[Senate Hearing 116-408]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 116-408
 
 SERVICEMEMBER, FAMILY, AND VETERAN SUICIDES AND PREVENTION STRATEGIES

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

                                HEARING

                               before the

                       SUBCOMMITTEE ON PERSONNEL

                                 of the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            DECEMBER 4, 2019

                               __________

         Printed for the use of the Committee on Armed Services
         
         
         
         
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             U.S. GOVERNMENT PUBLISHING OFFICE 
43-315 PDF           WASHINGTON : 2021                 
                 


                      COMMITTEE ON ARMED SERVICES

    JAMES M. INHOFE, Oklahoma,    JACK REED, Rhode Island
             Chairman
ROGER F. WICKER, Mississippi      JEANNE SHAHEEN, New Hampshire
DEB FISCHER, Nebraska             KIRSTEN E. GILLIBRAND, New York
TOM COTTON, Arkansas              RICHARD BLUMENTHAL, Connecticut
MIKE ROUNDS, South Dakota         MAZIE K. HIRONO, Hawaii
JONI ERNST, Iowa                  TIM KAINE, Virginia
THOM TILLIS, North Carolina       ANGUS S. KING, Jr., Maine
DAN SULLIVAN, Alaska              MARTIN HEINRICH, New Mexico
DAVID PERDUE, Georgia             ELIZABETH WARREN, Massachusetts
KEVIN CRAMER, North Dakota        GARY C. PETERS, Michigan
MARTHA McSALLY, Arizona           JOE MANCHIN, West Virginia
RICK SCOTT, Florida               TAMMY DUCKWORTH, Illinois
MARSHA BLACKBURN, Tennessee       DOUG JONES, Alabama
JOSH HAWLEY, Missouri                
                  
                                     
                      John Bonsell, Staff Director
                   Elizabeth L. King, Minority Staff 
                             Director


                       Subcommittee on Personnel

   THOM TILLIS, North Carolina, 
             Chairman
             
MIKE ROUNDS, South Dakota           KIRSTEN E. GILLIBRAND, New York
MARTHA McSALLY, Arizona             ELIZABETH WARREN, Massachusetts
RICK SCOTT, Florida                 TAMMY DUCKWORTH, Illinois
                                     
                               (ii)


                         C O N T E N T S



                         December 4, 2019

                                                                   Page

Servicemember, Family, and Veteran Suicides and Prevention            1
  Strategies.

Orvis, Karin A., Ph.D., Director, Defense Suicide Prevention          4
  Office, Office of the Secretary of Defense, Department of 
  Defense.
Colston, Captain Michael J., M.D., USN, Director for Mental           5
  Health Programs, Health Services Policy and Oversight Office, 
  Department of Defense.
Miller, Matthew A., Ph.D., Acting Director, Suicide Prevention       11
  Program, Department of Veterans Affairs.
McKeon, Richard, Ph.D., Suicide Prevention Branch Chief, Center      21
  for Mental Health Services, Substance Abuse and Mental Health 
  Services Administration, Department of Health and Human 
  Services.
Kessler, Ronald C., Ph.D., McNeil Family Professor of Health Care    27
  Policy, Department of Health Care Policy, Harvard Medical 
  School.

Questions for the Record.........................................    47

                                 (iii)



 SERVICEMEMBER, FAMILY, AND VETERAN SUICIDES AND PREVENTION STRATEGIES

                              ----------                              


                      WEDNESDAY, DECEMBER 4, 2019

                      United States Senate,
                         Subcommittee on Personnel,
                               Committee on Armed Services,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 3:19 p.m. in 
Room SR-222, Russell Senate Office Building, Senator Thom 
Tillis (chairman of the Subcommittee) presiding.
    Committee Members present: Senators Tillis, McSally, Scott, 
and Gillibrand.
    Other senators present: Senator Sullivan.

            OPENING STATEMENT OF SENATOR THOM TILLIS

    Senator Tillis. The hearing will come to order.
    Senate Armed Services Subcommittee on Personnel meets this 
afternoon to receive testimony about servicemember, family, and 
veteran suicides, and to learn about effective evidence-based 
suicide prevention strategies.
    We're fortunate today to have a panel of experts from 
government and academia. We will hear from five witnesses: 
Captain Michael Colston, M.D., U.S. Navy, Director for Mental 
Health Programs for the Health Services Policy and Oversight 
Office at the Department of Defense (DOD); Dr. Orvis, Director, 
Defense Suicide Prevention Office for the Office of Force 
Resiliency at the Department of Defense; Dr. Miller, Acting 
Director of the Suicide Prevention Program at the Department of 
Veterans Affairs (VA); Dr. McKeon, Suicide Prevention Branch 
Chief, Center for Mental Health Services of Substance Abuse and 
Mental Health Services Administration (SAMHSA) at the 
Department of Health and Human Services (HHS); and Dr. Kessler, 
McNeil Family Professor of Health Care Policy, Department of 
Health Care Policy at the Harvard Medical School.
    Thank you all for being here, and we're sorry we are a bit 
late.
    Our topic today is a heavy one, one that is difficult to 
discuss, but we must address it to ensure the readiness and the 
well-being of our troops, their families, and veterans. Suicide 
is a homefront threat to servicemembers and veterans. 
Tragically, rates of suicide for Active Duty servicemembers and 
veteran populations have increased in the latest reports, 
particularly affecting young men under 30, who make up nearly 
half the military. Veteran suicide is a national epidemic. As a 
member of the Veterans Affairs Committee, working to reduce the 
number of veterans who die by suicide is one of my top 
priorities.
    The Departments of Defense and Veterans Affairs have 
improved capacity and access to mental health and other 
services, yet the rates of suicide have not decreased. I see 
today as an opportunity to understand what more we can do as a 
subcommittee to take--make a positive impact in this area.
    Military families are also affected by suicide. For the 
first time, the Department of Defense released data on suicides 
by spouses and dependents. I hope to hear more about how the 
DOD will track and support spouses and dependents affected by 
suicide in the future.
    While suicide represents a growing public health challenge 
in the civilian world, the unique composition and mission of 
our military makes this challenge one of particular importance 
that we must address. Ensuring adequate care and support for 
servicemembers, families, and veterans facing stressors of 
deployments, transitions, financial difficulties, and access to 
healthcare, it must be a top priority.
    I look forward to hearing from the DOD and VA witnesses on 
how they're developing evidence-based suicide prevention 
methods to combat the rise in suicides among servicemembers, 
veterans, and their families, and also from Dr. McKeon and Dr. 
Kessler about civilian suicide prevention research and methods 
and strategies that can help combat suicide in the military.
    I want to thank all the witnesses for being here today. I 
look forward to your testimony.
    I now turn to Ranking Member Gillibrand for an opening 
statement.

           STATEMENT OF SENATOR KIRSTEN E. GILLIBRAND

    Senator Gillibrand. Thank you, Chairman Tillis, for holding 
this important hearing.
    Suicide in the military is a serious and growing problem. 
Not enough is being done to address the factors that contribute 
to this tragedy.
    To all of our witnesses, welcome, and thank you for sharing 
your expertise with us today. Your insight of the prevalence 
and contributing factors of these suicides is crucial to 
helping our committee support our servicemembers.
    I appreciate, Mr. Chairman, you inviting an expert from the 
Veterans Administration, as it's critical for us to understand 
the connections and distinctions between military and veteran 
suicides to be able to address both.
    According to the 2019 Department of Defense Annual Suicide 
Report, the rate of suicide experienced by our servicemembers 
has steadily increased over the last 6 years, spiking in 2018 
by over 6 percent from 2013. There's been a narrative for a 
long time that military suicide is due primarily to PTSD and 
combat missions, and we must take--and we must take the toll of 
combat on military members very seriously. But, the report 
clearly demonstrates that combat missions are not directly 
correlative to the servicemembers who die by suicide. Suicide 
is complex and individual.
    There are a multitude of factors that lead to mental health 
challenges and can, in turn, lead to the devastation of 
suicide. Military service is very difficult. Our services--our 
servicemembers make sacrifices that are hard for some of us to 
even fathom. When Americans enter into military service, they 
lose control of where and how often they must relocate, the 
kind of housing they will live in, which schools their children 
will attend. It's often impossible to maintain a healthy work/
life balance, and frequently our servicemembers are expected to 
sacrifice the needs of their families to accomplish a mission.
    Our gratitude for their sacrifices isn't enough. We must 
also recognize the unique burdens that they face, and that 
those burdens can lead to persistent mental health challenges, 
like chronic anxiety and depression. And too often those mental 
health challenges can contribute to suicidal ideations.
    Of course, some of the burdens are integral to the way of 
the military--to the way the military functions and to ensuring 
that our servicemembers learn critical skills and are prepared 
to serve in a war zone. But, it's incumbent upon the leaders in 
this committee to determine when such factors are problematic 
enough that a greater system of support must be provided. 
Military and civilian leaders also must determine when factors 
are most disruptive than is necessary to accomplish the 
mission, so that they can develop more appropriate strategies 
for today's military.
    The military and the Department of Defense spend more and 
more each year on suicide prevention, but the results are not 
nearly good enough. I'd like to challenge our civilian and 
military leaders to think about military suicide in a more 
holistic way, understanding the factors that contribute to 
mental health challenges and to suicide. If the military is 
able to understand how the day-to-day stressors of serving can 
impact servicemembers, they can work to minimize those 
stressors based on mission requirements and create the systems 
of support servicemembers need to be successful.
    This also means taking a real look at the existing systems 
of support. Currently, the Department of Defense has a policy 
that requires mental health professionals to report many cases 
of mental health concerns of servicemembers to a commander. 
This policy leads to mistrust and acts as a barrier to 
treatment, because servicemembers fear the repercussions to 
their career if they come forward with their mental health 
challenges.
    Of course, DOD must have policies to keep their 
servicemembers and colleagues safe, but their standards for 
reporting mental health challenges are vague and go much 
further than the standards for civilian mental health 
professionals or even military chaplains. This policy is more 
likely to force servicemembers to suffer in silence, and does 
nothing to help commanders maintain good order and discipline. 
I urge the Department of Defense to review the reporting rules 
for mental health professionals to ensure that they are 
allowing for maximum confidentiality for our servicemembers 
while also protecting them from those around them. If we can 
eliminate the barriers that stand between our servicemembers 
and access to mental health care, I believe we can begin to 
make progress towards addressing our suicide rate.
    Mr. Chairman, I look forward to hearing from our witnesses, 
and I'm committed to working with you, our colleagues on the 
committee, the military, the DOD, to further support our 
servicemembers and their well-being.
    Senator Tillis. Thank you, Senator Gillibrand.
    We'll just start from left to right.
    Dr. Orvis.

 STATEMENT OF KARIN A. ORVIS, Ph.D., DIRECTOR, DEFENSE SUICIDE 
    PREVENTION OFFICE, OFFICE OF THE SECRETARY OF DEFENSE, 
                     DEPARTMENT OF DEFENSE

    Dr. Orvis. Chairman Tillis and Ranking Member Gillibrand, 
thank you for the opportunity to be--appear before you with our 
colleagues from VA, SAMHSA, and Harvard University.
    With me today is my colleague, Captain Mike Colston, the 
Director of Mental Health Programs. Like you, we are very 
concerned about the suicide rates in our military, and we look 
forward to discussing the Department's suicide prevention 
efforts.
    We are disheartened that the rates of suicide in our 
military are not going in the desired direction. The loss of 
every life is heartbreaking, and each one has a deeply personal 
story. With each death, we know there are families, and often 
children, with shattered lives. The DOD has the responsibility 
of supporting and protecting those who defend our country, and 
it's imperative that we do everything possible to prevent 
suicide in our military community.
    Because data informs our ability to take meaningful steps 
and fulfill our commitment to transparency, the Department has 
expanded our reporting on suicide-related data. This past 
September, we published our first Annual Suicide Report, or 
ASR, to supplement our longstanding DOD Suicide Event Report. 
In brief, the calendar year 2018 suicide rates are consistent 
with the prior 2 years across all components. When compared to 
the past 5 years, the rates have been steady for the Reserve 
and the National Guard; however, we've seen a statistically 
significant increase for the Active component. While hardly 
acceptable, military suicide rates are comparable to the U.S. 
population rates after accounting for age and sex differences, 
with the exception of the National Guard. We continue to 
observe heightened risk for our youngest servicemembers and our 
National Guard members.
    As part of the ASR, the Department published suicide data 
for our military family members for the first time. Suicide 
rates for our military spouses and dependents in calendar year 
2017 were comparable to or lower than the U.S. population rates 
after accounting for age and sex. Based on the ASR findings, 
the Department must, and will, do more to target our areas of 
greatest concern--our young and enlisted members and our 
National Guard members--as well as continue to support our 
families.
    We know suicide is a complex interaction of many factors, 
and our efforts must address the many aspects of life that 
impact suicide. We're committed to addressing suicide 
comprehensively through a public health approach.
    Guided by the Defense Strategy for Suicide Prevention, the 
DOD has many ongoing and future efforts underway. These efforts 
support seven evidence-informed strategies, which include 
identifying and supporting people at risk, strengthening access 
and delivery of suicide care, teaching coping and problem-
solving skills, creating protective environments, strengthening 
economic supports, and lessening harms and preventing future 
risk.
    To provide a few examples, take for example identifying and 
supporting people at risk. We will be teaching young 
servicemembers how to recognize and respond to suicide red 
flags on social media to help others who might be showing 
warning signs.
    With respect to strengthening access and delivery to 
suicide care, we're partnering with the VA to increase National 
Guard members' accessibility to mental health care via Mobile 
Vet Centers during drill weekends.
    With respect to teaching coping and problem-solving skills, 
we are piloting an interactive educational program to teach 
foundational skills early in a member's career to help with 
everyday life stressors.
    As a final example with respect to creating protective 
environments, we're developing a communications campaign to 
promote social norms for safe storage of firearms and 
medication to ensure family safety.
    In our written testimony, we provide additional current 
efforts, as well as new promising practices we are piloting and 
evaluating that align to these seven strategies. I'm happy to 
discuss any of these in more detail. We also have developed an 
enterprise-wide program evaluation framework to better measure 
effectiveness of our suicide prevention efforts.
    Partnerships are integral to reaching our goals. We work 
closely with the Federal, State, local, and other 
nongovernmental stakeholders to continue to enhance our toolkit 
and ensure availability of suicide prevention resources for our 
servicemembers and their families.
    In closing, I thank you for your unwavering dedication to 
the support of our men, women, and families who defend our 
great Nation. I welcome your insights, your input, and your 
partnership. I fully recognize that we have more to do, and I 
take this charge incredibly seriously, and I look forward to 
your questions.
    Senator Tillis. Captain Colston.

 STATEMENT OF CAPTAIN MICHAEL J. COLSTON, M.D., USN, DIRECTOR 
    FOR MENTAL HEALTH PROGRAMS, HEALTH SERVICES POLICY AND 
            OVERSIGHT OFFICE, DEPARTMENT OF DEFENSE

    Dr. Colston. Chairman Tillis, Ranking Member Gillibrand, 
Members of the Subcommittee, thank you for the opportunity to 
discuss DOD's public health challenge: suicide. I'm honored to 
be here with our suicide prevention directors, our SAMHSA 
colleague, and Dr. Kessler.
    Every life lost is a tragedy. As a physician and former 
line officer, I've been shaken by suicides, so let me discuss 
what I've seen.
    Our military suicide rate was once low. When I was a 
resident at Walter Reed in 2001, our Active Duty suicide rate 
was half the rate of a similar population. But, like the rest 
of America, DOD has seen suicides increase. Even as we created 
a centralized suicide prevention infrastructure and enlarged 
community care, our Active Duty suicide rate now approaches 25 
per 100,000. The National Guard rate is yet higher.
    So, what are we doing? First, we're being transparent. 
We've been working, over the past 10 years, to decrease the 
suicide rate, and clearly our rates show more needs to be done.
    How might we reach our goal? By ensuring all evidence-based 
interventions for suicide are used and evaluated in regard to 
suicide outcomes.
    Our VA/DOD Clinical Practice Guideline for Suicide Risk, 
shaped with me by co-champions Dr. Lisa Brenner, renowned VA 
suicidologist, and Dr. Amy Bell, chair of Army's Public Health 
Review Board, was recently refereed, published, and synopsized 
in the ``Annals of Internal Medicine,'' found evidence for 
cognitive behavioral therapy, crisis response planning, and 
lethal-means restriction as avenues to prevent suicide. On the 
other hand, our evidence base remains thin. Many domains of 
intervention require evidence development, and the effect sizes 
of interventions are small. This means we need to treat a 
number of people with a treatment that's been proven to work to 
achieve a single changed outcome.
    We need to translate public health successes from other 
domains into the management of suicide. DOD stemmed an opiate 
crisis in its ranks with evidence-based practice, achieving a 
death rate from intentional and accidental overdoses under one-
fourth of the national rate, along with low rates of addiction 
and positive drug screens. Our public health effort included 
hard assessments of policies, pain protocols, screening, 
pharmacy controls, and training efficacy. Implemented policies 
and procedures stem from outcomes. Our efforts saved lives.
    We need to continue work on precipitants of suicidal 
behavior. As a line officer, I found enlistees, like other 
young Americans, were easily separated from their money, 
placing them in financial peril. There are more ways for 
servicemembers to find trouble today. Despite our gains on drug 
abuse, the force still uses too much alcohol, and I never 
anticipated that mentoring sailors on safe relationships would 
be a leadership skill, but it remains so. We must rid our 
Nation of intimate-partner violence, sexual trauma, and child 
abuse. Our partners and kids are a source of strength, and our 
children sustain military culture.
    Interventions we leverage now are critical. Veterans who 
get healthcare at VA die less by suicide. So, we aid transition 
into VA care as we share 130 clinical spaces. When I served at 
Lovell Federal Health Care Center in north Chicago, shared 
clinical spaces worked.
    Finally, we'll stay focused on the people in front of us. 
The hopelessness of suicide can stem from a loss of belonging. 
All of us and our families can bring meaning to one another as 
we protect freedom worldwide.
    Thank you. I look forward to answering your questions.
    [The prepared joint statement of Dr. Karin A. Orvis and Dr. 
Colston follows:]

