas 102 is partnering with their local 
elected officials as part of VA's Governor's and Mayor's Challenge to 
prevent suicide among servicemembers, veterans, and their families. 
They also recognized the need to help bridge the gap between local 
communities and VA services, and created position called the Suicide 
Prevention Officer (SPO). This officer will serve as a liaison to local 
services for veterans in their communities. The SPO will be trained in 
peer-to-peer training, have close connections with local mental health 
providers, police departments, first responders, EMT services, schools, 
primary health care providers, other veteran service originations, and 
VA programs.
    The Florida Department Chaplain is developing training for 
ministers and clergy on the characteristics of veterans' trauma. In 
addition, Legionnaires in Florida created a 2.2-mile ``ruck'' walk, 
called Challenge 22, designed to raise awareness for veteran suicide. 
The event's motto, 22 Until Zero, was adopted in recognition of the 
number of veterans that die by suicide each day. The event raised 
$31,000 in 2017, and $33,000 in 2018. This year's event is scheduled to 
take place November 16, 2019, with a goal to raise $100,000 in support 
of local programs for veterans with PTSD including: PROJECT VetRelief, 
Kine9line, Warrior Beach Retreat, Veterans Counseling Veterans, 
Camaraderie Foundation, and Florida 4 Warriors.

Moving Suicide Prevention to a Public Health Model

    The public health approach to preventing veteran suicide has four 
components as defined by the Center for Disease Control (CDC). These 
components include population approach, primary prevention, commitment 
to science, and multidisciplinary strategies. \8\ The public health 
model uses a population approach to improve health on a large scale. A 
population approach means focusing on prevention approaches that impact 
groups or populations of people, as opposed to treatment of 
individuals. \9\ The American Legion supports the population approach 
component of the public health model and understands that reducing 
veteran suicide will involve looking beyond individuals' suffering, to 
those willing to support them.
---------------------------------------------------------------------------
    \8\ Centers for Disease Control and Prevention, Enhanced Evaluation 
and Actionable Knowledge for Suicide Prevention Series. Suicide 
Prevention: A Public Health Issue (n.d.). Accessed March 2, 2018, at 
www.cdc.gov/violenceprevention/pdf/ASAP--Suicide--Issue2-a.pdf
    \9\ National Strategy for Preventing Veteran Suicide 2018-2028
---------------------------------------------------------------------------
    Using a population approach is a proactive strategy to increase 
suicide prevention readiness because it draws on the power of the 
collective, as opposed to the reactive strategy of focusing on the 
individual. The first line of defense in preventing veteran suicide is 
the veteran's primary social circle - close friends and family. Those 
individuals closest to the veteran are the most likely to notice small 
changes in mood and behavior. They are also best equipped to approach 
the veteran with concerns of suicide due to their established level of 
trust.
    The primary prevention component of the public health model focuses 
on preventing suicidal behavior before it occurs and addresses a broad 
range of risk and protective factors. \10\ The American Legion supports 
the primary prevention component of the public health model and 
recognizes the importance of addressing the risks of suicide before 
they become critical. Individuals with knowledge of suicidal warning 
signs and risk factors can help curve this alarming trend. Furthermore, 
individuals who identify at-risk veterans, must have available 
resources and tools to mitigate the risk of suicide.
---------------------------------------------------------------------------
    \10\ Id.
---------------------------------------------------------------------------
    The commitment to science component of the public health model is 
centered on scientifically increasing the understanding of suicide 
prevention and developing new and better solutions. The American 
Legion's support of this component of the public health model can be 
found in Resolution No. 160 which states, ``.The American Legion urge 
Congress to provide oversight and funding to the Department of Veterans 
Affairs (VA) for innovative, evidence-based, complementary and 
alternative medicine (CAM) in treating various illnesses and 
disabilities.'' Treatments addressing the comorbidity of symptoms of 
PTSD, TBI, and suicide, are powerful protective factors contributing to 
suicide reduction. \11\ The American Legion recognizes the only way to 
consolidate safe and effective treatments for the comorbidity of 
symptoms relating to PTSD, TBI, and suicide is to build upon evidence 
established by the scientific community.
---------------------------------------------------------------------------
    \11\ Resolution No. 160
---------------------------------------------------------------------------
    The multidisciplinary strategies component of the public health 
model advocates for collaboration, bringing together many different 
perspectives to engineer solutions for diverse communities. \12\ The 
American Legion supports this component of the public health model and 
has endeavored to collaborate with local communities in an effort to 
reduce veteran suicide.
---------------------------------------------------------------------------
    \12\ National Strategy for Preventing Veteran Suicide 2018-2028

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Solutions

    The American Legion urges Congress to pass legislation to improve 
VA's tedious hiring process and increase VA's recruitment, retention 
and relocation budget. It will allow VA to retain quality mental health 
providers, incentivize exemplary performance, and increase employee 
morale. Improvements in these areas will lead to increased customer 
satisfaction and overall quality of care for veterans. The American 
Legion recommends state-level prescription drug monitoring program 
databases share data (Resolution No. 160: Resolved, The American Legion 
urges legislation that would improve pain management policies for the 
Department of Defense (DoD) and VA.). Implementing a strategy for 
state-level prescription drug monitoring programs to share data will 
reduce the unknowing prescription of risky drug combinations, and the 
overprescribing of potentially dangerous medication.

Conclusion

    In closing, The American Legion appreciates the leadership of this 
committee and remains committed to eradicating veteran suicide. 
Further, The American Legion is committed to working with the 
Department of Veterans Affairs and this committee to ensure that 
America's veterans are provided with the highest level of support and 
healthcare. Chairman Takano, Ranking Member Roe, and distinguished 
members of this committee, The American Legion thanks this subcommittee 
for holding this important hearing and for the opportunity to explain 
the views of the nearly 2 million members of this organization. For 
additional information regarding this testimony, please contact Mr. 
Larry Lohmann, Senior Legislative Associate of The American Legion's 
Legislative Division at (202) 861-2700 or [email protected]

                                 
                   Vietnam Veterans of America (VVA)
    Submitted by
    John F. Rowan
    National President

    Chairman Takano, Ranking Member Dr. Roe, and other distinguished 
members of this very important committee, Vietnam Veterans of America 
(VVA) thanks you for the opportunity to present our views for the 
record on ``Suicide Prevention Among Veterans,'' with particular 
emphasis on, as Chairman Takano has written, ``the heartbreaking trend 
of veteran suicide on the grounds of VA facilities.'' First, though, we 
want to thank the committee for your consistent and unwavering concern 
about the mental health care afforded our veterans.
    Suicide is not an easy subject to discuss. It is a topic that most 
of us would prefer not to think about. Considering the purpose of this 
hearing, it should be noted that accurate statistics on deaths by 
suicide, despite the intense focus during the wars in Afghanistan and 
Iraq by both the VA and Defense Department, do not, and cannot, paint a 
true picture because many incidents are not reported, are misreported, 
or just fall through the cracks.
    Two salient statistics stand out when considering, and confronting, 
the loss of too many of those men and women who have served in a combat 
zone. One: of the 20 or so veterans who are estimated to take their 
life each day, the vast majority, some 70%, are over the age of 55. 
They are, for the most part, Vietnam-Era veterans. We don't have solid 
statistics about who among them was afflicted with PTSD or depression 
borne of their experiences in the military that have plagued them, nor 
of the problems caused or exacerbated by their repeated long absences 
from home due to deployments. Although these experiences may have 
altered the arc of their life (and of their family relationships), more 
immediate concerns may have led them into the abyss: the loss of a job 
or a house or a spouse or a child; or a malady that is too painful or 
debilitating or inevitably fatal.
    And two: During the fighting in Afghanistan and Iraq, of the 20 or 
so veteran suicides a day, 14 were not patients at a VA or clients at a 
Vet Center. So when a veteran immolates himself in the parking lot of a 
VA medical center, this naturally gets immediate attention via the 
media. Or if he puts a gun to his head and pulls the trigger, or if she 
downs half a bottle of sleeping pills and was recently back from a 
combat zone - or whose unit was about to be sent back into the fray - 
such an action will likely attracts attention.
    Certainly, whenever a veteran returned from the war takes his or 
her own life, this is a very real public health concern for our 
military and veteran communities. Because we know, from more than a few 
studies, e.g., a 12-year study published in the June 2007 issue of the 
journal Epidemiology and Health, that the risk of suicide among male 
veterans, after adjusting for a host of potentially compounding 
factors, including age, time in service, and health status, is more 
than two times greater than that of the general population. A report 
released more than a decade ago by the VA Inspector General noted that 
``veterans returning from Iraq and Afghanistan are at increased risk 
for suicide because not all VA clinics have 24-hour mental care 
available . . . and many lack properly trained workers.''
    Under the glare of publicity, much of it focusing on how the VA and 
Defense Department, despite spending hundreds of millions of dollars 
searching for answers as to why troops and veterans choose oblivion 
over life, you in Congress, and we in the VSO and MSO communities, have 
grappled with the problem without much success. You must acknowledge, 
however, that the VA has found ways to deter an uncounted number of 
veterans from making that final, fatal decision.
    In the early years of the Global War on Terror, DOD to its 
discredit, hid suicides on official casualty lists as ``accidental non-
combat deaths,'' even lying to the parents of dead soldiers. The Army 
insisted that they could not to find a connection between PTSD, between 
the stresses of combat and the type of combat waged in Iraq, and 
suicide.
    We as a nation have come a long way in acknowledging the connection 
between PTSD and suicide. One of the characteristics of PTSD is that 
the onset of symptoms is often delayed, sometimes for decades, 
triggered by stories and images of combat and the casualties of combat, 
and aggravated by other personal losses, hurts, or issues.
    VVA's position on suicide is clear: one suicide of a veteran, or an 
active-duty troop, is one too many, and there have been far too many. 
We need to focus not on why veterans take their life; this is no great 
mystery. We need instead to concentrate on what we, collectively, can 
do to get more at-risk veterans the counseling that might save their 
life.
    And we urge you not to be taken in by the assertion of some that we 
need more expertise from entities having little or no connection with 
the military or with veterans.
    One significant first step that needs to be done is to do a 
complete analysis of all aspects of the suicide soldier or veteran's 
life, including medical, psychiatric, familial, social, spiritual, and 
financial situation. For example, if married, is it a solid marriage- 
Has there been a marital separation or other negative event in the 
family's life- Is there a steady stream of income that is adequate to 
cover the basic needs of the family- Is there a VA claim for 
compensation that is currently held up or recently denied- Are they 
behind on their VA guaranteed mortgage-
    VVA will send you a more complete explication of what we strongly 
believe should be included in such an analysis, and what efforts of the 
entire VA team may allow us collectively to intervene in time for some 
suicidal service member or veteran in the future. It was clear in the 
Roundtable on Suicide sponsored earlier by Chairman Takano and Ranking 
Member Dr. Roe that neither VA nor DOD was even thinking in these 
terms. Since that Roundtable VVA and the major VSOs participated in a 
discussion with the current Executive in Charge of Veterans Health 
Administration (VHA) and the current head of the Suicide Prevention 
office that not only are they not doing such a thorough analysis, but 
that the Suicide Prevention people were not even thinking in an action 
oriented modality of how can we discern key triggers, and then as a 
total team at VA/DOD, with assistance from the Veterans Service 
Organizations/Military Service Organizations move swiftly to save 
future lives.
    It's too easy, at this point in time, to create commissions or task 
forces to give the impression that we are taking this issue seriously. 
Instead, we need to focus on the lessons we, and specifically the VA, 
know works, what suicide prevention initiatives and programs have saved 
lives, and what other interventions show promise. In other words, while 
more data will be helpful, it is action that is needed rather than 
further cogitation.
    It is up to all of us, with your leadership, to do the very best 
that we can to provide enough help and guidance to the men and women 
who need it most.
    VVA thanks you for the opportunity to share our views on this 
issue.

                                 
                     Wounded Warrior Project (WWP)
Introduction

    Chairman Takano, Ranking Member Roe, and distinguished Members of 
the Committee on Veterans' Affairs - thank you for inviting Wounded 
Warrior Project (WWP) to submit this statement for the record of 
today's hearing on veteran suicide prevention. Suicide prevention is 
the Department of Veterans Affairs' highest clinical priority and among 
the greatest challenges WWP is working to address in the community we 
serve. For these reasons, we appreciate the Committee's continued 
commitment to bringing veteran suicide into greater focus with this 
hearing.

Framing WWP's Approach to Suicide Prevention

    Wounded Warrior Project is transforming the way America's injured 
veterans are empowered, employed, and engaged in our communities. Since 
our inception in 2003, we have grown from a small group of friends and 
volunteers delivering backpacks filled with comfort items to the 
bedsides of wounded warriors here in our nation's capital, to an 
organization of nearly 700 employees spread across the country and 
overseas delivering over a dozen direct-service programs to warriors 
and families in need. Our foundational principle to ensure that today's 
generation of warriors and families successfully transition into 
civilian life and thrive in their communities guides all that we do 
internally and what we fund externally.
    Wounded Warrior Project is constantly striving to be as effective 
and efficient as possible and we are in continual communication with 
the warriors and caregivers we serve to ensure that we are constantly 
adapting our programs and approach to their unique challenges and 
needs. To learn more about their physical, social, economic, and mental 
health needs, WWP has conducted the nation's largest and most 
comprehensive survey of post-9/11 veterans who have sustained both 
physical and hidden injuries while serving the nation. Since its first 
edition in 2010, this annual survey has helped us identify trends and 
needs among registered warriors, to compare their outcomes with those 
of other military and veteran populations, and to measure the impact of 
continual programmatic engagement - all to determine how we can better 
serve veterans, service members, and their families.
    Wounded Warrior Project released the results of its 2018 Annual 
Survey to a gathering of congressional staff in December 2018. Over 
33,000 warriors completed this edition of the Annual Survey and, for 
the fourth year in a row, post-traumatic stress disorder (PTSD) was the 
most frequently reported health problem from service (78.2 percent), 
followed closely by depression (70.3 percent), anxiety (68.7 percent), 
and even sleep problems (75.4 percent), an issue frequently linked to 
mental health challenges. Accordingly, mental health programs are WWP's 
largest programmatic investment - in 2018, WWP spent $63.4 million on 
our mental health programs - and we hope the lessons we have learned as 
the leading provider and funder of mental health programming in the 
veteran service community can help guide Congress and the Department of 
Veterans Affairs (VA) to reverse the haunting trends in veteran 
suicide.

Complementing VA Efforts to Prevent Veteran Suicide

    In September 2018, WWP testified that our approach to addressing 
veteran suicide is encompassed by our belief that suicide prevention 
must move beyond the healthcare/crisis management model towards an 
integrated and comprehensive public health approach focused on 
resilience and prevention. A multi-disciplinary approach to treatment - 
whether clinical, community-focused, or a combination - is required. We 
also recognize that our efforts are part of a community approach being 
driven in large part by VA:

    ``In the Department of Veterans Affairs FY 2018-2024 Strategic 
Plan, we have identified preventing Veteran suicide as our highest 
clinical priority, one that will require all of government, as well as 
public-private partnerships, to achieve. [.]
    VA has embraced a comprehensive public health approach to reduce 
Veteran suicide rates, one that looks beyond the individual to involve 
peers, family members, and the community. Yet we know we cannot do it 
alone, as roughly half of all Veterans in the U.S. do not receive 
services or benefits from VA. This means we must collaborate with 
partners and communities nationwide to use the best available 
information and practices to support all Veterans, whether or not 
they're engaging with VA.''

    Dr. Carolyn Clancy, Executive-in-Charge, Veterans Health 
Administration
    VA National Strategy for Preventing Veteran Suicide 2018-2028 
(2018)

    In this context, VA has recently adopted a public health model to 
address veteran suicide prevention - a move WWP has encouraged and 
supported in a variety of both direct and complementary ways. As the 
Committee looks to address VA's recent shift towards prevention as part 
of a public health model, we offer this statement through the lens of 
that model and offer perspective on how WWP approaches its mission to 
honor and empower wounded warriors through the model's four 
foundational pillars: (1) population approach, (2) commitment to 
science, (3) primary prevention, and (4) multidisciplinary strategies.

Population Approach

    As stated by the Centers for Disease Control (CDC), ``while suicide 
is often thought of as an individual problem, it actually impacts 
families, communities, and society in general. The long-term goal of 
public health is to reduce people's risk for suicidal behavior by 
addressing factors at the individual (e.g., substance abuse), family 
(e.g., poor quality parent-child relationships), community (e.g., lack 
of connectedness to people or institutions), and societal levels (e.g., 
social norms that support suicide as an acceptable solution to 
problems; inequalities in access to opportunities and services) of the 
social ecology.''
    Whether because of psychological (``invisible wounds'') or physical 
(``visible wounds'') trauma or a combination of both, every warrior who 
registers with WWP is provided with a unique path of individual and 
collective recovery that he or she can pursue through our direct 
services and other support networks. While there is no predetermined 
path for each warrior registering with WWP, a warrior's first 
engagement with our organization is often through our Alumni Program. 
While in the military, many service members form bonds with one another 
that are as strong as family ties. WWP helps re-form those 
relationships by providing wounded warriors opportunities to connect 
with one another through community events and veteran support groups 
housed within this program. WWP also provides easy access to local and 
national resources through outreach efforts and with the help of 
partners like The Mission Continues, Team Red White & Blue, Team 
Rubicon, and over 30 funded partner organizations. While most events 
are warrior focused, WWP also hosts a variety of family-based 
activities.
    Additionally, WWP-sponsored Peer Support Groups are led by, and 
designed for, warriors who want to discuss personal challenges and lend 
support to one another. Peer Support Groups can lead to new 
friendships, provide a renewed sense of community, strengthen bonds 
through shared experiences, and introduce new solutions to challenges. 
WWP trains Peer Support Group leaders to facilitate productive 
discussions and maintain a safe, judgment-free environment for 
warriors. These groups not only serve as ``force multipliers'' for our 
organization but also assist WWP with identifying individuals in 
crisis.
    While engagements may range from recreational activities and 
sporting events to professional development opportunities and community 
service projects, the Alumni Program was formed with an appreciation 
for the fact that a desire for post-service camaraderie is what often 
brings veterans to our organization. In this context, our Alumni 
Program focuses on engagement and connection and not simply the 
activity or event itself. We diversify our connection-focused offerings 
in regions to attract a wide variety of warriors and families, and it 
is through these events that they develop a relationship with the 
organization and trust WWP to help resolve more challenging and 
personal obstacles in their rehabilitation and recovery. Our 
organization averages more than 11 engagements like this every day.
    While not specifically focused on suicide prevention, the Alumni 
Program's value becomes clearer when we conceptualize WWP 
``membership'' and engagement as a possible first step in recovery for 
those seeking or in need of help. Obstacles to seeking mental health 
care support may be difficult to overcome, especially when amplified by 
stigmatizing messages. In many ways, these obstacles can be challenging 
to overcome and serve to further isolate those who may already feel 
marginalized. A possible first step to overcome those hurdles is 
engagement with peers. During such peer engagement warriors may be 
exposed to peer testimonies and guided towards seeking mental health 
treatment and expose them to WWP programs that can lead them towards 
paths to career fulfillment, financial security, physical wellness, and 
other protective factors against suicide. Warriors may attend an 
engagement event to spend time with fellow veterans but may leave with 
newly acquired psychoeducational information and new friendships that 
empower them to take an additional step in their recovery.
    Suicide prevention should not be limited to saving an individual 
life when they are in crisis; it must be about creating a life worth 
living - and providing coping skills and resiliency for dealing with 
future stressors. Meaningful relationships are vital to the success of 
warriors' transitions back into civilian life, and suicide is best 
combated through preventive measures such as providing mental health 
programs, connection opportunities, and pathways to build confidence 
and a sense of purpose. We must be proactive when engaging warriors and 
showing them how their lives matter in their homes and communities. 
Offerings like WWP's Alumni Program and Peer Support Groups provide 
avenues to recurring engagement and a way to stay connected prior to a 
crisis.
    POLICY CONSIDERATION - Encourage and enable VA to improve 
collaboration with private sector programs and services assisting 
veterans: As Congress and VA work to expand VA's clinical footprint 
through the MISSION Act, there remains great opportunity to integrate 
not only medical services, but also to build from that foundation, 
linking to existing referral networks of non-clinical community 
supports. The creation of a network bridging non-profit with 
governmental - clinical with non-clinical - could help veterans better 
navigate the many services that are available to them. If done 
correctly, this has the potential to be transformative; non-clinical 
supports are in many cases as essential for a veteran's success as high 
quality clinical care. Section 201 of the Commander John Scott Hannon 
Veterans Mental Health Care Improvement Act of 2019 (S. 785) embraces 
this concept and we encourage the Committee to consider similar 
legislation.

Primary Prevention

    The CDC states that ``public health emphasizes efforts to prevent 
violence (in this case, toward oneself) before it happens. This 
approach requires addressing factors that put people at risk for, or 
protect them from, engaging in suicidal behavior.'' At WWP, we 
recognize that mental health treatment works, but every individual has 
unique needs, and there is no one-size-fits-all solution. We take a 
comprehensive approach to mental health care that is focused on 
improving the levels of resilience and psychological well-being of 
warriors. Our end goal is continual engagement until the warrior is far 
enough in their recovery to ``live our logo'' (i.e., help carry a 
fellow warrior) - the last step in what we refer to as our Mental 
Health Continuum of Support.
    Our Mental Health Continuum of Support is comprised of a series of 
programs, both internal to WWP and in collaboration with external 
partners and resources, intended to assist warriors and their families 
along their journey to recovery. The Mental Health Continuum of Support 
provides diverse programming and services to better meet their needs. 
At WWP, we understand that warriors have individualized paths of 
recovery and that engaging all warriors with the same program or even 
in a linear fashion may not be optimal. WWP's Mental Health Continuum 
of Support addresses and meets warriors where their needs are at their 
current stage of recovery. Warriors are engaged with the appropriate 
mental health program (i.e., the program that can best address current 
levels of psychological well-being and resiliency). This allows for 
warriors to be empowered by programs that can best address their needs 
and increase both psychological resilience and psychological well-
being.
    Recovery is not accomplished in a vacuum - life may present 
challenges that derail or hamper the recovery process. The continuum 
was designed to address such challenges and to allow for nonlinear 
progress through programs. Warriors sometimes need to take foundational 
steps (for example, to learn and hone coping skills) before proceeding 
forward into the next program in the continuum. By focusing on such an 
approach, we can reach warriors with relevant programs at time-
sensitive and critical moments. By the third quarter of fiscal year 
2018, programs that comprise the mental health continuum had over 
67,000 engagements through Mental Health and Wellness programs. This 
includes outreach and referrals along with WWP programs known as Talk, 
Project Odyssey, and Warrior Care Network. Engagements are interactions 
of varying depth and scale that drive impact within each focus area.
    Wounded Warrior Project has built its Mental Health Continuum of 
Support with a recognition that some veterans will not reach out to VA 
for help; however, WWP also recognizes that some veterans may not reach 
out for help at all because of stigma. WWP as an organization 
challenges these stigmas and tries to normalize the help-seeking 
process as all programming engagements, particularly within our 
Continuum of Support, are ultimately focused on normalizing mental 
health. For instance, in September 2018, WWP launched a social media 
campaign to bring awareness to veteran suicide. As our organization 
reaches millions of individuals across several platforms including 
Facebook (3.2 million), Twitter (190,000), Instagram (88,700), and 
LinkedIn (94,000) - we are hopeful to raise meaningful awareness across 
the country. Recently, and for the third year in a row, WWP facilitated 
a live Facebook discussion in conjunction with DoD, VA, and the Bush 
Institute Warrior Wellness Alliance to address veteran suicide, the 
challenges warriors face transitioning to civilian life, and the 
resources available to help with those challenges. Metrics taken 36 
hours after the stream reported 128,121 unique views, which is an 
encouraging sign that such initiatives are reaching individuals. 
Internally, WWP has organization-wide Applied Suicide Intervention 
Skills Training (ASIST). In September 2018 alone, our organization 
trained 228 individuals in ASIST as part of our goal to have all 
program staff - as well as external partners and communities - trained 
with the appropriate skills and tools needed to enhance the effect of 
suicide awareness as well as interactions with suicidal warriors.
    POLICY CONSIDERATION - Using value-based reimbursement models to 
enhance mental health care quality: Section 101(i) of the MISSION Act 
allows VA to incorporate value-based reimbursement principles to 
promote the provision of high-quality care, and this permission can and 
should be used to help encourage innovative models in physical and 
mental health treatment. While the health care industry has embraced 
bundled payment approaches to address episodes of care for hip surgery, 
diabetes, stroke, cancer treatment, and others, VA lags behind, and the 
expanded migration of this practice to mental health would allow VA to 
be a pioneer in an area where veterans are catastrophically suffering 
and drive the wider mental health care industry towards better quality 
and more cost-effective outcomes.

Commitment to Science

    As framed by VA, ``public health uses science to increase our 
understanding of suicide prevention so we can develop new and better 
solutions.'' Such an approach involves tracking suicide trends and 
identifying risk and protective factors for suicidal behavior. This 
information helps frame suicide prevention strategies that can be 
developed and evaluated to identify the most effective interventions 
and then bring successful models of intervention to scale.
    Although the WWP Mental Health Continuum of Support is comprised of 
several programs designed to meet warriors where they are in their 
recovery, the Warrior Care Network and Project Odyssey stand out as 
models for best practices and integration across multiple entities 
committed to improving outcomes for veterans with mental health needs. 
Both are also carefully tracked to measure their effectiveness and 
guide improvements where they are needed. Through the implementation of 
the Connor Davidson Resiliency and the VR12 Rand Quality of Life 
scales, WWP measures outcomes of services and provides the most 
effective programming based on the needs of warriors and their 
families. And while we highlight these two specific programs, it is the 
combination of programs across our continuum that provides our warriors 
and their families with a successful path to follow to increase 
resilience and improve their psychological well-being.