  Prepared Joint Statement by Dr. Karin A. Orvis and Dr. Mike Colston
    Chairman Tillis, Ranking Member Gillibrand, and other distinguished 
Members of the subcommittee, thank you for the opportunity to appear 
before you today with our colleagues from the Department of Veterans 
Affairs (VA) and the Substance Abuse and Mental Health Services 
Administration (SAMHSA), and Harvard. Like you, we are very concerned 
about the suicide rates in our military. We look forward to discussing 
the Department of Defense's (DOD's) suicide prevention efforts, 
including the monitoring and reporting of data on suicide in our 
military community, the deliberate evidence-based strategies we are 
currently implementing, and the new promising practices we are piloting 
based on research advances from the civilian sector to enhance our 
public health approach to suicide prevention.
    Our rates of suicide are not going in the desired direction. Every 
life lost is a tragedy and each one has a deeply personal story. With 
each death, we know there are families)--and often children--with 
shattered lives. We know this is a shared challenge. Nationwide, 
suicide rates are increasing. None of us has solved this issue, and no 
single case of suicide is identical to another case. Though many have 
similar patterns, in a great number of other cases, even close friends 
and family members are surprised by an individual's suicide.
    The DOD has the responsibility of supporting and protecting those 
who defend our country, and so it is imperative that we do everything 
possible to prevent suicide in our military community. Our commitment 
is from this lens, from the debt of gratitude that we owe to 
servicemembers and their families, to encourage help-seeking behaviors, 
eliminate stigma, and increase visibility and access to critical 
resources. Our efforts must address the many aspects of life that 
impact suicide, and we are committed to addressing suicide 
comprehensively through a public health approach to suicide prevention.
                calendar year 2018 annual suicide report
    Because data informs our ability to take meaningful steps and 
fulfill our commitment to transparency with you and the American 
public, the Department has expanded our reporting on suicide-related 
data. This past September, the DOD published the Annual Suicide Report 
(ASR) for calendar year (CY) 2018. We were able to meet with many of 
you and your staff on the ASR findings, and we appreciate the continued 
interest and support on suicide prevention efforts. The ASR, along with 
the complementary DOD Suicide Event Report (DODSER) Annual Report, 
provides increased transparency and frequency of reporting to 
strengthen our program oversight and policies.
    The calendar year 2018 suicide rates are consistent with rates from 
the past 2 years across the military (for the Active component, 
Reserve, and National Guard), and have been steady over the past 5 
years for the Reserve and National Guard. However, we have seen a 
statistically significant increase in the Active component over the 
past 5 years (since 2013). In calendar year 2018, there were 541 
servicemembers who died by suicide. We are disheartened that the trends 
in the military, as in the civilian sector, are not going in the 
desired direction.
    We are often asked how the military compares to the U.S. 
population. While hardly acceptable, military suicide rates are 
comparable to the U.S. population rates after accounting for age and 
sex differences, with the exception of the National Guard. The National 
Guard rate is statistically higher than the rate for the U.S. 
population, after accounting for age and sex differences. Consistent 
with prior years, servicemembers who died by suicide were primarily 
enlisted, male, and less than 30 years of age, regardless of whether 
they were serving in the Active component, Reserve, or National Guard.
    We are equally committed to the well-being of our military 
families. This was the first time the Department published suicide data 
for our military family members. This is an important step forward. 
These results integrate data from both departmental data sources and 
the most comprehensive U.S. population data available--the Centers for 
Disease Control and Prevention's National Death Index. The Department 
estimates there were 186 military spouses and dependents who died by 
suicide in calendar year 2017, which is the most recent data available 
on military family members. Suicide rates for military spouses and 
dependents in calendar year 2017 were comparable to, or lower than, the 
U.S. population rates after accounting for age and sex. The Department 
will continue to work to effectively capture military family suicide 
data and report out on this important information in a transparent and 
timely manner, reporting on these data each year.
    The Department is focused on fully implementing and evaluating a 
multi-faceted public health approach to suicide prevention that targets 
our military populations of greatest concern--young and enlisted 
servicemembers, and members of the National Guard--and continue to 
support to our military families. Specific initiatives include:
      Young and Enlisted Servicemembers: We are piloting an 
interactive educational program to teach foundational skills early in 
one's military career to help address life stressors, and to enable 
these individuals as they progress in their career to teach others 
these skills under their leadership. We will also teach young 
servicemembers how to recognize and respond to suicide ``red flags'' on 
social media--to help servicemembers recognize how they can reach out 
to help others who might show warning signs.
      National Guard Members: National Guard servicemembers 
face unique challenges in comparison to their Active component 
counterparts, including geographic dispersion, significant time between 
drill activities, access to care, and healthcare eligibility. We are 
seeking ways to expand access to care and promote help-seeking 
behavior, for example through formal partnerships, such as with the VA 
to increase National Guard members' accessibility to readjustment 
counseling services through VA Mobile Vet Centers during drill 
weekends. The VA mobile teams provide support services such as care 
coordination, financial support services, and readjustment counseling, 
including facilitating support to servicemembers who are not eligible 
for other VA services. We are also working closely with the National 
Guard Bureau (NGB) to better understand this unique and critical force, 
and assist in identifying unique protective factors, risks, and 
promising practices related to suicide and readiness in the National 
Guard. For example, we fully support their efforts to implement the new 
Suicide Prevention and Readiness Initiative in the National Guard 
(SPRING). This comprehensive initiative leverages predictive analytics 
and improved reporting protocols to allow NGB to pioneer a unified 
approach to data-driven decision-making and suicide prevention.
      Military Families: The Department is committed to the 
well-being of military families and ensuring families are best equipped 
to support their servicemembers and each other. We continue to pilot 
and implement initiatives focused on increasing family members' 
awareness of risk factors for suicide--to help our military community 
recognize when they are at risk so they seek help. We continue to 
develop initiatives on safe storage of lethal means (e.g., safely 
storing medications and firearms to ensure family safety), as well as 
how to intervene in a crisis--to help others who might show warning 
signs.
      Measuring Effectiveness: The Department has developed a 
joint program evaluation framework to better measure effectiveness of 
our non-clinical suicide prevention efforts. This evaluation will 
inform retention of effective practices and elimination of ineffective 
practices.
              public health approach to suicide prevention
    We know suicide results from a complex interaction of many 
factors--environmental, psychological, biological, and social. There is 
no one fix. Our efforts must address the many aspects of life that 
impact suicide, and we are committed to addressing this issue--not only 
because it affects our missions--but, more importantly, because it is a 
moral responsibility to take care of our people. We also know that no 
two individuals have identical experiences in life, which is why the 
DOD has taken a comprehensive, public health approach to suicide 
prevention. This approach focuses on reducing suicide risk of all 
servicemembers and their families by attempting to address the myriad 
of underlying risk factors and socio-demographic factors (e.g., 
reluctance towards help-seeking and relationship problems), while also 
enhancing protective factors (e.g., social connections, problem-
solving, and coping skills). A public health approach looks at 
promoting health and prolonging life through the strength of a 
connected and educated community--it includes medical care and 
treatment, as well as community-based prevention efforts involving 
military leaders, family, peers, spouses, and chaplains. We all have a 
role to play in suicide prevention for both our military community and 
the Nation as a whole.
    Guided by the Defense Strategy for Suicide Prevention, the DOD has 
many efforts underway as we strive to implement a comprehensive public 
health approach. Below we describe multiple initiatives--highlighting 
both institutionalized, ongoing efforts, as well as new promising 
practices from the civilian sector that we are currently piloting and 
evaluating. These examples are by no means an exhaustive list of 
current initiatives. In alignment with the joint program evaluation 
framework developed to better measure effectiveness of our non-clinical 
suicide prevention efforts, we are dedicated to evaluating the 
effectiveness of our policies and programs to retain effective 
practices and eliminate ineffective practices.
    Strengthening Economic Supports. Financial stress (or anticipation 
of future financial stress) may increase one's overall stress and, when 
combined with other factors, may increase risk for suicide. The 
Department is continuing to provide relevant programs, resources, and 
professional support to help servicemembers achieve financial 
readiness, maintain skills to make informed financial decisions, and 
meet personal and professional goals throughout the military lifecycle.
    Strengthen Access and Delivery of Suicide Care. While most people 
with mental health problems do not attempt or die by suicide, and the 
level of risk conferred by different types of mental illness varies, 
mental illness is an important risk factor for suicide. Access to and 
receiving quality mental health care is critical.
    The DOD recently partnered with VA to complete a Clinical Practice 
Guideline on the assessment and management of suicide. This evidence 
review found clinical practices that can reduce suicide--particularly 
in specific high-risk patient populations. It is important to note that 
all of the clinical practices listed below have small effect sizes, 
meaning that a clinician must treat several patients to achieve one 
changed outcome. These interventions include: cognitive behavioral 
therapy-based interventions focused on suicide prevention for patients 
with a recent history of self-directed violence; dialectical behavioral 
therapy for individuals with borderline personality disorder and recent 
self-directed violence; and crisis response plans for individuals with 
suicidal ideation or a lifetime history of suicide attempts. 
Additionally, other clinical practices are promising, such as problem-
solving based therapy for patients with a history of more than one 
incident of self-directed violence to reduce repeat incidents of self-
directed violence, patients with a history of recent self-directed 
violence to reduce suicidal ideation, and patients with hopelessness 
and a history of moderate to severe traumatic brain injury.
    Medications also have some effect in patients with the presence of 
suicidal ideation and major depressive disorder, such as ketamine 
infusion as an effective adjunctive treatment for short-term reduction 
in suicidal ideation. Lithium alone (among patients with bipolar 
disorder) or in combination with another psychotropic agent (among 
patients with unipolar depression or bipolar disorder) decreases the 
risk of death by suicide in patients with mood disorders. Clozapine 
decreases the risk of death by suicide in patients with schizophrenia 
or schizoaffective disorder and either suicidal ideation or a history 
of suicide attempt. Lastly, caring contacts have evidence of 
effectiveness. This could include periodic caring communications (e.g., 
postcards) or home visits after a suicide attempt.
    Note that a commonly used method for suicide attempts is 
medication. Access to opioid medications has been associated with 
increased rates of intentional and unintentional overdose death. DOD 
has an opiate overdose death rate that is one-fourth of the civilian 
rate, and its successful efforts can be considered a successful suicide 
prevention initiative. Examples of those efforts include: random drug 
testing for all servicemembers; pharmacy controls for all opiate 
medications; ready access to stepped pain care for all individuals (100 
percent of servicemembers receive medical care annually); and wide 
availability of the opiate reversal medication, naloxone.
    Likewise, within the realm of clinically-focused efforts, an 
increased use of administrative separation for personality disorder may 
help. A review of data shows a trend between the decrease in 
administrative separations for personality disorder and an increase in 
suicide, which may stem from persons with personality disorders having 
high rates of suicidality, or their suicidality having contagion 
effects.
    In addition to ensuring access to, and participation in, evidence-
informed clinical care, we must also address the perceived stigma we 
know our servicemembers face when deciding if and when to get help to 
be successful in suicide prevention. Among servicemembers who 
experienced significant distress, the greatest barrier to receiving 
care is stigma. Stigma reduction efforts need to be messaged with real 
data that make someone likely to seek care. A common misconception is 
that accessing credentialed mental health care will result in loss of 
one's security clearance. The reality is that among several million 
security clearance application questionnaires, only a small handful of 
individuals lost a security clearance by answering ``yes'' to questions 
about mental health history. Furthermore, about 25 percent of 
servicemembers access credentialed mental health care in the year 
before they separate, and far more access these services over the 
course of their career. The chance of being separated for a self-
referred mental health condition, particularly one that is not a 
disability, is low.
    The Department has launched several pilot initiatives striving to 
reduce stigma and strengthen access and delivery of care. For example, 
the Department is piloting a barrier reduction training designed to 
address the most prevalent help-seeking concerns of servicemembers 
(e.g., career and security clearance loss concerns, loss of privacy and 
confidentiality), and encourage servicemembers to seek help early on, 
before life challenges become overwhelming.
    Creating Protective Environments. Prevention efforts that focus not 
only on individual behavior change (e.g., help-seeking, treatment 
intervention), but on changes to the environment, can increase the 
likelihood of positive behavioral and health outcomes. We know that the 
act of suicide can be impulsive. Research has shown that the time a 
person goes from thinking about suicide to acting on it can be less 
than 10 minutes--so putting time and distance between an individual and 
a lethal means may save a life. As such, the Department has several new 
initiatives focused on means safety for servicemembers and their 
families.
    For example, the Department is currently piloting training to help 
non-medical military providers, such as military and family life 
counselors, implement counseling strategies to reduce accessibility to 
lethal means (e.g., promoting safe storage) for individuals at risk for 
suicide. The Department is also developing a collaborative 
communication campaign to promote social norms for safe storage.
    Promoting Connectedness. Our data show relationship stressors, such 
as failed or failing intimate partner relationships, are frequently 
cited risk factors for suicide, and research suggests strong social 
connections protect against suicide, along with enhancing the quality 
of life. By facilitating access to additional support by phone or web, 
or implementing active contacts from health professionals after a 
crisis, promoting connectedness may have multi-faceted, positive 
effects. The Department provides access to non-medical counselors 
through Military OneSource and military and family life counseling, 
including embedded military family life counselors to provide 
assistance to our members and families with an additional ability to 
``surge'' if necessary to locations where there is a heightened need.
    Teaching Coping and Problem-Solving Skills. Building life skills 
prepares individuals to successfully tackle every day challenges and 
adapt to stress and adversity. Addressing coping and problem-solving, 
particularly among young servicemembers at this formative stage in 
life, may normalize how servicemembers address stress, seek help when 
needed, and solve problems without violence or self-harm. The 
Department is piloting an interactive educational program to teach 
foundational skills, such as rational-thinking, emotion regulation and 
problem-solving, early in one's military career to help address life 
stressors.
    Identifying and Supporting People at Risk. To identify and support 
people at risk, the Department is building on existing training to 
identify and intervene with servicemembers at risk of suicide by 
teaching young servicemembers how to recognize and to respond to 
warning signs of suicide on social media and intervening in an 
effective manner. With respect to the National Guard, we fully support 
their efforts to implement the new Suicide Prevention and Readiness 
Initiative in the National Guard (SPRING), as well as the establishment 
of their new Warrior Resilience and Fitness Program Office to 
synchronize their multiple lines of prevention efforts into a holistic 
and integrated model to enhance the readiness and resilience of their 
total force. As a final example, the Department is piloting a training 
program to teach military chaplains cognitive behavioral strategies 
aimed at reducing suicide risk.
    Lessening Harms and Preventing Future Risk. Risk of suicide has 
been shown to increase among people who have lost a friend/peer, family 
member, co-worker, or other close contact to suicide. Also, how suicide 
is discussed in the media, in a town hall, or informally in a group of 
individuals may add to this risk among vulnerable individuals. The 
Department has several efforts underway to lessen these potential harms 
and prevent future risk. For example, we are continuing to provide 
training, education, and to engage with DOD Public Affairs Officers, 
military senior leaders, and media sources on how to safely talk about 
suicide prevention and a suicide death, as well as how to have 
conversations that will encourage those at risk of suicide to seek 
help. Whether in media or other communications, sharing stories of hope 
and resilience, and support resources available, has been found to 
increase coping skills and increase help-seeking. As another example 
initiative, the Department is developing a comprehensive resource guide 
for DOD postvention providers (e.g., commanding officers, chaplains, 
casualty assistance officers, Suicide Prevention Program managers, and 
military first responders) regarding evidence-informed practices for 
delivery of bereavement and postvention services to unit members and 
next of kin who survive a military suicide loss.
        partnerships enhance a public health approach to suicide
    Partnerships with national and local organizations, such as other 
Federal agencies, non-profit organizations, and academia, are essential 
in creating a robust safety net for our military community and 
advancing our public health approach to suicide prevention. These 
partnerships are especially important for the Reserve and National 
Guard and their families, who usually do not have ready access to 
installation-level resources. We work closely with leadership across 
the Reserve component to ensure we understand the unique challenges of 
this population and remove barriers to care.
    Our partnerships with other Federal agencies are also critical to 
implementing a public health approach to suicide prevention. For 
example, our partnership with the National Institute of Mental Health, 
which includes ex officio membership in its National Advisory Council, 
guides research priorities for suicide prevention in a National 
Research Action Plan. We partner with the SAMHSA in multiple forums, 
such as the Suicide Prevention Federal Working Group. The DOD has 
particularly close collaborations with the VA. In addition to the 
Suicide Data Repository, we share a military suicide research 
consortium. We co-develop clinical practice guidelines, not just for 
suicide, but for conditions that increase suicide risk such as post 
traumatic stress disorder, traumatic brain injury, depression, and 
substance use disorders. The DOD and VA host a biennial suicide 
prevention conference--representing the only national conference that 
specifically addresses suicide in military and veteran populations. The 
conference provides an opportunity for leaders, servicemembers, 
clinicians, behavioral health and suicide prevention experts, and 
community health providers to share their expertise and learn about the 
latest research and promising practices for preventing suicide in our 
military and veteran communities.
    The Department also has a robust effort with the VA and the 
Department of Homeland Security (DHS) focusing on the higher risk 
population of transitioning servicemembers. In 2017, DOD and VA 
leadership created an interagency governance structure to address this 
higher-risk population. These efforts received a boost when the 
President signed Executive Order (E.O.) 13822 in January 2018, 
requiring the Secretaries of DOD, VA, and DHS to work together to 
create a robust Joint Action Plan to ensure seamless access to mental 
health care and suicide prevention resources for transitioning 
servicemembers and veterans during their first year after retirement or 
separation from the military. Examples of completed initiatives to date 
include expanding Military OneSource to provide confidential counseling 
to servicemembers and their families from 180 days to 365 days after 
the date of separation or retirement; extending a warm handover (e.g., 
to VA or Military OneSource) for transitioning servicemembers in need 
of additional psychosocial support; and instituting a mandatory 
separation health assessment. Moreover, the VA, DOD, and DHS continue 
strong collaborative efforts (in partnership with other Federal 
agencies) via E.O. 13861, focusing on developing a comprehensive public 
health roadmap for the prevention of suicide at the national and 
community level. The Department is working in close collaboration with 
other Federal agencies, state and local governments, as well as 
stakeholders from the private sector on this important endeavor.
                               conclusion
    In closing, we would like to reaffirm that we are grateful for the 
opportunity to speak with you today and discuss the Department's 
suicide prevention efforts. We fully recognize we have more work to do, 
and much more progress to make, to prevent this devastating loss of 
life. We take this charge very seriously. We will do more to target our 
initiatives to our servicemember populations of greatest concern, while 
continuing to support our military families. Our efforts will continue 
to address the many aspects of life that impact suicide, and we are 
committed to addressing suicide comprehensively through a public health 
approach to suicide prevention. In closing, Mr. Chairman, we thank you, 
Ranking Member Gillibrand, and the other Members of this Subcommittee 
for your unwavering dedication and support of the men, women, and their 
families who proudly support, protect, and defend our great Nation.
    Senator Tillis. Thank you.
    Dr. Miller.

STATEMENT OF MATTHEW A. MILLER, Ph.D., ACTING DIRECTOR, SUICIDE 
       PREVENTION PROGRAM, DEPARTMENT OF VETERANS AFFAIRS

    Dr. Miller. Good afternoon, Chairman Tillis, Ranking Member 
Gillibrand.
    I'd like to submit this letter, written by the Secretary of 
the VA, for the record, if I may.
    Senator Tillis. Without objection.
    [The information referred to follows:]
      
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    Dr. Miller. I appreciate the opportunity you have both 
created----
    [Audio malfunction.]
    Dr. Miller.--deaths of my fellow veterans to suicide. I'm 
honored to be in attendance today among this distinguished 
panel as part of our collaborative efforts addressing veteran 
suicide.
    Within my position, I'm often asked ``Why?'' in the context 
of suicide. I've asked this question myself for several years 
after losing my friend and my colleague, a Marine Cobra driver, 
to suicide during OEF/OIF [Operation Enduring Freedom/Operation 
Iraqi Freedom]. In my quest to learn what I may have done wrong 
or what I may have missed with John, it's become clear to me 
that suicide is a complex issue, with no single cause. Beyond, 
it's a national issue that affects people from all walks of 
life, not just veterans and servicemembers. Suicide is often 
the result of a complicated combination of risk and protective 
factors at the personal, communal, and societal levels. Thus, I 
have wholeheartedly signed on to fully commit heart and mind to 
the secretaries, to the executive in charge, and to the VA's 
top clinical priority: suicide prevention.
    In response and in daily action, the VA is implementing a 
comprehensive public health approach to reach all veterans, 
including those who do not receive VHA [Veterans Health 
Administration] health services. In this context, we look to 
the 2019 National Veteran Suicide Annual Report to inform our 
current situational awareness.
    One of the key ways in which this year's report is 
different from those in prior year is that it places veteran 
suicide in the broader context of suicide deaths in America. 
From the report, we know that the suicide rate is alarmingly 
rising in and across our Nation. The average number of adult 
suicides per day rose from 86.6 in 2005 to 124.4 in 2017. These 
numbers included 15.9 veteran suicides per day in 2005 and 16.8 
per day in 2017. We know that suicide is one of the leading 
causes of death in the United States. As the father of four 
young daughters, the fact that suicide has become the second 
leading cause of death within their current age demographic is 
difficult for me to even comprehend.
    Amidst the haunting questions and the daunting data, there 
is hope. Although the rates of suicide are increasing across 
the Nation, we know that the rate of suicide is rising more 
slowly for veterans engaged in VHA care compared to those not 
engaged in care. We know that depression and suicide all too 
often share a tragic relationship, but suicide rates have 
meaningfully decreased among veterans with a diagnosis of 
depression and who are engaged in recent VHA care. This rate of 
decrease translates to 87 veteran lives saved in 2017, compared 
to 2016. Although female veterans are at higher risk for 
suicide than their nonveteran peers, there was not an increase 
in suicide among female veterans with recent VHA care, compared 
to the rising rate of suicide in female veterans not recently 
using VHA services.
    We know that evidence-based treatments can effectively 
address suicide. The VA is, therefore, a national leader in 
advancing best practice in universal screening for suicide, as 
well as same-day access in mental health and primary care 
services. Over 4 million veterans have been screened for 
suicide within the last year alone. Over 1 million same-day-
access mental health appointments have been fulfilled in 2018.
    We know that providing around-the-clock, unfailing access 
to suicide crisis prevention services is meaningful. Often, the 
time between the decision to enact suicide and suicide attempt 
or death can be as brief as 50 to 60 minutes. The VA, 
therefore, has become the worldwide leader in the provision of 
crisis services through the Veterans and Military Crisis Line, 
1800 calls per day answered within an astounding average of 8 
seconds.
    Amidst positive anchors of hope and progressive actions, we 
fully acknowledge and commit to the fact that more must be done 
in the name of suicide prevention. The mission is obviously and 
painfully far from complete. One life lost to suicide is one 
too many. We, therefore, appreciate this committee's 
partnership with the VA, DOD, and beyond to facilitate 
crosscutting and silo-breaking evidence-based clinical and 
community suicide prevention strategies.
    This concludes my testimony. I'm prepared to answer any 
questions.
    [The prepared statement of Dr. Miller follows:]

             Prepared Statement by Matthew Miller, PhD, MPH
    Good afternoon, Chairman Tillis, Ranking Member Gillibrand, and 
Members of the subcommittee. I appreciate the opportunity to discuss 
the critical work VA is undertaking to prevent suicide among our 
Nation's veterans. I am pleased to be in attendance with Dr. Karin 
Orvis and CAPT Michael Colston of the U.S. Department of Defense (DOD), 
Dr. Ronald C. Kessler, a McNeil Family Professor of Health Care Policy 
of Harvard Medical School, and Dr. Richard McKeon, the Director, Mental 
Health Services of the Substance Abuse Mental Health Services 
Administration.
                              introduction
    Suicide is a complex issue with no single cause. It is a national 
public health issue that affects people from all walks of life, not 
just veterans. Suicide is often the result of a multifaceted 
interaction of risk and protective factors at the individual, 
community, and societal levels. Thus, VA has made suicide prevention 
our top clinical priority and is implementing a comprehensive public 
health approach to reach all veterans--including those who do not 
receive VA benefits or health services.
    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 offerings that consider 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.

    Through the National Strategy we are implementing broad, community-
based prevention initiatives, driven by data, to connect veterans in 
and outside our system with care and support at both the national and 
local facility levels.
         va and dod veteran suicide data tracking and reporting
    The veteran and non-veteran U.S. population is changing. The 
overall population is increasing while the veteran population is 
decreasing over time. Still, suicide is one of the leading causes of 
death in the U.S. In 2017, 45,390 American adults died from suicide, 
including 6,139 U.S. veterans.
    Each year, VA and DOD produce separate annual reports on veteran 
and current servicemember suicide mortality, respectively. VA and DOD 
partner in preventing suicide for all current and former 
servicemembers, but do not use the same data sources for suicide 
surveillance reporting, with VA reporting on veterans and former 
servicemembers, and DOD reporting on current servicemembers. This 
allows VA's report to focus on former servicemembers who most closely 
meet the official definition of veteran status that is used by VA and 
other Federal agencies. For this report, a veteran is defined as 
someone who had been activated for Federal military service and was not 
currently serving. In addition, the report includes information in a 
separate section on suicide among former National Guard or Reserve 
members who were never Federally activated.
    For VA suicide surveillance reporting, VA and DOD partner to submit 
a search list of all identified current and former servicemembers to 
the Centers for Disease Control and Prevention's (CDC) National Death 
Index (NDI) each fall. After processing, which can take several months, 
NDI returns all potentially matching mortality information. 
Additionally, internal processing and coordination occurs between VA 
and DOD to identify veteran and servicemember deaths, finalize 
mortality information, conduct statistical analyses, and interpret 
results.
    Due to the different data sources, DOD data on mortality among 
current servicemembers is available in a more timely fashion. DOD uses 
the Armed Forces Medical Examiner System (AFMES) as its data source for 
current Active Duty servicemember suicide mortality information. A data 
source similar to AFMES is not available to VA, so VA relies on 
national reporting to identify dates and causes of death per State 
death certificates, through NDI, which are reported up through local 
medical examiners and coroners to respective states and territories.
VA 2019 National Veteran Suicide Prevention Annual Report
    The 2019 National Veteran Suicide Prevention Annual Report is VA's 
most recent analysis of veteran suicide data from 2005 to 2017. It 
reflects the most current national data available through CDC's 2017 
NDI.
    One of the key ways in which this year's report is different is 
that it sets veteran suicide in the broader context of suicide deaths 
in America and the complex cultural context of suicide. From the 
report, we know the average number of suicides per day among U.S. 
adults rose from 86.6 in 2005 to 124.4 in 2017. These numbers included 
15.9 veteran suicides per day in 2005 and 16.8 in 2017. The report 
highlights suicide as a national problem affecting veterans and non-
veterans, and VA calls upon all Americans to come together to take 
actions to prevent suicide.
    The data presented in the report is an integral part of VA's 
comprehensive public health strategy and enables VA to use tailored 
suicide prevention initiatives to reach various veteran populations. 
The report includes a section on key initiatives that have been 
developed since 2017 to reach all veterans. The report is designed for 
action based upon a stratification with the public health 
classification of universal (all), selective (some), and indicated 
(few) population framework as noted in National Strategy.
    When we look at our data, there are indicators that trends among 
veterans in VA care offer anchors of hope that we can continue to build 
upon. For example, suicide rates among veterans in recent VHA care, 
(veterans who had a VHA health encounter in the calendar year of 
interest or in the prior calendar year), with a diagnosis of depression 
have decreased from 70.2 per 100,000 in 2005 to 63.4 per 100,000 in 
2017. After adjusting for age and sex, between 2016 and 2017, the 
suicide rate among veterans in recent VHA care increased by 1.3 percent 
while increasing by 11.8 percent among veterans who did not use VHA 
care. 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 and did not increase for women 
veterans in VHA care between 2016 and 2017, women veterans are still 
more likely to die by suicide than non-veteran women.
    This data underscores the importance of our programs for this 
population. VA is working to tailor services to meet their unique needs 
and has 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.
    Efforts are already underway to better understand this population 
and other groups that are at elevated risk, such as never Federally-
activated Guard and Reserve members, recently separated veterans, and 
former servicemembers with Other Than Honorable (OTH) discharges.
    We need to consider the social determinants of health, defined 
broadly as well-being, and look at how things like economic 
disparities, homelessness, and social isolation may create a context 
that markedly increases someone's risk. Veterans who are employed, have 
a stable place to live, and are affiliated with a community of veterans 
and others for support are more likely than others to be optimistic 
about their future.
    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 post-
traumatic 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.
              evidence-based suicide prevention strategies
VA-DOD Collaboration for Suicide Prevention Among servicemembers in 
        Transition
    VA collaborates closely with DOD to provide a single system 
experience of lifetime services for the men and women who volunteer to 
serve in our Military Services. Our partnership with DOD and the 
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. VA provides several outreach 
programs and services that facilitate enrollment of veterans who may be 
at risk for mental health needs, to include VA liaisons stationed at 21 
military medical treatment facilities (MTF) as well as multiple 
outreach programs to support enrollment in mental health services at VA 
or in the community. 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 and 10 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 third quarter of fiscal year 2019, 86 percent of 
11,226 TSM respondents on the TAP exit survey reported being informed 
about mental health services.
    VA and DOD are united by a shared goal: to deliver compassionate 
support and care, whenever and wherever a servicemember or veteran 
needs it. This includes collaborating to implement programs that 
facilitate enrollment and transition to VA health care; increasing 
availability and access to mental health resources; and decreasing 
negative perceptions of mental health problems and treatment for 
servicemembers, veterans, and providers. 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 VA medical center (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, is now available to veterans for 1 year following 
separation; and
      Veterans will also be able to receive support through VA 
partners and community resources outside of VA, like veteran service 
organizations (VSO).

    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 impacts suicide prevention efforts far beyond 
its 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.
Public Health Approach to Suicide Prevention
    Maintaining the integrity of VA's mental health care system is 
vitally important, but it is not enough. 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. This highlights that VA alone cannot end veteran suicide.
    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 Nation-wide 
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 and the 
implementation of strategies and initiatives at the universal, 
selective, and indicated levels. 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 disorders, 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; and
      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, to 
training on how to increase effective messaging around firearms in 
rural communities, to the creation of thoughtful interventions around 
lethal means safety by clinicians when someone is in crisis, the ``All-
Some-Few'' framework permeates the work that we do.
    Guided by this framework and the National Strategy, VA is creating 
and executing a targeted communications strategy to reach a wide 
variety 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; and
      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 and mental health services
    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. 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 
initiatives, as well as with multiple external partners and 
organizations. In an effort to increase resiliency, VA must empower and 
equip veterans, through internal and external partners like these to 
take charge of their health and well-being and to live their life to 
the fullest.
    VA acknowledges and appreciates Congress as an important ally in 
reaching vulnerable veterans. The Improve Well-Being for Veterans Act, 
(S. 1906, and its companion bill, H.R. 3495), would require VA to 
provide financial assistance to eligible entities approved under this 
section through the award of grants to provide and coordinate the 
provision of services to veterans and veteran families to reduce the 
risk of suicide. This grant model is premised on VA's Supportive 
Services for Veteran Families (SSVF) program. The proposed legislation 
modifies elements of the SSVF program to address the suicide epidemic 
among veterans. In addition, the legislation would require VA to 
consult with VSOs and various national, State, and local organizations 
on the selection criteria, metrics, and plan for the design and 
implementation of this new grant program.
    There is no single medical or clinical diagnosis that is all-
encompassing to identify persons at risk from suicide. The Department 
and its stakeholders, including Congress, seek to position this type of 
``closest to the veteran'' community level engagement between grantees 
and veterans. VA recognizes that suicidal propensities are not simply 
associated with a mental health disorder but can be brought on by other 
factors such as the following: financial instability, loss of a loved 
one, loss of freedom, divorce or separation, homelessness, addiction, 
or other factors not medical in nature. Community partners and services 
may be in a better position to identify and help veterans with these 
risk factors or concerns. This grant program aims to use partners 
within a veteran's community to help prevent suicides and focus on the 
root causes, rather than when a veteran is in crisis.
    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 to 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 suicide contagion 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 we also use paid media and advertising to 
increase our reach.
    Through the Clay Hunt SAV Act (Public Law 114-2), VA instituted the 
pilot peer support community outreach program to engage veterans in 
care. The program commenced in January 2016. As of September 31, 2018, 
ten Veterans Integrated Service Networks (VISN) (6, 7, 9, 15, 16, 17, 
19, 20, 22, and 23) had pilot programs and community partnerships in 
place. A final report on the pilot programs was sent to Congress on 
January 3, 2019.
    Outreach efforts include care enhancements for at-risk veterans, 
the #BeThere campaign, and in partnership with Johnson & Johnson, 
releasing a PSA titled ``No Veteran Left Behind,'' featuring Tom Hanks 
through 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 2019, VA's #BeThere campaign 
reminded audiences that everyone has a role to play in preventing 
veteran suicide. It also emphasized that even small actions of support 
can make a big difference for someone going through a challenging time 
and can ultimately help save a life. Through shareable content and 
graphics, VA reached over 200 partners and potential partners through a 
news bulletin and quarterly newsletter emails. In partnership with 
Twitter, a custom icon--an orange awareness ribbon--was linked to the 
#BeThere hashtag in tweets. This positioned veterans as part of the 
global Twitter conversation about Suicide Prevention Month. Veteran-
specific posts that used the #BeThere hashtag had almost 84 million 
potential impressions. Government agencies, VSOs, and VA partners were 
among the many organizations that used #BeThere during September. 
Examples of accounts with a significant number of followers that used 
#BeThere included the following:

      U.S. Department of Defense (@DeptofDefense)--5.9 million 
followers;
      U.S. Army (@USArmy)--1.4 million followers;
      U.S. Department of Health and Human Services (@HHSGov)--
781,000 followers; and
      Senator Tammy Duckworth (@SenDuckworth)--555,000 
followers.

    As noted earlier, data is integral to our strategy and 
interventions, including our outreach approach. 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.
    We are leveraging new technologies and working with partners on 
social media events while continuing our digital outreach through 
online advertising. However, VA also continues to rely on our 
traditional partners like VSOs, non-profit organizations, and private 
companies to help us spread the word through their person-to-person and 
online networks.
    VA's premier and award-winning digital mental health literacy and 
anti-stigma resource, Make the Connection (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 campaign. 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 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 through 11 regional hubs, expert consultation for patients 
through the National Telemental Health Center, and telemental health 
services between any U.S. location--into clinics, homes, mobile 
devices, and non-VA sites through 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 fiscal year 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 fiscal year 2018, VA's apps were downloaded 
700,000 times.
    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 
earlier this year, 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.
    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 Nation-wide 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 (93) 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 at VA facilities Nation-wide, as well as by 
many of our VSOs [veteran service organizations].
                               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 
suicide prevention coordinators Nation-wide, 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. I am prepared to answer any questions 
you may have.