Warrior Care Network

    Within the Continuum of Support, warriors needing intensive 
treatment for moderate to severe PTSD can take part in the Warrior Care 
Network. This innovative program is a partnership with WWP and four 
national academic medical centers (AMCs): Massachusetts General 
Hospital, Emory Healthcare, Rush University Medical Center, and UCLA 
Health. Warrior Care Network delivers specialized clinical services 
through innovative two- and three-week intensive outpatient programs 
that integrate evidence-based psychological and pharmacological 
treatments, rehabilitative medicine, wellness, nutrition, mindfulness 
training, and family support with the goal of helping warriors thrive, 
not just survive.
    Through these two- to three-week cohort-style programs, 
participating warriors receive more than 70 direct clinical treatment 
hours (e.g. cognitive processing therapy, cognitive behavioral therapy, 
and prolonged exposure therapy) as well as additional supportive 
intervention hours (e.g. yoga, equine therapy). Each academic medical 
center has specific programming for caregivers and family members at 
some point during the intensive outpatient program, including family 
weekend retreats, psychoeducation, or telehealth communications. For 
example, UCLA's Operation Mend PTSD track includes three weeks for both 
veterans and caregivers to go through treatment and psychoeducation 
sessions. This provides caregivers with clinical outlets, as well as 
in-depth knowledge of PTSD symptoms, effects, and recovery process. 
Family and caregiver support is extremely important to WWP, and our 
Warrior Care Network includes support for these groups because if a 
treatment program does not offer a family or caregiver component, and 
warriors go through clinical processes then return home, it may leave 
the family or caregiver to feel left in the dark about what occurred.
    Providing warriors with best in class care that combines clinical 
and complementary treatment is still only part of the Warrior Care 
Network's holistic approach to care. While AMCs provide veteran-centric 
comprehensive care, aggregate data, share best practices, and 
coordinate care in an unprecedented manner, a Memorandum of Agreement 
(MOA) between WWP and VA has been structured to further expand the 
continuum of care for the veterans we treat. In February 2016, VA 
signed this MOA with WWP and the Warrior Care Network to provide 
collaboration of care between the Warrior Care Network and VA hospitals 
nationwide. Four VA employees act as liaisons between each site and VA, 
spending 1.5 days per week at their respective sites to facilitate 
coordination of care and to meet with patients, families, and care 
teams. Each VA liaison facilitates national referrals throughout the VA 
system as indicated for mental health or other needs, but also provides 
group briefings about VA programs and services, and individual 
consultations to learn more about each patient's needs. In November 
2018, that MOA was renewed with a growing commitment from VA - VA has 
created full-time billets for liaisons at each AMC to enhance their 
contribution to the partnership. All told, this first-of-its-kind 
collaboration with VA is critical for safe patient care and enables 
successful discharge planning. At WWP, we believe cooperation and 
coordination like this can serve as a great example of ``responsible 
choice'' in the VA health care system.

Measuring Results:

    Warriors who complete the Warrior Care Network program are seeing 
results. Prior to treatment, over 83 percent of patients reported PTSD 
symptoms at the severe to moderate range based on the PCL-5 clinical 
assessment, with the aggregate average being 51.1 (severe PTSD). 
Following treatment in the intensive outpatient programs, PTSD symptoms 
decreased 19.4 points to 31.7 (minimal PTSD) \1\. A similar pattern was 
seen for symptoms of depression, with a mean score of 16.0 at intake 
and a decrease to 10.2 at follow-up on the PHQ-9 assessment. These 
changes translate into increased functioning and participation in life, 
based on the decrease of psychological distress caused by severe to 
moderate levels of PTSD and depression.
---------------------------------------------------------------------------
    \1\ Note: A change in score greater than 5 is indicative of 
clinically significant change rather than statistical change.
---------------------------------------------------------------------------
    It is also worth noting that, although effective if completed, many 
who begin evidence-based mental health treatment (cognitive processing 
therapy and prolonged exposure) in non-intensive outpatient (IOP) 
formats - including highly controlled and selective clinical trials \2\ 
- discontinue care before completion. While drop-out rates in those 
formats are between 30 and 40 percent \3\, the IOP model used by 
Warrior Care Network has a completion rate of 94 percent. When combined 
with clinically significant decreases in mental health symptoms, this 
figure is illustrative of the successful approach the Warrior Care 
Network has taken - and patients agree. Ninety-six percent (96.3 
percent) of warriors reported satisfaction with clinical care received, 
and 94 percent of warriors indicate they would tell another veteran 
about WCN, a possible indication of reduced mental health stigma.
---------------------------------------------------------------------------
    \2\ Imel, Z., Laska, K., Jakcupcak, M., Simpson, T. (2013). Meta-
analysis of Dropout in Treatments for Post-traumatic Stress Disorder. 
Journal of Consulting and Clinical Psychology, 81(3), 394-404.
    \3\ Kehle-Forbes, S., Meis, L., Spoont, M., Polusny, M. (2015). 
Treatment Initiation and Dropout From Prolonged Exposure and Cognitive 
Processing Therapy in a VA Outpatient Clinic. Psychological Trauma: 
Theory, Research, Practice, and Policy, 8(1), 107-14.; Gutner, C., 
Gallagher, M., Baker, A., Sloan, D., Resick, P. (2015). Time Course of 
Treatment Dropout in Cognitive-Behavioral Therapies for Posttraumatic 
Stress Disorder. Psychological Trauma: Theory, Research, Practice, and 
Policy, 8(1), 115-21.
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    Lastly, and perhaps most important to the discussion on suicide 
prevention, a recent study of veterans at risk for suicide \4\ 
evaluated the link between PTSD symptoms and suicidal ideation (SI) by 
using evidence-based treatments, specifically Prolonged Exposure 
therapy (an approach embraced and used at Warrior Care Network AMCs), 
to reduce PTSD symptoms and monitor subsequent changes in SI. The study 
indicated that a reduction in PTSD symptoms led to reduced SI among 
patients although the reduction followed the PTSD symptom reduction and 
did not occur simultaneously. Thus, reduced PTSD symptoms were 
predictive of later reduced SI among patients. Researchers also 
hypothesize that this correlation between PTSD symptoms and SI could be 
the result of a reduction in generalized distress. The study concluded 
that inclusion of evidence-based treatments in PTSD treatment are 
advisable to both reduce PTSD symptoms and prevent suicide.
---------------------------------------------------------------------------
    \4\ Keith S. Cox, et. al., Reducing Suicidal Ideation Through 
Evidence-Based Treatment for Posttraumatic Stress Disorder, 80 J. 
PSYCHIATRIC RES. 59, 59-62 (2016).

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Project Odyssey

    Aside from clinical treatment, warriors may also need additional 
resources to improve resilience and cope with PTSD. WWP provides 
Project Odyssey, a 90-day program consisting of a multi-day adventure-
based mental health workshop that helps warriors find resiliency in 
their transition from military to civilian life and continued follow-up 
over the weeks thereafter to build upon the lessons learned at the 
workshop. This non-clinical intervention takes place in locations 
across the country. Each workshop includes psychoeducational activities 
or evidence-based exercises that provide information and support to 
those who live with mental health issues. Project Odyssey has both 
warrior specific (male and female exclusive cohorts) and warrior/
partner programming (i.e., Couples Project Odyssey). Each warrior 
cohort learns how to accept and process emotions in a productive way to 
build resiliency instead of avoidance and control techniques. Couples 
Project Odyssey focuses on friendship as the core of any relationship, 
with trust and commitment as the main support. Being able to better the 
relationship as a couple allows for a built-in accountability partner 
to better the individual in terms of bouncing back from life's 
challenges.
    Project Odyssey provides specific coping mechanisms that can be 
practiced in daily life as stressors return. Prior to the end of the 
workshop, each participant establishes SMART goals - an acronym for 
specific, measurable, attainable, relevant, and timebound - which are 
set with the intention of supporting the individual or couple while 
they implement the resiliency skills learned into their daily routines. 
WWP works directly with the participants through a 90-day follow-up 
program to help them achieve their goals, connecting them with 
additional resources as needed. A common resource WWP provides is a 
referral for outpatient therapy so that the warrior or family member 
can continue building their coping skills. WWP has external partners 
that provide individual, family, or couples therapy delivered by a 
culturally competent therapist in the closest possible geographic 
location.

Measuring Results:

    One crucial goal of Project Odyssey is to increase resiliency. 
Increased levels of resiliency may help in a warrior's psychological 
hardiness and in his or her ability to navigate future challenges that 
may cause psychological distress. When warriors successfully cope with 
stressors, it empowers them and may serve to lessen current and future 
distress. WWP uses the 10-item version of the Connor-Davidson 
Resilience Scale (CD-RISC) to assess resilience as one measure to 
determine the impact of programming. Over the last several years we 
have had over 10,000 participants in our Project Odyssey program with 
almost 3,000 in this year alone. We conducted an internal review of 
over 2,000 participants and found that after attending Project Odyssey, 
both warriors (t(2,293)=-9.62, p<.001) and family members (t(500)=-
3.46, p<.001) on average experienced statistically significant 
increased levels of resilience. Moreover, 92 percent of warriors and 
family members rated the resiliency skills learned as very useful and 
83 percent said the skills were still useful 90 days after completing 
the Project Odyssey.
    In addition, preliminary analysis of PTSD symptoms (i.e., PCL-5) 
seem to indicate that Project Odyssey, a non-clinical intervention, is 
having clinical results in lowering the severity of PTSD symptoms. Our 
goal is to further analyze this data to confirm these initial findings 
and statistically covary potential influential variables.
    POLICY CONSIDERATION - Embrace innovation in care delivery and 
payments: Section 152 of the MISSION Act authorized - and VA has since 
established - a Center for Innovation for Care and Payment to develop 
new, innovative approaches to testing payment and service delivery 
models to reduce expenditures while preserving or enhancing the quality 
of and access to care furnished by VA. As the steward of taxpayer 
dollars dedicated to the health and well-being of veterans, Congress 
has a vested interest in tracking the developments of this center and 
encouraging action and partnership with the private sector on 
successful, scalable models of both care and payment.
    POLICY CONSIDERATION - Increase studies of Vietnam Era veterans: 
According to VA data from 2015, rates of suicide were highest among 
younger veterans (ages 18 to 34) and lowest among older veterans (ages 
55 and older). However, 58.1 percent of all veteran suicides in 2015 
were among older veterans. While Congress should strive to reduce 
suicide rates and volume among all veteran demographics, it should 
consider directing more research on Vietnam Era veterans to gain a 
clearer understanding of the underlying psycho-social and biological 
challenges that tend to be exacerbated with age. Scientific studies may 
provide valuable insight into issues that are plaguing older veterans. 
That insight may also provide greater awareness into an aging 
population of Operation Enduring Freedom (OEF) and Operation Iraqi 
Freedom (OIF) veterans so that essential, time-sensitive resources can 
be better focused as younger veterans - both current and future - begin 
to age.

Multidisciplinary Strategies

    Lastly, the public health model advocates for multidisciplinary 
collaboration, convening many different disciplines across multiple 
sectors. While WWP's top programmatic spend was on direct mental health 
programs, other programming investments are delivering results along 
similar lines.
    Research has long found that mental health and physical health tend 
to be intertwined to form a wholistic index of health. At WWP, the 
Physical Health & Wellness (PH&W) team promotes the notion that by 
enhancing the physical health of warriors, mental health tends to also 
be improved. The PH&W program targets at-risk warriors in the 
categories of obesity, impaired mobility, and poor nutritional quality. 
A host of complementary issues often accompany warriors entering the 
program: substance abuse, sleep disruption, low self-esteem, 
depression, and an elevated risk for diabetes, heart disease, cancer, 
and all-cause mortality.
    The team's coaching program begins with a multi-day onsite 
experience, educating participants in the practices of bodyweight 
resistance training, high-quality nutrition, recovery strategies, 
bettering the sleep environment, a mobility assessment, and SMART 
(Specific, Measurable, Achievable, Relevant, and Time-bound) goal 
setting. Participants are then followed for 90-days, interacting with 
their coach bi-weekly, maintaining accountability and adherence to 
their self-determined goals.
    There is a recognition that the veteran does not achieve success 
alone. The family and community play a role in behavior modification 
and ongoing mechanisms of motivation and support. Pilot programs 
continue to run, assessing the impact on the inclusion of the family 
member throughout the coaching process. Community resources are 
leveraged to provide warriors with fitness, nutrition, and mindfulness-
related outlets within their home area. For instance, WWP has recently 
been collaborating with VA's Whole Health office by providing a 
platform for VA to present its initiative to warriors attending the 
multi-day PH&W coaching program. As warriors become familiar with VA 
resources and the agency's holistic approach to wellness, we are 
helping raise awareness for a program spotlighted in the Joint Action 
Plan promulgated after the January 9, 2018 Executive Order addressing 
mental health and suicide prevention for separating and recently 
separated service members - and one which we hope will attract more 
veterans to the VA health system.
    Testing outcomes pre- and post-program, 50% of warriors demonstrate 
improvements in physical and psychological wellbeing (VR-12 Quality of 
Life), lose an average of 11 pounds, 50% meet the physical standard for 
weekly activity (150 minutes of moderate intensity work), 54% 
experience improved nutritional quality, while the great majority 
achieve better mobility, sleep quality, self-esteem, mood, and the 
symptoms of stress, anxiety, and depression. The evidence is clear - a 
continued-care and physically-focused approach dramatically improves 
mental health outcomes.
    A final point of consideration is the crossover between mental 
health and preparation for separation from service. The transition 
between the military and civilian culture can be stressful, as warriors 
are forced to change roles and how they self-identify. The resulting 
acculturation or transition stress may be an integral time to target 
interventions with warriors; however, transition is not often a time 
when service members are thinking about their long-term mental and 
physical health. As transitioning warriors are focused on their 
departure, their career prospects, and opportunities for post-service 
education, community stakeholders should be more educated on the 
resources available to veterans that talk about the importance of 
engagement, camaraderie, counseling, and physical activity as a 
protective factor - in essence, reaching them before they are in active 
crisis.
    POLICY CONSIDERATION - Pursue postvention programming with family 
members: While VA is appropriately dedicating considerable resources to 
veteran-centric pursuits to reduce suicide, much can be gleaned from 
working with survivors to identify better approaches to identifying 
warning signs and empowering families to intervene effectively. A 
partnership WWP helps fund between Massachusetts General Hospital and 
the Tragedy Assistance Program for Survivors (TAPS) that created a 2-
week intensive clinical program for traumatized families of the fallen 
and helped develop an after-care network that is saving lives by 
raising awareness about suicides among veterans and active duty service 
members. \5\
---------------------------------------------------------------------------
    \5\ Brian McQuarrie, I Couldn't Be the Only One Having this 
Experience, BOSTON GLOBE (Feb. 23, 2019) available at https://
www.bostonglobe.com/metro/2019/02/22/couldn-only-one-having-this-
experience/Mx8wUfUEVV2RaSgvPsQ9eM/story.html.
---------------------------------------------------------------------------
    POLICY CONSIDERATION - Maintain focus on improving military 
transitions: As highlighted by DoD's Defense Suicide Prevention Office, 
service members transitioning out of DoD are at a higher risk of 
suicide within the first 90 days of separation - a trend consistent 
over a 14-year period. Over that period, approximately 50 percent of 
suicide deaths occurring in the first three months of separation 
happened within the first 17 days of separation. As Congress continues 
to work with the executive branch to improve and monitor military-to-
civilian transition, WWP encourages the committees to review The 
Veterans Metric Initiative (TVMI) study commissioned by the Henry 
Jackson Foundation - and funded, in part, by WWP - which focuses on 
post-military well-being. The TVMI study's findings regarding vocation, 
finances, health, and social relationships may provide compelling 
evidence to guide future initiatives.

Conclusion

    Wounded Warrior Project thanks the House Committee on Veterans' 
Affairs, its distinguished members, and all who have contributed to the 
policy discussions surrounding today's discussion about veteran 
suicide. We share a sacred obligation to serve our nation's veterans, 
and Wounded Warrior Project appreciates the Committee's effort to 
identify and address the issues that challenge our ability to carry out 
that obligation as effectively as possible. We are thankful for the 
invitation to submit this statement for record and stand ready to 
assist when needed on these issues and any others that may arise.

                                 
                   Center For Diseasse Control (CDC)
    Written statement on behalf of the Centers for Disease Control and 
Prevention

    Thank you to the Committee for the opportunity to discuss suicide 
prevention in the United States, the federal response, and the Centers 
for Disease Control and Prevention (CDC)'s role. The Trump 
administration has made addressing Veteran suicide a top priority which 
was emphasized by the issuance of an executive order on March 5th to 
empower Veterans and end a national tragedy of suicide. As directed in 
the executive order, the Department of Health and Human Services (HHS) 
will join a federal task force charged with developing a comprehensive 
public health approach to better understand the underlying factors of 
suicide and the tools needed to empower Veteran communities and provide 
needed services.
    CDC shares the Administration's commitment to preventing suicide, 
which is exacting a toll on individuals, families, and communities 
across the country. As the Nation's public health agency, CDC is 
uniquely poised to help prevent suicide amongst all populations 
especially those most at risk, including Veterans and active duty 
personnel. The latest data tell us that approximately 47,000 people 
died by suicide in 2017 \1\ (an increase of 33 percent since 1999), 
which includes roughly 6,500 Veterans and active duty service members 
\2\. There is no single determining cause. Instead, suicide occurs in 
response to multiple biological, psychological, interpersonal, 
environmental and social influences that interact with one another, 
often over time. In the first ever Vital Signs report CDC published on 
suicide, CDC reported that more than half of people who died by suicide 
did not have a known diagnosed mental health condition \3\. Many of 
these deaths were preceded by economic losses, relationship issues, 
substance misuse, physical health problems, and housing stress. This 
underscores the importance of strategically including a focus outside 
of the realm of mental health to help prevent suicide. Successful 
suicide prevention requires a coordinated approach that engages 
multiple sectors, including public health. CDC's unique role is to lead 
the Nation's prevention efforts by reducing factors that contribute to 
suicide and suicidal behavior and by using data to inform action.
---------------------------------------------------------------------------
    \1\ Hedegaard H, Curtin SC, Warner M. Suicide mortality in the 
United States, 1999-2017. NCHS Data Brief, no 330. Hyattsville, MD: 
National Center for Health Statistics. 2018.
    \2\ Department of Veterans Affairs, Veterans Health Administration, 
Office of Mental Health and Suicide Prevention. Veteran Suicide Data 
Report, 2005-2016. September 2018 and Department of Defense, Defense 
Suicide Prevention Office. Quarterly Suicide Report, 4th Quarter, 
CY2017, October 2017.
    \3\ Stone DM, Simon TR, Fowler KA, et al. Vital Signs: Trends in 
State Suicide Rates - United States, 1999-2016 and Circumstances 
Contributing to Suicide - 27 States, 2015. MMWR Morb Mortal Wkly Rep 
2018;67:617-624.
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    CDC assists states and communities in tracking and monitoring 
suicide injuries and deaths and identifying factors that may have 
contributed to suicides; this tracking is done through the National 
Violent Death Reporting System (NVDRS). NVDRS is the only state-based 
surveillance system that pools information from multiple data sources 
into a usable, anonymous database. This unique system combines multiple 
types of data including medical examiner reports, coroner reports, law 
enforcement notes, and vital statistics records. It allows CDC to 
better understand the individual circumstances surrounding a death, and 
helps to determine how it could have been prevented. With the increase 
in appropriations in fiscal year (FY) 2018, CDC was able to expand this 
system to all 50 states, Washington DC, and Puerto Rico. This recent 
expansion will allow CDC, states, and communities to better understand 
the characteristics of violent deaths and inform prevention strategies.
    In the past, CDC worked with the Department of Defense (DoD) to 
link NVDRS data to Department of Defense Suicide Event Reports (DoDSER) 
among active duty Army personnel. This linkage allowed scientists from 
the DoD and CDC to see more comprehensive details on suicide incidents 
than one system alone could provide. This was one of the earliest 
studies to provide evidence on how the combination of health, 
relationship, and environmental related risk factors can precipitate 
suicide in the military. In addition, CDC used NVDRS data to map the 
military and Veteran suicide deaths by U.S. county to show which 
counties shoulder the greatest burden. Currently, CDC is working with 
both the DoD and the Department of Veterans Affairs (VA) to expand this 
project to help agencies not only identify where suicides for each 
population are concentrated but also the service gaps in the high 
burden locales.
    Also, Colorado conducted an analysis of their VDRS data to better 
understand suicide deaths among first responders, categorized as 
traditional fire, EMS, and police/law enforcement occupations, as well 
as security, corrections, and dispatchers (related to emergency 
service). Colorado's VDRS data showed that suicide victims who were 
first responders were more likely to have been Veterans, compared to 
the general population of suicide victims in their state. These 
findings helped Colorado direct their outreach services, and led them 
to enhance an online suicide prevention program for men and to promote 
resources focused on positive mental and physical health for first 
responders, active military personnel, Veterans, and their families.
    In addition, CDC recognizes a need to provide near real-time data 
on suicide-related behavior, or suicide attempts. These data can enable 
states and communities to respond more quickly to changes in trends or 
suicide methods and deliver prevention and intervention resources where 
they're needed.
    Being able to plan for a surge capacity response, for example, in 
the wake of high profile suicides can help save lives. To that end, CDC 
will begin piloting the use of emergency department data from the 
National Syndromic Surveillance Program to collect data on suicide risk 
behavior in near real-time. This system will allow CDC, states, and 
communities understand what is happening in the community to determine 
if there is an increase in suicides or a suicide cluster so the 
community can respond quickly.
    Many states and communities want to do more to prevent suicide and 
look to CDC expertise and leadership for assistance. In the last year, 
CDC has been asked by multiple states to provide epidemiologic 
assistance or Epi-Aids to respond to suicide clusters. Epi-Aids are 
investigations of an urgent public health problem in which CDC provides 
a rapid, short-term, onsite examination of data in order to determine 
the best action to prevent and control the problem. For example, in 
2018 Stark County and Ohio state health officials requested a CDC Epi-
Aid to guide immediate programmatic action to prevent suicide, 
following an uptick of youth suicide in the area. A survey on 
connectedness, social media, mental health, suicidal ideation, and 
resiliency was administered to over 15,000 students in 7th-12th grade. 
Over half of the students experienced loneliness and 25 percent of the 
students experienced 3 or more adverse childhood experiences (ACEs), 
including verbal and emotional abuse, depression, and substance use in 
the home. Eighty percent of youth who had 3 or more ACEs and used 
opioids disclosed suicidal ideation. Based on key findings across data 
sources, CDC provided Stark County with a number of recommendations 
including increasing access to health and psychological care for youth, 
training community members to identify people at risk, collaborating 
with local news sources to promote safe suicide reporting, and 
regularly assessing the wellbeing of students through ongoing surveys. 
The Stark County community will use these recommendations to guide 
future prevention strategies and direct resources to areas of greatest 
need.
    One of the strongest tools CDC has released to help states and 
communities take advantage of the best available evidence to prevent 
suicide is Preventing Suicide: A Technical Package of Policy Programs, 
and Practice. The technical package includes seven strategies focused 
on preventing the risk of suicide in the first place as well as 
approaches to lessen the immediate and long-term harms of suicidal 
behavior for individuals, families, communities, and society. The seven 
strategies are:

      Strengthening economic supports
      Strengthening access and delivery of suicide care
      Creating protective environments
      Promoting connectedness
      Teaching coping and problem-solving skills
      Identifying and supporting people at risk
      Lessening harms and preventing future risk

    In 2018, as part of the Governor's Challenge, seven states 
(Arizona, Colorado, Kansas, Montana, New Hampshire, Texas, and 
Virginia) convened to develop an implementation plan for the National 
Strategy for Preventing Veteran Suicide, utilizing the evidence-based 
CDC Preventing Suicide technical package strategies. In addition, since 
2009, The Arizona Coalition for Military Families public/private 
partnership has utilized evidence-based strategies from the technical 
package to leverage existing resources in a sustainable effort to 
address active military service members, Veterans, and their families 
to prevent suicide through capacity-building, outreach, increased 
connectedness and support among Arizona communities and all branches of 
military service.
    One critical need in the area of Veteran suicide prevention is to 
help Veterans at risk for suicide who are not accessing or using 
Veterans Health Administration (VHA) services. An estimated 20 Veterans 
die by suicide each day on average. Of those 20, approximately 14 of 
them were not using VHA services \4\. CDC has been applying a Veteran-
centered approach along with a public health lens to better understand 
how to reach young Veterans not accessing VHA services. This project 
also helped to gain insights from the Veterans' perspectives on how to 
prevent suicide among this population as they are transitioning out of 
military service. Through that effort, CDC gathered insights directly 
from Veterans in six different, highly affected communities across the 
United States (Columbus, Ohio; Houston, Texas; Raleigh, North Carolina; 
Denver, Colorado; Colorado Springs, Colorado; Atlanta, Georgia). This 
deep level of engagement with Veterans and their communities helped CDC 
gain additional ideas for how public health might play a unique and 
complementary role in Veteran suicide prevention. CDC is testing out 
one of those new ideas by funding an evaluation demonstration project 
among Veteran-serving organizations. Specifically, CDC is partnering 
with the CDC Foundation to directly fund five Veteran-serving 
organizations that are implementing programs that align with an 
upstream suicide prevention approach-including America's Warrior 
Partnership, Arizona Coalition of Military Families, The Mission 
Continues, The Warrior Alliance, and Stack Up. CDC is providing 
resources and technical assistance to build these organizations' 
evaluation capacity and their ability to measure the impact of their 
programs. Ultimately, this project is contributing to an increased 
understanding of what works to prevent Veteran suicide at the 
community-level.
---------------------------------------------------------------------------
    \4\ U.S. Department of Veterans Affairs, Office of Suicide 
Prevention. Suicide among Veterans and other Americans 2001-2014. 
Viewed March 23, 2017 at https://www.mentalhealth.va.gov/docs/
2016suicidedatareport.pdf. 2016.
---------------------------------------------------------------------------
    We know that suicide is preventable; therefore, a comprehensive 
public health approach is needed to reduce suicides. The National 
Center for Injury Prevention and Control (NCIPC) at CDC has prioritized 
this important public health issue. CDC brings a unique and important 
perspective to suicide prevention by tracking and monitoring suicide 
trends, identifying risk and protective factors, and evaluating suicide 
prevention programs, policies, and practices to determine impact. With 
CDC's help, states and communities can support people at risk of 
suicide; teach coping and problem-solving skills to help people manage 
challenges with their relationships, jobs, health, or other concerns; 
promote safe and supportive environments at the workplace and at home; 
and lessen harms and prevent future risk. CDC is committed to 
identifying the best evidence and partnering with other federal 
agencies and organizations to limit the devastation communities feel 
and ultimately, save lives.