    Senator Tillis. Thank you.
    Dr. McKeon.

 STATEMENT OF RICHARD McKEON, Ph.D., SUICIDE PREVENTION BRANCH 
 CHIEF, CENTER FOR MENTAL HEALTH SERVICES, SUBSTANCE ABUSE AND 
MENTAL HEALTH SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Dr. McKeon. Chairman Tillis, Ranking Member Gillibrand, 
Members of the Subcommittee, thank you for inviting SAMHSA to 
participate in this important hearing on suicide prevention.
    An American dies by suicide every 11 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've 
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. 
The National Survey on Drug Use and Health has also shown that 
approximately 1.4 million American adults reported attempting 
suicide each year, and over 10 million adults report seriously 
considering suicide.
    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 life span. While Federal efforts to prevent suicide 
have been steadily increasing over time, thus far they have 
been insufficient to halt this tragic rise. We know that our 
efforts must engage multiple sectors, including healthcare, 
schools, workplaces, faith communities, and many others.
    We have seen that concerted coordinated efforts can save 
lives. Evaluation of SAMHSA's Youth Suicide Prevention Grants 
has shown that counties with grant-supported youth suicide 
prevention activities had fewer youth suicides than matched 
counties that were not. The greatest impact was in counties 
that had the longest period of sustained funding for their 
suicide prevention efforts.
    This underscores the need to embed suicide prevention in 
the infrastructure of States, local government, and tribal 
communities. In the White Mountain Apache Tribe in Arizona, 
youth suicide was reduced by almost 40 percent. In that 
community, youth who are experiencing suicidal thoughts, 
wherever they may be on the reservation, will be seen rapidly 
by a trained Apache community worker.
    SAMHSA also provides grants to support the Zero Suicide 
Initiative. Zero Suicide is a package of interventions that 
uses the most recent evidence-based science on screening, risk 
assessment, collaborative safety planning, care protocols, 
treatments, and care transitions. It's inspired by the success 
of the Henry Ford Health Care System and reducing suicide by 
more than 60 percent. Centerstone, in Tennessee, has shown 
similar results. The State of Missouri achieved a 32-percent 
decrease in suicide deaths among clients served in community 
behavioral health centers.
    SAMHSA has also been working to improve follow-up after 
discharge from inpatient psychiatric units and emergency rooms. 
In a study of youth on Medicaid in 33 States who had been 
admitted to a psychiatric hospital, the odds of death by 
suicide was 76 percent lower for youth who had a mental health 
visit within 30 days of discharge.
    NIMH's [National Institute for Mental Health] ED-SAFE study 
demonstrated that rapid telephonic follow-up after emergency 
department discharge reduced the number of suicide attempts. 
Similarly, the VA's SAFE VET study showed that a combination of 
collaborative safety planning in the emergency department and 
rapid telephonic follow-up reduced suicide attempts and 
increased linkage to VA care.
    The ED-SAFE study showed that universal screening for 
suicide risk in emergency rooms led to a doubling of the 
identification of people experiencing suicidal thoughts. And 
those that were identified were at equivalent risk to those 
being seen in the emergency room because of known suicide risk.
    The SAMHSA Suicide Prevention Program that touches the 
greatest number of people is the National Suicide Prevention 
Lifeline, a network of over 165 crisis centers across the 
country that answers calls to the 800-273-TALK number through 
which the Veterans Crisis Line and the Military Crisis Line can 
be accessed by pressing ``1.'' Last year, more than 2.2 million 
calls were answered. Evaluation studies have shown that callers 
to the Lifeline experience decreased suicidal thoughts and 
hopelessness by the end of the call. SAMHSA, the VA, and the 
FCC [Federal Communications Commission] have worked together to 
implement the National Suicide Hotline Improvement Act, and the 
FCC has recommended that the number 988 be assigned as a new 
National Suicide Prevention Hotline number.
    SAMHSA and VA have worked together to fund a series of 
mayors' and Governors' challenges to prevent suicide among all 
veterans, servicemembers, and their families. SAMHSA and VA 
have convened cities and States for policy academies to promote 
comprehensive suicide prevention.
    We believe that this type of strong interdepartmental 
effort that incorporates States and communities as partners is 
necessary to reduce veteran suicide. SAMHSA, VA, and DOD also 
work together through the Federal Working Group on Suicide 
Prevention as well as through the National Action Alliance on 
Suicide Prevention.
    SAMHSA and the entire Federal Government is engaged in an 
unprecedented number of suicide prevention activities, but we 
know we all need to do more if we are to halt the tragic rise 
in suicide. We need to implement a comprehensive public health 
approach that incorporates everything we now know about 
preventing suicide. 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 the people we have lost to suicide, as well as to those who 
have loved them, to strive to improve until suicide among 
veterans, servicemembers, and among all Americans is 
dramatically reduced.
    Thank you. This concludes my testimony. I'll be happy to 
answer any questions.
    [The prepared statement of Dr. McKeon follows:]

         Prepared Statement by Richard T. McKeon, Ph.D., M.P.H.
    Chairman Tillis, Ranking Member Gillibrand, and 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. I am Richard McKeon, Chief of 
the Suicide Prevention Branch in the Center for Mental Health Services, 
SAMHSA. I also serve as Chair of the Federal Working Group on Suicide, 
and I co-lead the State and Local Line of Effort for the PREVENTS Task 
Force established under the President's Executive Order to Reduce 
Veteran Suicide. Previously, I was privileged to be able to serve on 
the Department of Defense Task Force on the Prevention of Suicide by 
Members of the Armed Forces.
    An American dies by suicide every 11 minutes. In 2018, the Centers 
for Disease Control and Prevention (CDC) issued a major analysis of 
deaths by suicide during the time period between 1999 and 2016. The CDC 
Vital Signs analysis showed that the tragic toll of suicide has been 
increasing all across the country. Suicide is the tenth 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 17 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. While we do not know all we need to know about 
what is driving these increases in suicide, there is much we do know 
about what puts people at risk for suicide, what protects them from 
suicide, and about what needs to be done to strengthen our national 
efforts. We know from CDC's National Violent Death Reporting System 
that mental health issues play a critical role, but only about 50 
percent of those who die by suicide have had a mental health issue 
identified and only 25-30 percent are receiving any mental health 
treatment. Additionally, problematic substance use is involved with 
approximately 28 percent of suicide deaths.
    We also know that there are many distressing events and 
circumstances that can precipitate suicidal ideation or attempts, 
particularly among those with pre-existing vulnerabilities. These 
vulnerabilities may include homelessness, unemployment, medical 
illness, or interpersonal losses. We know that a suicide attempt is the 
single strongest predictor of death by suicide, and for those 
individuals we must provide proactive outreach and coordinated care and 
treatment. However, we also need to intervene even earlier as the 
majority of people who die by suicide have never made a suicide 
attempt, illustrating that we need to intervene earlier, before people 
act on suicidal thoughts, or ideally, to prevent the onset of suicidal 
thoughts. We know that our efforts must engage multiple sectors and 
must include multiple levels. We need a greater scientific foundation 
for efforts that can prevent individuals from experiencing the onset of 
suicidal thoughts. We need stronger efforts to apply what we already 
know to identify people who are thinking about suicide and then to get 
them the treatment and support they need. In addition, we need to 
improve both the quality and continuity of care to those who have 
attempted suicide. We need to make suicide prevention stronger in 
health care, but also need to engage schools, workplaces, faith 
communities, and many others. We need to have an infrastructure to 
support this work in States, tribes, and communities, and need to bring 
what we already know to scale nationally.
    While we have not been able yet to halt the tragic rise in suicide, 
we have seen that concerted, coordinated, and sustained efforts can 
save lives. We have made a concerted national effort in youth suicide 
prevention which 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 deaths and suicide attempts than matched counties that 
were not. However, this life-saving impact fades 2 years after the 
activities have ended as it has been shown that there is no longer a 
difference in suicide rates between counties who implemented youth 
suicide prevention activities and counties that did not. The greatest 
impact was seen in counties that have had the longest period of 
sustained funding for their suicide prevention effort. This underscores 
the need to embed suicide prevention in the infrastructure of States, 
local government, and tribal communities. While all 50 states have 
received a Garrett Lee Smith (GLS) state grant at some point in the 
lifetime of the grant series, too often the suicide prevention 
activities cannot be sustained 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 suicide deaths. In that community, youth who experience 
suicidal thoughts, 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 timely 
access to effective suicide prevention and intervention services and 
the demonstrated success of these grants at the county level show the 
potential for a comprehensive, coordinated county based effort to 
prevent suicide across the lifespan.
    In fiscal years 2017 and 2018, Congress provided SAMHSA, $11 
million dollars to implement the National Strategy for Suicide 
Prevention, with a focus on adult suicide prevention, including $9 
million appropriated to the Zero Suicide initiative specifically. 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 research 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 across the whole healthcare system. 
The Zero Suicide initiative uses the most recent evidence-based science 
on screening, risk assessment, collaborative safety planning, care 
protocols, 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, achieving a 32 percent decrease in suicide deaths 
among clients served in community behavioral health centers. 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 contemplating suicide. Instead, he came to Centerstone and 
agreed to participate in treatment. SAMHSA has funded 19 States, 
tribes, and health care systems to incorporate Zero Suicide and 
technical assistance in implementing this approach, has been provided 
too many more through the Suicide Prevention Resource Center and 
through SAMHSA's Mental Health Technology Transfer Centers. Improving 
the training in suicide prevention for all healthcare providers is a 
key component of the Zero Suicide approach.
    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 from Inpatient 
Psychiatric Units and from Emergency Rooms and prompt link to 
outpatient services can prevent suicide attempts. While we would all 
wish that discharge from an Inpatient Unit or from an Emergency Room 
meant that all risk for suicide had been eliminated, in reality suicide 
risk persists or re-emerges and there is a demonstrated benefit in 
maintaining contact with people during this very vulnerable time at 
least until they can be successfully linked to outpatient care. In a 
study of over 1 million U.S. veterans treated for depression, the 
period immediately after inpatient discharge was found to be the time 
of highest risk. In a study of youth on Medicaid in 33 states who had 
been admitted to a psychiatric hospital, the odds of death by suicide 
was 76 percent lower for youth who had a mental health visit within 30 
days of discharge.
    The National Institute of Mental Health's Emergency Department 
Safety Assessment and Follow Up Evaluation, which studied universal 
screening, safety planning, and follow up phone calls showed that rapid 
telephonic follow up after discharge reduced the number of suicide 
attempts. Similarly, the Veterans Administration's Suicide Assessment 
and Follow Up Engagement Veteran Emergency Treatment (SAFE VET) study 
showed that a combination of collaborative safety planning and rapid 
telephonic follow up reduced suicide attempts and increased linkage to 
VA care. In a study by the Mental Health Research Network on variations 
in patterns of health care before suicide, emergency rooms were 
identified as of particular importance because they combine high 
utilization with substantial relative risk. The ED-SAFE study showed 
that universal screening for suicide risk in emergency rooms lead to a 
doubling of the identification of people experiencing suicidal thoughts 
and that those identified were at equivalent risk to those being seen 
in the emergency department because of known suicide risk.
    The SAMHSA suicide prevention program that touches the greatest 
number of people thinking about suicide is the National Suicide 
Prevention Lifeline (the Lifeline). The Lifeline is a network of over 
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 Veterans Crisis Line also serves as 
the Military Crisis Line. The Lifeline is available 24 hours a day, 7 
days a week, and in many communities in America, it is the only 
immediately available option for a person thinking about suicide to 
reach out for help. Last year, more than 2.2 million calls were 
answered through the Lifeline, and that number has been growing 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. Both the initial calls to the Lifeline as well as follow-up 
calls from Lifeline centers are frequently experienced as lifesaving. 
In this way, the calls themselves are actual interventions not simply a 
triage to another service, although referral for emergency rescue using 
police or ambulance is utilized when necessary when risk is both acute 
and imminent. SAMHSA, VA, and the Federal Communications Commission 
(FCC) have worked together to implement the National Suicide Hotline 
Improvement Act and this past August the FCC recommended that the 
number ``988'' be assigned as a new, national suicide prevention 
hotline number.
    Community crisis centers are responsible for responding to calls 
and chats. While many of them receive a very small amount of funding 
from the Federal Government through SAMSHA, these crisis centers are 
not directly operated by SAMHSA. Lifeline community crisis centers 
largely depend on local, private, 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, highlighting the importance of local crisis center capacity.
    SAMHSA and 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, servicemembers, 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 for 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. We believe that this type of strong, continuing, 
interdepartmental effort that incorporates states and communities as 
partners is necessary to reduce veteran suicide.
    SAMHSA, VA, and DOD also work together through the Federal Working 
Group on Suicide Prevention, which includes Department of Justice, 
Department of Homeland Security, CDC, National Institute of Mental 
Health (NIMH), Indian Health Service, Administration for Community 
Living, and the Health Resources and Services Administration. SAMHSA, 
VA, DOD, NIMH, CDC and other Federal agencies and Departments also work 
with other public and private organizations through the National Action 
Alliance for Suicide Prevention (Action Alliance), 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.
    In summary, SAMHSA, and the entire Federal Government is engaged in 
an unprecedented number of suicide prevention activities, but we know 
we all need to do more if we are to halt 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 across 
the Federal Government along with States, tribes, communities, and 
private partners across America to implement a comprehensive public 
health approach that incorporates everything we now know about 
preventing suicide. 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 the people we 
have lost to suicide, as well as to those that loved them, to 
continually strive to improve until suicide among veterans, 
servicemembers, and all Americans is dramatically reduced.

    Senator Tillis. Thank you.
    Dr. Kessler.

STATEMENT OF RONALD C. KESSLER, Ph.D., McNEIL FAMILY PROFESSOR 
   OF HEALTH CARE POLICY, DEPARTMENT OF HEALTH CARE POLICY, 
                     HARVARD MEDICAL SCHOOL

    Dr. Kessler. Thank you. Chairman Tillis, Ranking Member 
Gillibrand, and Members of the subcommittee, thank you for the 
opportunity to talk to you today.
    As Matt mentioned, suicide is a national problem, it's not 
a military or VA problem. The suicide rate in the United States 
has been going up for the last 15 years. It's one of the few 
countries in the world that that's the case. In most countries, 
it's flatter, going down.
    Suicide is also fundamentally a mental health problem. The 
vast, vast majority of people who die by suicide, psychological 
autopsies show, had mental health problems. Most people with a 
mental health problem have an onset in childhood or 
adolescence. In the United States, the best estimates suggest 
that the median age of onset, so 50 percent of the people who 
will ever in their life have a mental disorder, it starts at 
the age of 13, and military is no exception. When we, in the 
Army STARRS [Study to Assess Risk and Resilience in 
Servicemembers] study, which is a big prospective study that 
I'm involved in with the Uniformed Services University of the 
Health Sciences, assessed a representative sample of people in 
the Army. The vast majority of the people who had a mental 
health problem told us that it started when they were a kid, 
before they came into the military. Now, those early problems 
are, typically, relatively mild, they're not the kind of thing 
that would get somebody excluded from being in the service. 
They're also not the kind of thing that people get treatment 
for. It's only a number of years later when the problem gets 
more recurrent and persistent and severe, and the suicidality 
starts. That's when people get into treatment, and it's tougher 
to treat it at that point. If they were nipped in the bud, it 
would be a much easier thing to do.
    So, what we need to do, one thing that would be of enormous 
value, would be to develop more focus at the early end of the 
spectrum rather than late into the spectrum. Let's not wait 
till they're jumping off the bridge and Matt Miller's guys try 
to grab them back. If we could find people who have relatively 
mild problems and get them into treatment early enough, that 
could be of enormous value.
    As Senator Gillibrand said, though, it's a challenge 
because there's a--there's reluctance to report these kind of 
things, and how to figure out how to get people to admit 
relatively mild problems is tough. As we all know, everybody 
wants to stop smoking after they get cancer, not before they 
get cancer. You know, so, I mean, it's sort of--it's a tough 
thing. But, working on that problem could have enormous payoff.
    It's important to realize that these early treatments of 
relatively mild mental disorders compare very favorably to the 
treatment of cancer, heart disease, diabetes, and so forth. So, 
we know now to treat these people. It's tougher when they get 
to the point of having suicidality, where there are some things 
we know, but it just is tough. But, for the relatively mild 
things, cost-effectively, they can be treated.
    The big difference is that, when we have physical 
disorders, there's usually only a small number of things that 
happen. If we break our arm, you know what to do. You go to the 
emergency room, and they set it. If you get depressed, you can 
go to your minister, priest, rabbi, go to a social worker, you 
go to a family doctor, who gives you a pill, you go to--I mean, 
which one of these things--the National Center for PTSD [post-
traumatic stress disorder], which is a VA center, it's the 
leading PTS data research center in the world. They list, on 
their website, ten different kinds of psychotherapy for PTSD, 
seven different kinds of pills that have been shown to work. 
Each one of them works with 30 or 40 percent of people. There's 
nothing that works for everybody, and there's no one that's 
best. As a result of that, most treatments for mental disorders 
is trial and error. You get the first treatment, which the 
doctor you see is the one who has most experience dealing with 
that. Whether that's the best one for you or not is a different 
matter, and so, trial and error is the way these things go. 
Because people who are depressed are depressed, they give up 
early, they don't stick through the whole trial-and-error 
process. Very often, they quit, and often with tragic 
consequences.
    There are ways of doing a better job than trial and error, 
and they're called, as you probably know, precision medicine. 
Precision medicine in cancer and cardiovascular disease is 
really a developed area. We could do a heck of a lot better 
than that than we are right now in the mental health domain. VA 
and DOD are both making beginning efforts in that. We really 
need to do more to get the right treatment to the right people 
right away.
    There are some other things we could do much more 
concretely, and I'll just mention a few of them. I have them in 
my testimony. One is, there's been an idea around for a long 
time to do an inception survey. When people join DOD, have 
everybody do a survey about their history of mental disorders 
and problems so that we can find people quickly, nip it in the 
bud. That's something we should explore in a serious way. There 
are some challenges in doing it, to get people to admit things, 
and so forth, but it's something that could be doable.
    It would also be great to figure out a principled way of 
evaluating, when we do those early interventions: How do you 
know which one works? So, we need a commitment to a strong 
evaluation process, where you have a--you decide whether it 
works or not. The people who develop it don't do the 
evaluations, some independent people do, so you kind of stick 
with the good things and cut your losses on the bad things.
    We need to integrate the many systems that DOD has.
    I'm running out of time, so I'll stop now, but there are 
several things along those lines that we could do. They're very 
concrete, very doable.
    VA and DOD are extraordinary organizations that have the 
wherewithal to do these kind of things because they're the 
biggest integrated healthcare systems in the country. Because 
of their organization and their high level of expertise, they 
really could do this in a way that other places in the country 
can't. I would urge you to help them do that.
    So, Mr. Chairman, thank you again for the opportunity to 
share these thoughts with you and your subcommittee, and I look 
forward to answering your questions.
    [The prepared statement of Dr. Kessler follows:]