                                 
          Veterans Of Foreign Wars Of The United States (VFW)
    CARLOS FUENTES, DIRECTOR
    NATIONAL LEGISLATIVE SERVICE

    Chairman Takano, Ranking Member Roe, and members of the committee, 
on behalf of the men and women of the Veterans of Foreign Wars of the 
United States (VFW) and its Auxiliary, thank you for the opportunity to 
provide recommendations on suicide prevention.
    Eliminating suicide among our nation's veterans continues to be a 
top priority for the VFW. The most recent analysis of veteran suicide 
data from 2016 found suicide has remained fairly consistent within the 
veteran community in recent years. An average of 20 veterans and 
service members die by suicide every day. While this number must be 
reduced to zero, it is worth noting that the number of veterans who die 
by suicide has remained consistent in recent years, while non-veteran 
suicides have continued to increase.
    Congress must ensure sufficient resources are available and used 
for effective Department of Veterans Affairs (VA) suicide prevention 
efforts, including to identify veterans at increased risk of suicide, 
adopt new interventions, and effectively treat those with previous 
suicide attempts. Programs such as the Veterans Crisis Line, the 
placement of suicide prevention coordinators at all VA medical centers 
and large outpatient facilities, integration of behavioral health into 
primary care, and joint campaigns between the Department of Defense and 
VA must continue to be improved and expanded. The VFW also supports the 
recent executive order to establish the Veteran Wellness, Empowerment, 
and Suicide Prevention Task Force to coordinate suicide prevention 
efforts at the national and local levels, and expanding efforts with 
community partners like the VFW.
    The Government Accountability Office has identified several key 
barriers that deter veterans from seeking mental health care. These 
include stigma, lack of understanding or awareness of the potential for 
improvement, lack of child care or transportation, and work or family 
commitments. Early intervention and timely access to mental health care 
can greatly improve quality of life, promote recovery, prevent suicide, 
obviate long-term health consequences, and minimize the disabling 
effects of mental illness.
    The VFW is proud to have partnered with VA, and community and 
corporate partners to raise awareness of mental health conditions, 
foster community engagement, improve research and provide intervention 
for those affected by invisible injuries and emotional stress through 
the VFW Mental Wellness Campaign. Since Fall 2016, nearly 300 VFW posts 
around the world and 13,000 volunteers have successfully reached 25,000 
people in the past three ``Day to Change Direction'' events, hosted in 
partnership with Give an Hour's Campaign to Change Direction.
    The focus of the VFW's Mental Wellness Campaign is to teach 
veterans and caregivers how to identify when they or their loved ones 
are experiencing the signs of emotional suffering--personality change, 
agitation, being withdrawn, poor self-care, and hopelessness. In an 
effort to destigmatize mental health, participants are informed that 
mental health conditions such as post-traumatic stress disorder (PTSD) 
are common reactions to abnormal experiences.
    The goal is to also reduce the number of veterans who die by 
suicide each day without having made contact with VA health care 
services. Research indicates that veterans who do not use VA for their 
health care are at an increased risk of suicide. This comes as no 
surprise to the VFW, as our members have continuously informed us that 
they prefer VA health care because of the high-quality and veteran-
centric care VA provides. To better assist all veterans, veterans 
service organizations, VA, and Congress must know more about the two-
thirds of veterans who die by suicide each day without any contact with 
VA. The VFW urges VA to analyze the demographics, illnesses, 
socioeconomic status, and military discharges of the 14 veterans and 
service members who die by suicide every day and do not use VA health 
care. There are questions that need to be answered in order to properly 
address this epidemic. Did those 14 use private sector care- Were they 
eligible to use VA- Were they among the many who were discharged 
without due process for untreated or undiagnosed mental health 
disorders- Were they discharged for unjust and undiagnosed personality 
disorders due to transgenderism or during the era of ``Don't Ask, Don't 
Tell- Have they used other VA benefits such as the GI Bill-
    However, VA must stand ready to assist veterans who take the bold 
step of seeking assistance when they are suffering from suicidal 
ideation. Over the past decade, the VA Office of Mental Health Services 
has developed a comprehensive set of services to treat the 
approximately 1.7 million veterans who received VA mental health 
services in fiscal year (FY) 2018, which is a significant increase from 
the 927,000 veterans who received such care in FY 2006. Since 2016, VA 
has strived to provide same day access to veterans who need urgent and 
emergent health care. While this and other suicide prevention 
initiatives have resulted in VA saving the lives of veterans in crisis, 
it must do more to ensure veterans who need help receive it.
    It is unconscionable for veterans who experiencing mental health 
care crises to be turned away. For example, the VFW was informed of a 
veteran who presented to a VA mental health clinic with suicidal 
thoughts and asked to be seen immediately because she feared she would 
take her own life. The front desk clerk informed her that she could not 
be seen immediately because she had just completed a mental health care 
appointment the previous day and the next available appointment was in 
a week. Luckily, the veteran was able to cope with her crisis without 
VA assistance, and is alive and well.
    Too many veterans have died because VA has turned them away in 
their time of need or failed to identify the seriousness of their 
health conditions. For example, it is unacceptable for a veteran who is 
in a VA waiting room to complete suicide without someone noticing the 
veteran needed immediate assistance. VFW commends VA for looking into 
ways to protect its employees and patients at VA medical facilities. 
However, enhanced safety procedures at VA medical facilities will not 
address the underlying problem. VA employees have become desensitized 
to veterans with mental health concerns. I have personally witnessed a 
VA employee disregard a veteran as ``just another crazy veteran.'' Such 
mentality must stop. VA must train its employees to identify and assist 
veterans in crisis. VA must also encourage its employees to take action 
when they identify a veteran in crisis, without fear of reprisal.
    Another reason VA is required to turn veterans away is eligibility 
for VA health care. The VFW lauds Congress and VA for recent action to 
expand VA mental health care services to recently discharged veterans 
and veterans with Other Than Honorable discharges. VA also has the 
ability to treat any veteran who is not eligible for VA care through 
its humanitarian care authority under section 1784 of title 38, United 
States Code (U.S.C.). However, VA is required to charge veterans the 
full cost of urgent or emergent mental health care. It is 
understandable for VA to bill other health insurance for such care, but 
VA must not be required to place an undue burden on veterans who have 
survived a mental health crisis, particularly because financial 
instability is often a contributing factor to mental health crises.
    The VFW is working with a veteran who was rushed to a VA hospital 
during a mental health crisis caused by untreated bipolar disorder and 
depression. The veteran was admitted to the medical center's inpatient 
mental health care clinic for two weeks, despite not being eligible for 
VA health care. VA saved his life, but now he has a $20,000 bill. His 
mental health crisis was exacerbated by unemployment and his inability 
to provide for his family. With proper treatment he has been able to 
return to work, but still lacks the resources to pay the VA bill. The 
VFW is working on having his bill waived, but he will never return to 
VA if he has another mental health crisis.
    The fear of being turned down or billed for care should never 
prevent a veteran from seeking the urgent or emergent VA mental health 
care they need. Congress must amend section 1784 of title 38, U.S.C., 
to exempt those who have worn our nation's uniform who receive urgent 
or emergent mental health care under VA's humanitarian care authority 
from having to pay the full cost of such care.
    The Office of Inspector General (OIG) report determining Veterans 
Health Administration (VHA) staffing shortages continues to list 
psychiatry clinics as having the most need, with the fourth being 
psychology. Out of 141 facilities surveyed, 98 had a shortage for 
psychiatrists and 58 had a shortage for psychologists. By not 
adequately staffing VA, the capacity to serve veterans and provide the 
necessary access to mental health care needed by so many veterans will 
continue to be limited. With the entire nation experiencing a critical 
shortage of mental health providers, such need cannot be sufficiently 
addressed by simply increasing use of community care. VA must utilize 
the tools it was given by the VA MISSION Act to hire more providers 
with enhanced recruitment and retention incentives, train more mental 
health providers with increased Graduate Medical Education 
opportunities, and maximize its current capacity with its anywhere to 
anywhere authority.
    The VFW is proud to be part of the solution. Through Project 
Advancing Telehealth through Local Access Stations (ATLAS), the VFW has 
worked with VA and Philips to leverage VA's anywhere to anywhere 
authority to expand telehealth options for veterans who live in rural 
areas. In this partnership, VA has identified highly rural areas where 
veterans must travel far distances to receive VA health care. The VFW 
identifies posts in those areas to serve as access points for VA health 
care. Once the post is modified to VA's specifications, it is equipped 
with Philips-donated telehealth technology to provide veterans access 
to VA health care at a convenient veteran-centric location. More than 
20 VFW posts have been identified as possible telehealth centers. The 
primary use for the first Project ATLAS site in Eureka, Montana, will 
be for mental health care. Veterans in Eureka are required to travel 
more than 70 miles to the nearest VA clinic for mental health care. 
Soon they will have the ability to receive VA health care closer to 
home.
    VA is making concerted efforts to ensure it appropriately uses 
pharmaceutical treatments when providing mental health care. Under the 
Opioid Safety Initiative, VA has reduced the number of patients to whom 
it prescribes opioids by more than 22 percent. Prescribed use of 
opioids for chronic pain management has unfortunately led to addiction 
to these drugs for many veterans, as well as for many other Americans. 
VA uses evidence-based clinical guidelines to manage pharmacological 
treatment of PTSD and SUD to ensure better health outcomes. However, 
many veterans report being abruptly taken off opioids they have relied 
on for years to cope with their pain management, without receiving a 
proper treatment plan to transition them to alternative therapies. 
Doing so leads veterans to seek alternatives outside of VA or to self-
medicate. VA must continue to expand research of non-traditional 
medical treatments, such as medical cannabis and other holistic 
approaches, for mental health care conditions.
    In the past several years PTSD and traumatic brain injury (TBI) 
have been thrust into the forefront of the medical community and the 
general public in large part due to suicides and overmedication of 
veterans. Medical cannabis is currently legal in 33 states and the 
District of Columbia. This means veterans are able to legally obtain 
cannabis for medical purposes in more than half the country. For 
veterans who use medical cannabis and are also VA patients, they are 
doing this without the medical understanding or proper guidance from 
their coordinators of care at VA. This is not to say VA providers are 
opting to ignore this medical treatment, but that there is currently a 
lack of federal research and understanding of how medical marijuana may 
or may not treat certain illnesses and injuries, and the way it 
interacts with other drugs.
    This is regardless of the fact that many states have conducted 
research for mental health, chronic pain, and oncology at the state 
level. States that have legalized medical cannabis have also seen a 15-
35 percent decrease in opioid overdose and abuse. There is currently 
substantial evidence from a comprehensive study by the National Academy 
of Sciences and the National Academic Press that concludes cannabinoids 
are effective for treating chronic pain, chemotherapy-induced nausea 
and vomiting, sleep disturbances related to obstructive sleep apnea, 
multiple sclerosis spasticity symptoms, and fibromyalgia--all of which 
are prevalent in the veteran population.
    The VFW urges Congress to pass legislation to require VA to conduct 
a federally funded study with veteran participants for medical 
cannabis. This study should include participants who have been 
diagnosed with PTSD, chronic pain, and oncology issues.
    The VFW has also long advocated for the expansion of VA's peer 
support specialists program. VA peer support specialists are healthy 
and recovered individuals with mental health or co-occurring conditions 
who are trained and certified by VA standards to help other veterans 
with similar conditions and/or life situations. Veterans who obtain 
assistance from peer support specialists continuously sing their high 
praises. Peer-to-peer programs are also critically important for 
minorities, LGBT and women, or any group within the veteran community 
that is ostracized or misunderstood. This is instrumental in helping 
veterans avoid loneliness, which can lead to suicidality.
    Aside from veterans receiving support from fellow veterans who have 
recovered from similar health conditions, and experiencing the bond and 
trust veterans share, peer support specialists also greatly assist in 
destigmatizing mental health conditions such as PTSD. For a veteran to 
become a peer support specialist, they must have actively gone through 
treatment, and be living a relatively healthy lifestyle. This allows 
veterans who may be struggling to see that their condition is 
treatable, manageable, and not something that has to negatively impact 
or control their lives.

                                 
                          The Independent Fund
    Thank you for the opportunity to provide this testimony to the 
Committee on Suicide Prevention.

Operation RESILIENCY

    The Independence Fund recently embarked on one of the most 
ambitious suicide prevention programs, in partnership with the VA. 
Called, ``Operation RESILIENCY'', this program brings together tactical 
combat units who suffered high casualty rates during those deployments, 
and then suffered high suicide rates upon redeployment. The concept is 
to bring the company or battalion sized units together in reunion 
retreats, build upon the strong unit cohesion borne of battle, and 
leverage that cohesion to renew a sense of belonging amongst the 
military veterans, as well as to build accountability amongst the unit 
members.

Inaugural Retreat

    The Independence Fund recently hosted the first of these retreats 
April 4-7, 2019, in Charlotte, NC, with members of Bravo Company, 2nd 
Battalion, 508th Parachute Infantry Regiment (B Co., 2/508 PIR), from 
their 2009-2010 combat deployment to Afghanistan. Of the 115 surviving 
members of the Company, 95 participated, some of them still active duty 
or reserve component, but most discharged or retired veterans. This 
unit suffered more than a 50% Purple Heart award rate, lost two members 
Killed in Action, and dozens Wounded in Action. Equally troubling, 
since that deployment, of the approximately 300 members of the 
Battalion, six members died from suicide.
    During this four-day reunion, while members of B Co. enjoyed unit 
building activities such as white- water rafting, Top Golf outings, 
unit physical training, and bonfires, they also participated in 
clinical group and individual therapy sessions facilitated by mental 
health professionals from the VA's Office of Suicide Prevention, and 
led by Dr. Keita Franklin. The clinical therapy sessions focused on 
connectiveness and reigniting the bonds these Paratroopers have. On the 
final day, after more unit physical training, a Resource Fair was held 
with representatives from local Congressional offices, Veteran and 
Military Service Organizations, mental health providers, and various 
Veterans Benefits Administration, Veterans Health Administration, and 
other federal government agencies, as well as local governments, to 
provide a ``whole of society'' approach to addressing the panoply of 
contributors to veteran behavioral health and suicide prevention.
    In addition to the representatives of the VA's Suicide Prevention 
Office, local VA medical facility and VISN officials, as well as 
representatives of various benefits offices, participated in the 
weekend.
    Members of the North Carolina Congressional delegation, the Afghan 
Ambassador to the United States, and VA and Independence Fund officials 
all participated in various programs with the unit members.

Post Reunion Retreat Engagement

    Together with the VA, the participants of the retreat complete a VA 
designed pre-retreat, post-retreat, and 30-day follow-on post-retreat 
survey, a copy of which is attached. This survey is used to measure 
individual changes in participants' individual Resilience Score, using 
the Connor-Davidson Resiliency Scale (CD-RISC). The VA conducts these 
surveys and collects this data as this program is a pilot program for 
the VA, in large part to determine the efficacy of this approach in 
improving individual resilience.
    Furthermore, the VA is conducting follow-on engagement calls for 
all participants, with the initial contact completed by May 3, 2019. 
The participants will also receive a post-retreat survey via e-mail by 
May 8, 2019, as well as additional follow-on calls at 60- and 90-day 
points after the retreat, and at six and 12 months. The calls will be 
used to determine if the participants connected to resources identified 
during the retreat weekend, and if The Independence Fund and the VA can 
provide them additional support obtaining these resources. An 
additional purpose of the calls is to remind them of the connection 
with their accountability partners within the unit, and possibly 
identify those in or approaching crisis who may need immediate 
intervention.
    Another key goal of the retreat is to get those participants who 
need it into therapy with the Department of Defense or VA, as 
appropriate. Since the retreat, three participants started therapy, and 
another three presented themselves as in crisis, where The Independence 
Fund and the VA were able to get them into immediate care.
    For those present, the impact on the participants was palpable. The 
reconnection with battle buddies, assurance from unit leadership that 
seeking behavioral health assistance was normal and acceptable, and 
resiliency training all appeared to have a visible and quick impact on 
the participants. As one participant stated post-retreat, ``This 
retreat saved lives. Maybe not today or tomorrow, but lives will be 
saved because of what happened here.''

Additional Reunion Retreats

    The Independence Fund will host at least two additional retreats in 
2019 and plans to host four to six retreats per year moving forward. 
From May 8-11, 2019, the Independence Fund will host the 3rd Battalion 
of the 67th Armored Regiment, who deployed to Fallujah, Iraq, at a 
reunion retreat in Houston, TX. From September 26-29, 2019, the 
Independence Fund will host a retreat for Bravo Company, 2nd Battalion, 
504th Parachute Infantry Regiment, in Nashville, TN.
    Members of this Committee and both Committee and personal office 
staff are more than welcome to join us at these retreats. Local 
Congressional offices are also invited to set up booths at the 
retreats' Resource Fairs on the last day to advise constituent 
participants on the services those Congressional offices can provide 
active duty, reserve component, and veteran participants. Further, if 
Members of the Committee know of other military units, active or 
reserve component, who fit these criteria and might benefit from an 
Operation RESILIENCY retreat, please contact us and we will work with 
you to support those units.

Operation RESILIENCY Summits

    Building on the ``whole of community'' approach championed by the 
VA through their Governors' Challenge and Mayors' Challenge, The 
Independence Fund is also hosting a series of regional Operation 
RESILIENCE Summits to support the local community planning to execute 
these veteran suicide prevention efforts. The Independence Fund hosted 
the first Summit April 23, 2019 in Charlotte, NC supporting Mecklenburg 
County, and focusing on student veteran suicide. In addition to the 
support of national leadership of Student Veterans of America, 
representatives of eight regional colleges and universities joined 
local government officials and The Independence Fund with workshops and 
panel discussions such as ``Pre/Post Military Stress for Student 
Veterans'', ``Invitation to a Tribe: Connecting in the Community'', 
``Student Veteran with Healthcare Needs - Navigating and Collaborating 
with VA and Community Resources'', and ``Working Through Obstacles and 
Creating Support for Veteran Resiliency & Success''. The Independence 
Fund will work with SVA, Mecklenburg County and other participants to 
continue to engage Student Veterans in the weeks and months following.
    In July 2019, the Independence Fund will host a second Summit in 
Houston, TX, which will focus on older veteran suicide. Specific goals 
of these summits are to ``Invitation to a Tribe: Connecting in the 
Community'', ``Senior Veteran with Healthcare Needs - Navigating and 
Collaborating with VA and Community Resources'', and ``Working Through 
Obstacles and Creating Support for Veteran Resiliency & Success''. We 
are currently reviewing other communities in which to host further 
Summits this year and following years. The Independence Fund plans to 
host four to six of these Summits per year. If Members of this 
Committee know of suitable partner communities where we could host 
future Summits, we would very much appreciate the opportunity to work 
with your offices to coordinate that.

Legislative & Policy Proposals

    The Independence Fund fully supports the whole of community 
approach presented in the President's PREVENT Executive Order, and 
believe including non-governmental community organizations, along with 
State and local governments, in such veteran suicide prevention 
programs is the only way to fully address the issue of veteran suicide. 
As both this Committee, the Senate Veterans Affairs Committee, and the 
Administration are all proceeding with similar community engagement 
grant programs, The Independence Fund would appreciate the opportunity 
to present what we believe should be governing principles as these 
legislative, regulatory, and Executive Branch actions move forward.
    Keep a Behavioral Health Focus: While many factors can contribute 
to an individual's death by suicide, it is ultimately a behavioral 
health issue. Factors such as employment, finances, housing, and 
personal relationships can all contribute to suicide and suicidal 
ideation. But many other veterans suffer setbacks in all those areas 
without looking at suicide as a response. The decisions which lead to 
suicide are cognitive and are best treated by proper behavioral health. 
The Independence Fund is concerned government grant and community 
engagement programs will be diluted below a level of minimum capability 
if these programs attempt to address too many non-behavioral health 
issues.
    Strengthen the Behavioral Health Capabilities of Community Care 
Providers: With most veterans dying by suicide not enrolled in the VA 
system, it is doubtful expanding VA behavioral health capabilities 
alone will adequately address veteran suicide rates. Government to 
community engagement programs and grants should seek to broaden, 
strengthen, and deepen the capabilities of community care behavioral 
health capabilities to reach as many veterans as possible. This 
Committee should also remain aware there is still deep mistrust of the 
VA within many parts of the veterans community, which will require 
exorbitant levels of marketing and engagement to overcome. The 
Independence Fund believes those funds would better be spent on 
community care programs where those issues of mistrust are not as 
prevalent.
    Grants Should Provide Sufficient Funds to Run a Meaningful 
Programs: Too often government grant programs seek to meet broad 
demographic, policy, and geographic diversity goals, which then may 
lower the amount awarded in individual grants below a level where the 
program can be efficiently executed and unnecessarily raising per 
capita costs. The Independence Fund believes it is better to award a 
smaller number of larger grants than a larger number of smaller grants 
in order to prevent funds provided will be consumed by overhead and 
administrative expenses and not address the key behavioral health 
issues.
    Maximize Community Partner Engagement in the Government Processes: 
Current regulations allow grant making agencies to have stakeholders 
serve on grant selection committees. This Committee should encourage 
the VA and the PREVENT Task Force to bring such veteran suicide 
prevention stakeholders into the process for determining the grant 
criteria and to have such stakeholders serve on the grant-making 
committees. Further, this Committee should encourage the Administration 
to establish an advisory subcommittee of the PREVENT Task Force where 
veteran suicide prevention stakeholders and community partners can 
effectively serve.
    The Independence Fund appreciates this opportunity to testify 
before the Committee and looks forward to the opportunity to work with 
you further in preventing veteran suicide.

                                 
                        Questions For The Record

Representative Lauren Underwood to National Institute of Mental Health 
                                 (NIMH)
    Questions:

    1. In your written testimony for this hearing, you outlined the 
effectiveness of the REACH-VET suicide risk identification system.

    a. Please provide information on the specific patient 
characteristics that REACH-VET analyzes.

    b. Please provide more detailed information on how REACH-VET's 
effectiveness is evaluated.

    c. Has there been any effort to export the predictive system used 
by the REACH-VET model for use by other health care providers?

    2. Your written testimony includes a section addressing several 
research studies supported by the VA that have uncovered benefits from 
an intervention called ``caring communications.'' Please provide a 
summary of the current status of implementation of caring 
communications intervention methods, including the number of facilities 
using the methods, any research analyzing their effectiveness, and any 
plans or proposals for expanding use of the methods.

    Answer to Question 1:

    The U.S. Department of Veterans Affairs' (VA) Recovery Engagement 
and Coordination for Health - Veterans Enhanced Treatment (REACH-VET) 
program highlights the potential of identifying people at suicide risk 
using electronic health records (EHRs).
    Building on the Army Study to Assess Risk and Resilience in 
Servicemembers (Army STARRS) \1\, the largest study of mental health 
risk and resilience ever conducted among military personnel, VA 
initiated efforts to develop predictive models of suicide risk among 
veterans receiving VA healthcare. \2\ The VA also worked with Michael 
Schoenbaum, Ph.D. from the National Institute of Mental Health (NIMH) 
and later Ronald C. Kessler, Ph.D. from Harvard Medical School. Suicide 
data used in the REACH-VET analyses were National Death Index results 
from the VA/DoD Suicide Data Repository and predictors were measured 
from Veteran Health Administration (VHA) clinical records. The 
predictive model incorporated demographic measures (e.g., age, gender, 
race/ethnicity, marital status, urban or rural residence, and 
geographic region), contextual factors (e.g., military service-
connected disability, homelessness, and previous self-directed 
violence), mental health measures (e.g., receipt of any mental health 
or substance abuse diagnoses and specific diagnoses), and medical 
measures (e.g., specific diagnoses, including common conditions, and 
pain-related diagnoses). This analysis demonstrated the feasibility of 
developing algorithms to identify patients within the VA system whose 
predicted suicide risk was 20-30 times higher than average.
---------------------------------------------------------------------------
    \1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286426/
    \2\ https://www.ncbi.nlm.nih.gov/m/pubmed/26066914/
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    The analysis described above led directly to the development of the 
VA's REACH-VET program, which currently applies an algorithm each month 
to the VA patient care population to identify a small fraction (0.1 
percent) of patients with the highest predicted suicide risk. NIMH 
defers to the VA to provide information on the administration and 
evaluation of the effectiveness of the REACH-VET program. It is our 
understanding that the REACH-VET algorithm examines an individual's 
EHRs for the following model predictors: demographics, prior suicide 
attempts, diagnoses, VHA use, medications, and interactions. \3\ REACH-
VET coordinators work with mental health and primary care providers to 
re-evaluate care, provide a suicide-focused clinical assessment, and 
consider ways to enhance treatment for veterans identified at high-risk 
for suicide. It is also NIMH's understanding that the VA Serious Mental 
Illness Treatment Resource and Evaluation Center conducts ongoing 
evaluation regarding REACH VET effectiveness. This includes assessment 
of REACH VET program effects on measures of care processes, treatment 
utilization, and mortality outcomes, using difference-in-difference 
techniques.
---------------------------------------------------------------------------
    \3\ https://www.hsrd.research.va.gov/for--researchers/cyber--
seminars/archives/3527-notes.pdf
---------------------------------------------------------------------------
    While the VA was the first healthcare system in the United States 
to use data from EHRs to help identify people with suicide risk, other 
healthcare systems are now using similar data to develop and validate 
suicide prediction tools to use with civilian populations. For example, 
seven of the 13 healthcare systems across the United States that are 
part of NIMH's Mental Health Research Network (MHRN) examined data from 
EHRs and responses to self-report questionnaires to predict suicide 
attempts and deaths. \4\ The MHRN model predictors include demographic 
and clinical characteristics, prior suicide attempts, mental health and 
substance use diagnoses, medical diagnoses, psychiatric medications 
dispensed, inpatient or emergency department care, and routinely 
administered depression questionnaires. MHRN researchers found that 
prediction models incorporating both EHR data and responses to self-
report questionnaires outperform existing suicide risk prediction tools 
that do not use EHR data. \5\
---------------------------------------------------------------------------
    \4\ https://www.ncbi.nlm.nih.gov/pubmed/29792051
    \5\ https://www.ncbi.nlm.nih.gov/pubmed/29792051

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    Answer to Question 2:

    Multiple agencies, including the NIMH and the VA, are supporting 
several research studies that have uncovered benefits from \6\``caring 
\7\ communications \8\.'' \9\ Caring communications includes a wide 
range of interventions in which patients are sent follow-up written 
communication - by postcard, letter, or text message - in the weeks and 
months after they are identified with suicide risk. Such 
communications, which provide regular and supportive contact with the 
patient during a critical period when they transition between 
structured healthcare settings and the community, have been found to 
reduce suicidal behaviors.
---------------------------------------------------------------------------
    \6\ https://www.ncbi.nlm.nih.gov/pubmed/30758491
    \7\ https://projectreporter.nih.gov/project--info--description.cfm-
aid=9687746
    \8\ https://clinicaltrials.gov/ct2/show/NCT01473771
    \9\ https://clinicaltrials.gov/ct2/show/NCT01829620
---------------------------------------------------------------------------
    NIMH-supported researchers have also shown that caring 
communications is a very high-value intervention; that is, it is a 
relatively low-cost intervention compared to its benefits. \10\ The 
researchers found that sending caring postcards or letters following an 
emergency visit is more effective and less expensive than usual care. 
While telephone or written follow-up communications can be provided by 
the hospital where the patient was identified, from a centralized 
facility coordinated by the health system, or by staff from Crisis Line 
programs such as the National Suicide Prevention Lifeline or the 
Veterans Crisis Line, this type of proactive follow-up is not yet part 
of standard practice.
---------------------------------------------------------------------------
    \10\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750130/
---------------------------------------------------------------------------
    NIMH continues to support research to identify how and why these 
follow-up interventions work, and how these methods can be scaled up 
for broader implementation. NIMH will continue to work with our federal 
and public partners to inform evidence-based care and prevent suicide. 
NIMH defers to the VA regarding the current status of implementation of 
caring communications methods within the VA healthcare system, 
including the number of facilities using the methods, and any plans or 
proposals for expanding use of these methods for veterans and military 
personnel.

                                 
   Representative Lauren Underwood to Dr. Richard Ston , Dr. Shelli 
                               Avenevolie
    1. Your written testimony mentions a national network of Women's 
Mental Health Champions created by VA. Please provide a brief written 
overview of the Women's Mental Health Champions Program, including any 
evidence-based practices that have influenced the development of that 
program, and a list of program participants located in Illinois.

    2. Given the recent incidences of veteran suicides at VA medical 
facilities, has VA enacted any new policies or procedures to reduce the 
number of on-site suicides?

    a. Have any internal reviews have been conducted with regard to 
improving onsite security and threat screening?

    b. If so, when will those review findings become available?

    3. In your written testimony you highlighted VA as a national 
leader in providing ``telemental'' health services. Please provide data 
regarding the efficacy of ``telemental'' health programs as a useful 
means of reaching, retaining, and providing effective mental health 
care to patients.

    4. In Dr. Shelli Avenevoli's written testimony for this hearing, 
she outlined the effectiveness of the REACH-VET suicide risk 
identification system.

    a. Please provide information on the specific patient 
characteristics that REACH-VET analyzes.

    b. Please provide more detailed information on how REACH-VET's 
effectiveness is evaluated.

    c. Has there been any effort to export the predictive system used 
by the REACH-VET model for use by other health care providers?

    5. The written statement provided by Disabled American Veterans for 
this hearing praised the utility of a personal workbook distributed by 
VA, ``Your Personal Safety Plan,'' to identify stressors and to create 
a strategy for veterans for staying safe in times of emotional crisis. 
Given the elevated risk factors among the veteran population, has VA 
considered proactively providing the ``Your Personal Safety Plan'' 
workbook to all veterans as a presumptive positive intervention method?

    6. Dr. Avenevoli's written testimony includes a section addressing 
several research studies supported by the VA that have uncovered 
benefits from an intervention called ``caring communications.'' Please 
provide a summary of the current status of implementation of caring 
communications intervention methods, including the number of facilities 
using the methods, any research analyzing their effectiveness, and any 
plans or proposals for expanding use of the methods.

    7. In your written testimony you highlighted several times the need 
to better understand and target prevention efforts towards the 14 
veterans who die by suicide each day who were not recent users of VA 
health services. Please provide an overview of any current methods to 
identify the demographics of 14 veterans.

    a. Please provide information on what data is being collected on 
these individuals, including their character of service; medical 
history; and access to VA, military, or private sector care, etc.

    8. The written statement provided by Veterans of Foreign Wars 
referenced an August 2018 report from the Department of Veterans 
Affairs Office of Inspector General (Report #17-05248-241) detailing 
the VA's staffing shortages in the area of mental health care. Please 
provide a roadmap with specific and measurable goals toward reducing 
the shortage of mental health staff in VA facilities, along with an 
outline of the resources you need to successfully implement the plan.

    9. In her testimony during the hearing, Dr. Keita Franklin stated, 
``If it were up to me, we'd train the entire VA on how to talk about 
lethal means.'' Are there any existing barriers that would hinder VA 
from expanding lethal means training for its staff?

    10. Dr. Franklin also highlighted official partnerships between the 
VA and outside organizations to promote firearm safety. Please provide 
an overview of VA's current partnerships with organizations (such as 
firearm dealers and firearm ownership groups) aimed at reducing veteran 
suicide rates. Please include data on any funding provided, the number 
of involved organizations, and the number of veterans reached by these 
efforts.

    To Dr. Shelli Avenevoli:

    1. In your written testimony for this hearing, you outlined the 
effectiveness of the REACH-VET suicide risk identification system.

    a. Please provide information on the specific patient 
characteristics that REACH-VET analyzes.

    b. Please provide more detailed information on how REACH-VET's 
effectiveness is evaluated.

    c. Has there been any effort to export the predictive system used 
by the REACH-VET model for use by other health care providers?

    2. Your written testimony includes a section addressing several 
research studies supported by the VA that have uncovered benefits from 
an intervention called ``caring communications.'' Please provide a 
summary of the current status of implementation of caring 
communications intervention methods, including the number of facilities 
using the methods, any research analyzing their effectiveness, and any 
plans or proposals for expanding use of the methods.

                                 
      Chairman Mark Takano to Department of Veterans Affairs (VA)
Regarding the Public Health Model (Generally)

    Question 1: How does VA collect and use data on veteran suicides to 
inform its prevention efforts?

    VA Response: Data informs all of our suicide prevention efforts. VA 
is using data to tailor the best possible targeted prevention 
strategies to reach all Veterans - not just those who are identified as 
being at elevated risk. To better understand Veteran suicide as a 
whole, we look at trends among both the broader Veteran population, as 
well as sub-groups of Veterans, over time. This helps us identify areas 
of particular concern, to develop appropriate programs and resources 
and to better measure our progress.

    Question 1a: For example, how does VA examine various factors (e.g. 
location of the suicide, last contact with a VA health care provider) 
and use this information in all of its suicide prevention programs (not 
just REACH VET)?

    VA Response: VA analyzes data about risk factors and completed 
suicides and uses this information to develop targeted programming and 
align resources to the areas that need it most. Additionally, VA is 
examining the association between suicide risks and factors including 
no-show medical appointments and high-risk flags.
    Based on data findings on suicide rates for never federally 
activated members of the Guard and Reserves, VA developed a toolkit of 
resources for this population; published an Executive in Charge memo to 
the field encouraging facility staff to provide gunlocks, conduct 
community outreach, and use the humanitarian/emergency care authority 
in 38 United States Code (U.S.C.) 1784 to provide mental health and 
suicide prevention services; and began working with Guard and Reserve 
leadership on strategies to provide resources to this population.
    VA's data showed that transitions in care are a critical time-
period for suicide prevention. This led to a pilot program called 
Caring Contacts, where suicidal patients received text messages or 
letters with brief, non-demanding expressions of care over a year or 
more. Veterans overwhelmingly found these expressions to be helpful, 
and VA is exploring options to bring this pilot to other facilities.
    When a suicide or suicide attempt occurs at a VA Medical Center 
(VAMC), staff will complete a Root Cause Analysis (RCA) to review a 
larger systems issue, or a Peer Review, to focus on a specific aspect 
of a Veteran's care. An RCA is a multidisciplinary approach to study 
health care-related adverse events and close calls, which involves a 
systematic process for identifying ``root causes'' of problems or 
events, as well as an approach for responding to them. The goal of the 
RCA process is to find out what happened, why it happened, and how to 
prevent it from happening again. The Patient Safety Manager is 
responsible for identifying RCA team members to complete the RCA 
process, including Facility Suicide Prevention Coordinators (SPC) and 
VA Police, as needed.
    VA also realized that Veterans with Lesbian, Gay, Bisexual, 
Transgender (LGBT) or related identities may be at increased risk for 
suicide. To help provide comprehensive care to this population, VA 
developed a toolkit of resources that helps VA providers and their 
patients have open, culturally appropriate conversations about issues 
related to LGBT health care. We also recently launched the Connect. It 
can save a life. campaign to encourage VA providers and their patients 
to talk about gender identity and sexual orientation as part of routine 
health care.
    Additionally, based on our data findings regarding suicide deaths 
by firearms and other lethal means, VA implemented a nationally-
standardized Suicide Prevention Safety Planning Template that ensures 
that Veterans receive high-quality suicide prevention safety plans that 
address feasible steps to reduce access to lethal means.
    We have also analyzed data on employment rates and homelessness to 
ensure that we have the right partners and capabilities in place to 
target these risks.

    Question 1b: How does VA collect and use data to ``target groups'' 
like female veterans?

    VA Response: VA compiles data from multiple sources, including VA, 
the Department of Defense (DoD), and public records systems (e.g., the 
Centers for Disease Control and Prevention's (CDC) National Death Index 
(NDI)), to understand Veteran suicide. Each data source and measure 
provide new information that can help characterize risk for a Veteran 
subgroup. Ongoing monitoring enables longitudinal assessments. In these 
ways, for example, we know that suicide rates among female Veterans are 
particularly elevated compared to non-Veteran women.
    Once we identify this data point, we work with VA's Women Health 
Services office to share findings and develop specific programming. We 
also engage with other offices to develop pilot projects and 
programming tied to this risk. An example of this is a new pilot 
project with the Army, Navy, and Marine Corps on a women's health 
transition program. This pilot is currently in the testing phase with 
the Air Force.

    Question 2: How do VA and DOD share data with each other to help 
prevent veteran suicides?

    VA Response: VA's most comprehensive source of Veteran suicide 
mortality data on the entire Veteran population, including those not 
receiving care from the Veterans Health Administration (VHA), is the 
Joint VA/DoD Suicide Data Repository (SDR). Data for the SDR are 
obtained from the CDC's NDI, considered the national ``gold standard'' 
for mortality data. The NDI includes indicators of date, state, and 
cause of death.

    Question 2a: Are there any challenges with collecting and/or 
accessing data across agency lines?

    VA Response: Yes, there are several challenges, including the need 
to improve mortality surveillance by the inclusion of additional fields 
available on the death certificate such as address of residence and 
county of death. Current resources used by VA, such as the CDC's NDI, 
do not currently have this information.
    An additional challenge is that the timing of current data 
availability prevents near real time monitoring of suicide data to 
appropriately assess program efforts. NDI releases death records for 
request approximately 11 months after the end of the calendar year, at 
which time a coordinated VA/DoD search of millions of records is 
completed, leading to the identification of the matching death records 
and cause of death for Veteran decedents, followed by follow-on 
analyses within our VHA data systems and then developing the report and 
the dissemination of this information. This coordinated, multiagency 
process leverages the best available data to report and track Veteran 
mortality and can take up to 18 months for completion. DoD and VA both 
pay CDC for this data as well - close to 3 million dollars in total, 
and there are hurdles with making sure that the vehicle is in place to 
make the payment in order to receive the data in a timely matter.

Regarding REACH VET Predictive Analysis Modeling

    Question 1: Has VA monitored whether all VISNs and VAMCs have 
successfully implemented REACH VET in all required patient care 
settings?

    VA Response: Yes. Recovery Engagement and Coordination for Health - 
Veterans Enhanced Treatment (REACH VET) is fully implemented in VHA and 
identifies approximately 30,000 at risk Veterans for care review, 
enhancement, and outreach. The target for the program for fiscal year 
(FY) 2019 is 90 percent of those identified receiving review and 
outreach within two weeks and that target was reached in March 2019.

    Question 2: How has VA ensured that VHA providers responsible for 
conducting VA's new standardized suicide risk screening and assessment 
processes have been properly trained in this process?

    VA Response: Prior to the implementation of the Universal Screening 
Protocol in May 2018, an informational memo was distributed to the 
field outlining the new protocol. A Suicide Risk Screening and 
Assessment SharePoint was established, a single technical assistance 
email group was established, and all facilities identified a Facility 
Champion/Point of Contact for training and questions. Educational 
webinars were held throughout August and September, which were made 
available on the Talent Management System (TMS) for sites to utilize. 
Weekly technical assistance calls were also held during this period.
    The assignment and management of training and education is done 
locally. There are no national metrics to track training as facilities 
must determine appropriate staff based on scope of practice. Local 
facilities may assign training to appropriate staff and track this 
training through TMS.
    Virtual training remains available and provides details and 
guidance on VA's new, national three-stage screening and evaluation 
process. Three courses are available in TMS, including Suicide Risk 
identification Strategy - Overview (TMS item number VA 36829), Primary 
and Secondary Screening Tools (TMS item number VA 36816), and 
Comprehensive Suicide Risk Evaluation (CSRE) (TMS item number VA 
36830). VA's Suicide Risk Identification SharePoint training documents 
folder includes training resources such as Frequently Asked Questions, 
Suicide Risk Identification Clinical Reminder Flowchart, and Suicide 
Risk Stratification Table. In addition, the SharePoint hosts a 
discussion board for questions.
    The VA Suicide Risk Identification Technical Assistance Group hosts 
a weekly technical assistance phone call. Questions can be emailed to 
the VA Suicide Risk Identification Technical Assistance Group at 
[email protected].
    To ensure that facilities are made aware of updates related to 
national memos, release of educational materials, changes to 
requirements or guidance documents and any other information related to 
the risk ID process, each facility was required to identify a Facility 
Champion/Point of Contact. The Facility Champion receives updated 
information as it becomes available and disseminates the information to 
the local facility.
    The Suicide Risk Management Consultation Program is available to 
consult on a specific case or talk about suicide risk management 
strategies more generally.

Regarding the Executive Order on a National Roadmap to Empower Veterans 
        and End Suicide

    Question 1: As part of the March 5th Executive Order on Suicide 
Prevention, the President calls for the creation of a task force that 
will, among other things, develop a plan to be known as the President's 
Roadmap to Empower Veterans and End a National Tragedy of Suicide, or 
PREVENTS, within one year of March 5, 2019. It has been more two months 
since the issuance of the order and details have been scarce.

    Question 1a: Could you inform the Committee who has been assigned 
to represent the various agencies and organizations listed as part of 
this task force?

    VA Response: VA is working closely with the White House on efforts 
associated with the Executive Order. Task Force work has already 
started three lines of effort (LOE): Research, State and Local Action, 
and Enabling Supports. Each LOE is comprised of working groups with 
representation from the Task Force identified agencies as well as a 
variety of other organizations.
    The Research LOE is responsible for developing a research strategy 
which will advance the efforts to improve quality of life and reduce 
suicide among Veterans by better integrating existing efforts of 
governmental and non-governmental entities and by improving the 
development and use of metrics to quantify progress of these efforts. 
The State and Local Action LOE is responsible for developing the 
legislative proposal that establishes a program for awarding grants to 
local communities to enable them to increase their capacity to 
collaborate with each other, to integrate service delivery to Veterans 
and to coordinate resources for Veterans. The Enabling Supports LOE is 
responsible for completing essential activities to support 
determination and implementation of professional development and to 
engage and coordinate with national, state, and local stakeholders and 
partners.
    The Task Force is co-chaired by the Secretary of Veterans Affairs 
and the Assistant to the President for Domestic Policy and is comprised 
of the following cabinet members or their designees:

    (i) the Secretary of Defense;
    (ii) the Secretary of Labor;
    (iii) the Secretary of Health and Human Services;
    (iv) the Secretary of Housing and Urban Development;
    (v) the Secretary of Energy;
    (vi) the Secretary of Education;
    (vii) the Secretary of Homeland Security;
    (viii) the Director of the Office of Management and Budget;
    (iv) the Assistant to the President for National Security Affairs; 
and
    (x) the Director of the Office of Science and Technology Policy.

    A formal Task Force Kick-Off is planned for June 2019 and cabinet 
members will identify their designees for Task Force membership at that 
time.

    Question 2: The March 5th Executive Order on Suicide Prevention 
requires the development of (1) a grant-based system to assist in the 
coordination of federal, state and local resources available to 
veterans, (2) a research strategy and metrics to quantify the progress 
of research to prevent suicides, and (3) a legislative strategy to 
support the steps associated with greater coordination and research.

    Question 2a: Given the importance of research, does the 
administration intend to assign a representative from VA's Office of 
Research Development to the taskforce as a designee of the taskforce?

    VA Response: Yes, our formal VA Office of Research & Development 
(ORD) Task Force member will be Dr. Rachel Ramoni, Chief Research & 
Development Officer. VA appointees to manage the Research LOE will be 
Dr. Wendy Tenhula, Deputy Chief Research & Development Officer and Dr. 
Terri Gleason, Director, Clinical Science Research & Development 
Service.

Regarding the Support Systems (State and Local) Needed as Part of the 
    Public Health Approach

    Question 1: The Arizona Coalition for Military Families has spent 
the last decade developing the BE CONNECTED Program. For those that are 
not aware, this program connects veterans in need of resources such as 
financial counseling, legal assistance, or transportation to both VA 
and Community-based regionally specific resources. I understand the 
intent of the EO on Suicide Prevention is to expand this pilot program 
nationwide.

    Question 1a: Because the resources are specific to a region, such 
as a county or zip code, it seems most effective to set up state-based 
agencies or organizations like Arizona's Coalition to collect, review, 
organize, and oversee these resources. What barriers do you foresee to 
its expansion nationwide?

    VA Response: VA is taking a public health approach to suicide 
prevention by working across sectors in communities nationwide to reach 
Veterans with lifesaving resources and support. At VA, we know that 
successful interventions in one location may not work in all 
communities, and suicide prevention interventions on the local level 
must consider the needs of each individual community. We intend to work 
with local entities to fulfill this mission and do not foresee any 
barriers on implementing best practices nationwide at this time.
    In March 2018, VA and the Substance Abuse and Mental Health 
Services Administration (SAMHSA) partnered to launch the inaugural 
Mayor's Challenge to prevent suicide among Service members, Veterans, 
and their families. Now in its second year, this initiative brings 
together interagency teams from twenty-four cities to develop local 
action plans tailored to their individual communities to prevent 
Veteran suicide. Based on the success of the Mayor's Challenge, VA and 
SAMHSA launched the Governor's Challenge in February 2019, replicating 
the goals of the Mayor's Challenge with seven states.
    During the Mayor's and Governor's Challenges, leaders from the 
participating states, cities, and counties created tailored plans for 
their communities to implement the National Strategy for Preventing 
Veteran Suicide, which provides a framework for identifying priorities, 
organizing efforts and contributing to a national focus on Veteran 
suicide prevention.
    Community and state teams can share best practices and innovative 
approaches through the Mayor's and Governor's Challenge work. This 
cross-team communication about programs such as the BE CONNECTED 
program allows teams to adapt and tailor such programs based on their 
community's unique needs and resources.
    Executive Order (EO) 13861, the President's Roadmap to Empower 
Veterans and End a National Tragedy of Suicide, also referred to as 
PREVENTS, will allow for communities to access grants that will help 
them better connect Veterans with resources such as employment, 
housing, benefits, recreation, education, and more. VA is looking 
forward to Congress providing VA with grant making authority which is 
needed to comply with EO 13861 PREVENTS. The Administration included a 
legislative proposal for grant making authority tin its FY 2020 Budget. 
We would welcome working with Congress to have you and other members 
sponsor the legislation. In the meantime, VA is working to develop the 
infrastructure needed to issue the grants for suicide prevention once 
we are provided that authority.

Regarding the Budget for Suicide Prevention

    Question 1: In 2018, the President signed an Executive Order 
focused on creating a seamless transition between DoD and VA mental 
healthcare for transitioning servicemembers. This EO required the 
development of a Joint Action Plan and status update 6 months following 
the development of the Joint Action Plan. The development of these 
strategic planning documents has allowed veterans, stakeholders, and 
Congress to more easily envision the ultimate goal of the EO, as well 
as to track the agency's progress toward the completion of the EO's 
goals. As part of your 2020 budget request, you've asked for a 63% 
increase in funds for ``implementation of the National Strategy on 
Preventing Veterans Suicide.''

    Question 1a: In an effort to better assist veterans and 
stakeholders understanding of your ``ultimate goal'' and to assist 
Congress in oversight, would you commit to developing an ``Action 
Plan'' that lays out each of the 14 goals, reliable metrics by which 
you intend to judge success, and targets, including dates, that reflect 
what that ``success'' looks like?

    VA Response: We have an ``Action Plan'' for this effort. A Joint 
Action Plan was submitted and accepted by the White House on May 3, 
2018 and is publicly available at: https://www.va.gov/opa/docs/Joint-
Action-Plan-05-03-18.pdf. The Joint Action Plan outlined the strategy 
and associated 14 tasks to implement the actions mandated in the EO. 
This effort is governed by a cross agency working group that met 
biweekly/monthly for over a year and monitored the implementation of 
each task. The work is also overseen by the Joint Executive Committee. 
Since the action plan was submitted there continues to be progress in 
all lines of work. An updated plan was developed and is used to track 
the metrics.
    We have developed comprehensive measurement strategies, including 
assessment of numerous reliable metrics for each line of effort to 
track and measure the impact of activities on suicide reduction.
    The following list focuses on some of the metrics associated with 
VA's suicide prevention priorities that are regularly tracked to 
monitor trends to include our enhanced care delivery, education and 
training, and outreach and awareness interventions:

      Lethal Means and Safety Planning:
        Suicide Risk Identification using a 3-step approach to 
ensure universal suicide risk screening for all Veterans seen in 
clinics throughout VHA;
        High Risk for Suicide Flag (HRF) patient record flag 
for patients assessed to be at high risk for suicide - VA tracks 
numerous metrics tied to the HRF program to ensure compliance and 
appropriate follow up for these vulnerable Veterans;
        Number of gunlocks we deliver;
        Pounds of medication disposed of by Veterans through 
the Pharmacy Medication Disposal Program;
        Suicide safety planning throughout VHA;
        Operation S.A.V.E. training compliance among VA staff, 
tracked through the TMS training portal (Operation S.A.V.E. consists of 
five components: Signs of suicide, Asking about suicide, Validating 
feelings, Encouraging help, and Expediting treatment);
        Operation S.A.V.E. trainings provided externally in the 
community; tracked through various means including the Suicide 
Prevention Application Network (SPAN), that is used by SPC to track 
external presentations, through the TRAIN.ORG training portal 
(connected to TMS and tracked by VA's Employee Education System), 
through the YouTube views, and through PsychArmor (the non-profit that 
assisted in the creation of the Operation S.A.V.E. video training), 
which, in all cases, we regularly collect and track usage/completion; 
and
        Veterans Crisis Line (VCL) use and metrics associated 
with efficient and effective VCL efforts.
      Partnerships, Outreach, and Awareness:
        Awareness campaigns - Online interaction with our 
campaign materials to gauge how effectively we are reaching the right 
people with the right information: site usage patterns, traffic to 
site, time on site, number of pages visited, public service 
announcement views, impressions and distribution, broadcast and 
billboard efforts;
        Engagements with other key resources-downloads of 
campaign materials, uses of Operation S.A.V.E. training, views of our 
educational videos, and Public Service Announcements;
        Outreach events completed by VHA staff within their 
communities and number of participants in attendance at these outreach 
events;
        The number of community partners, and assessing the 
gaps in sectors to ensure VA is developing partnerships across all 
areas that intersect with suicide; and
        Action plans and efforts from Mayor's and Governor's 
Challenge partners.
      Enhanced Health Care Services:
        Mental Health and Suicide Prevention Coordinator 
staffing metrics;
        Number of Veterans identified by predictive analytics 
that receive the recommended interventions;
        New mental health appointments within 30 days;
        Same day access to mental health appointments;
        Mental Health appointments delivered by telehealth; and
        Post discharge follow up from inpatient care, emergency 
department, residential facilities, substance abuse, etc. to engagement 
in outpatient care.