             Prepared Statement by Ronald C. Kessler, Ph.D.
    Chairman Tillis, Ranking Member Gillibrand, and Members of the 
subcommittee, thank you for the opportunity to talk to you today about 
risk reduction and resilience-building to prevent suicide and suicide-
related behaviors in DOD and among veterans.
    As you know, the rising suicide rate in DOD and VA is a national 
problem, not just a problem of the military, and it is fundamentally a 
problem of unresolved or unidentified mental illness. Psychological 
autopsy studies show clearly that the vast majority of people who die 
by suicide in the U.S. suffered from some type of mental illness, most 
commonly a mood disorder, but often a complex combination of comorbid 
mood, anxiety, and substance use disorders. If these mental disorders 
had been resolved, many of the suicides would not have occurred.
    Epidemiologic surveys of the U.S. general population show that 
people with complex mental disorder profiles typically have first 
onsets of disorders in childhood or adolescence, with a median age-of-
onset of 13 years in the U.S. That is, half the people who will ever in 
their life have a mental disorder have a first onset by age 13. 
Military personnel are no exception. The Army STARRS study found that 
the majority of soldiers identified to have mental disorders reported 
that their first problems started well before they joined the Army.
    These initial problems typically are not severe, but rather 
manifest as childhood phobias, social anxiety disorders, or mild 
depressions, sometimes coupled with secondary alcohol or drug abuse in 
adolescence as a form of self-medication. The vast majority of these 
early disorders go untreated even though they are eminently treatable. 
They come to clinical attention only later, sometimes many years later, 
when they have evolved into more complex comorbid syndromes that are 
more difficult to treat. We have to do a better job of early detection 
and intervention. Importantly, these early disorders are very common 
and are not severe enough at the time of military enlistment to be 
exclusionary. Instead, early intervention is needed to ameliorate these 
problems before they progress.
    It is also important to note that the success of treating mental 
disorders among patients who have not gotten to the point of becoming 
suicidal compares favorably with the treatments of most physical 
disorders. However, there is one big difference: that the range of 
treatments available for mental disorders is much greater than for most 
physical disorders. For example, the web site of the VA National Center 
for PTSD, the leading clinical research center for PTSD in the world, 
lists no fewer than 10 types of evidence-based psychotherapy and 7 
types of evidence-based medication, not to mention the 10 x 7 
combinations of psychotherapy and medication that are sometimes used to 
treat patients with PTSD.
    Not all of these treatments work for all patients, although at 
least one works for the vast majority of patients. And some treatments 
also work for patients who have gotten to the point of being suicidal. 
But very little is known about how to pick the right treatment for the 
right patient. Trial and error is consequently the norm. However, this 
leads to many treatment failures. After one or more treatment failures, 
many patients give up and drop out of treatment, often with tragic 
consequences, even though they would have been helped if they had 
continued with subsequent treatment trials. We need a better way to 
pick the right treatment for the right patient right away.
    The investigation of that issue is known as ``precision medicine.'' 
Great progress has been made along these lines in other areas of 
medicine, but progress in precision psychiatry has been slow because 
the known biological markers of mental disorders that have been the 
focus of work to select the best medications for treating mental 
disorders are too weakly related to treatment response to provide much 
guidance in picking optimal pharmacologic treatments and tell us 
virtually nothing about the likely success of psychological treatments. 
However, a growing body of evidence based on small trials carried out 
by psychologists shows that psychosocial factors hold out great promise 
in precision treatment planning for people with mental disorders. We 
need to invest in the development of precision treatment tools based on 
these factors to advance the agenda of getting the right treatments to 
the right patients right away.
    In carrying out this work, which will involve both evaluating new 
interventions and determining which of them work for which patients, it 
will be important to establish a rigorous and consistent evaluation 
process. Both DOD and VA have taken important steps in this direction 
by initiating measurement-based treatment systems to assess behavioral 
health functioning and suicidality in multiple clinical settings. The 
DOD in particular has amassed the Nation's largest repository of 
patient-reported clinical outcome data, which includes over 4 million 
instances where military beneficiaries have rated how effectively their 
treatment is working. But more could and should be done. Some examples:
      The idea has been discussed for many years of 
implementing an inception survey for all DOD personnel beginning 
service in order to assess pre-enlistment mental disorders, childhood 
adversities, and other risk and resilience factors for suicidality that 
might profit from early intervention. Army STARRS carried out such a 
survey and the results continue to be very important as we follow 
soldiers over nearly a decade. An ongoing inception survey of this sort 
for all new recruits coordinated across all DOD branches might be of 
considerable value in pinpointing new personnel for early intervention 
as well as for obtaining information that could be used to help guide 
precision treatment planning. But experimentation and rigorous cost-
benefit analysis would be needed to find the best way to present such a 
survey so as to encourage honest reporting and to determine if the 
survey has value either in finding new recruits who benefit from early 
interventions and/or in providing unique background information needed 
to support precision treatment planning.
      But how would we know if these interventions worked and 
for whom? As noted above, rigorous evaluation is needed that builds on 
the existing measurement-based care programs already implemented in DOD 
and VA. But the current system would have to be expanded and staff 
added with expertise in advanced statistical methods (e.g., artificial 
intelligence, other types of machine learning methods) to make that 
happen.
      It would also be of great value to integrate the many DOD 
administrative data systems into a consolidated data warehouse that 
could be used to target, evaluate, and refine clinical interventions 
for personnel throughout their military careers. Work along these lines 
is already underway, but needs to be strengthened and sustained.
      Increased coordination is also needed between DOD and VA. 
Although progress is being made, the DOD and VA electronic medical 
records are still not compatible. And the enormous richness that exists 
in the many other DOD administrative data systems is not available to 
VA. This needs to change.
      One place in which this need is especially acute is in 
the transition between Active Duty and veteran status. The suicide rate 
increases substantially after separation, especially in the first 2 
years. The VA Benefits Delivery at Discharge (BDD) Program was 
developed to help address this problem through improved transition 
planning. Other pilot initiatives are also currently underway to 
strengthen these activities. And the STARRS team is using machine 
learning methods to pinpoint the subset of soon-to-separate personnel 
who are at greatest risk of post-discharge suicidality for more 
intensive and prolonged case management, but ongoing implementation of 
such a system would require greater integration than currently exists 
across DOD data systems.
      The Veterans Crisis Line (VCL) and other components of 
the VHA system could also profit from access to integrated DOD data to 
help with evidence-based targeting and expansion of interventions, 
including such things as determining when to ``break the glass'' on 
confidentiality if callers are interested in looping in a provider and 
when VCL personnel should become involved in outbound case management 
calls.
      And VHA could also profit from an expansion of currently 
preliminary efforts to develop precision medicine guidelines for 
choosing among alternative interventions. I am being a bit self-serving 
in saying this in that I am involved in several initiatives of this 
sort with the VA Center of Excellence for Suicide Prevention in 
Canandaigua, New York. But it is clear that these kinds of initiatives 
have enormous potential value and should be the focus of more effort 
than they are currently.
    Mr. Chairman, thank you again for the opportunity to share these 
thoughts with you and your subcommittee. I know my list of potential 
actions is a long one, but there is much to be done to address the 
problem of military and veteran suicide. DOD and VA are leaders in 
tackling the national suicide problem, but numerous opportunities exist 
to build on their unique strengths. I look forward to answering your 
questions.
    Senator Tillis. Thank you all for your opening statements.
    I've decided I'm going to miss the next vote, because I 
don't want to miss any of the testimony. I think my staff have 
instructed the floor to call it.
    Senator Sullivan is not on this subcommittee, but he's very 
much concerned with a trend up in Alaska, so I've offered to 
have Senator Sullivan speak in my turn. I'll speak at the end, 
after the other members, and then----
    Senator Sullivan. Thank you----
    Senator Tillis.--we will move to Senator Gillibrand.
    Senator Sullivan.--Mr. Chairman. I appreciate you and 
Senator Gillibrand holding this very important hearing.
    Let me just ask a couple of, basic questions, and I will 
get to the question that's going on in my State. But, Dr. 
Kessler, what do you think's driving the increased rates in 
America? It's very troubling. Does anyone know?
    Dr. Kessler. Yeah, I wish I knew. The common mental 
disorders--depression and anxiety disorders--seem to be 
illnesses of affluence. People in developing countries that are 
worrying about starving to death don't get depressed. They're 
just happy to be alive, and so, there's something of that going 
on.
    But, why it is--you know, there's all kinds of things you 
can say. It's the social media, it's the destruction of the 
family. We just don't know. It's clear that there are 
biological factors that are involved. We know that stresses are 
involved. There's a combination between individual 
vulnerability and things that happen in the environment that 
come together in a synergistic way. But, as everybody said here 
today, if there was one magic bullet, we wouldn't be in the 
pickle we are today. So, there's a lot of things going on.
    Senator Sullivan. Thank you.
    Dr. Orvis, Captain Colston, the Chairman referenced, you 
know, we have a--I was actually just up there last weekend, 
Fort Wainwright, in Fairbanks, Alaska. That's an Army base. 
It's not a huge Army base. It's got a--the 1st Stryker Brigade, 
which is now over in Iraq, is headquartered there. In the last 
18 months, they've had 10 suicides and one attempted suicide, 
which is an astounding number for a unit that's not that big. I 
understand you were informed about the EPICON [epidemiological 
consultation] that the Army conducted at Fort Wainwright this 
summer. Are there any recommendations you'd like to highlight, 
either positive or negative, from that report? Not just that 
would make a difference at this base that's struggling--and it 
is a remote base, and, you know, very cold in winters and--but, 
maybe more broadly for the military.
    Dr. Orvis. Thank you for the question.
    Certainly, what's happening in Fort Wainwright is very 
concerning. And yes, we are aware of the EPICON that the Army 
undertook to understand why is there such a high concentration 
in a small period of time within that installation.
    What I would say, first, broadly, in terms of the Services 
and whether it's the Army, and Fort Wainwright in particular, 
or other Services, is, all the Services have processes in place 
to look at, Are they seeing higher concentrations, and what 
might be occurring? And, commend the Army for doing the EPICON 
to really look into what might be factors unique to that 
installation.
    We also have a body, General Officer Steering Committee for 
Suicide Prevention, that's enterprise wide, where we discuss 
these issues. So, the Army briefed on the EPICON to share those 
lessons learned and best practices with all the other services 
and with my office in Health Affairs so that we could 
promulgate those lessons learned more broadly than Wainwright 
itself.
    In terms of specific lessons learned, some of the takeways 
that I saw are, first of all, some of our common challenges 
that we see as risk factors for suicide were present at that 
installation--relationship issues, financial issues--but there 
were unique factors that were coupled with that for the Arctic 
conditions, the more isolated and remote areas, and 
understanding ways that the Army could implement specific 
policies and programs to get after some of those specific 
challenges, too, are underway.
    Senator Sullivan. Thank you.
    Captain Colston.
    Dr. Colston. I'd just add a couple of things. I mean, 
obviously, way up there--and I've been up there on 
deployments--it's really dark in the winter. And, that's 
associated with mood disorders. And mood disorders are a common 
precipitant.
    The other thing I'd say is, science really isn't there. 
Suicides are anisotropic, and what I mean by that is, if you 
have, say, a Stryker brigade of 4,000 folks--and our suicide 
rate is one in 4,000--you might get three or four suicides. But 
ten? That's a huge, a huge number, and one that, I think we 
need to run through all the biopsychosocial stressors.
    It is very hard to look back and say what, exactly, it was, 
and that's one of the frustrating things about suicide. We are 
taking prospective measures to--in regard to the treatment of 
mood disorders, anxiety disorders, substance-use disorders, 
things along those lines.
    Another thing that, just culturally, that I've known, and, 
going to college up in Upstate New York, is--there's a lot more 
drinking in the winter than there was in the summer. That's 
always a concern, especially with young folks, vis-a-vis 
impulsivity and the propensity to be impulsive, and the effect 
on mood, and the effect on sleep that alcohol has.
    Senator Sullivan. Thank you.
    Thank you, Mr. Chairman.
    Senator Tillis. Thank you, Senator Sullivan.
    Senator Gillibrand.
    Senator Gillibrand. Thank you, Mr. Chairman.
    I want to share a story of someone whose parents shared 
that story with me. One thing that stands out in this year's 
report is the acknowledgment that suicide is not caused by a 
single condition, but that it is linked to a number of 
contributing factors. I believe that we need to do more to 
listen to our servicemembers when it comes to these stress 
factors. I'm concerned that lost in the research reports are 
the stories of those who are no longer able to tell us about 
the crippling factors that led them to feel so hopeless that 
they take their own lives. So, I want to share Brandon 
Caserta's story.
    Brandon joined the Navy to become a SEAL, but a broken leg 
during the qualification course ended that dream. According to 
his family and other members of the unit, in the midst of these 
professional setbacks, once arriving at his new unit, Brandon's 
supervisor verbally abused, degraded, and demeaned him and 
others on a daily basis. Even though his immediate supervisor 
was found by a command investigation to have had a history of 
abusive behavior towards his subordinates, and had been 
previously relieved for his behavior, Brandon's command did 
nothing to protect those in his charge. Brandon attempted to 
transfer by multiple means, but a broken collarbone meant that 
he would be forced to remain in this environment for at least 
another year. On June 25th, 2018, Brandon Caserta was so 
unhappy and felt so hopeless that he walked out on the flight 
line, approached an MH-60 helicopter, apologized to a nearby 
sailor for what she was about to see, and ended his life by 
jumping into the aircraft's spinning tail rotor.
    Dr. Kessler, Brandon faced personal setbacks combined with 
daily abuse from his superiors, and had little hope that 
anything would change. What would be the effect on Brandon's 
mental state, given these circumstances? What risk factors 
would he be experiencing?
    Dr. Kessler. Well, the mental state of hopelessness is, in 
fact, a mental state, and why it is that some people become 
hopeless in the face of adversity, and others not, is a tricky 
thing. Now, as an actuarial matter, stresses in people's lives, 
and stresses that seem to not just be stresses that are 
manageable, but things that get you in a box and there's just 
no way out--a lot of people who commit suicide, when you--if 
they end up not dying by mistake and you say, ``What were you 
doing? Why did you do it?''--they say, ``There wasn't anything 
else I could do, that it was--I tried everything else. It's--it 
was the last resort.'' So, the kind of thing where you get into 
life situations where there's no way out is this sense of 
hopelessness. And that sense of hopelessness, we know, as I 
said, actuarially, the two biggies are financial problems and 
your love life. We don't--you know, having the bad--bad leaders 
is not a good thing, but that's not one of the top three or 
four or five. When we've done these big surveys of 100,000 
people, ``What's going on in your life? What relates this to 
suicidality?''--it's maybe 10 in the list, something like that.
    The trick in a lot of therapy with people who are suicidal 
is to say to them, ``You know what? It's not the only way out. 
I could tell you some other ways. You don't like that, you want 
to prove to her that you really loved her, so you're going to 
kill yourself? How about you prove to her that you really loved 
her by going off and having a nice life and saying''--in other 
words, you try to show people that there are other ways out and 
scaffold them forward. But, it seems to me that's what we've 
got to do.
    Senator Gillibrand. Captain Colston, would you agree that 
leaders ignoring a toxic environment would dissuade military 
members like Brandon from seeking mental health treatment and, 
in fact, fearing retribution from supervisors, and that the 
possibility of a mental health care provider contacting his 
command may have dissuaded Brandon from seeking help?
    Dr. Colston. I think that's a great point, ma'am. I was 
actually--just when I came here, in 2011, my office promulgated 
the stigma instruction that we sent over a couple days ago.
    It's a hard question, and one that we don't always have 
answers for, other than we do have a zero-tolerance policy, 
vis-a-vis hazing, vis-a-vis bullying, and these aren't--I've 
been a naval officer for 34 years--these aren't things that are 
culturally acceptable. These aren't things that are okay, and, 
to the extent that they happen, they're leadership failures. I 
think, whenever we get into the investigation phase of these 
types of things, that's what we see.
    I did want to take one point off of Ron. I remember, in an 
earlier--in an earlier STARRS meeting, he mentioned that people 
with sergeants who were a little older, a little more mature, 
seemed to do better vis-a-vis suicidality than folks----
    Senator Gillibrand. Yeah.
    Dr. Colston.--who might have hard-charging young sergeants 
who are less socially astute.
    Senator Gillibrand. Yeah.
    Dr. Colston. So, those are important. Those are important 
things.
    My view, as a child psychiatrist is, the military--the best 
way to raise children is to parent them gently, catch them 
being good. You know, that's----
    Senator Gillibrand. Could I----
    Dr. Colston. Oh, go ahead, ma'am.
    Senator Gillibrand. Just to address your thing. So, I think 
there's--this is one of the barriers to mental health 
treatment. The DOD's current rules for mental health providers 
identifies nine conditions under which a mental health provider 
must report treatment to a patient's chain of command. These 
rules include vague requirements, such as harm to mission, and 
present a significant challenge to providers.
    So, Captain, one of the requirements for reporting is in 
the case of harm to mission. Are mental health providers 
generally briefed on specific missions? Is it reasonable to 
think that a mental health provider would understand a 
patient's role in that mission?
    Dr. Colston. So, we have a split--as you know, ma'am, we 
have a split fiduciary role, as psychiatrists, and, in that 
role, I don't remember ever telling a commander that someone 
wasn't fit for duty, vis-a-vis the mission. We have changed our 
culture, and I've mentioned that in this room before. A lot of 
times, when folks would struggle, especially early in this 
century, we would administratively separate them, which also 
had a chilling effect on accessing care. We don't do that 
anymore.
    We do have, obviously, some mission imperatives around 
insider threat. I think that, in the Devin Kelly case, some of 
those concerns were heralded. But, we need to strike a balance, 
and as a provider, that balance usually goes to the patient. I 
think that we get it, and that's the way we train our residents 
right now at Walter Reed and Fort Belvoir. But, I'm not 
surprised to hear that we've fallen short of the mark at times, 
and I'm sorry about that.
    Senator Gillibrand. Thank you.
    Senator Tillis. Senator McSally.
    Senator McSally. Just want to say thanks to the Chairman 
and the Ranking Member for having this really important hearing 
today, and for everybody's testimony.
    I served 26 years in uniform. This issue, as I think back, 
first touched me personally when a cadet in my squadron at the 
Air Force Academy took his own life. This is something, as we 
see the trends going on in our society, all of us know someone 
or love someone who has either been in mental health crisis and 
suicide risk or taken their own lives. Someone close to me 
said, after having gone through this, that, suicide doesn't 
transfer the pain that you're feeling--sorry--it doesn't end 
the pain you're feeling, it just transfers it to those who 
survive, and the deep wounds for children and other loved ones 
when somebody feels like they have no other hope.
    Twenty veterans every day are taking their own lives right 
now. Twenty. I just--you know, they deploy, they survive 
combat, and come back, and come to this place where the enemy 
hasn't taken their lives, but they've taken their own lives. 
And so, this is so important that we take all the efforts that 
are happening, both across the Federal Government, throughout 
society, and, I think, at the State and local level, our best 
efforts to try and address this issue. But, our veterans come 
from society, and we're seeing the trends that are going up. We 
are, a part of what's going on in our society, as well. It's 
not all combat related. It's these other factors that are 
happening.
    There's a couple of examples in Arizona, which ASU [Arizona 
State University] has done a study. Veterans are two times more 
likely, overall, to commit suicide than the regular population, 
and, for the female veterans, it's three times more likely in 
Arizona. These rates are just way too high, and they're 
unacceptable.
    And so, with a sense of urgency, I think we all really need 
to not just throw more money at the issue, but really have to 
think outside the box. What is not working? What is working? 
What else can we do?
    In just a couple of examples of Arizonans, 2015, 53-year-
old Army veteran Thomas Murphy drove to the Phoenix VA on a 
Sunday night with a suicide note and a gun, and shot himself. 
In the note, he described his physical pain and the difficulty 
he was having getting treatment that he felt he needed from the 
VA. There's countless stories like that. But, the vast majority 
of our veterans are not even in the VA system.
    But, I want to highlight, a good-news example in Arizona. 
We have this Be Connected Program. In 2017, it started, and 
it's really working to connect veterans, servicemembers, 
families to whatever support they have that goes back to not in 
the immediate crisis, but what are the--earlier-on in the chain 
of events that happens.
    There's one example of a--in rural Arizona, a disabled 
veteran called Be Connected, and the question was, Can someone 
help come clean up after his pets? In reality, once a volunteer 
showed up, they realized the pet and caring for the pet was 
actually a barrier for him to get treatment for substance 
abuse, but he wanted to make sure he wasn't going to lose his 
dog. And so, they were able to meet him where he was and show 
that they had someone who's going to take care of his dog while 
he actually went in and got the treatment that he needed 
through a 28-day program. And so, this is a great example. I've 
got many more. I know I don't want to spend all the time of 
where, at the local level, with local volunteers, with Federal 
support, we really could be empowering local communities in 
order to be the neighbor, be the friend, remove those barriers, 
and get people the care they need.
    You know, what else can we do, Dr. Miller, for these types 
of programs, to incentivize them, especially for those vast 
majority veterans that are taking their lives but you don't 
even have them in the VA system?
    Dr. Miller. I was in Arizona 2 weeks ago, and I was working 
with the Be Connected individuals, and am very impressed by 
what's occurring----
    Senator McSally. Yeah.
    Dr. Miller.--there. I was trying to count, when you were 
talking, how many times you said ``local'' and ``Federal,'' and 
the importance of the relationship between them. That's what I 
think that we can work on together, is combining the power and 
the resources at the Federal level with the local level, 
realizing that, at the Federal level, in the VA, we can't do it 
on our own. There are local-specific data and resources that we 
can't cover, but they can be covered in other ways, and 
partnered with that which we can do, and do so well. That's 
where taking a look at suicide prevention, not just from a 
clinically-based perspective, but from a community-based 
perspective, is so important, and your example is a great one.
    Senator McSally. Well, there's another example, too. The 
Veteran Treatment Courts and--introduced bipartisan legislation 
last week to expand these. But, there have been lives saved in 
Arizona, where, instead of a veteran spiraling down to be 
behind bars or taking their own life, they're given a chance to 
spiral up, with accountability and treatment and support. So, 
we need these types of programs, I think, in every community, 
fit for that community.
    The other concern I have is, if somebody is in crisis and 
they're a suicide risk--again, I've seen this firsthand 
recently with a friend--not a veteran, but--there's not a lot 
of choices. They go to the emergency room, they get locked down 
because they're a risk, or then they get put into an inpatient 
mental health ward, where they are high-functioning, but they 
need some help, and they don't fit in with the other population 
there. It can put them into a worse crisis. There's not a lot 
of great options in that moment for somebody who's high-
functioning but really needs help.
    Dr. McKeon, Dr. Kessler, I know I'm late, here, but any 
other comments on that? I just really think there's a gap for 
what people need who are crying out for help, but they're high-
functioning, and they just need a path forward.
    Dr. McKeon. Yeah. I think that is a great question. Let me 
mention a couple of things.
    So, one option that doesn't require bringing someone to the 
emergency room but can--but where that will be done, but only 
if needed--is by contacting the National Suicide Prevention 
Lifeline so that somebody can be spoken to or a family member 
who's concerned about a loved one can be spoken to, where risk 
can be assessed, and a determination made about what kind of 
help is needed without going to the emergency room.
    But, there are other forms of crisis services when there's 
a comprehensive crisis continuum that has things like mobile 
outreach so that, rather than somebody being transported to an 
emergency room to receive an evaluation, that same evaluation 
can be done where the person is. There are also crisis 
stabilization units. There are some excellent ones in Arizona, 
in Phoenix and Tucson, that provide 72 hours of crisis 
stabilization, not in a--where police officers can drop 
somebody off if the police need to be involved. So, I think 
that improving crisis services is one very important 
component--not the only component, but one very important 
component of improving our national suicide efforts.
    Senator McSally. Great. Thanks.
    I'm way over my time, here, but thank you so much. I know 
Dr. Kessler was going to say something, but I'm going to have 
to wait for the record.
    Thank you.
    Senator Tillis. [Inaudible.]
    Senator McSally. Is that okay? Thank you.
    Go ahead.
    Dr. Kessler. Well, Matt mentioned the coordination between 
local and national, and here's a great example where it's the 
case. Because there are an enormous number of really creative 
programs that are local, that exist one place and nobody else 
knows they exist.
    Senator McSally. Right.
    Dr. Kessler. So, to have the national perspective to sort 
of mix and match the right things is one thing.
    The other thing, the big challenge of getting the right 
treatment to the right person, which is one of the things I 
mentioned, is that veterans are much more rural than the rest 
of Americans. The reason is, you know, the States with the 
highest proportion of veterans in America, in Kentucky, West 
Virginia, Tennessee, because they all came from there, they 
joined the military, then they moved back. And it's hard to get 
the specialized--if you live in Los Angeles, they have, you 
know, these little ultra, ultra specialized things. So, how to 
figure out----
    Senator McSally. Yeah, but they don't join the military.
    Dr. Kessler. That's right. That's right, yeah.
    So, the kind of thing that Richard's saying, get things 
that you can have that could be remote things, you could put in 
place, get the right thing to the right person, even if it 
means moving them a little bit. But, there's a lot of 
coordination of figuring out how to get a system to work in a 
coordinated way, to take advantage of the really good ideas 
that exist right now, many of which we don't really know about.
    Senator McSally. Right.
    Dr. Kessler. But, I think we could.
    Senator McSally. Thank you. Appreciate it.
    Dr. Kessler. There's a lot more.
    Senator Tillis. Thank you, Senator McSally.
    The--I want to go back, just in terms of a level set on 
data. I think I have read that the incidents of suicide, 
adjusted for age and sex, in the whole of the military, is 
roughly equivalent to civil--civilian society, but for the 
National Guard. Is that right?
    Dr. Kessler. Yes, sir.
    Senator Tillis. Within the VA, Dr. Miller, is that roughly 
the same?
    Dr. Miller. No, sir. It's higher.
    Senator Tillis. It's much higher?
    Dr. Miller. Yes.
    Senator Tillis. The--I guess, the question--the first 
question that I have--you all have talked about programs. We've 
heard State, we've heard local, we've heard Federal, we've 
heard nonprofit, we've heard community. What effort has there 
been, you know, as a national effort, to try and identify best-
practices programs with demonstrable efficacy and in a way to 
start leading these well-intentioned efforts that may not be 
achieving the same level of efficacy into programs that work? 
You don't want to completely stifle innovation, because the 
next-best idea may come out. But, what sort of national effort, 
Dr. McKeon, either at--in your department--I know that we're 
looking at programs within the DOD and VA to determine where we 
should invest our resources, but, at a national level, what 
concerted effort, if any, exists today to try and identify a 
consistent approach to what are the consistent causes of 
suicide?
    Dr. McKeon. Well, I would mention a couple of things, 
Senator.
    So, I mean, I think that you've identified, and VA is 
utilizing in the Zero Suicide Initiative--have used a number of 
evidence-based approaches that can be used in healthcare 
systems. So, improving suicide prevention in healthcare is one 
piece. But, it's only one piece.
    We know, from the National Violent Death Reporting System, 
that only between 25 and 30 percent of those who've died by 
suicide have received current or recent mental health 
treatment. So, we need broader community efforts. There's not 
nearly as much evidence around community evidence and what's 
effective. So, that's a really important area.
    It's incorporated in the U.S. National Strategy for Suicide 
Prevention. The National Action Alliance for Suicide Prevention 
has made it a priority to try to help. As part of a recent 
meeting in--at SAMHSA, as part of the International Initiative 
for Mental Health Leadership, we met with mental health leaders 
from nine different countries to look at what we were doing in 
our different nations to prevent suicide, and how we can 
approach it comprehensively--What were the different components 
that were working in different places?--so that we can all 
learn from each other. So, it's a critical--but, we definitely 
need a comprehensive public health approach, but we also need 
more information about what can be most effective to help in 
the community.
    For our youth suicide efforts, we try to use both 
strengthening healthcare for youth suicide prevention, but also 
strengthening work in the communities. We show some evidence of 
success for that in our evaluations. But, there's a lot more 
work to be done.
    Senator Tillis. Dr. Miller, Captain Colston, and Dr. Orvis, 
one of the--I'm not an expert in this field. I'm trying to 
learn so that we can be instructive with public policy choices. 
But, one thing that just strikes me is, if we have a 
disproportionately high number of men and women in the National 
Guard. They have a unique circumstance, particularly now, with 
the operations tempo being what it is. Many are going--I don't 
know if we have data about how many of them were actually in 
deployments or away from home and then coming back away from 
the structure of the military. But, in some ways, you would 
almost--I could--the layperson could draw the conclusion that 
if that seems to be a disproportionally high number of suicides 
in that population, and, Dr. Miller, we know that the suicides 
among veterans is much higher among those who have no 
connection to the VA or VHA, what does that tell us about what 
more we need to be doing? You mentioned there's a Mobile Vet 
Center when they're on deployment. The problem is, oftentimes 
their suicides happen when they're not on deployment. So, what 
are we doing to better connect and provide access to our 
servicemembers and veterans who are--what initiatives are going 
on right now that can give us some hope?
    Dr. Miller. Historically, I think that--historically, I 
believe that we have been speaking from a perspective of 
accountability. Clinically, we've been over-reliant on a pure 
clinical perspective and addressing the situation within the 
walls, both metaphorically and literally, of a medical center 
sort of setting. I think that what we need to continue to do is 
find ways to engage, as Ron has said, the right care at the 
right time for the right person, from a clinical perspective, 
but then, in addition, as Richard has said, heavily investing, 
engaging, and measuring the effectiveness of community-based 
interventions that address broader issues that we know are 
related to suicide and suicide prevention.
    Dr. Orvis. I'll add, as well. Certainly, we know the 
National Guard has unique challenges, and locality and whether 
more geographically dispersed is a key factor there. We have a 
number of--in addition to the VA Mobile Vet Centers, which I 
think is an exciting new initiative, and it's also on drill 
weekends, which is a--more opportunity to have that regular 
care--we've been partnering very closely with the National 
Guard Bureau with the approach of providing as many different 
doors or avenues as we can. So, partnering with local resources 
in the community. There is Military OneSource that is 
available, getting--to prevention if you're having financial 
challenges, relationship issues, parenting challenges, the 
whole host of everyday life challenges. Military OneSource is 
available to everyone and all family members in the military.
    We have our Military Family Life Counselors, both directly 
specific for youth and also more broadly for our military 
community family, and they are embedded within communities, as 
well, and can be called upon for surge opportunities if there's 
a need in a particular community to have additional support.
    I will pass this to my colleague in a moment, but we have a 
number of avenues, in terms of mental care access, whether it's 
within the DOD or partnering with local organizations. ``Give 
an Hour'' is a great example of free mental health care that's 
available for all of our military members, including the 
National Guard and their family.
    Dr. Colston. I'd just add, sir, financial security and 
healthcare security are big issues for this cohort. I have seen 
patients from the National Guard who were on Medicaid shortly 
before, patients who didn't have access to healthcare recently. 
When I've--was deployed, I once saw a young man who had an 
opiate addiction, who was on buprenorphine, which is a great 
treatment. That's exactly what he needed to be on, but he 
didn't need to be in the desert on that particular therapy. So, 
we need to standardize and optimize care for our Guard cohort, 
just as we do for the Active Duty forces.
    Senator Tillis. Thank you.
    Senator Gillibrand.
    Senator Gillibrand. Thank you.
    Dr. Miller, servicemembers who are transitioning or 
experiencing a move seem to be particularly vulnerable. My 
understanding from the Department's own statistics is that 37.8 
percent of servicemembers who died by suicide had either 
entered, exited service, or had experienced a geographical move 
in the last 90 days, or would be in the coming 90 days. 
Servicemembers who are exiting the service are dealing with a 
number of very stressful factors, as well as the culture shock 
of transitioning to civilian life. Both unemployment and 
suicide rates among veterans must be directly impacted--by the 
lack of adequate coordination between the DOD and VA as 
military members are exiting service.
    In a recent survey, Iraq and Afghanistan Veterans of 
America found that 65 percent of its members knew a fellow 
post-9/11 veteran who attempted suicide, and 59 percent knew 
one that succeeded. Does your office reach out to these 
veterans for insight and advice how you can better serve 
younger veterans?
    Dr. Miller. Yes. The--you are 100 percent correct that the 
time of transition is--represents a higher risk period for 
individuals, veterans, servicemembers, with regard to suicide. 
That time of transition can be embodied by exactly what you're 
talking about with that which occurs from servicemember to 
veteran. I am optimistic regarding that which we have spent the 
last year working carefully on with regard to wraparound 
services, 365 days before separation to 365 days post. I'm 
optimistic about what started on Monday of this week, which was 
initiation of Executive Order 13822, step 1.1, which was the VA 
callbacks. Within the first month of separation, we are 
contacting every veteran that we receive on the list of those 
separating. We're introducing them to the VA, we're introducing 
them to services with the VA, and we're offering them 
connection and resources within that conversation. We offer 
them a follow-up letter to reiterate the sources, and we offer 
them connection to mental health services.
    Again, that began on Monday. We'll be monitoring the 
progress of that within our agency broad goals. I look forward 
to positive results, ma'am.
    Senator Gillibrand. Have you also looked into this issue? 
We passed some legislation in early 2019 on overmedication of 
veterans, that sometimes veterans are given four or five 
medications, and there's some correlation between increase in 
suicide susceptibility because of overmedication. Have you 
begun to look at that? Have you had any findings up until now?
    Dr. Miller. Yes, ma'am. I feel that we've been looking at 
this for a few years, at the--at least, particularly with 
opioids, and then opioid combinations, such as with 
benzodiazepines.
    Senator Gillibrand. Right.
    Dr. Miller. We have been carefully monitoring, as a whole 
system, opioid prescribing rates, opioid and benzodiazepine 
combinations, and we've been working on addressing and tracking 
down on that. However, within that there are--and Mike knows 
this better than the rest of us, but there are important 
clinical practice guidelines to attend to. You could exacerbate 
issues if you taper too quickly or in a way that's not advised. 
So, making sure that we're doing this in a way that is 
consistent with clinical practice guidelines is also important. 
We've had a significant emphasis on that within our system, as 
well.
    Senator Gillibrand. Okay.
    Dr. Kessler, part of your testimony, you said that you 
thought it would be interesting to have an inception survey, 
since a lot of the data shows that many of our servicemembers 
come in with mental health challenges. But, as I said in my 
opening remarks, a lot of servicemembers don't want their 
commanders to know that they have a history of mental illness 
or that there might be some impediment to exemplary service. 
So, have you any thoughts about, if we did create an inception 
survey, how to allow it to be confidential? I'm thinking about 
the fact that our chaplains are able to provide guidance, 
spiritual counseling on a confidential basis that never goes to 
the commander. Is there an argument to be made to allow mental 
health guidance, mental health services to be given in a 
confidential setting, included with the inception survey, and 
then continue that throughout a servicemember's career, and 
then again upon separation, so that you have an entire 
continuum of care for mental health that is outside of the 
chain of command so it--so that there's not that barrier, the 
fear of being degraded or devalued or being sidelined?
    Dr. Kessler. You know, in the work that we've been doing 
with new soldiers, where we have, 50,000 new soldiers we survey 
right in the--in reception week, you know, within 48 hours of 
them getting into the service, we tell them that this is all 
confidential, that some university guy's doing it, their 
commanders will never know about it. We find 1 percent of 
people who told us they tried to kill themselves in the past. 
Well, that's a--if you admit that in your thing, you're not in 
the Army. So, all those people didn't say that. That's about 
half of the people who will ever make a suicide attempt while 
they're in the Army, they made it before they joined, and they, 
on purpose, didn't talk about it. So, it's clear that there's 
stuff going on of that sort. The--as I mentioned before, most 
of these problems are relatively mild, but there are some that 
are pretty severe.
    What do you do about that? It's a challenge. There are 
several things we've been working on in other populations, like 
with college students, the same kind of age group, saying, 
``You know, you want to be all you can be, you want to be a 
master of the stresses, and so we're going to teach you some 
ways of being more resilient.'' So, it's a--''You're a winner, 
you're not a loser, for going in and getting help.'' So, I 
think there's some rebranding that can be done and probably do 
some good.
    It's tough to rebrand that you tried to kill yourself. You 
know what I mean? It's just sort of--and so, the idea of doing 
something that's more confidential, that sort of goes beyond 
Military OneSource--and a lot of people do know that they can 
go to the chaplains. And chaplains are feeling beleaguered now, 
because they're getting a lot of this stuff. It makes a lot of 
sense. But, it's really--I mean, as an outsider, it makes a lot 
of sense, but you really have to turn to the folks here who are 
the DOD people. But, as an outsider, I certainly think that is 
a--has a lot of common sense to it.
    Dr. Miller. Ma'am, I have a 20-second follow-up to that----
    Senator Gillibrand. Yeah, anyone can----
    Dr. Miller.--if I may.
    Senator Gillibrand.--speak on this issue.
    Dr. Miller. The most trouble I was in in the military when 
I was an officer and a clinical psychologist was when I did not 
report that the spouse of an F-16 driver was experiencing 
substance-use-disorder issues. When there was an on-
installation event involving this situation, the commanding 
officer was livid at me for not telling him about this. I said, 
``Why would I tell you?'' And he said, ``Because I wouldn't 
have assigned this person to be a 16 driver if I knew that.'' 
And I said, ``How fair is that?'' What was really underlying 
his emotion was the fact that he was afraid that he was going 
to get in trouble and that fingers were going to get pointed.
    So, at all levels, I think we also need to take a look at 
the culture in which we blame and point fingers, and we allow 
people to take a chance, in some cases, and use clinical 
discretion and use interpersonal discretion instead of blaming 
when something bad happens, as a first resort.
    Senator Gillibrand. Related, so we've been working for a 
long time on trying to deal with the scourge of military sexual 
violence, and that more than half of the survivors are men, in 
terms of raw numbers. But, the number of men who are willing to 
report is very low, because they don't want to be devalued or 
made fun of or just appear that they're not strong enough or 
tough enough for the job, and so, they don't report. Then we've 
seen some evidence that untreated sexual trauma, particularly 
among men, is one of the leading reasons for suicide amongst 
that cohort.
    So, one of the reforms we've put in place a long time ago 
is that we let people report if they've been sexually 
assaulted, confidentially, so they can get access to the 
services. It does not--it is not really working, because the 
men still have very low reporting. But, at least we've put that 
into place.
    I'm thinking that, to the extent any of you have any 
thoughts on this issue, making a recommendation to the 
committee about how to create a safe space for mental health 
reporting, similar to the allowance we make for military sexual 
trauma reporting, to just get services in to these people so 
they don't lose hope, and don't decide--or don't fall prey to 
suicide.
    Dr. Colston. I think one thing--Matt was--by the way, was 
absolutely right when he spoke about nondisclosing. Policywise, 
he was totally fine on that nondisclosure, and I think 
something along those lines, codified in law, might not be a 
bad idea. Because right now it really is, it's just a--it's a 
training issue. It's more----
    Senator Gillibrand. Right.
    Dr. Colston.--a cultural issue of how we practice, as 
psychologists and psychiatrists.
    Senator Gillibrand. Well, I'd be grateful if you'd each do 
a recommendation to the committee by letter after you've had 
some time to think about this, because I do believe having a 
requirement by the chain of command to report any mental health 
issue is a significant barrier to seeking treatment. And we've 
seen it in the military sexual traumas context. So, I'd love 
your recommendations about ways you could implement something 
like this that you think would be productive, based on your 
years of experience and expertise.
    [The information referred to follows:]