    Metrics related to our enhanced care delivery interventions have 
been developed through several automated dashboards to identify 
Veterans at highest risk for suicide to aid providers in improved 
decision making and safety planning. These include:

      Suicide Prevention Quarterly Dashboard - reports 
quarterly metrics on core suicide prevention priorities, tracking 
trends, needs, successes and gaps for quality improvement, and is 
adaptable to track new priorities. This dashboard tracks and reports 
metrics mentioned above;
      REACH VET, which identifies patients at statistical risk 
of death by suicide in the next month;
      The Stratification Tool for Opioid Risk Mitigation 
(STORM), which identifies patients at statistical risk of overdose or 
suicide-related health care events or death in the next year;
      The Suicide Prevention Population Risk Identification and 
Tracking for Exigencies (SPPRITE) - unifies information from the 
following: HRF, STORM, REACH VET, Post-Discharge Engagement (PDE), 
positive secondary suicide risk screens (C-SSRS), and intermediate or 
above risk levels captured by the comprehensive suicide risk evaluation 
(CSRE) to identify and reduce care gaps and ensure high levels of care 
for patients identified at high risk for suicide; and

      SPAN - a database that allows SPC to report suicides and 
suicide attempts, manage treatment plans, follow patient progress, and 
provide outreach. SPAN is designed to capture the number of suicides 
and non-fatal suicide attempts among the Veteran population. This 
information is calculated monthly and continuously updated.

    VA developed the Strategic Analytics for Improvement and Learning 
Value (SAIL) Model to measure, evaluate, and benchmark quality and 
efficiency at medical centers to promote high quality, safety, and 
value-based health care. SAIL assesses 25 Quality measures including 
specific metrics assessing mental health care. These metrics are 
reviewed and utilized for decision making and technical assistance to 
close gaps to offer the best care. These reports are publicly available 
on VA's Web site: https://www.va.gov/qualityofcare/measureup/
strategic--analytics--for--improvement--and--learning--sail.asp.

    Question 2: Over the last few years, VA has shifted towards a 
``public health'' approach to suicide prevention. You've described 
community engagement as a central part of this new approach. However, 
you've only requested an increase of $275,000 for ``Local Facility and 
Community Outreach and Activities.''

    Question 2a: How does VA intend to leverage this additional 
$275,000 to begin creating the community support that will be integral 
to the ``public health'' approach that is currently being pursued by 
VA?

    VA Response: The additional $275,000 under line item ``Local 
Facility and Community Outreach and Activities'' is specifically for 
funding that the National Suicide Prevention Program sends to local SPC 
for September's Suicide Prevention Month. This funding, used at the 
local level, is spent on local outreach, communication efforts, and 
programming focused on engaging Veterans, families, and communities 
around suicide prevention.
    Our outreach and community engagement efforts extend beyond just 
this line item. We've also requested an increase in the line item 
``National Suicide Prevention Strategy Implementation'' where our 
communications and paid media funding is captured as well as our 
ongoing collaboration with the Department of Health and Human Services' 
SAMHSA for the Governor's and Mayor's Challenges, as examples.

Regarding Trans Veterans

    Question 1: As a result of the President's April 12 ban on 
transgender people serving in the armed forces, we have heard from 
advocacy groups and health care providers about the increased 
likelihood the ban will trigger increased suicidality amongst trans 
veterans.

    Question 1a: What is the VA doing to reach out to these veterans 
who are particularly vulnerable?

    VA Response: Every VA facility has an LGBT Veteran Care Coordinator 
(VCC). The role of the VCC is to create a welcoming environment for 
Veterans with LGBT or related identities, to provide education and 
clinical consultation for VA health care providers, to provide 
resources and information for Veterans with LGBT or related identities, 
and to build community partnerships. LGBT VCCs conduct community 
outreach to transgender Veterans by holding collaborative public events 
with community LGBT organizations. To help provide comprehensive care 
to this population, VA developed a toolkit of resources that helps VA 
providers and their patients have open, culturally appropriate 
conversations about issues related to LGBT health care.

    Question 1b: What interventions have been developed that are 
specific to this population?

    VA Response: VA health care includes services that are particularly 
important for Veterans with LGBT or related identities, including 
hormone treatment, substance use/alcohol treatment, tobacco use 
treatment, treatment and prevention of sexually transmitted infections, 
intimate partner violence reduction and treatment of after effects, 
heart health, and cancer screening, prevention, and treatment. 
Information about LGBT Veteran health services are available on every 
VAMC Web site.
    Additionally, the LGBT Health Program of VA's Patient Care Services 
provides ongoing educational programs for VHA staff about LGBT health 
care. Many of the trainings are available on-demand for providers who 
work with Veterans outside of VA. VA also offers consultation to 
providers related to transgender-specific health care via regional e-
consultation teams.
    The Suicide Prevention Program (SPP) worked closely with the LGBT 
Health Program in Patient Care Services to launch the Connect. It can 
save a life campaign. The campaign encourages Veterans and their 
providers to talk about sexual orientation and gender identity as part 
of routine health care so that providers can give Veterans with LGBT or 
related identities the highest-quality care.

Regarding Native American Veterans

    Question 1: American Indians and Alaska Natives (AI/AN) have a 
disproportionately high rate of suicide-more than 3.5 times those of 
racial/ethnic groups with the lowest rates, according to a 2019 CDC 
study. And the rate has been steadily rising since 2003.

    Question 1a: What is VA doing to ensure tribal veterans have access 
to suicide prevention outreach?

    VA Response: Community building to address the needs of Veterans in 
tribal communities presents unique opportunities and challenges. We 
recently began working (in FY 2018) with Dr. Nate Mohatt on a program, 
partnered with two VA facilities and the VHA Office of Rural Health, to 
develop a model and program to guide Native community engagement on 
suicide prevention. Additionally, the VA Office of Tribal Government 
Relations works to strengthen and build relations between VA, tribal 
governments, and other key federal, state, private, and non-profit 
partners to more effectively and respectfully serve Veterans.

Regarding Women Veterans

    Question 1: Dr. Franklin: Women veterans die by suicide at twice 
the rate of non-veteran women. What are some of the factors unique to 
women veterans that put them at greater risk of suicide?

    VA Response: Multiple factors contribute to the higher rates of 
suicide deaths among women Veterans as compared to non-Veteran women. 
As compared to their civilian peers, women Veterans experience higher 
rates of psychiatric and psychosocial suicide risk factors, and these 
differences may partially account for the relatively higher rates of 
death by suicide observed in women Veterans. For example, there is a 
well-established link between mental illness and suicide risk. Women 
Veterans, as compared to their civilian peers, experience higher rates 
of mental illness and substance use disorder (Ilgen et al., 2010).
    Women Veterans are also at higher risk than non-Veteran women of 
experiencing adverse life effects associated with heightened suicide 
risk. For instance, women Veterans are at higher risk than non-Veteran 
women for intimate partner violence (Dichter, Cerulli, & Bossarte, 
2011). The experience of intimate partner violence is associated with 
known suicide risk factors, including mental and physical health 
conditions, hopelessness and social isolation (Iovine-Wong et al., 
2019), as well as suicidal ideation and attempts (Cavanaugh et al., 
2011; Simon et al., 2002). Women Veterans are also at greater risk for 
experiencing sexual trauma, including military sexual trauma (Kimerling 
et al., 2016; Monteith et al., 2015; Rosellini et al., 2017). For both 
women and men, sexual trauma is associated with suicidal ideation, 
suicide attempts, and death by suicide. Research also suggests that 
sexual trauma, unlike other types of trauma, may directly increase risk 
for suicide, above and beyond the effects of related mental health 
conditions (Davidson et al., 1996; Gradus et al., 2012).
    Finally, women Veterans are more likely than non-Veteran women to 
use firearms as a method of suicide; they are also more likely to have 
access to firearms as a result of living in a household with firearms. 
It is likely that the higher rates of suicide among women Veterans are, 
at least in part, due to women Veterans' more frequent use of this 
highly lethal means when attempting suicide (Department of Veterans 
Affairs, April 2019).

Citations

    Cavanaugh, C.E., J. T. Messing, M. Del-Colle, C. O'Sullivan, and J. 
C. Campbell. 2011. Prevalence and correlates of suicidal behavior among 
adult female victims of intimate partner violence. Suicide and Life-
Threatening Behavior 41, no. 4:372-83.
    Davidson J.T., Hughes D.C., George L.K., & Blazer D.G. (1996). The 
association of sexual assault and attempted suicide within the 
community. Archives of General Psychiatry, 53(6):550-555. doi:10.1001/
archpsyc.1996.01830060096013.
    Department of Veterans Affairs, Office of Mental Health and Suicide 
Prevention, Suicide Among Women Veterans: Facts, Prevention Strategies, 
and Resources, April 2019, available online: https://
www.mentalhealth.va.gov/suicide--prevention/ docs/Women-- Veterans--
Fact--Sheet--508.pdf
    Dichter, M. E., C. Cerulli, and R. M. Bossarte. 2011. Intimate 
partner violence victimization among women veterans and associated 
heart health risks. Women's Health Issues 21, no. 4:S190-94.
    Gradus, J.L., Qin, P., Lincoln, A.K., Miller, M., Lawler, E., 
Sorensen, H.T, & Lash, T.L. (2012). Sexual victimization and completed 
suicide among Danish female adults. Violence Against Women, 18, 552-56. 
doi: 10.1177/1077801212453141.
    Ilgen, M. A., A. S. Bohnert, R. V. Ignacio, et al. 2010. 
Psychiatric diagnoses and risk of suicide in veterans. Archives of 
General Psychiatry 67, no. 11:1152-58.
    Iovine-Wong, P.E., C. Nichols-Hadeed, J. T. Stone, et al. 2019. 
Intimate partner violence, suicide, and their overlapping risk in women 
veterans: A review of the literature. Military Medicine:usy355 (e-
publication ahead of print).
    Kimerling, R., K. Makin-Byrd, S. Louzon, R. Ignacio, & J. McCarthy. 
2016. Military sexual trauma and suicide mortality. American Journal of 
Preventive Medicine 50, no. 5:684-91.
    Monteith, L. L., D. S. Menefee, J. E. Forster, J. L. Wanner, and N. 
H. Bahraini. 2015. Sexual trauma and combat during deployment: 
Associations with suicidal ideation among OEF/OIF/ OND veterans. 
Journal of Traumatic Stress 28, no. 4:283-88.
    Rosellini, A., J., A. E. Street, R. J. Ursano, et al. 2017. Sexual 
assault victimization and mental health treatment, suicide attempts, 
and career outcomes among women in the US Army. American Journal of 
Public Health 107, no. 5:732-39.
    Simon, T.R., M. Anderson, M. P. Thompson, A. Crosby, and J. J. 
Sacks. 2002. Assault Victimization and Suicidal Ideation or Behavior 
Within a National Sample of U.S. Suicide and Life-Threatening Behavior 
32, no. 1:42-50.

    Question 1a: How is VA improving peer-support programs for women 
veterans?

    VA Response: VA requested and the Office of Personnel Management 
verbally approved a waiver to allow VA to recruit for and hire only 
female Peer Specialists for peer support positions established as part 
of Section 506 of the VA Maintaining Internal Systems and Strengthening 
Integrated Outside Networks (MISSON Act), which requires female peer 
specialists be available in all 30 facilities mandated to expand peer 
support in primary care. In addition to those facilities participating 
in this section, we are encouraging each medical center to employ women 
peer specialists and to make them available for women Veterans.

Regarding Peer Support Specialists

    Question 1: VA has found peer support specialists to be an integral 
part of increasing access to VA's mental health programs. These 
specialists also often offer assistance accessing other parts of VA 
such as VBA and even NCA services.

    Question 1a: Does VA intend to expand this program and the training 
associated with it to service lines outside of Primary Care and Mental 
Health Care- For example, to Community Living Centers, Substance Abuse 
Programs, Long and Short-Term Rehabilitation Programs, and Women's 
Health Care?

    VA Response: Expanding peer support services beyond Mental Health 
is part of the overall strategic plan for the Office of Mental Health 
and Suicide Prevention (OMHSP). Therefore, VA recognizes the importance 
and the impact of peer support and is exploring expanding peer support 
into other areas as well, including, Community Living Centers (CLC), 
traumatic brain injury programs, and spinal cord injury programs; 
however, there is no immediate plan other than the Mission Act for such 
staffing currently. Decisions to support increasing the peer workforce 
are made at the local level and based on balancing local resources and 
clinical needs. OMHSP continues to encourage VISNs and facilities to 
expand peer support.

    Question 2: In response to the President's 2018 Executive Order on 
Transitioning Servicemembers, it was suggested that veterans should 
receive ``peer support for life.'' Why was this never fully realized- 
What barriers did you run into and what were some of the issues with 
the provision of peer support as described?

    VA Response: As part of the executive order there were barriers 
with executing one peer support number for service members and veterans 
that started when a service member joined the military and extended 
throughout the life of a veteran. DoD wanted to offer the peer support 
for just the first year after service members leave the military 
through their existing capability - Military One Source. This is what 
was completed. Subsequently VA began actions to develop a call center 
for ``peer support for the life of the Veteran'' - and those plans are 
well underway for completion.
    While VA strongly believes in the transformational power of peer 
support, we believe that any treatment option should be provided only 
as long as the Veterans with mental health conditions need that 
treatment. In a recovery-oriented health care system, the ultimate goal 
is to help the Veterans develop self-sufficiency so that they rely less 
on institutional care and more on the support of the community in which 
they live, which includes many formal and informal peer networks. While 
they may re-engage with peer support services when the need arises, 
providing ``peer support for life'' would be contrary to the concepts 
of recovery-oriented care. In addition, it would require a significant 
investment in additional staff, and such an investment would be better 
used to expand peer support to programs outside Mental Health.

Regarding VA's Transformation towards Whole Health Programs

    Question 1: As part of the VA's response to the President's 2018 
Executive Order to assist transitioning veterans in accessing seamless 
care, VA began offering ``Introduction to Whole Health'' sessions to 
newly transitioning veterans. However, the Whole Program has not been 
fully implemented at all facilities.

    Question 1a: How is VA serving veterans interested in Whole Health 
that may not have access to a facility that offers all components of 
Whole Health such as Yoga, Mindfulness, or Financial Counseling?

    VA Response: VHA Directive 1137 outlines specific requirements for 
the provision of complementary and integrative health services. This 
directive requires all facilities to offer evidence based Complementary 
and Integrative Health (CIH) approaches as part of standard medical 
benefits, when clinically appropriate, and includes acupuncture, 
biofeedback, clinical hypnosis, guided imagery, massage therapy, 
meditation, tai chi/qi gong, and yoga. These services need to be 
available either in house, in the community, online or via telehealth.
    Telehealth modalities are continuing to grow to facilitate a 
smoother Provider and Veteran experience of Whole Health and CIH. The 
most recent innovation is the VA Video Connect modality which is 
popular among both group and one-on-one TeleWholeHealth encounters such 
as Tele Coaching, Tele Facilitated Groups and TeleWholeHealth Clinical 
Care encounters. With this modality, Veterans can access their Health 
Coach or Provider from anywhere they have an internet connection. The 
provider and Veteran enter a virtual medical room where they can 
complete the encounter.
    VA's Whole Health System does not include non-health care benefits 
such as financial counseling.

Regarding Surveillance as Part of the Public Health Approach

    Question 1: Researchers from various organizations and companies 
often reach out to our offices seeking access to the wealth of data VA 
collects regarding veteran's healthcare and healthcare outcomes. It 
would seem, according to these scientists that VA is a VERY data rich 
environment. However, we still know very little about veterans and 
military personnel that complete suicide - especially the nearly 70% of 
those that never entered VA's healthcare system.

    Question 1a: How can we ensure VA, DoD, DHS, and HHS are sharing 
data in real-time so that the development of effective interventions is 
not further delayed?

    VA Response: Multiple data sets are available for suicide 
prevention by researchers funded by ORD. One specific highlight has 
been the development of a Memorandum of Agreement (MOA) between ORD and 
OMHSP for ORD researchers to access data from the Suicide Prevention 
Data Repository maintained by OMHSP and include DoD data that have been 
accessed by OMHSP. This MOA is an agreement by ORD to support OMHSP's 
ongoing work in the acquisition of vital status and cause of death data 
from the CDC National Death Index Plus.
    In collaboration with DoD, OMHSP has established the VA/DoD Suicide 
Data Repository (SDR) (also known as the Military Mortality Database), 
and, as authorized by the SDR's Board of Governance, has made these 
data available for all approved VA research projects. The SDR consists 
of results from VA/DoD searches of the NDI, with information regarding 
date and cause of death for Service members and those who have 
separated from the military, as well as data from DoD and the Veterans 
Benefits Administration (VBA). Support from ORD, which is committed to 
supporting this important OMHSP work that has important benefits for VA 
research and development, will now promote broader use of these data 
among ORD investigators.
    Additionally, analyses of these data will permit the identification 
and examination of Veterans who completed suicide and were not in VA's 
healthcare system. The strong collaboration between ORD and OMHSP is 
reflected in our continued sharing of the SDR data. During the period 
of October 2017 to April 2019, OMHSP has completed 84 requests for data 
from ORD from 70 investigators.
    Other activities of note include close collaboration with DoD on 
the Study to Assess Risk and Resilience in Service Members--
Longitudinal Study, as well as new funding opportunities that focus on 
at-risk Veterans in transition out of the military and on empowering 
them by funding public health and community interventions, based on 
rigorous surveillance and epidemiological data.

    Question 2: Hypothetically, if VA had access to the complete 
records of every veteran and military personnel that has completed 
suicide in the past 10 years, would VA have the technology necessary to 
fully analyze that data in-house?

    VA Response: Yes, we do have this capability in house, and in 
addition, VA and DoD have partnered with the Department of Energy Oak 
Ridge National Laboratory (ORNL) to enable use of advanced 
supercomputing to develop advanced analytics to assess and utilize 
information from VA and DoD data sources.

    Question 2a: If not, how can we allow VA access to such technology 
so that its researchers and investigators are well versed in its use 
once that magnitude of data is obtained?

    VA Response: The technology is available via partnership with ORNL. 
The partnership with ORNL is not a core funded resource and requires 
ongoing funding from VA and DoD that potentially limits sustainability.

Regarding the Development of Interventions as Part of the Public Health 
    Approach

    Question 1: How are you using assessments performed by both 
internal and external sources to guide your path forward?

    VA Response: The Institute of Defense Analyses (IDA) is currently 
examining our organizational relationships within Central Office and 
the field, especially as it relates to suicide prevention, and to 
identify opportunities for improvement. The goal is to improve support 
for frontline work done by local staff and the engagement of facilities 
with their local communities. IDA is a Federally Funded Research and 
Development Center that works in support of the government agencies.
    Pursuant to Title VII, Subtitle C, Sec.  726(c) of the National 
Defense Authorization Act of 2013, Public Law (P.L.) 112-239, Congress 
included a mandate for the National Academies of Sciences, Engineering, 
and Medicine (the National Academies) to conduct a study to assess the 
VHA's mental health care services and provide recommendations to assist 
VHA with improving its services. The National Academies appointed the 
Committee to Evaluate the Department of Veterans Affairs Mental Health 
Services assigned to comprehensively assess the quality, capacity, and 
access to mental health care services for Veterans who served in the 
Armed Forces in Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND). Findings of the committee included:

      The majority of OEF/OIF/OND Veterans report positive 
experiences with VA Mental Health Services;
      VA has a strong history of implementing innovative 
practices to expand reach and spread care to all Veterans;
      VA can improve awareness of how to connect with mental 
health care and streamline access for ease and expediency;
      VA can better use social media and telehealth to improve 
access and help seeking behavior while reducing stigma and barriers to 
mental health care; and
      VA can improve quality across facilities and 
subpopulations including recruiting adequate staff at facility that 
struggle to fill positions.

    OMHSP is actively engaged in review of the Committee's 
recommendations for inclusion in its strategic plan. VA is already 
engaged in active recruitment and incentives in hard to fill areas. As 
directed by EO 13822, VA is actively working to improve the transition 
experience and expedite connections of discharging service members to 
VA healthcare.
    Pursuant to the 2015 Clay Hunt Suicide Prevention for American 
Veterans Act (Clay Hunt SAV Act) P.L. 114-2, VA's mental health care 
and suicide prevention programs are evaluated annually. The first 
evaluation sent to Congress in December 2018 stated in key findings 
that ``Most of the mental health programs that could be evaluated 
demonstrated a positive impact on psychological well-being or 
functioning of the veterans who use them.''
    The Clay Hunt SAV Act was enacted to ensure that Veterans at 
highest risk of suicide have access to effective mental health and 
suicide prevention services provided by VHA. Although there was a small 
reduction in number of deaths from 2015-2016 in the most recent VA 
suicide data report, and despite the general effectiveness of VA mental 
health program, we have not yet produced the reduction in suicide among 
Veterans that we are so strongly dedicated to achieving.
    VA is aggressively working to do more, and VA has directed the team 
to work with the contractor who developed the annual report to 
determine how the next annual report can be restructured to more 
directly look at the impact of our mental health and suicide prevention 
programs on reducing and eliminating veteran death by suicide.

    Question 2: What are some of the most effective interventions VA 
currently utilizes? Have they been adopted nationwide? How are you 
tracking their successful implementation?

    VA Response: Some of VA's most effective nationally-available 
interventions include:

Suicide Risk Identification Strategy

    OMHSP has implemented a national, standardized process for suicide 
risk screening and evaluation, using high-quality, evidence-based tools 
and practices.

      The Primary Screen is a single item intended to broadly 
screen for individuals who may be at increased risk for suicide in all 
clinics. Those who screen positive receive the second level screen.
      The Secondary Screen is conducted using the C-SSRS. The 
C-SSRS consists of three to eight additional questions that 
specifically query about suicidal thoughts, plan, intent, and behavior. 
Those who screen positive receive the VA CSRE.
      The VA CSRE was developed by a team of subject matter 
experts to include evidence-based factors that may be used to determine 
acute and chronic risk levels and inform a risk management plan.
        This plan is developed to meet the individual needs of 
the Veteran and can be initiated at the time the Veteran is being seen 
and reporting suicidal ideation or behavior, regardless of setting 
type.
        Using one instrument across all VA settings will result 
in standardization of evaluation and management, thereby improving 
quality of care for at-risk Veterans and helping reduce stigma 
associated with discussions about suicide.
        Metrics are tracked weekly, monthly and quarterly, 
including numbers of Veterans screened at all 3 levels and in which 
settings.
        Since October 1, 2018, in ambulatory care more than 2.3 
million Veterans have received a standardized risk screen, with over 
70,000 receiving the secondary screener, with one-half of one percent 
being referred for a full clinical assessment. Over 90,000 Veterans in 
all settings have completed the CSRE, the full clinical risk 
assessment.

Patient Record Flag (PRF) - High Risk for Suicide and Enhanced Care

      Providers identify Veterans at potential high-risk for 
suicide, with a flag activated in the electronic medical record 
alerting all providers that see this Veteran, and refers the Veteran to 
the facility Suicide Prevention Coordinator (SPC) team for enhanced 
care that included the following:
        Completion of a Suicide Prevention Safety Plan 
including restriction of lethal means;
        Four follow-up appointments within 30 days of 
activation of the PRF or discharge;
        Ensuring follow-up for no-shows to scheduled mental 
health appointments
        Making personal contact;
        Establishing United States Postal Service mail contact; 
and
        Collaborating with the mental health provider and 
ensuring review and update of the PRF every 90 days.

      Numerous metrics are tracked and reported regularly, 
locally and nationally, to ensure compliance with directive, and 
trouble shoot barriers.

Dashboards to Aid Providers in Real Time

      REACH VET uses predictive (statistical) modeling to 
identify Veterans at risk for suicide and other adverse outcomes. The 
patients identified by the model are at increased risk for outcomes 
including suicide attempts, deaths from accidents, overdoses, injuries, 
all-cause mortality, hospitalizations for mental health conditions, and 
medical/surgical hospitalizations.
        Each facility has a REACH VET coordinator focused on 
implementing the program, engaging providers, and ensuring that 
providers are aware of which of their patients are at risk. Providers 
for Veterans identified are asked to review the care Veterans receive 
and to enhance as appropriate.
      STORM uses a predictive model to identify patients at-
risk for opioid overdose and suicide-related adverse events or death, 
specifically patients with active opioid prescriptions and patients 
with an opioid use disorder diagnosis in the past year. STORM provides 
patient-centered opioid risk mitigation strategies by displaying:
        Estimates of individual risk of opioid drug overdose or 
suicide based on predictive models;
        Risk factors that place patients at-risk;
        Risk mitigation strategies, including non-
pharmacological treatment options, employed and/or to be considered; 
and
        Patients' upcoming appointments and current providers 
to facilitate care coordination.
      SPPRITE dashboard unifies critical patient-level 
information for patients identified at high-risk for suicide through 
clinical determination and predictive models, specifically: HRF, STORM, 
REACH VET, PDE, positive C-SSRS and intermediate or above risk levels 
identified by the CSRE, so providers can:
        Engage in integrated case management of high-risk 
patients at their facility/on their patient panel;
        Enhance care coordination and communication with 
providers in other settings/programs;
        Facilitate outreach efforts;
        Track suicide risk screening and evaluation results: 
and
        Identify and reduce care gaps and ensure high levels of 
care for patients identified at high-risk for suicide.

VA Opioid Education and Naloxone Distribution Program (OEND)

      This program aims to reduce harm and risk of life-
threatening opioid-related overdose and deaths among Veterans.
      Key components of the OEND program include education and 
training of providers and Veterans regarding opioid overdose 
prevention, recognition of opioid overdose, opioid overdose rescue 
response, and issuing naloxone kits.
      The Opioid Safety Initiative Toolkit, developed in 
conjunction with the National Pain Management Program Office, contains 
resources and presentations that can aid staff in clinical decisions 
about starting, continuing, or tapering opioid therapy, and other 
challenges related to safe opioid prescribing.
        The toolkit is available at www.va.gov/painmanagement/
opioid--safety--initiative--osi.asp.

Operation S.A.V.E. Training

      In early 2017, VA implemented mandatory, annual Operation 
S.A.V.E. training for all VHA non-clinical staff. The Operation 
S.A.V.E. Training is an online suicide prevention video that was 
developed by VA in partnership with PsychArmor Institute and is 
publicly available to help everyone play a role in preventing Veteran 
suicide.
      Since its launch, 93 percent of VHA non-clinical staff 
are compliant with their assigned Operation S.A.V.E. or refresher 
Operation S.A.V.E trainings, and the video has been viewed over 18,500 
times on the PsychArmor website and social media platforms.
      VHA clinicians also engage in mandatory, initial training 
on suicide prevention/risk management and take yearly refreshers, with 
more than a 94 percent completion rate.

Suicide Prevention Coordinators

      As an integral part of Veterans' care teams implementing 
VA suicide prevention programs, SPC are experts on suicide prevention 
best practices. SPC work closely with other providers to ensure that 
Veterans living with mental health conditions and experiencing di-cult 
life events receive specialized care and support.
      Over 400 SPC nationwide support Veterans in VHA care who 
are at risk for suicide or who have attempted suicide. SPC also play an 
integral role in helping build networks of support outside of VA, by 
providing education, outreach, and engagement to Veterans, providers, 
and partners in the community. In 2017, SPC engaged over 1.5 million 
people at over 14,000 suicide prevention outreach events nationwide.

Regarding the Targeting of Interventions as Part of the Public Health 
    Approach

    Question 1: How is VA ensuring the modernization of the Electronic 
Health Records includes data collection necessary to the further 
development of effective interventions?

    VA Response: The native design of the VA's new electronic health 
record (EHR) solution will enable VA to capture an increased amount of 
discrete patient data. This increase in measurable and reportable data 
collected by the EHR solution, combined with the various commercial 
reporting and analytics tools integrated in the EHR's capabilities 
suite, will support VA in effectively intervening on behalf of at-risk 
Veterans. Cerner's extensive report writing tools allow access to all 
data captured within the EHR solution and will support VA's clinical, 
operational, and outcome reporting needs. The reporting interface will 
enable VA to run a variety of reports and identify opportunities for 
intervention.
    VA is currently configuring Cerner's population health and 
analytics platform, which will provide VA new data collection and 
aggregation methods and support improved outcomes not only for 
individual patients at the point of care, but for larger Veteran 
populations. Clinicians will have a comprehensive view of Veterans' 
health history, as the new EHR solution collects data from legacy EHR 
sources, claims data, pharmacy dispense data, and open source data. The 
platform cleans, normalizes, and reconciles the data, allowing 
clinicians to identify patients with care needs, assess risk, build a 
plan of care, and empower individuals, their families, and care 
providers to act in support of our Veterans.

    Question 2: How is VA ensuring the new EHR incorporates systems 
that will allow frontline providers and support staff to target those 
effective interventions to veterans that need them most?

    VA Response: VA's new EHR solution includes subsystems, 
capabilities, and solutions that provide decision support, 
recommendations, and alerts at the point of care enabling front-line 
personnel to provide effective interventions to Veterans in need. The 
EHR solution will increase the measurable data captured within 
Veterans' health records, support the data analysis process, and 
increase visibility of at-risk individuals. Capabilities embedded in 
the EHR solution allow VA to insert advanced decision support directly 
into care teams' workflows. Clinicians will be able to identify, score, 
and predict health risks of Veterans to implement targeted 
interventions. Care providers will be able to monitor both population-
wide interventions as well as Veteran-specific interventions using one 
EHR solution. Recommended interventions will be embedded within the 
user's workflow, prompting the clinician to take the requisite action 
before or during a Veteran's appointments. Clinicians will also have 
the ability to generate lists of patients with outstanding 
interventions in order to proactively engage those Veterans and assist 
in facilitating the necessary care. VA administrators can leverage EHR 
tools to analyze, monitor, and create targeted engagement strategies 
for populations of Veterans with similar needs.

Regarding Limiting Access to Lethal Means

    Question 1: Sixty nine percent of Veterans completed suicide via 
firearm. However, it has come to my attention [by staff from APA] that 
VA staff have been directed to stop using the term ``lethal means'' 
even though it is a standard phrase used throughout the mental health 
industry. Is this true? If so, what is your reasoning?

    VA Response: OMHSP has not stopped using the term ``lethal means.'' 
Current guidance on discussing lethal means with patients and 
stakeholders does include an observance of terminology on the part of 
the provider and avoiding terms that could potentially create 
opportunity for the patient to become defensive, as discussions related 
to firearms, specifically, can be harder to manage on the part of a 
provider, especially in times of higher risk.
    There is ongoing discussion in the field of lethal means as to 
which terms are best used in research, intervention, and messaging, 
with a focus on ensuring patients and stakeholders remain open to 
dialogue. For example, VA, in partnering with the National Shooting 
Sports Foundation (NSSF) and the American Foundation for Suicide 
Prevention (AFSP), is moving away from the term ``firearm safety'' when 
discussing lethal means and is now using the term ``safe firearm 
storage,'' as that is more direct and accurate in the goals of lethal 
means safety discussions. Currently, ``lethal means'' continues to be 
the terminology of choice.

    Question 2: During Committee Staff's recent trip to the Phoenix VA 
Medical Center, VA staff stated that approximately 800-gun locks are 
given away to veteran patient's each week. These locks are not issued 
by staff, but rather placed in areas such as primary care, mental 
health, and women's health clinics, as well as, in the Emergency Room 
so that veterans can take them without fear of being judged or tracked.

    Question 2a: What is other ways VA is ensuring veterans are fully 
aware of the staggering amount of suicides completed via firearm? And 
what resources, besides gun locks and video training, does VA offer to 
veterans that may choose to limit their access to firearms?

    VA Response: VA has implemented a new, nationally-standardized 
Suicide Prevention Safety Planning Template that ensures Veterans 
receive high-quality suicide prevention safety plans through 
collaboration with their providers and will facilitate the reporting 
and analysis of utilization, completion, and timing of safety planning. 
Access to lethal means are addressed within the safety plan. Safety 
plans are meant to be innovative, individualistic, and geared toward 
feasible actions that can be taken to reduce access to lethal means. 
Not all Veterans have access to the same opportunities, whether in 
their homes or in the community. For example, some states allow gun 
shops to store firearms from individuals, while others do not. When 
developing safety plans with Veterans, VA providers focus on being 
collaborative and innovative, with an emphasis on realistic actions 
that put time and space between suicidal thought and actions.
    Safety Planning is mandated for all Veterans who have a PRF High 
Risk for Suicide flag and recommended for Veterans who have made a 
recent suicide attempt, express suicidal ideation, or have otherwise 
been determined to be at high or intermediate acute or chronic risk for 
suicide, based on a comprehensive suicide risk assessment.
    VA is working to provide suicide prevention training throughout all 
offices. For example, we are working with the Office of Geriatrics and 
Extended Care on how to have conversations around firearm safety with 
Veterans and their family members with dementia. We recently hosted a 
training for SPCs about lethal means safety and how to have 
conversations with Veteran patients about safe storage. This training 
will be available to all VA providers through our internal training 
platform.
    VA has also partnered with AFSP and NSSF to develop a program 
guided by a toolkit to facilitate community engagement in suicide 
prevention and firearm safety to decrease risk for firearm suicide 
among service members and Veterans. The program aims to:

      Educate the community about the significance of safely 
storing firearms when not in use and motivate engagement in safe 
storage practices;
      Increase awareness that suicide is preventable and 
endorse the role of safe storage to reduce firearm injury; and
      Educate firearm owners, family members, and friends about 
ways they can help prevent suicides by firearm.

Regarding Interventions for the Aging Veteran Population

    Question 1: Male veterans age 55 and older had the highest count of 
suicide according to the 2016 National Suicide Data Report. Kaiser 
Health News and PBS NewsHour also found that an alarming number of 
seniors, not only veterans, are committing suicide in Long Term Care 
Facilities. The article suggests that depression, debility, access to 
deadly means, and disconnectedness are the main risk factors for senior 
suicide.

    Question 1a: How is VA working to track these risk factors in its 
Community Living Clinics? How are CLC staff being trained to deliver 
interventions in response to veterans that exhibit these risk factors?

    VA Response: As part of the VHA Suicide Risk Identification 
Strategy, Veterans admitted to a CLC must be screened for suicide risk 
within 24 hours of admission and 24 hours before discharge from the 
CLC. Those screening positive must be engaged in secondary screening 
and, if positive, a comprehensive suicide risk evaluation must be 
completed within that same 24-hour timeframe. In order to support CLC 
teams in addressing this requirement, guidance entitled VHA Suicide 
Risk Screening and Evaluation Standards: Guidance Regarding Application 
to Community Living Center Practice was developed and disseminated 
nationally. An educational webinar devoted to this topic was also 
developed.
    In addition, every employee is required to take Operation S.A.V.E. 
Training for Employees which focuses on recognizing and addressing 
signs of suicide risk (Signs of suicidal thinking should be recognized; 
Ask the most important question of all; Validate the Veteran's 
experience; Encourage treatment and Expedite getting help). Every 
employee is also required to take an annual refresher in this training.

    Question 2: How does VA track suicide attempts and death by suicide 
in its Community Living Clinics?

    VA Response: Each CLC is required to report suicide attempts and 
completed suicides to the leadership of the Medical Center, the 
Veterans Integrated Service Network, and to VA Central Office.

    Question 3: What is the readmission policy surrounding previously 
suicidal veterans once they have been treated for their mental health 
concerns?

    VA Response: If a CLC resident becomes acutely suicidal, he/she 
will be transitioned to an inpatient mental health care setting with an 
environment of care designed for safety of individuals at risk for 
suicide. Once that individual has stabilized, he/she may be re-admitted 
to the CLC with a clear plan for monitoring risk and supporting the 
Veteran's safety.

    Question 4: Does VA intend to offer peer support in its Community 
Living Clinics?

    VA Response: Expanding peer support services beyond Mental Health 
is part of the overall strategic plan for OMHSP. While peer support 
has, to date, been primarily focused on mental health settings, it has 
expanded to Primary Care as a result of an Executive Action in 2014, 
which required Peer Specialists in the Patient Aligned Care Teams 
(PACT) in 25 facilities. The MISSION Act now requires Peer Specialists 
in PACT in 30 facilities. There have also been discussions to expand 
peer support into the CLCs, however, there is no immediate plan for 
such staffing at this time.

    Question 5: Does VA intend to offer the Whole Health Program at its 
Community Living Clinics?

    VA Response: VA CLCs offer Whole Health Programs to the residents 
who live there. As stated above, the medical benefits package includes, 
as clinically appropriate, biofeedback, clinical hypnosis, guided 
imagery, meditation, yoga, Tai Chi/Qi Gong, massage therapy, and 
acupuncture. VHA has also identified optional approaches that are 
generally considered to be safe, such as aromatherapy. As VA continues 
to implement Whole Health throughout the system, CLCs are participating 
and included in this effort.

    Question 6: How is VA ensuring aging veterans enjoy a high quality 
of life at its Community Living Clinics?

    VA Response: VA CLCs have focused for many years on creating a 
culture of individualized, Veteran-Centered care to address each 
resident's values and preferences. The resident is asked on admission 
about his/her daily routine and preferences in care. These are 
incorporated as much as possible into the resident care plan and goals 
for their stay in the CLC. The resident and/or family is part of the 
interdisciplinary care team that establishes the plan while the 
resident lives in the CLC.
    For residents with dementia-related distress behaviors (e.g., 
agitation, aggression), the Staff Training in Assisted Living 
Residences (STAR-VA) program has trained teams in a majority of CLCs to 
provide resident-centered, interdisciplinary behavioral care that 
emphasizes each Veteran's individualized needs and preferences; the 
STAR-VA intervention includes a focus on integrating individualized 
``pleasant events'' into each Veteran's daily life.

    Question 7: More broadly, given that depression presents 
differently in older adults, how has VA adjusted its screenings for 
this cohort?

    VA Response: VHA's primary depression screening tool, the Patient 
Health Questionnaire (PHQ) 2, has been demonstrated to be a valid 
screening tool for major depression in older adults. The full PHQ-9, 
which includes the PHQ-2, is integrated into the Resident Assessment 
Instrument Minimum Data Set 3.0 questions for every new CLC resident, 
as required in all nursing homes in the United States. For residents 
who are unable to complete self-report on this instrument due to 
moderate/severe cognitive impairment, there is a staff observation 
version, ``Staff Assessment of Resident Mood.''
    In addition, the Geriatric Depression Scale, a validated tool for 
screening for depression among older adults, is available for use by VA 
clinicians via an electronic health record template.

Gaps in Medical Training

    Question 1: Dr. Avenevoli or Dr. McKeon, could one or both of you 
elaborate on the existing gaps in formal medical training for suicide 
risk assessment and management and the impact that has, as America as a 
whole, adopts this public health approach to suicide? (NOTE: THIS IS 
NOT A QUESTION FOR VA TO ANSWER).

    Question 1a: Dr. Stone, would you agree that VA plays a significant 
role in educating America's future medical workforce?

    VA Response: Yes. VA conducts the largest education and training 
effort for health professionals in the United States. In 2018, 120,890 
trainees received some or all of their clinical training in VA. VA's 
physician education program is conducted in collaboration with 145 of 
152 Liaison Committee Medical Education accredited medical schools, and 
34 out of 35 Doctor of Osteopathic granting schools (American 
Osteopathic Association accredited medical schools). In addition, more 
than forty other health professions are represented by affiliations 
with over 1,800 unique colleges and universities. Among these 
institutions are Minority Serving Institutions such as Hispanic Serving 
Institutions and Historically Black Colleges and Universities. Over 60 
percent of all U.S.-trained physicians, and 70 percent of VA physicians 
have had VA training prior to employment. Approximately 50 percent of 
U.S. psychologists and 70 percent of current VA psychologists and 
optometrists have had VA training prior to employment.
    VHA conducts education and training programs to enhance the quality 
of care provided to Veterans within the VA health care system. Building 
on the long-standing, close relationships among VA and the Nation's 
academic institutions, VA plays a leadership role in defining the 
education of future health care professionals that helps meet the 
changing needs of the Nation's health care delivery system. Title 38 
U.S.C. Sec.  7302 mandates that VA assist in the training of health 
professionals for its own needs and those of the Nation.

    Question 1b: In that case, what is VA doing to ensure the 70 
percent of medical professionals who spend time at VA receive adequate 
training and exposure to suicide risk assessment and management?

    VA Response: It is VHA policy that all VHA employees must complete 
their required suicide risk and intervention training module (either 
Suicide Risk Management Training for Clinicians or Operation S.A.V.E. 
training for non-clinicians) and, for providers/clinicians, pass the 
post-module test within 90 days of entering their position. It is also 
policy that all employees must complete the appropriate annual 
refresher training specific to their position (Operation S.A.V.E. 
Refresher Training for non-clinicians or Suicide Risk Management 
Training for Clinicians). VHA has also developed a Suicide Risk 
Management Training for Registered Nurses that may be assigned annually 
as an alternative training option to Suicide Risk Management Training 
for Clinicians, understanding that the roles may be different in some 
cases.

Staffing

    Question 1: A number of VA OIG reports on VA's efforts to reduce 
veteran suicide found issues, weaknesses, or mistakes by Suicide 
Prevention Coordinators. Our Suicide Prevention Coordinators are 
central to so many of VA's efforts to reduce veteran suicides.

    Question 1a: In your opinions Dr. Stone and Franklin, do the 
workloads and responsibilities of these Coordinators align with the 
resources they are provided?

    VA Response: The National Suicide Prevention Program (SPP) 
recognizes that SPC are the ``frontline'' in the fight to end Veteran 
suicide, however SPC are not adequately resourced currently. To support 
that effort, SPP has been pushing the Secretary's Mental Health Hiring 
Initiative (MHHI), currently ongoing since July 2017, which addresses 
increasing the number of SPCs in the field, as well as retention of 
SPCs.

    Question 1b: Currently, how many vacancies are there in these roles 
across VA?

    VA Response: SPC occupy a variety of mental health occupations and 
data is tracked by occupational series. Currently, there are 2,696 
vacancies (10.5 percent rate) for all Mental Health occupations.

    Question 1c: Given the nature of the work, are these roles 
susceptible to high turnover rates?

    a.If yes, what do the exit surveys tell us about why these critical 
staffers are leaving? And what is being done to address these findings?

    VA Response: The turnover rates for the mental health occupations 
are typical of other VHA occupations. We do not have data to report if 
turnover is high for SPC nor do we have exit surveys for this specific 
cohort, as SPC occupy a variety of mental health occupations and this 
data is tracked by occupational series; however, turnover is not high 
for mental health occupations. The attached table shows detailed 
vacancy and onboard data for all mental health occupations. Tab 1 shows 
onboard as of April 30, 2019, and loss rates for FY 2018 and Tab 2 
shows vacancies and vacancy rates as of December 31, 2018.
    Reasons for leaving VA for all mental health occupations cannot be 
determined currently. We do have information on psychologists. The top 
two reasons psychologists leave are advancement opportunity (44 percent 
of respondents endorsed) followed by personal/family reasons (24 
percent of respondents endorsed). Psychologists have been shown to be 
extremely positive in their assessment of their VA employment 
experience.

Family & Provider Support

    Question 1: Following the tragic loss of a veteran from suicide, 
thoughts and prayers are sent to their loved ones. I suspect it is 
particularly distressing for the psychiatrists, psychologists, social 
workers and nurses in mental health who provided direct care. 
Naturally, the process of case review for completed suicides may pose a 
particular challenge for these team members. Many are interested in 
better understanding potential missteps or ways to better engage their 
patients in care.

    Question 1a: Dr. Stone, could you outline how VA creates an 
environment of support, free of judgement, for frontline staff impacted 
by a patient's suicide?

    VA Response: Facility Suicide Prevention Staff, Chaplain Services, 
and Clinic Coordinators offer support to VA staff impacted by a Veteran 
suicide. The VA Suicide Risk Management Consultation Program offers 
postvention consultation and support to staff members affected by a 
Veteran suicide. In addition, employees are encouraged to use the 
Employee Assistance Program and local community resources if further 
assistance is needed processing the suicide after the initial crisis 
period. VA also has suicide postvention teams that assist with the 
notification of suicides and provide support for affected staff. 
Postvention educational materials are underway.
    Uniting for Suicide Postvention (USPV) was created to offer a 
community of shared healing to connect family members, friends, co-
workers, providers, and workplace supervisors who have been touched by 
suicide loss. The USPV website will house infographics, films, and 
resources designed to support ANYONE who has lost someone to suicide 
with anticipated completion in summer of 2019. The USPV podcast series 
is available to learn more about suicide postvention topics, visit 
https://www.mirecc.va.gov/visn19/education/media/#PostventionPodcasts

    Question 2: I think we can all agree it is important to surround a 
vulnerable individual, such as a suicidal veteran, with support. Often, 
we find support amongst our family, friends, and colleagues.

    Question 2a: How is VA ensuring that those closest to veterans are 
prepared to identify risk factors and empowered to connect that veteran 
with the resources he or she may need - such as a mental health 
professional or the veteran's crisis line?

    VA Response: Every day, more than 400 VA SPC and their teams, 
located at every VAMC, connect Veterans with care and educate their 
surrounding communities about suicide prevention programs and 
resources. VA is partnering with hundreds of organizations and 
corporations at the national and local levels - including Veterans 
Service Organizations, professional sports teams, and major employers - 
to raise awareness of VA's suicide prevention resources and educate 
people about how they can support Veterans and service members in their 
communities.

    Some specific resources include:

      The VCL connects Servicemembers, Veterans, and their 
families and friends with qualified, caring VA responders through a 
confidential toll-free hotline, online chat, or text. Veterans and 
their loved ones can call 1-800-273-8255 and Press 1, chat online, or 
send a text message to 838255 to receive confidential crisis 
intervention and support 24 hours a day, 7 days a week, 365 days a 
year. More information is available at https://
www.veteranscrisisline.net/.
      The #BeThere campaign emphasizes that everyday 
connections can make a big difference to someone going through a 
difficult time and that individuals don't need special training to 
safely talk about suicide risk or show concern for someone in crisis. 
Learn more at VeteransCrisisLine.net/BeThere.aspx.
      Make the Connection provides Veterans, their family 
members and friends, and other supporters with information on and 
solutions to issues affecting their lives. Visit MakeTheConnection.net/
Conditions/Suicide.
      Coaching Into Care is a national telephone service from 
VA that aims to educate, support, and empower family members and 
friends who are seeking care or services for a Veteran. Call (888) 823-
7458 to learn more.
      PsychArmor Institute's Operation S.A.V.E. online training 
describes how to talk with Veterans who may have suicidal thoughts and 
provides specific recommendations for what to do and say during these 
critical conversations. Watch the Operation S.A.V.E. video at 
psycharmor.org/courses/s-a-v-e. This training is also available 
directly on YouTube.
      Walgreens has partnered with VA to help reduce the stigma 
about mental health and help seeking behaviors among Veterans and has 
worked to trained staff at their health clinics in the warning signs of 
suicide.
      The Warrior Wellness Alliance, part of the George W. Bush 
Institute, is organizing best-in-class peer support and mental health 
providers, including VA, to find innovative ways that post 9/11 
Servicemembers and Veterans can reach peer support services and mental 
health services nearest to where they live. CaringBridge is a global 
nonprofit social network dedicated to helping family and friends 
communicate with and support loved ones during any health journey 
through the use of free personal websites. A CaringBridge Web site can 
be used to share updates and coordinate support for Servicemembers, 
Veterans, their caregivers and families during any health journey 
including mental health and substance use. Through the partnership with 
VA and CaringBridge, a tailored destination page www.caringbridge.org/
military-service/ to directly focus on the needs of Servicemembers, 
Veterans, caregivers and their families is now available.

    Question 2b: What barriers have you identified that would prohibit 
the distribution of information and access to training for these 
families, friends and colleagues?

    VA Response: We do not see any barriers. Preventing Veteran suicide 
is VA's top clinical priority. However, not all Veterans receive 
services from VA. To accomplish its goal of reducing suicide rates 
among all Veterans, the SPP is using innovative strategies and 
partnerships to serve Veterans who do not-and may never -seek services 
within the VA health care system. VA's public health approach to 
suicide prevention is driven by data and best practices and looks 
beyond the individual to involve peers, family members, and the 
community. This comprehensive view considers the full range of factors, 
including those unrelated to mental health, that contribute to risk for 
suicide. Using the public health approach, the Suicide Prevention 
Program can deliver resources and support to Veterans earlier -before 
they reach a crisis point. No single group can effectively prevent 
Veteran suicide. To save lives, multiple systems must work in a 
coordinated way to reach Veterans where they are.
    Operation S.A.V.E. Training is available for anyone who cares 
about, or interacts with, Veterans and can be taken on the PsychArmor 
Web site at psycharmor.org or directly on YouTube. This training 
provides an understanding of the problem of suicide in the United 
States; how to identify a Veteran who may be at risk for suicide; and, 
finally, teaches what to do if they identify a Veteran at risk.

      VA has partnered with Objective Zero Foundation which is 
a nonprofit organization that uses technology to enhance social 
connectedness and improve access to mental health resources. The 
Objective Zero mobile application connects Servicemembers, Veterans, 
their families, and caregivers to peer support through 
videoconferencing, voice calls, and text messaging. Users also get free 
access to resources on mental health and wellness. Volunteer 
ambassadors sign up for the application, receive training including 
VA's own Operation S.A.V.E. Training course to then be on the receiving 
end of those in need of connecting. Objectize Zero aims to be more 
upstream than the Veterans Crisis Line and allows Servicemembers, 
Veterans their families and caregivers to both volunteer and connect to 
others when they need it most. You can download the free Objective Zero 
mobile application at https://www.objectivezero.org/app .
      Through its suicide prevention partnership with The 
Independence Fund, VA is helping to provide wellness and mental health 
education to Servicemembers and Veterans who are reunited with their 
former military units to enhance social connection and prevent suicide.