    Dr. Kessler. That is an exceedingly difficulty problem. DOD 
personnel know that mental health problems can damage career 
chances. In civilian industry, this problem is managed in two 
ways that could be used in DOD: (i) by having laws put in place 
that make it illegal to discriminate based on health problems, 
although we know that these are often honored in the breach in 
the civilian world; and (ii) by putting in place external EAPs 
[employee assistance programs] that allow workers 
confidentially to seek help without their employers knowing. I 
see no reason the latter cannot be done in DOD. The argument 
that military personnel need to have their commanders know of 
their emotional problems should be equally true among civilian 
first-responders, like police, firefighters, and other 
emergency services workers. Yet police and firefighters 
typically have unions and external EAPs that protect their 
rights while making sure these personnel are able to do their 
jobs. There will continue to be some difficulties, as we would 
not want an actively suicidal soldier to deploy to a combat 
theatre in a combat arms MOS [military occupational specialty], 
yet we know that career advancement in the Army is enhanced by 
having combat deployments. Some cases will exist when 
confidentiality has to be broken, much as in the case where the 
confidentiality of a priest has to be broken in some cases of 
extreme danger. But these cases would be much fewer if an 
external EAP existed in DOD than under the current system. 
Military One Source and the confidentiality of chaplains are 
examples of work arounds that already exist in DOD, so there 
should be no fundamental problem creating a more general 
external EAP function.

    Dr. Orvis. The issue of disclosure of mental health issues 
to the chain of command is a complex one. While the intent of 
DOD policy is to effectively meet the dual requirements of 
caring for our servicemembers and accomplishing DOD's mission, 
we understand it is our responsibility to ensure our policies 
and procedures do not have unintended consequences. Matters 
related training for medical providers on when disclosures are 
required or not required, fall under Health Affairs. Whether 
barriers to seeking care are perceived or actual, we must 
continue to identify and address them so as to provide our 
servicemembers with the resources and support they deserve. 
This issue is one of the calendar year 2020 focus areas for the 
enterprise-wide Department of Defense (DOD) Suicide Prevention 
General Officer Steering Committee (SPGOSC).

    Dr. Colston. In the event a DOD mental health professional 
determines that command should be informed, it must be done in 
a manner that prioritizes the servicemember's privacy and 
confidentiality. DOD Instruction 6490.08 requires that mental 
health professionals inform commanders in very specific, 
limited circumstances and then provide only the minimal 
required information to allow the commander to make decisions 
about risk management and unit operations. Commanders are also 
expected to protect the privacy of the information provided to 
them and restrict access to a servicemember's health 
information to only those with a need to know.

    Dr. Orvis. I appreciate that, and I just wanted to share 
one additional new thing that we're doing to--I think the panel 
has all spoken to the importance of--that we're trying to 
change the culture around help-seeking, around how we view 
mental health, around how we view suicide. Certainly, we need 
to do that, not only within the military community, but 
nationally.
    Senator Gillibrand. Yep.
    Dr. Orvis. But, one of the new pilot initiatives that we're 
working on is a training program focused on trying to talk 
about a lot of those concerns that servicemembers may have of 
what are those perceived barriers they're having, the concerns 
they have that it may have them, the impact it may have on 
their security clearance or the confidentially concern or their 
privacy concern, and talking through, What are the different 
resources that they can use? They could use chaplains, you 
know, the variety of different options, in addition to mental 
health professionals, to seek help. So, I think that's an 
important initiative that we're beginning, to help break that 
concern of, ``I can't reach out,'' or maybe, ``I'm not aware of 
the various portals of where I could reach out for support and 
resources.''
    Senator Gillibrand. Thank you.
    Senator Tillis. Dr. Orvis, I wanted to come back--in your 
opening statement, you were talking about identifying at-risk 
persons. I think you may have referred to it as a red flag. It 
brings up something else that I want to talk about. If the 
existence of a program like that is known, then could it have 
the unintended consequence of having other people try to do 
everything they can not to be flagged? Which actually relates 
to one thing that I think is a fundamental problem that I 
haven't seen anybody fix. I always use the example of, anytime 
you talk about mental health and removing--I've sat on a panel 
talking about removing the stigma of mental health. And then I 
get off the panel and somebody comes up to me, and they whisper 
about a family member or a friend who has mental health, which, 
by itself, is stigmatizing the--just, basically, perpetuating 
the stigma. So----
    And then, Dr. Kessler, in your opening statement, you were 
talking about how a lot of the at-risk signs are in 
adolescence, when you probably have parents who may observe 
something, and they would write it off as the child going 
through puberty or teenage years if it's--I think you referred 
to about 13 years old. So, how do we work on that, or what work 
is being done to where, very early in someone's life, we're 
identifying it?
    And then, Dr. Orvis, how are we making sure that these 
things that are well-intentioned to identify people that may 
need to seek help do not have the opposite effect of making 
them feel like they're about to get flagged and, therefore, 
perpetuating the stigma?
    Dr. Orvis. That's a really important question.
    Share a little bit about the initiative, first, and the 
intent is for peers to help each other. We know our young 
servicemembers, and our young individuals across the Nation, 
are using social media on a regular frequency. I think there 
was a recent statistic that over 75 percent of our young 
individuals across the Nation regularly use social media. We 
have also done research in the DOD that has shown that 
individuals do disclose, when they're having suicide ideations 
or troubles, in social media. So, this is a tool to help--if 
you're seeing your buddy or your peer saying these things in 
their social media, and maybe nobody else is seeing it, what 
can you do? What should you do? How can you reach out? What can 
you say? What resources are available? We are evaluating it 
right now, so the training video is complete, but we're 
currently doing evaluations with our servicemembers to 
understand the effectiveness and efficacy before we roll it out 
broadly.
    I think what I would also add, too, is--and we were talking 
about this earlier--is, many times--suicide is so complex, and 
it's caused by so many different factors. And there are, 
frankly, simple things that we can all do. Being connected with 
one another, having those conversations makes a difference. And 
that's part of what this particular training is trying to do, 
is just open up an avenue to have that conversation, to not be 
afraid of saying, ``Are you thinking about harming yourself?'' 
We know that's a misconception, ``If I say something, I could 
be at risk of putting a thought in someone's head, and they 
hadn't thought about it before.'' In fact, we know it's 
helpful. It allows that release in someone to share what they 
might be going through and get that connectedness and support.
    Senator Tillis. Dr. Kessler or Dr. McKeon.
    Go ahead.
    Dr. Kessler. It's the $64,000 question, you know, that the 
challenge is, Do we want to, as I said earlier, repackage it to 
say, when things are mild enough that you're building strength, 
``You're going to be a--you're going to have a great 
resilience''? When it's bad enough that you can't do that 
anymore, there's got to be a thing where people say, ``You 
know, I've been depressed before. I've had PTS.'' A general 
comes up and talks about this, or a famous person. But, as Dr. 
Orvis said, it can backfire. You know, for many years, the week 
with the highest suicide rate in America was the week after 
Marilyn Monroe killed herself, and that's been supplanted now 
recently. The week after Robin Williams killed himself is now 
the highest week of suicide. So, ``If they--if he thinks life 
is worth living, you know, what hope is there for me?'' So, 
it's a tricky thing.
    But, to have stories of resilience, say, ``Look, I've been 
through tough times, and I came out the other end.'' You might 
recall Rich Carmona, who was a Surgeon General at one point. He 
was a trauma surgeon, and he was really into, ``Real men can 
get depressed. You know, I've been through hell, and anybody 
who has blood running through their veins would be depressed at 
a situation like that. Of course I was feeling depressed, just 
like people--real men get scared. You know, I was scared. Of 
course I was scared. If you say you're not, you're lying. So, 
the real people who are strong enough are the ones who admit 
they have it and confront it.'' We're going to have to go there 
eventually with this. How to do it in an intelligent way, how 
to get from here to there and not have potholes along the way, 
I don't know, but it's got to be something we've got to 
confront in a direct way eventually.
    Dr. McKeon. One thing that I would add is that recent 
research has indicated that stories of hope and recovery of 
people who are encountering difficult times, including suicidal 
crises, but get through it and can still thrive, are 
particularly important in having positive impacts. It's--for a 
long time within the suicide prevention field, there's been a 
lot of concern about depictions of suicide leading to an 
increase. And that--and safe messaging is important. But, this 
recent research about stories of hope and recovery, I think, is 
important.
    I also would want to mention that--to reiterate something 
that Matt had mentioned, that it's so important that, to the 
extent we can, things occur within a just culture and not one 
of blame. It's very important within healthcare systems to--you 
know, every--if someone dies by suicide, they're under care, 
it's really important to take a look at that. But, we won't 
learn from those tragic events if everyone's--if the 
psychiatrists, the psychologists, the physician, the social 
worker are afraid that they're going to be blamed. So, we need 
to look at these situations in a situation for the just 
culture, a culture that is not blaming, that's not looking to 
find the fault that caused the suicide, but that's hoping to 
understand it better and to learn from each death, to find ways 
that we can improve.
    Dr. Miller. Sir, if I may add, there's an article coming 
out of--I believe it's the Albany News, out of Senator 
Gillibrand's State, today, where they're talking about State 
leadership investing significantly in mental health counselors 
in the schools--elementary, middle schools--and then not just 
counselors, an increasing availability of clinical-type care, 
but also increasing education about mental health and mental 
health issues, and normalizing aspects of it at a very young 
age. I think that that's extremely powerful. I think that it's 
a great example of where we need to go, and I think it's an 
example of the power of the PREVENTS Task Force, and what we 
can do through PREVENTS by combining the VA, the DOD with the 
Department of Education, and taking a look at how to extend 
this beyond the State of New York.
    Senator Tillis. Thank you.
    Senator Gillibrand.
    Senator Gillibrand. No, thank you, Mr. Chairman.
    Senator Tillis. Well, I could--as you can see, we've gone 
through a few rounds ourselves up here, and I could go on 
forever. We're going to need to, because there's not going to 
be any one solution, and it's a--it's an effort that will 
continue for many Congresses.
    But, one thing I am interested in, in your feedback--and I 
do have questions for the record that we will submit and, 
hopefully, get your responses back--but, the--any even meager 
steps or minor steps that we could be looking at as we 
prepare--we go into next year, and we look at the next NDA 
[National Defense Authorization]. I thought the point that 
Senator Gillibrand brought up--in your case, Dr. Miller, where 
perhaps we need to codify what you were doing, which was proper 
practice--is one little thing that we can do to make sure the 
command understands how they should be behave. But, any 
suggestions that you may have for our consideration as we begin 
to work on the next mark for the National Defense 
Authorization, and anything independent of that, we'd be very 
interested in your ongoing dialogue and feedback.
    Again, I apologize for the hearing starting a little bit 
late, but I think you see the Members who came here have 
expressed an interest. We're very, very interested and 
committed to doing everything we can.
    So, thank you all for being here. We'll keep the record 
open for one week. And we look forward to your continued 
feedback.
    Committee is adjourned.
    [Whereupon, at 4:42 p.m., the Committee adjourned.]