Questions from Congresswoman Julia Brownley

    Question 1: Drs. Stone and Franklin: As you know, a 2018 VA OIG 
report found that 49 percent of military sexual trauma-related claims 
were incorrectly denied, meaning that women and men were perhaps not 
receiving the benefits they were owed. Obviously, MST is linked to the 
topic of this hearing. Can you provide information on what the VA is 
doing to correct these mistakes? Are each of these denied claims being 
reviewed to ensure accuracy and that veterans receive the care they are 
owed?
    VA Response: VBA implemented a plan to conduct a review of denied 
military sexual trauma (MST)-related claims decided between October 1, 
2016, through June 30, 2018, and take corrective actions based on the 
review if an incorrect decision was made. On November 14, 2018, VBA 
began the first phase of its plan at the Columbia Regional Office (RO) 
to validate the process established for the review. The second phase of 
the review began in March 2019. VA has added the Muskogee, Cleveland, 
Huntington, and Portland ROs to the review. All reviews are expected to 
be completed by September 30, 2019.
    VBA released and mandated two training courses for those employees 
who have been designated by their ROs as MST processors. The first, 
``MST Checklists'' - TMS #4483955 - was mandated for completion by 
October 31, 2018. The second, ``Military Sexual Trauma (MST): Claims 
Development and Rating'' - TMS 4500994 - was released on April 12, 
2019, with a mandated completion date of May 31, 2019. VBA also teaches 
``MST - Soft Skills Training'' - TMS #4177413 - as part of the Veterans 
Service Representative / Rating Veterans Service Representative after-
Challenge training curriculum.
    On November 2018, VBA required stations to designate specially 
trained VSRs and RVSRs to process MST-related claims. Additionally, VBA 
updated its adjudication manual specifying that all rating decisions on 
MST claims are subject to a second signature review until the 
specialized RVSR demonstrates an accuracy rate of 90 percent or greater 
based on a review of at least 10 MST cases.
    VBA is planning to conduct a special focus quality review of denied 
MST claims during FY 2019. This review will be completed by October 
2019. Errors found during this review will be returned to field offices 
to take corrective action.
    Receipt of MST-related health care is separate from the disability 
and compensation claims process. Veterans do not need for their MST-
related conditions to be service-connected to receive free MST-related 
care. Nor do they need (as a condition precedent) to be enrolled in 
VA's health care system or eligible for other VA care. For example, the 
minimum length of active-duty service requirements does not apply to 
those covered by the special MST-treatment authority. Nor do Veterans 
need to have reported their MST experiences while still in the Armed 
Forces or have other service documentation to receive a request for 
MST-related care.

    Question 2: Drs. Stone and Franklin: During your testimony, you 
discussed a national network of Women's Mental Health Champions. Can 
you provide more background on this program, the duties and 
responsibilities of these champions, and the practices they use to 
support women's mental health?

    VA Response: VA has a national network of Women's Mental Health 
Champions at every VAMC. The Women's Mental Health Champion position 
was developed in 2016 to ensure at least one point of contact for 
Women's Mental Health within each VA healthcare system. The Women's 
Mental Health Champion role is a collateral position which means they 
perform these responsibilities outside of their clinical assignment. A 
minority of Champions receive some protected time for this position. 
None is full-time.
    Champions disseminate information, facilitate consultations and 
support the development of women's mental health resources at their 
local facility. Specific duties vary by site, local priorities, and 
resources.
    All Women's Mental Health Champions undergo specialized training in 
women Veterans' mental health, including completion of a Women's Mental 
Health Mini-Residency. The Women's Mental Health Mini-Residency is an 
intensive, three-day clinical training during which nationally 
recognized experts lead sessions on a broad range of topics related to 
the treatment of women Veterans, including gender-tailored 
psychotherapies and pharmacotherapies, with a focus on the influence of 
hormonal changes and the reproductive cycle. As part of the mini-
residency curriculum and requirements, all Champions are required to 
apply new learning by developing and implementing an Action Plan to 
improve women's mental health clinical resources at their local 
facilities. Collaboration with local stakeholders is strongly 
encouraged and all plans are reviewed by facility mental health 
leadership prior to initiation. Action Plans commonly include the 
development of gender-sensitive mental health intake processes, 
screening strategies and/or new treatment options. Gender-sensitive 
intake and screening strategies, for example, include standardized 
processes to better identify disordered eating, sexual trauma-related 
sexual dysfunction, and exacerbations of mental health problems during 
perimenopause. Gender-sensitive treatment approaches include gender-
tailored pharmacotherapy considerations (e.g., when working with women 
who are pregnant or planning to become pregnant) and psychotherapy 
approaches that target women's unique mental health treatment needs, 
such as Skills Training in Affective and Interpersonal Regulation 
(STAIR). STAIR addresses areas of functioning that are often disrupted 
in female survivors of severe interpersonal traumas, such as sexual 
assault, including teaches skills for managing strong emotions and 
building healthy interpersonal relationships (including parenting 
relationships).

    Question 3: Studying suicide and developing medications to prevent 
it has been challenging. To prevent suicides, one successful approach 
so far has been treating related mental health conditions. Do you think 
that suicide prevention should focus on treating underlying conditions 
such as Schizophrenia, Bipolar, Depression and PTSD or is there another 
approach you favor?

    VA Response: There is no single cause of suicide. Suicide is often 
the result of a complex interaction of risk and protective factors at 
the individual, community, and societal levels. Certain mental health 
conditions are risk factors for suicidal behavior, and efforts should 
be made to treat these conditions in Veterans with evidence-based 
approaches. The mental illnesses identified are impairing and a 
significant cause of morbidity and mortality, warranting treatment 
independent of the impact on death from suicide.
    Other risk factors for suicide include prior suicide attempt 
history, access to lethal means, and stressful life events, such as 
divorce, job loss, or the death of a loved one. Suicide prevention 
efforts should focus on minimizing risk factors and promoting 
protective factors that help to offset these risk factors. Some 
protective factors for suicide include access to mental health care, 
feeling connected to other people, and positive coping skills.

    Question 4: PTSD is a major factor in many Veteran suicides, but a 
recent VA report found that ``most [PTSD] patients are treated with 
medications or combinations for which there is little empirical 
guidance regarding benefits and risks,'' and there is ``no visible 
horizon for advancements in medications that treat.PTSD.'' This is a 
big challenge. How is the VA positioning itself to reduce barriers to 
partnerships on clinical trials and big data research and work with 
companies of all sizes to encourage new therapies and diagnostics for 
PTSD?

    VA Response: VA Research has been positioning itself to develop 
partnerships for supporting our efforts on advancements in medications 
for posttraumatic stress disorder (PTSD), beginning with a published 
statement at https://doi.org/10.1016/j.biopsych.2017.03.007 that we 
need attention on this issue. The VA PTSD Psychopharmacology Initiative 
has since conducted an industry day, outreach with partners, and 
investigator training. We have launched multiple new medication trials 
as a result, with a goal to be supporting 12 clinical trials of 
medications for PTSD by 2020. In addition to medications, we are 
focused on the potential testing of new therapies and diagnostic 
approaches.

Questions from Congressman Chris Pappas

    Question 1: Dr. Franklin: I appreciate your response to my question 
on providing care for transgender veterans in light of the 
implementation of the ban on their serving openly in the Armed Forces. 
Could you please elaborate on what specifically VHA/VA is doing to 
ensure a ``positive handoff'' of these service members from DOD to VA, 
recognizing their increased risk for suicidal ideations?

    VA Response: Through the Joint Action Plan developed under EO 
13822, ``Supporting Our Veterans During Their Transition from Uniformed 
Service to Civilian Life,'' all transitioning Servicemembers are 
receiving mental health screening by DoD prior to military separation. 
Data sharing logistics of this mental health screening between VA and 
DoD are currently in process with a plan to share all data to allow for 
appropriate referrals to VA mental health care for eligible Veterans 
and DoD's inTransition program. Those Servicemembers who have had 
contact with mental health care in the year prior to transition are 
contacted by inTransition coaches within 30 to 90 days prior to 
separating from the military. The inTransition coaches initiate contact 
with Servicemembers via phone to offer assistance with transitioning 
into VA mental health care, as appropriate. These efforts benefit all 
transitioning Servicemembers and Veterans in the effort to ensure 
access and capture all Servicemembers and Veterans in need of mental 
health services, including those who are transgender.

                                 
                          Chairman Mark Takano

Regarding the Public Health Model (Generally):

    1. How does VA collect and use data on veteran suicides to inform 
its prevention efforts?

    a. For example, how does VA examine various factors (e.g. location 
of the suicide, last contact with a VA health care provider) and use 
this information in all of its suicide prevention programs (not just 
REACH VET)?

    b. How does VA collect and use data to ``target groups'' like 
female veterans?

    2. How do VA and DOD share data with each other to help prevent 
veteran suicides?

    a. Are there any challenges with collecting and/or accessing data 
across agency lines?

Regarding REACH VET Predictive Analysis Modeling:

    1. Has VA monitored whether all VISNs and VAMCs have successfully 
implemented REACH VET in all required patient care settings?

    2. How has VA ensured that VHA providers responsible for conducting 
VA's new standardized suicide risk screening and assessment processes 
have been properly trained in this process?

Regarding the Executive Order on a National Roadmap to Empower Veterans 
    and End Suicide:

    1. As part of the March 5th Executive Order on Suicide Prevention, 
the President calls for the creation of a task force that will, among 
other things, develop a plan to be known as the President's Roadmap to 
Empower Veterans and End a National Tragedy of Suicide, or PREVENTS, 
within one year of March 5, 2019. It has been more two months since the 
issuance of the order and details have been scarce.

    a. Could you inform the Committee who has been assigned to 
represent the various agencies and organizations listed as part of this 
task force?

    2. The March 5th Executive Order on Suicide Prevention requires the 
development of (1) a grant-based system to assist in the coordination 
of federal, state and local resources available to veterans, (2) a 
research strategy and metrics to quantify the progress of research to 
prevent suicides, and (3) a legislative strategy to support the steps 
associated with greater coordination and research.

    a. Given the importance of research, does the administration intend 
to assign a representative from VA's Office of Research Development to 
the taskforce as a designee of the taskforce?

Regarding the Support Systems (State and Local) Needed as Part of the 
    Public Health Approach:

    1. The Arizona Coalition for Military Families has spent the last 
decade developing the BE CONNECTED Program. For those that are not 
aware, this program connects veterans in need of resources such as 
financial counseling, legal assistance, or transportation to both VA 
and Community-based regionally specific resources. I understand the 
intent of the EO on Suicide Prevention is to expand this pilot program 
nationwide.

    a. Because the resources are specific to a region, such as a county 
or zip code, it seems most effective to set up state-based agencies or 
organizations similar to Arizona's Coalition to collect, review, 
organize, and oversee these resources. What barriers do you foresee to 
its expansion nationwide?

Regarding the Budget for Suicide Prevention:

    1. In 2018, the President signed an Executive Order focused on 
creating a seamless transition between DoD and VA mental healthcare for 
transitioning servicemembers. This EO required the development of a 
Joint Action Plan and status update 6 months following the development 
of the Joint Action Plan. The development of these strategic planning 
documents has allowed veterans, stakeholders, and Congress to more 
easily envision the ultimate goal of the EO, as well as to track the 
agency's progress toward the completion of the EO's goals. As part of 
your 2020 budget request, you've asked for a 63% increase in funds for 
``implementation of the National Strategy on Preventing Veterans 
Suicide.''

    a. In an effort to better assist veterans and stakeholders 
understanding of your ``ultimate goal'' and to assist Congress in 
oversight, would you commit to developing an ``Action Plan'' that lays 
out each of the 14 goals, reliable metrics by which you intend to judge 
success, and targets, including dates, that reflect what that 
``success'' looks like?

    2. Over the last few years, VA has shifted towards a ``public 
health'' approach to suicide prevention. You've described community 
engagement as a central part of this new approach. However, you've only 
requested an increase of $275,000 for ``Local Facility and Community 
Outreach and Activities.''

    a. How does VA intend to leverage this additional $275,000 to begin 
creating the community support that will be integral to the ``public 
health'' approach that is currently being pursued by VA?

Regarding Trans Veterans:

    1. As a result of the President's April 12 ban on transgender 
people serving in the armed forces, we have heard from advocacy groups 
and health care providers about the increased likelihood the ban will 
trigger increased suicidality amongst trans veterans.

    a. What is the VA doing to reach out to these veterans who are 
particularly vulnerable?

    b. What interventions have been developed that are specific to this 
population?

Regarding Native American Veterans:

    1. American Indians and Alaska Natives (AI/AN) have a 
disproportionately high rate of suicide-more than 3.5 times those of 
racial/ethnic groups with the lowest rates, according to a 2019 CDC 
study. And the rate has been steadily rising since 2003.

    a. What is VA doing to ensure tribal veterans have access to 
suicide prevention outreach?

Regarding Women Veterans:

    1. Dr. Franklin: Women veterans die by suicide at twice the rate of 
non-veteran women. What are some of the factors unique to women 
veterans that put them at greater risk of suicide?

    a. How is VA improving peer-support programs for women veterans?

Regarding Peer Support Specialists:

    1. VA has found peer support specialists to be an integral part of 
increasing access to VA's mental health programs. These specialists 
also often offer assistance accessing other parts of VA such as VBA and 
even NCA services.

    a. Does VA intend to expand this program and the training 
associated with it to service lines outside of Primary Care and Mental 
Health Care? For example, to Community Living Centers, Substance Abuse 
Programs, Long and Short-Term Rehabilitation Programs, and Women's 
Health Care?

    2. In response to the President's 2018 Executive Order on 
Transitioning Servicemembers, it was suggested that veterans should 
receive ``peer support for life.'' Why was this never fully realized? 
What barriers did you run into and what were some of the issues with 
the provision of peer support as described?

Regarding VA's Transformation towards Whole Health Programs:

    1. As part of the VA's response to the President's 2018 Executive 
Order to assist transitioning veterans in accessing seamless care, VA 
began offering Intro to Whole Health sessions to newly transitioning 
veterans. However, the Whole Program has not been fully implemented at 
all facilities.

    a. How is VA serving veterans interested in Whole Health that may 
not have access to a facility that offers all components of Whole 
Health such as Yoga, Mindfulness, or Financial Counseling?

Regarding Surveillance as Part of the Public Health Approach

    1. Researchers from various organizations and companies often reach 
out to our offices seeking access to the wealth of data VA collects 
regarding veteran's healthcare and healthcare outcomes. It would seem, 
according to these scientists that VA is a VERY data rich environment. 
However, we still know very little about veterans and military 
personnel that complete suicide - especially the nearly 70% of those 
that never entered VA's healthcare system.

    a. How can we ensure VA, DoD, DHS, and HHS are sharing data in 
real-time so that the development of effective interventions are not 
further delayed?

    2. Hypothetically, if VA had access to the complete records of 
every veteran and military personnel that has completed suicide in the 
past 10 years, would VA have the technology necessary to fully analyze 
that data in-house?

    a. If not, how can we allow VA access to such technology so that 
its researchers and investigators are well versed in its use once that 
magnitude of data is obtained?

Regarding the Development of Interventions as Part of the Public Health 
    Approach:

    1. How are you using assessments performed by both internal and 
external sources to guide your path forward?

    2. What are some of the most effective interventions VA currently 
utilizes? Have they been adopted nationwide? How are you tracking their 
successful implementation?

Regarding the Targeting of Interventions as Part of the Public Health 
    Approach:

    1. How is VA ensuring the modernization of the Electronic Health 
Records includes data collection necessary to the further development 
of effective interventions?

    2. How is VA ensuring the new EHR incorporates systems that will 
allow frontline providers and support staff to target those effective 
interventions to veterans that need them most?

Regarding Limiting Access to Lethal Means:

    1. 69% of Veterans completed suicide via firearm. However, it has 
come to my attention [by staff from APA] that VA staff have been 
directed to stop using the term ``lethal means'' even though it is a 
standard phrase used throughout the mental health industry. Is this 
true? If so, what is your reasoning?

    2. During Committee Staff's recent trip to the Phoenix VA Medical 
Center, VA staff stated that approximately 800-gun locks are given away 
to veteran patient's each week. These locks are not issued by staff, 
but rather placed in areas such as primary care, mental health, and 
women's health clinics, as well as, in the Emergency Room so that 
veterans can take them without fear of being judged or tracked.

    a. What are other ways VA is ensuring veterans are fully aware of 
the staggering amount of suicides completed via firearm? And what 
resources, besides gun locks and video training, does VA offer to 
veterans that may choose to limit their access to firearms?

Regarding Interventions for the Aging Veteran Population:

    1. Male veterans age 55 and older had the highest count of suicide 
according to the 2016 National Suicide Data Report. Kaiser Health News 
and PBS NewsHour also found that an alarming number of seniors, not 
only veterans, are committing suicide in Long Term Care Facilities. The 
article suggests that depression, debility, access to deadly means, and 
disconnectedness are the main risk factors for senior suicide

    a. How is VA working to track these risk factors in its Community 
Living Clinics? How are CLC staff being trained to deliver 
interventions in response to veterans that exhibit these risk factors?

    2. How does VA track suicide attempts and death by suicide in its 
Community Living Clinics?

    3. What is the readmission policy surrounding previously suicidal 
veterans once they have been treated for their mental health concerns?

    4. Does VA intend to offer peer support in its Community Living 
Clinics?

    5. Does VA intend to offer the Whole Health Program at its 
Community Living Clinics?

    6. How is VA ensuring aging veterans enjoy a high quality of life 
at its Community Living Clinics?

    7. More broadly, given that depression presents differently in 
older adults, how has VA adjusted its screenings for this cohort?

Gaps in Medical Training

    1. Dr. Avenevoli or Dr. McKeon, could one or both of you elaborate 
on the existing gaps in formal medical training for suicide risk 
assessment and management and the impact that has, as America as a 
whole adopts this public health approach to suicide?

    a. Dr. Stone, would you agree that VA plays a significant role in 
educating America's future medical workforce?

    b. In that case, what is VA doing to ensure the 70 percent of 
medical professionals who spend time at VA receive adequate training 
and exposure to suicide risk assessment and management?

Staffing

    1. A number of VA OIG reports on VA's efforts to reduce veteran 
suicide found issues, weaknesses, or mistakes by Suicide Prevention 
Coordinators. Our Suicide Prevention Coordinators are central to so 
many of VA's efforts to reduce veteran suicides.

    a. In your opinions Dr. Stone and Franklin, do the workloads and 
responsibilities of these Coordinators align with the resources they 
are provided?

    b. Currently, how many vacancies are there in these roles across 
VA?

    c. Given the nature of the work, are these roles susceptible to 
high turnover rates?

    i. If yes, what do the exit surveys tell us about why these 
critical staffers are leaving? And what is being done to address these 
findings?

Family & Provider Support

    1. Following the tragic loss of a veteran from suicide, thoughts 
and prayers are sent to their loved ones. I suspect it is particularly 
distressing for the psychiatrists, psychologists, social workers and 
nurses in mental health who provided direct care. Naturally, the 
process of case review for completed suicides may pose a particular 
challenge for these team members. Many are interested in better 
understanding potential missteps or ways to better engage their 
patients in care.

    a. Dr. Stone, could you outline how VA creates an environment of 
support, free of judgement, for frontline staff impacted by a patient's 
suicide?

    2. I think we can all agree it is important to surround a 
vulnerable individual, such as a suicidal veteran, with support. Often, 
we find support amongst our family, friends, and colleagues.

    a. How is VA ensuring that those closest to veterans are prepared 
to identify risk factors and empowered to connect that veteran with the 
resources he or she may need - such as a mental health professional or 
the veterans crisis line?

    b. What barriers have you identified that would prohibit the 
distribution of information and access to training for these families, 
friends and colleagues?

Rep. Brownley

    1. Drs. Stone and Franklin: As you know, a 2018 VA OIG report found 
that 49 percent of military sexual trauma-related claims were 
incorrectly denied, meaning that women and men were perhaps not 
receiving the benefits they were owed. Obviously, MST is linked to the 
topic of this hearing. Can you provide information on what the VA is 
doing to correct these mistakes? Are each of these denied claims being 
reviewed to ensure accuracy and that veterans receive the care they are 
owed?

    2. Drs. Stone and Franklin: During your testimony, you discussed a 
national network of Women's Mental Health Champions. Can you provide 
more background on this program, the duties and responsibilities of 
these champions, and the practices they use to support women's mental 
health?

    3. Studying suicide and developing medications to prevent it has 
been challenging. To prevent suicides, one successful approach so far 
has been treating related mental health conditions. Do you think that 
suicide prevention should focus on treating underlying conditions such 
as Schizophrenia, Bipolar, Depression and PTSD or is there another 
approach you favor?

    4. PTSD is a major factor in many Veteran suicides, but a recent VA 
report found that ``most [PTSD] patients are treated with medications 
or combinations for which there is little empirical guidance regarding 
benefits and risks,'' and there is ``no visible horizon for 
advancements in medications that treat.PTSD.'' This is a big challenge. 
How is the VA positioning itself to reduce barriers to partnerships on 
clinical trials and big data research and work with companies of all 
sizes to encourage new therapies and diagnostics for PTSD?

Rep. Pappas

    1. Dr. Franklin: I appreciate your response to my question on 
providing care for transgender veterans in light of the implementation 
of the ban on their serving openly in the Armed Forces. Could you 
please elaborate on what specifically VHA/VA is doing to ensure a 
``positive handoff'' of these service members from DOD to VA, 
recognizing their increased risk for suicidal ideations?

                                 
          Representative Lauren Underwood to Veterans Affairs

    Question 1: Your written testimony mentions a national network of 
Women's Mental Health Champions created by VA. Please provide a brief 
written overview of the Women's Mental Health Champions Program, 
including any evidence-based practices that have influenced the 
development of that program, and a list of program participants located 
in Illinois.

    VA Response: Established in 2016, the Women's Mental Health 
Champions program is a network of individuals throughout the VA health 
care that serve as points of contact for Women's Mental Health. The 
Women's Mental Health Champion role is a collateral position which 
means they perform these responsibilities outside of their clinical 
assignment. A minority of Champions receive some protected time for 
this position. None are full-time.
    Champions disseminate information, facilitate consultations and 
support the development of women's mental health resources at their 
local facility. Specific duties vary by site, local priorities, and 
resources. All Women's Mental Health Champions undergo specialized 
training in women Veterans' mental health, including completion of a 
Women's Mental Health Mini-Residency. The Women's Mental Health Mini-
Residency is an intensive 3-day clinical training during which 
nationally recognized experts lead sessions on a broad range of topics 
related to the treatment of women Veterans, including gender-tailored 
psychotherapies and pharmacotherapies; the influence of hormonal 
changes; and the reproductive cycle. As part of the mini-residency 
curriculum and requirements, all Champions are required to apply new 
learning by developing and implementing an action plan to improve 
women's mental health clinical resources at their local facilities.
    Collaboration by Champions with local stakeholders is strongly 
encouraged and all plans are reviewed by facility mental health 
leadership prior to initiation. Action Plans commonly include the 
development of gender-sensitive mental health intake processes, 
screening strategies, and/or new treatment options. For example, 
Gender-sensitive intake and screening strategies include standardized 
processes to better identify disordered eating; sexual trauma-related 
sexual dysfunction; and exacerbations of mental health problems during 
perimenopause. Gender-sensitive treatment approaches include gender-
tailored pharmacotherapy considerations (e.g., when working with women 
who are pregnant or planning to become pregnant) and psychotherapy 
approaches that target women's unique mental health treatment needs, 
such as Skills Training in Affective and Interpersonal Regulation 
(STAIR). STAIR addresses areas of functioning that are often disrupted 
in female survivors of severe interpersonal traumas, such as sexual 
assault. STAIR teaches skills for managing strong emotions and building 
healthy interpersonal relationships (including parenting 
relationships).
    The development of the Women's Mental Champion program was not 
based on evidence-based practices but rather it aligns with policy and 
basic tenets of Veteran-centered care and as described above, the 
Women's Mental Health Mini-Residency includes training on evidence-
based psychotherapies and pharmacotherapies. All Illinois VA medical 
facilities (e.g., Jesse Brown VA Medical Center (Chicago); VA Illiana 
Health Care System (Danville); Edward Hines Jr. VA Hospital (Hines); 
Marion VA Medical Center (Marion); Captain James A. Lovell Federal 
Health Care Center (North Chicago) have a Women's Mental Health 
Champion.

    Question 2: Given the recent incidences of veteran suicides at VA 
medical facilities, has VA enacted any new policies or procedures to 
reduce the number of on-site suicides?

    VA Response: VA has not enacted any new national policies or 
procedures to reduce the number of on-site suicides because VA has 
policies that direct reporting, evaluation, and improving risk 
reduction for all suicide deaths, including those on VA campuses. These 
policies direct local efforts to review, evaluate, and update local 
guidance and practices to prevent Veterans Suicide on campus, while 
fitting the needs of our Veterans and their VA health care facility. VA 
is open to revisiting and refining policies and practices upon the 
findings of these recent tragic events and subsequent Root Cause 
Analysis.
    For reference, Veteran suicide deaths that occur on VA property are 
evaluated by the local facility and reported through a process known as 
an Issue Brief (IB). Issue Briefs are intended for internal use and are 
reviewed by senior leaders within our organization, including the 
Secretary. VA has a Guide to Veterans Health Administration (VHA) Issue 
Briefs that provides the processes VA medical centers should follow 
when evaluating and reporting Veteran suicide deaths.
    These reported events are monitored by the National Suicide 
Prevention Office (Office of Mental Health and Suicide Prevention) in 
near real-time with follow up back to the VA medical center, as 
appropriate. In addition, VA facilities complete Environment of Care 
Rounds, to include identification and recommendations for mediation of 
potential safety issues, including those specific to suicide and 
suicidal behavior.
    When VA medical centers decide to further investigate a suicide or 
suicide attempt, they do so by completing an RCA to review a larger 
systems issue, or a Peer Review to focus on a particular aspect of a 
Veteran's care. An RCA is a multidisciplinary approach to study health 
care-related adverse events and close calls. This involves a systematic 
process for identifying root causes of problems or events and an 
approach for responding to them. The goal of the RCA process is to find 
out what happened, why it happened, and how to prevent it from 
happening again.

    Question 2a: Have any internal reviews been conducted with regard 
to improving onsite security and threat screening?

    VA Response: As a result of recent suicides and violent events 
involving weapons, VHA has initiated an enterprise wide collection of 
security deficiencies and vulnerabilities. Action plans are being 
developed that will be used to prioritize corrective actions to address 
detected deficiencies and vulnerabilities. Facility police chiefs are 
collaborating with the Veterans Integrated Service Networks (VISN) 
leadership to adjust resources that improve protective postures at all 
facilities. VA Police currently perform annual physical security 
assessments and biennial vulnerability assessments at VA facilities to 
identify risks at each medical center. VA Police also provide suicide 
prevention training to community police. Additionally, VA have 
implemented: panic buttons, badge restricted access to certain areas, 
limited guest hours, secure camera monitoring, emergency preparedness 
training, and other site-specific security measures.

    Question 2b: If so, when will those review findings become 
available?

    VA Response: After a recent suicide on campus and shooting at the 
West Palm Beach VA Medical Center, a VHA team visited the West Palm 
Beach VA Medical Center to review its security processes and 
procedures. An internal review was conducted and is complete. The 
release of the internal review report to Congress requires a written 
request from the Chairman of the U.S. House of Representatives 
Veterans' Affairs Committee.

    Question 3: In your written testimony you highlighted VA as a 
national leader in providing ``telemental'' health services. Please 
provide data regarding the efficacy of ``telemental'' health programs 
as a useful means of reaching, retaining, and providing effective 
mental health care to patients.

    VA Response: Numerous studies have shown Telemental Health (TMH) to 
be safe, as clinically efficacious as the same treatments delivered in 
person, cost effective, engaging, and satisfying to patients. 
Particularly for mental health care that often requires weekly visits, 
TMH removes a major barrier to receiving care. From Fiscal Year (FY) 
2002 through FY 2018, VA has provided Veterans with more than 3,344,000 
TMH visits. TMH is VA's largest video telehealth clinical specialty and 
accounts for 46 percent of all Veterans who received video telehealth 
services. In FY 2018, 180,600 Veterans received over 593,000 TMH visits 
- a 19 percent increase in Veterans served over FY 2017 totals. VA is 
using telehealth to increase Veteran access to quality VA care, 
especially for Veterans in rural and underserved areas. Also in FY 
2018, more than 92,000 (over 50 percent) Veterans receiving TMH 
services were from rural areas - a 16 percent increase compared to FY 
2017.
    Established in FY 2010, the National Telemental Health Center 
(NTMHC) provides Veterans access to clinical experts throughout the 
country for a variety of disorders including but not limited to 
affective, psychotic, and substance use disorders. In FY 2018, NTMHC 
provided more than 2,600 consultation visits for approximately 600 
Veterans. The VA National Bipolar Telehealth Program, which is part of 
NTMHC, utilizes Bipolar specialists to deliver the evidence-based 
Collaborative Care Model from an expert hub to the patient's local VA 
clinic. Patients receive a comprehensive diagnostic assessment, 
psychopharmacologic consultation, and self-management skills sessions. 
Since FY 2011, the program has served over 50 patient sites and over 
1,600 Veterans, and Veterans who complete the program show improved 
mental health quality of life. In FY 2018, the program began a specific 
focus to identify at-risk Veterans with Bipolar Disorder.
    In FY 2016, VA established four regional TMH Hubs to increase VA 
mental health care for Veterans living in rural or other access-
challenged areas. Since then, VA has expanded to 11 TMH Hubs around the 
country. Through these Hubs, VA leverages providers to deliver timely 
care to underserved areas and reduce the impact of clinical staffing 
and/or service gaps. In FY 2018, TMH Hubs provided over 135,000 
telehealth visits to more than 36,000 Veterans at over 240 VA sites of 
care. In FY 2019, VA has begun development of Clinical Resource Hubs 
(i.e., integrated Primary Care and Mental Health Hubs) in all 18 VISNs. 
This collaborative effort enhances VA's provider capacity, broadens the 
mission and scope of the Hubs, and ensures they will serve as clinical 
care safety nets for a variety of high priority areas (e.g., staffing 
gap coverage, emergency management, etc.).
    VA has also developed the secure and private VA Video Connect (VVC) 
mobile application. Veterans around the country have the option of 
receiving evidence-based psychotherapy and pharmacotherapy via 
telehealth through their mobile devices, tablets, or computers at home 
or other preferred location. VVC makes VA health care more convenient 
and addresses barriers to mental health treatment engagement (e.g., 
lack of transportation, work/school schedules, stigma, distance to VA, 
and child care responsibilities). With no travel time required, VVC 
increases access for Veterans, especially in rural areas without nearby 
VA health care facilities. In FY 2018, over 16,400 Veterans connected 
with their VA mental health providers via VVC for 75,500 visits, an 88 
percent growth in Veterans served compared to FY 2017. Approximately 46 
percent of these Veterans live in rural areas. VA's vision is that all 
outpatient VA mental health providers will be VVC-capable (i.e., 
trained and equipped to provide a telehealth visit to a Veteran's home 
or other preferred location within the United States) by the end of FY 
2020.
    Because not all Veterans have access to the Internet or a mobile 
device for VVC, VA is collaborating with community, private, and 
alternate agency partners to establish telehealth access points in 
communities for use by Veterans. These pilots are part of VA's 
Advancing Telehealth through Local Access Stations project, which aims 
to help remove barriers to VA mental health care.
    To further increase access for Veterans who do not have their own 
mobile devices, VA provides mobile devices (e.g., VA telehealth iPads 
with built-in 4G data plans) through its Tablet to Home Initiative. 
This initiative started in FY 2016. VA has distributed over 18,000 
tablets to Veterans, including Veterans with mental health issues.

    Question 4: In Dr. Shelli Avenevoli's written testimony for this 
hearing, she outlined the effectiveness of the REACH-VET suicide risk 
identification system.

    Question 4a: Please provide information on the specific patient 
characteristics that REACH-VET analyzes.

    VA Response: The specific patient characteristics that REACH-VET 
analyzes are as follows:

  Demographics
    Age / 80
    Male
    Currently married
    Region (West)
    Race/ethnicity (White)/ (Non-white)
    Service Connected (SC) Disability Status
    SC / 30%
    SC / 70%
  Prior Suicide Attempts
    Any suicide attempt in prior 1 month, 6 months, or 18 months
    Diagnoses
    Arthritis (prior 12 or 24 months)
    Bipolar I (prior 24 months)
    Head and neck cancer (prior 12 or 24 months)
    Chronic pain (prior 24 months)
    Depression (prior 12 or 24 months)
    Diabetes mellitus (prior 12 months)
    Systemic lupus erythematosus (prior 24 months)
    Substance Use Disorder (prior 24 months)
    Homelessness services (prior 24 months)
  VHA Utilization
    Emergency Department visit (prior month or 2 months)
    Psychiatric Discharge (prior month, 6, 12, or 24 months)
    Any mental health (MH) treatment (prior 12 or 24 months)
    Days of Use (0-30) in the 13th month prior or in the 7th month 
prior
    Emergency Department visits (prior month or 24 months)
    First Use in Prior 5 Years was in the Prior Year
    Days of Inpatient MH (0-30) in 7th month prior, squared
    Days of Outpatient (0-30) in 7th month prior, 8th month prior, 15th 
month prior, 23rd month prior
    Days with outpatient MH use in prior month, squared
  Medications
    Alprazolam (prior 24 months)
    Antidepressant (prior 24 months)
    Antipsychotic (prior 12 months)
    Clonazepam (prior 12 or 24 months)
    Lorazepam (prior 12 months)
    Mirtazapine (prior 12 or 24 months)
    Mood stabilizers (prior 12 months)
    Opioids (prior 12 months)
    Sedatives or anxiolytics (prior 12 or 24 months)
    Statins (prior 12 months)
    Zolpidem (prior 24 months)
  Interactions
    Between Other anxiety disorder (prior 24 months) and Personality 
disorder (prior 24 months)
    Interaction between Divorced and Male
    Interaction between Widowed and Male

    Question 4b: Please provide more detailed information on how REACH-
VET's effectiveness is evaluated.

    VA Response: REACH VET is being evaluated from both an 
effectiveness and an implementation standpoint. An initial evaluation 
of effectiveness looked at 6-month outcomes for an initial cohort of 
identified Veterans and found the following:

      In comparison to the control groups, patients exhibited:
        More health care appointments;
        More mental health appointments;
        Decreases in the percent of missed appointments;
        Greater completion of suicide prevention safety plans; 
and
        Less all-cause mortality.

    Overall, findings on implementation and outcomes are positive. We 
are now finalizing a more extensive effectiveness evaluation and will 
be submitting that for peer-review for publication in June.

    Question 4c: Has there been any effort to export the predictive 
system used by the REACH-VET model for use by other health care 
providers?

    VA Response: Predictive risk models are built specifically on 
available data to model an outcome. Because the REACH VET model is 
built on the VHA electronic health record data, it is not directly 
exportable to other settings. Service connection, as an example, is a 
risk factor in the model but that data would not be available in 
another health care setting. It is possible to take the same approach 
and develop a model validated on available electronic health record 
data, but that would require a significant investment by the health 
care system to accomplish.

    Question 5: The written statement provided by Disabled American 
Veterans for this hearing praised the utility of a personal workbook 
distributed by VA, ``Your Personal Safety Plan,'' to identify stressors 
and to create a strategy for veterans for staying safe in times of 
emotional crisis. Given the elevated risk factors among the veteran 
population, has VA considered proactively providing the ``Your Personal 
Safety Plan'' workbook to all veterans as a presumptive positive 
intervention method?

    VA Response: The Safety Planning Intervention Manual: Veteran 
Version, 2018 is a guide for VHA clinicians that defines best practices 
for developing suicide prevention safety plans (safety plans) with 
Veteran patients. Safety planning should be used with Veterans who meet 
one or more of the following criteria: attempted suicide or engaged in 
suicidal behavior, reported suicidal ideation, psychiatric disorder 
that increases suicide risk, and are otherwise determined to be at risk 
for suicide. VA has a new universal screening mechanism to assist 
clinicians with identifying those Veterans who may need more targeted 
intervention such as safety planning. Safety Planning is only 
recommended when clinically indicated, therefore, VA is not considering 
offering a safety plan to all Veterans at this time.

    Question 6: Dr. Avenevoli's written testimony includes a section 
addressing several research studies supported by the VA that have 
uncovered benefits from an intervention called ``caring 
communications.'' Please provide a summary of the current status of 
implementation of caring communications intervention methods, including 
the number of facilities using the methods; any research analyzing 
their effectiveness; and any plans or proposals for expanding use of 
the methods.

    VA Response: Caring Communications (sometimes called ``Caring 
Letters'' or ``Caring Contacts'') has been studied in a number of 
clinical trials since the 1970s. A recent meta-analysis that 
statistically summarized the different studies found that Caring 
Communications reduced self-harm repetitions. \1\ Caring Communications 
are included in the Department of Defense (DoD)-VA Clinical Practice 
Guideline on the Assessment and Management of Patients at Risk for 
Suicide (currently under revision). \2\ In addition, the Joint 
Commission recently recommended that health care organizations consider 
Caring Communications, noting that it ``has a growing body of evidence 
as a post-discharge suicide prevention strategy.'' \3\
---------------------------------------------------------------------------
    \1\ Milner, A. J., Carter G., Pirkis, J., Robinson, J., Spittal, 
M.J. Br J. (2015). Letters, Green Cards, telephone calls and postcards: 
Systematic and Meta-Analytic Review of Brief Contact Interventions for 
Reducing Self-Harm, Suicide Attempts and Suicide. Psychiatry. 
206(3):184-90. doi: 10.1192/bjp.bp.114.147819.
    \2\ https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP--
SuicideRisk--Full.pdf.
    \3\ Joint Commission (February 24, 2016). Sentinel Event Alert: 
Detecting and treating suicide ideation in all setting, Issue 56.
---------------------------------------------------------------------------
    There has only been one clinical trial published to date that has 
examined Caring Communications in a military population. \4\ In that 
study, a text message version of the intervention reported mixed 
results. There was no significant effect on likelihood or severity of 
current suicidal ideation or likelihood of a suicide risk incident; 
there was also no effect on emergency department visits. However, 
participants who received Caring Communications had lower odds than 
those receiving standard care alone of experiencing any suicidal 
ideation between baseline and follow-up and they had fewer suicide 
attempts. This study also used Caring Communications as an adjunct to 
psychotherapy; it has generally been used as outreach for individuals 
not in care. A second study is underway; VA partnered with DoD to study 
the effects of an email version of Caring Communications with military 
personnel and Veterans; \5\ the results of that study are not yet 
available.
---------------------------------------------------------------------------
    \4\ Effect of Augmenting Standard Care for Military Personnel with 
Brief Caring Text Messages for Suicide Prevention: A Randomized 
Clinical Trial. Comtois KA, Kerbrat AH, DeCou CR, Atkins DC, Majeres 
JJ, Baker JC, Ries RK. JAMA Psychiatry. 2019 Feb 13. doi: 10.1001/
jamapsychiatry.2018.4530. [Epub ahead of print].
    \5\ https://clinicaltrials.gov/ct2/show/NCT01473771-
term=luxton+caring&rank=1.
---------------------------------------------------------------------------
    VA has several ongoing projects working to expand or improve the 
use of Caring Communications. In the REACH VET program, existing data 
from Veterans' health records are analyzed to identify those at a 
statistically elevated risk for suicide, hospitalization, illness, or 
other adverse outcomes. This allows VA to provide preemptive care and 
support for Veterans, in some cases before a Veteran even has suicidal 
thoughts. Caring Communications are one of many options considered when 
a Veteran is identified by the REACH VET program. To facilitate the 
implementation of Caring Communications, a provider template for 8 
Caring Cards was developed (based on messages used in prior successful 
studies) and tested with 154 high-risk Veterans. \6\ Eighty-five 
percent of the Veterans Agreed or Strongly Agreed that they would like 
to receive Caring Communications. The messages were overwhelmingly 
rated as caring and helpful; 84 percent believed that Caring 
Communications could help suicidal individuals.
---------------------------------------------------------------------------
    \6\ Veteran Preferences for the Caring Contacts Suicide Prevention 
Intervention. Reger MA, Gebhardt HM, Lee JM, Ammerman BA, Tucker RP, 
Matarazzo BB, Wood AE, Ruskin DA. Suicide Life Threat Behav. 2018 Nov 
19. doi: 10.1111/sltb.12528. [Epub ahead of print].
---------------------------------------------------------------------------
    Since repeated outreach is thought to be key to the Caring 
Communications intervention, streamlined business processes are 
important to ensure the administrative burden on busy providers is 
minimized. VA is currently testing a program to centralize the 
administrative work of sending Caring Communications across two 
facilities (VA Puget Sound and Central Arkansas Veterans Healthcare 
System). This program has been in operation for about 2 months. Future 
analyses will examine whether it increased the use of Caring 
Communications in the REACH VET population.
    VA is currently piloting another streamlined process for 
implementing Caring Communications in the VA emergency department 
setting in one facility (Central Arkansas Veterans Healthcare System). 
This pilot is focused on reaching Veterans who may not receive mental 
health care.
    This pilot will inform whether this initiative will spread to other 
facilities. VA is also piloting a potential improvement to the 
traditional Caring Communications model in which a provider signs the 
letter. Given the importance of peer support in the Veteran population, 
investigators at VA Puget Sound are testing a model in which the 
letters are written by a peer Veteran. In a small pilot (30 
participants), investigators recruited volunteers from a local Veterans 
Service Organization (the American Legion) to write six Caring letters 
(one mailed per month) to high-risk Veterans recently discharged from 
the psychiatric inpatient unit. This study should be completed by 
Winter 2019. The investigators are currently planning a larger clinical 
trial of peer Veteran Caring Letters.
    In addition, for Veterans identified as surviving a suicide attempt 
or identified as being at high-risk for suicide and placed on the 
facility's high-risk list, the VA Suicide Prevention Coordinator will 
make personal contact with the Veteran and establish a United States 
mail contact with him or her to ensure communication is maintained with 
the Veteran. Mailings are simple and personal messages. This process is 
codified in the Suicide Prevention Coordinator Guide, sections 2008.04 
and 2018.01 for Patients at High Risk for Suicide.

    Question 7: In your written testimony you highlighted several times 
the need to better understand and target prevention efforts towards the 
14 veterans who die by suicide each day who were not recent users of VA 
health services. Please provide an overview of any current methods to 
identify the demographics of 14 veterans.

    VA Response: Suicide is a national public health issue that impacts 
all Americans, Veterans and non-Veterans. Currently, only about 30 
percent of Veterans receive their health care through VA, and fewer 
than 50 percent use any VA benefits or services at all. To reach 
Veterans where they work, live, and thrive, VA is advancing a public 
health strategy to reduce deaths by suicide among the greatest number 
of Veterans possible. The public health approach cuts across all 
sectors in which Veterans may interact and includes collaborating with 
Veterans Service Organizations (VSO), State and local leaders, medical 
professionals, criminal justice officials, private employers, and other 
key stakeholders. Using the public health approach, the Suicide 
Prevention Program (SPP) can deliver resources and support to Veterans 
before they reach a crisis point.
    The March 5, 2019 Executive Order 13861, the President's Roadmap to 
Empower Veterans and End a National Tragedy of Suicide (PREVENTS), will 
empower Veterans to pursue an improved quality of life, prioritizes 
related research activities to improve interventions and the 
translation of knowledge, and facilitates collaboration across the 
public and private sectors. Influenced by the National Strategy for 
Preventing Veteran Suicide and progress from the private and nonprofit 
sectors, the Roadmap outlines the specific strategies needed to 
effectively lower the rate of veteran suicide among our nation's 
veterans, developing opportunities for collaboration within federal, 
state, local, tribal, and non-government entities. The Roadmap will 
utilize a public health approach and focus on changing the culture of 
mental health broadly and specifically how suicide is addressed 
nationally and focus on the continuum of the veteran's experience and 
will target interventions across multiple opportunities - including 
prevention and early intervention. The Roadmap focuses on three areas: 
community integration, research strategies, and implementation 
strategies.
    Understanding suicide risks among all Veterans is a VA priority. 
Through a collaborative effort between VA, DoD, and the Centers for 
Disease Control National Center for Health Statistics National Death 
Index, we identify suicide decedents among all military Servicemembers 
and Veterans. Available data sources from this collaborative effort, 
including military service personnel records, and benefit and service 
administrative records, are used to identify age, gender, and State of 
death for all Servicemembers and Veterans. Through additional sources 
and collaborations, we are able to identify other select demographics 
of Veterans such as race, ethnicity, and marital status, including 
among the 14 who are not recent users of VHA care.In addition, VA 
suicide data surveillance analyses have examined suicide risk among 
Veteran patients who received care from VA that are 65 and older, by 
receipt of mental health diagnoses from Medicare providers. Preliminary 
findings indicate Medicare diagnoses of mental health conditions are 
associated with increased suicide risks, adjusting for patient 
characteristics and receipt of mental health diagnoses from VHA 
providers.

    Question 8: Please provide information on what data is being 
collected on these individuals, including their character of service; 
medical history; and access to VA, military, or private sector care, 
etc.

    VA Response: VA obtains information on the cause, date, and State 
of death from the National Death Index for all Veterans and 
Servicemember suicide decedents, including the average of the 14 per 
day who are not recent users of VHA care. VA works closely with DoD's 
Defense Manpower Data Center (DMDC) to identify these individuals and 
some limited data on their military service histories. However, DoD 
electronic personnel data originated in the 1970s and for a significant 
proportion of decedents whose military service predated the 1970s, DMDC 
data are not available. Further, some decedents not accessing VHA care 
at the time of their death may have accessed VHA care in the non-recent 
past, or care from a non-VA provider that was paid for by VA. In these 
cases, some, possibly dated, medical information may be available. For 
persons with no history of VHA engagement, we do not have access to 
comprehensive private sector health care information to examine their 
health status at the time of death. Such limitations underscore the 
importance of a public health approach that seeks to reach all Veterans 
and their communities.

    Question 9: The written statement provided by Veterans of Foreign 
Wars referenced an August 2018 report from the Department of Veterans 
Affairs Office of Inspector General (Report #17-05248-241) detailing 
the VA's staffing shortages in the area of mental health care. Please 
provide a roadmap with specific and measurable goals toward reducing 
the shortage of mental health staff in VA facilities, along with an 
outline of the resources you need to successfully implement the plan.

    VA Response: VHA has made hiring mental health providers a 
priority. The current Mental Health Hiring Initiative has resulted in a 
net gain of over 1,000 additional providers in VHA. Ongoing efforts to 
continue to build the mental health workforce include:

    1) Ongoing enhanced coordination of VHA offices including Workforce 
Management and Consulting and the Office of Academic Affairs. 
Currently, we are coordinating the hiring efforts and recruitment 
strategies for VHA trained students, interns, and residents, providing 
local hiring support and national recruitment efforts.

    2) Actively tracking mental health staffing for efficiency and for 
population coverage. Tools have been built to monitor local changes in 
staffing to promote optimization for efficiency (eliminate waste or 
excess) and reach (coverage available for the population). Recently, 
the tools have been expanded to identify population gaps at the 
Community Based Outpatient Clinic level, allowing Medical Center 
leadership to make hiring decisions to enhance access. VHA has 
identified the most critical staffing gap sites based upon available 
staff and known Veteran population. Ongoing focused efforts are 
outlined to address staffing needs at these most critical sites.

    3) Continuing to be a leader in the implementation of telehealth 
services, expanding the pool of available providers through tele-video 
conferencing services. The current VHA initiative focuses on expansion 
of VA Video Connect (VVC) capacity and utilization to enhance Veteran 
care. Current metrics monitored include the percentage of mental health 
providers utilizing VVC.

    4) Locally, funding is the most commonly cited barrier to hiring 
additional mental health staff. VHA is coordinating ongoing discussions 
that evaluate current funding/utilization methodologies to update 
projections on the known mental health population. This will enhance 
the ability of local leadership to maintain ongoing hiring based upon 
population need rather than established workload.

    5) With growing Veteran demand and ongoing VHA hiring, a lack of 
available space for care is similarly an often-cited barrier to hiring. 
Current VHA space guides have been updated and population-based tools 
have been developed which will provide space planners the ability to 
plan future space needs based upon population-based modeling.

    6) Investigating and creating action plans to address barriers. 
Needs include:

    a. Dedicated Special Purpose funding for hiring mental health 
providers using population-based models.

    b. Dedicated funding for enhanced space to meet the rapidly growing 
clinical need.

    Question 10: In her testimony during the hearing, Dr. Keita 
Franklin stated, ``If it were up to me, we'd train the entire VA on how 
to talk about lethal means.'' Are there any existing barriers that 
would hinder VA from expanding lethal means training for its staff?

    VA Response: The goal of universal training for all of VA related 
to lethal means safety is obtainable. It requires, though, a further 
expansion of our previous efforts. We have national-level initiatives 
for VHA clinical staff that involve safe firearm storage and medication 
safety (lethal means) in our facilities, including the following:

      A universal Safety Plan document that clinicians engage 
with, when appropriate. This document includes specific interventions 
around lethal means, to be agreed upon by the Veteran and their 
clinician, and there is a mandated requirement for all VHA mental 
health clinicians to take the training that discusses the 
administration of the Safety Plan.
      Although not mandated, we also offer an adjunctive 
training on lethal means for clinicians. According to the most recent 
progress report, this training has been completed 16,128 times since it 
rolled out in 2018.

    Recently, the VA took a cursory step in expanding the dialogue 
across the system, not just in the clinical realm. Suicide Prevention 
staff was given the opportunity to provide information on lethal means 
for all VA staff who were able to attend a Summer Safety Stand-Down. 
The presentation was approximately 5 minutes and included a question 
and answer session where other resources were shared. This was not a 
full training, nor a comprehensive one, but a good start to introducing 
the topic across the system. The Stand-Down will also be placed on VA's 
training system, for staff to review in the future.
    With those points in mind, one major barrier to expansion of 
knowledge across the VA is that a general training needs to be created 
As a means to meet this lift head on, a lethal means working group has 
been added to the PREVENTS Taskforce, pulling together the team of 
subject matter experts needed to make this process a reality, not just 
in VA, but across the government enterprise.

    Question 11: Dr. Franklin also highlighted official partnerships 
between the VA and outside organizations to promote firearm safety. 
Please provide an overview of VA's current partnerships with 
organizations (such as firearm dealers and firearm ownership groups) 
aimed at reducing veteran suicide rates. Please include data on any 
funding provided, the number of involved organizations, and the number 
of veterans reached by these efforts.

    VA Response: VA's SSP currently has more than 60 non-monetary 
partners working in prevention, intervention, and/or postvention. 
Traditional partners cut across 14 partnership sectors, as defined in 
the National Strategy for Preventing Veteran Suicide, and include 
Federal, State, and local leaders, as well as community organizations 
such as VSOs, medical professionals and other community service 
providers, criminal justice officials, private employers, and many 
others.
    The VA has entered into a Memorandum of Agreement with the National 
Shooting Sports Foundation (NSSF) to provide firearm safety toolkits, 
to create coalitions to promote firearm safety, to suggest and explain 
safe firearm storage options, and to identify state laws for firearm 
storage and safety. VA and NSSF will share NSSF and VA public domain 
resources including NSSF's Project Child Safe public firearm safety 
materials, websites, and related materials with emphases on Service 
Members, Veterans, and their families. This is a Public-Private 
Partnership whereby NSSF is donating its time, energy, and resources at 
no cost to the public or to the Department of Veterans Affairs. The 
Department is accepting NSSF's philanthropy under its statutory 
authority to accept gifts and donations under 38 United States Code 
Sec.  8301.
    All partnerships are non-monetary agreements. Our goal is to reach 
all Veterans across the Nation.

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