    [Questions for the record with answers supplied follow:]

            Questions Submitted by Senator Elizabeth Warren
                military sexual trauma and mental health
    1. Senator Warren. Dr. Orvis, Captain Colston, and Dr. Miller, some 
former members of the Armed Forces who are survivors of military sexual 
trauma (MST) may not meet the definition of veteran as defined in 
section 101 (2) in Title 38. Do you believe that expanding MST 
counseling at Vet Centers (i.e., centers for readjustment counseling 
and related mental health services for veterans under section 1712A of 
title 38, United States Code) to all former members of the Armed 
Forces, regardless of time in service or where they served--assuming no 
Dishonorable Discharge or a discharge by court-martial--would help 
reduce gaps in access to mental health services for reservists and 
members of the National Guard in relation to their Active Duty 
counterparts?
    Dr. Orvis. Expanding access to resources across geographic 
locations and populations served may have a positive impact on help-
seeking and reduce gaps in access to mental health services. However, 
mental health treatment for survivors of military sexual trauma (MST) 
falls under a clinical purview and Health Affairs.
    Captain Colston. Yes, I believe that expanding MST counseling at 
Vet Centers to all former members of the Armed Forces would help reduce 
gaps in access to mental health services for reservists and members of 
the National Guard in relation to their Active Duty counterparts. 
Military sexual trauma can have a variety of short-and long-term 
effects on a victim's mental health and may include flashbacks of 
assault, and feelings of shame, isolation, shock, confusion, and guilt. 
Victims of rape or sexual assault may be at an increased risk for 
developing depression, post-traumatic stress disorder, substance use 
disorder, eating disorder, and anxiety. It is important that services 
and support, wherever provided, consider and address the trauma that 
many individuals have experienced, including but not limited to 
confidential hotline availability, mental health screening, counseling, 
and therapy.
    Dr. Miller. Yes, Readjustment Counseling Service (RCS) believes 
that expanding counseling for MST, through Vet Centers, to all former 
members of the Armed Forces, regardless of time in service or where 
they served, would help reduce some gaps for reservists and members of 
the National Guard. It is important to note that Vet Center services 
include individual, group, and marriage and family counseling. This 
could represent only a portion of what that individual requires to 
accomplish their goals.

    2. Senator Warren. Dr. Miller, according to a recent report by the 
House Veterans Affairs Committee, ``During the last 7 years, 
Readjustment Counseling Service (RCS) has provided 15 retreats to 
approximately 400 recently returning women veterans. Pre-retreat 
assessments and post-retreat evaluations have shown significant 
decrease in posttraumatic stress symptomology, and excerpts from 
feedback forms illustrate the positive experiences of participants.'' 
This is a women-only pilot program. Given its apparent success, do you 
believe it could benefit women veterans' mental health to make this 
program permanent?
    Dr. Miller. Yes, RCS agrees that participant feedback and outcome 
data illustrate the success of these retreats and recommends that 
permanent permissive authority be granted to continue them. Pre- and 
post-retreat evaluations have shown decreases in posttraumatic stress 
symptomology and excerpts from feedback forms illustrate the positive 
experiences of the participants of Women Veterans Retreats.

    3. Senator Warren. Dr. Miller, do you believe it could be 
beneficial to expand the RCS program in retreat settings beyond women 
veterans to include other veterans enrolled in the VA health care 
system, former members of the Armed Forces, and eligible survivors and 
dependents of veterans?
    Dr. Miller. Yes, RCS believes that other cohorts, in additional to 
women veterans, could benefit from counseling and instruction in 
retreat settings. Other cohorts could include those who have 
experienced military sexual trauma, veterans and their families, era 
specific veterans and servicemembers, and families that experience the 
death of a loved one while on Active Duty.
                va capacity to care for at-risk veterans
    4. Senator Warren. Dr. Miller, there are approximately 40,000 
health care personnel vacancies within the VA. These vacancies 
undermine the VA's capacity to deliver mental health care services in a 
timely manner. Is the VA currently taking every reasonable step to fill 
vacancies in mental health professionals?
    Dr. Miller. The VA has taken significant efforts to increase mental 
health providers and capacity and ensure timely delivery of excellent 
mental health care to veterans. VA is currently engaged in an ongoing 
Mental Health Hiring Sustainment Initiative to ensure that the gains 
achieved in the most recent Mental Health Hiring Initiative are 
sustained. Since June 2017, VHA has hired a total of 6,513 mental 
health providers, resulting in a net increase of 1,723 providers 
through January 2020. Demand for mental health care continues to grow 
so the sustainment initiative also involves continued engagement with 
facilities where staffing is below the minimum recommended staff to 
patient ratio. It should be noted that the vast majority of vacancies 
in the VA system do not reflect actual shortages or gaps in service, 
but rather are the result of the natural churn of an average annual 9.5 
percent turnover rate in staffing due to losses and an average annual 
growth rate of 2 to 5 percent. Year over year, VA continues to achieve 
substantial growth in the clinical provider workforce to meet the needs 
of veterans.

    5. Senator Warren. Dr. Miller, do you need additional authorities 
from Congress to adequately address vacancies in mental health 
professionals at the VA?
    Dr. Miller. Additional congressional authorities are not needed. VA 
remains focused on hiring mental health professionals.

    6. Senator Warren. Dr. Miller, in your written testimony, you 
acknowledge the introduction of proposed legislation, The Improve Well-
Being for Veterans Act (S. 1906/H.R. 3495), which ``would require VA to 
provide financial assistance to eligible entities [ . . . ] through the 
award of grants to provide and coordinate the provision of services to 
veterans and veteran families to reduce the risk of suicide.'' In order 
to maintain veterans' continuity of care and ensure accountability for 
that care, would you agree that it is important for any outside mental 
health services organization receiving a grant or a contract from the 
VA to keep veterans connected to the VA's mental health services and 
programs and protect these programs?
    Dr. Miller. Strong care coordination between VA and community 
providers ensures veterans receive timely, integrated, high-quality 
care. VA believes care collaboration is important across both mental 
health and medical services for veterans receiving care in the 
community and in the VA. VA endorses a public health approach that 
incorporates both community prevention strategies and clinical 
interventions to end veteran suicide. Related to clinical 
interventions, appropriate mental health staffing is required for 
delivery of evidence-based care.

    7. Senator Warren. Dr. Miller, in your written testimony, you 
acknowledge the introduction of proposed legislation, The Improve Well-
Being for Veterans Act (S. 1906/H.R. 3495), which ``would require VA to 
provide financial assistance to eligible entities [ . . . ] through the 
award of grants to provide and coordinate the provision of services to 
veterans and veteran families to reduce the risk of suicide.'' Please 
describe the criteria that the VA should use to ensure that only 
reputable organizations and other entities receive grants to provide 
mental health care services to veterans.
    Dr. Miller. H.R. 3495/S. 1906 provides specified criteria to ensure 
that organizations selected meet standards of care befitting our 
veterans. VA would follow all requirements outlined in final 
legislation. Paragraph (1) of H.R. 3495 states eligible entities must 
provide:
    1.  A description of the suicide prevention services proposed to be 
provided by the eligible entity and the identified need(s) for those 
services;
    2.  A detailed plan describing how the eligible entity proposes to 
deliver the suicide prevention services, including the community 
partners with which the eligible entity proposes to work in delivering 
such services, the arrangements currently in place between the eligible 
entity and such partners, and how long such arrangements have been in 
place;
    3.  A description of the types of veterans at risk for suicide and 
veteran families proposed to be provided such services;
    4.  An estimate of the number of the veterans at risk for suicide 
and veteran families proposed to be provided such services and the 
basis for such an estimate;
    5.  Evidence of the experience of the eligible entity (and the 
proposed partners of such entities) in providing suicide prevention 
services to individuals at risk for suicide, and particularly to 
veterans at risk for suicide and veteran families;
    6.  A description of the managerial capacity of the eligible 
entity--
        A.  to coordinate the provision of suicide prevention services 
with the provision of other services by the eligible entity and/or its 
proposed partners;
        B.  to assess continuously the needs of veterans at risk for 
suicide and veteran families for suicide prevention services;
        C.  to coordinate the provision of suicide prevention services 
with the services of the Department for which the beneficiaries are 
eligible;
        D.  to tailor suicide prevention services to the needs of 
veterans at risk for suicide and veteran families; and
        E.  to seek continuously new sources of assistance to ensure 
the continuity of suicide prevention services for veterans at risk of 
suicide and veteran families as long as the veteran is determined to be 
at risk for suicide.

    8. Senator Warren. Dr. Miller, in your written testimony, you 
acknowledge the introduction of proposed legislation, The Improve Well-
Being for Veterans Act (S. 1906/H.R. 3495), which ``would require VA to 
provide financial assistance to eligible entities [ . . . ] through the 
award of grants to provide and coordinate the provision of services to 
veterans and veteran families to reduce the risk of suicide.'' What is 
the VA's measure of success in such a program?
    Dr. Miller. As noted in H.R. 3495/S.1906 selected entities will be 
required to provide annual reports related to the services they provide 
and outcomes. Currently, suicide prevention programs can be measured 
through several supported avenues:
    1)  Multiple year suicide death and behavior rate surveillance;
    2)  Community partnerships;
    3)  Qualitative data to examine gaps between community programs;
    4)  Access to crisis care;
    5)  Mental health supports;
    6)  Outreach and awareness campaigns; and other components as 
determined by the suicide prevention program.
                              social media
    9. Senator Warren. Dr. Orvis and Captain Colston, in your written 
testimony, you observed, ``We will also teach young servicemembers how 
to recognize and respond to suicide `red flags' on social media--to 
help servicemembers recognize how they can reach out to help others who 
might show warning signs.'' Is this effort integrated with any ongoing 
DOD efforts to educate servicemembers regarding attempts by foreign 
adversaries (e.g., governments and their proxies and agents) to 
influence servicemembers as part of their malign influence campaigns?
    Dr. Orvis. To reach the online community, specifically young 
servicemembers that may see different aspects of an individual's life, 
the Department has recently developed a brief online training video 
about social media indications that may precede suicide ideation and 
behavior. The training video will educate individuals about the 
emergence of warning signs of suicide on social media, as well as the 
constructive steps to take to intervene in a crisis and refer to 
appropriate care, including an understanding of why individuals should 
or should not take specific actions. Educating servicemembers regarding 
attempts by foreign adversaries to influence servicemembers as part of 
their malign influence campaigns is out of scope for this current brief 
training video.
    Captain Colston. As stated by the Defense Suicide Prevention 
Office, educating servicemembers regarding attempts by foreign 
adversaries to influence servicemembers as part of their malign 
influence campaigns is out of scope of the current brief training 
video.
           mental health challenges of national guard members
    10. Senator Warren. Dr. Orvis and Captain Colston, in your written 
testimony, you observed that ``National Guard members face unique 
challenges in comparison to their Active Component counterparts[.]'' 
One of the ways you noted that the Defense Department is working to 
expand their access to mental health care services is ``working closely 
with National Guard Bureau (NGB) to better understand this unique and 
critical force, and assist in identifying unique protective factors, 
risks, and promising practices related to suicide and readiness in the 
National Guard.'' Please describe your office's work with the 
Massachusetts National Guard to reduce suicides among members of the 
Guard in the Commonwealth, including any notable achievements or 
milestones.
    Dr. Orvis. DSPO works closely with the National Guard Bureau (NGB) 
and supports their suicide prevention efforts with each State and 
Territory. The Warrior Resilience and Fitness Innovation Incubator 
(WRFII), overseen by the NGB, is a joint effort by the Army National 
Guard (ARNG) and the Air National Guard (ANG). WRFII aims to identify, 
select, evaluate, and disseminate evidence-informed practices to 
promote resiliency and prevent suicide and related harmful behaviors. 
WRFII operated 11 pilot programs in fiscal year 2019. In fiscal year 
2020, WRFII is adding 12 new pilots to the program, with a focus on 
five areas: barriers to care and resource utilization; integrated 
approaches to destructive behavior; promoting connectedness; management 
of lethal means; and support during transitions. Massachusetts ARNG and 
ANG were selected for two pilots:
      Alcohol and Drug Abuse Prevention Training (ADAPT): 
Quarterly educational services to restore back to duty substance-
impaired servicemembers who have the potential for continued military 
service. The program made updates to the ADAPT curriculum, completed 
one training in January, and scheduled two trainings in April and 
September 2020.
      Warrior Functional, Intensive Training (F.I.T): Expands 
the existing Warrior F.I.T. program by providing personnel with tools 
and training to meet physical readiness standards, optimize 
performance, and live a healthy lifestyle. Includes in-person training, 
assessments with personalized feedback, and an online learning portal.
    Captain Colston. Health Affairs and the National Guard have a 
relationship at the strategic level. Specific work being done by the 
states directly is coordinated within the National Guard and shared 
with Health Affairs as well as Personnel and Readiness for visibility 
when indicated.
         measuring effectiveness of suicide prevention programs
    11. Senator Warren. Dr. Orvis and Captain Colston, in your written 
testimony, you observed that the Defense Department ``has developed a 
joint program evaluation framework to better measure effectiveness of 
our non-clinical suicide prevention efforts. This evaluation will 
inform retention of effective practices and elimination of ineffective 
practices.'' Would you be willing to share a copy of this framework, 
when complete, with members of the Committee?
    Dr. Orvis. A copy of the framework is included as Attachment A.
    Captain Colston. Dr. Orvis has provided a copy of the framework in 
her response to this question--please see her response.
                              attachment a
                              
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    12. Senator Warren. Dr. Orvis and Captain Colston, in his written 
testimony, Dr. Kessler observed, ``The idea has been discussed for many 
years of implementing an inception survey for all DOD personnel 
beginning service in order to assess pre-enlistment mental disorders, 
childhood adversities, and other risk and resilience factors for 
suicidality that might profit from early intervention. Army STARRS 
carried out such a survey and the results continue to be very important 
as we follow soldiers over nearly a decade.'' Dr. Kessler continued, 
``An ongoing inception survey of this sort for all new recruits 
coordinated across all DOD branches might be of considerable value in 
pinpointing new personnel for early intervention as well as for 
obtaining information that could be used to help guide precision 
treatment planning.'' Do you agree?
    Dr. Orvis. Accessions policy within the Office of Military 
Personnel Policy is responsible for the Military Entrance Processing 
(MEPS) process and screening. It is standard to screen all recruits for 
mental health issues. Assessments are conducted upon accession, at 
periodic points throughout a servicemember's career, and as part of the 
transition from military to civilian life (in close coordination with 
the Department of Veterans Affairs). Matters related to screening for 
mental health issues closely align to efforts that fall under Health 
Affairs.
    Captain Colston. Additional research will help determine the value 
of an inception survey to identify early intervention, including 
comparisons to the civilian sector. Precision treatment planning may 
improve outcomes; however, pre-enlistment survey questions may 
inadvertently disqualify a recruit that may never present with mental 
illness throughout their service.

    13. Senator Warren. Dr. Kessler, based on your experience, what is 
your assessment of the effectiveness of suicide prevention and related 
mental health care programs implemented by the DOD and the VA for 
servicemembers and veterans in Massachusetts?
    Dr. Kessler. I'm not familiar with any special programs of this 
sort in Massachusetts. Furthermore, as an epidemiologist, my work 
focuses on the magnitude of the problem, predictors of the problem, and 
consequences of the problem, but not treatment effectiveness. The 
clinical researchers on the panel would be in a better position to 
address this question than me.

    14. Senator Warren. Dr. Kessler, what is your assessment of the 
partnerships between academic institutions in Massachusetts and the DOD 
and the VA with regard to suicide prevention and related mental health 
care programs assisting servicemembers and veterans? In your response, 
please include ways, if any, that these partnerships could be improved.
    Dr. Kessler. I'm more familiar with national partnerships than with 
partnerships in Massachusetts specifically. There are big differences 
between VA and DOD due to the fact that VA has a policy of encouraging 
joint appointments between academic institutions and VA, whereas this 
does not exist in DOD. In Boston, for example, faculty from Boston 
University (BU) Medical School and Harvard Medical School (HMS) both 
have joint VA appointments and work at the Boston-area VAs. The 
different VA locations in the Boston area are either BU-affiliated or 
HMS-affiliated. The same is true in many other communities across the 
country. This is less feasible in DOD because of the smaller size of 
DOD than VA, but this could be done in DC and San Antonio and Texas and 
other places with major DOD Medical Centers. But another thing that 
would make an enormous difference would be to have an extramural 
research program at VA. NIH has both a relatively small intramural 
research program (i.e., full-time NIH scientists working on research) 
and a large intermural research program (i.e., NIH giving grants to 
academics). But VA has only an intramural research program in which the 
only eligible applicants are those with 5/8th or more FTE [full time 
employees] in VA. I think the robustness of VA research would be 
increased dramatically if VA had an intermural research program that 
held the bulk of VA research dollars. As in NIH, where full-time NIH 
scientists can be collaborators in intermural research, this could be 
done in VA as well. That would dramatically increase the intellectual 
vitality of the VA research portfolio. Implicit in what I'm saying here 
is that a good deal of VA research is carried out by researchers who 
are more interested in protecting their turf than bringing in fresh 
ideas. That situation would change, probably radically, if an 
intermural research program came into existence.
             combating stigma in seeking mental health care
    15. Senator Warren. Dr. Orvis and Captain Colston, in your written 
testimony, you noted that ``the Department is piloting a barrier 
reduction training designed to address the most prevalent help-seeking 
concerns of servicemembers (e.g., career and security clearance loss 
concerns, loss of privacy and confidentiality), and encourage 
servicemembers to seek help early on, before life challenges become 
overwhelming.'' Please describe the stakeholders (e.g., servicemembers, 
clinicians, etc.) that the Department has consulted in developing this 
training.
    Dr. Orvis. The Office of Military Community and Family Policy is 
leading this effort, along with the Office of People Analytics, the 
Defense Suicide Prevention Office, and each of the Military 
Departments. All of these stakeholders were involved in developing the 
barrier reduction intervention called REACH (Resources Exist, Asking 
Can Help). Thus far, REACH has been piloted with servicemembers and 
leaders at select Navy, Air Force, and Army installations.
    Captain Colston. The Office of Military Community and Family Policy 
is leading this effort, along with the Office of People Analytics, the 
Defense Suicide Prevention Office, and each of the Military 
Departments. All of these stakeholders were involved in developing the 
barrier reduction intervention called REACH (Resources Exist, Asking 
Can Help). Thus far, REACH has been piloted with servicemembers and 
leaders at select Navy, Air Force, and Army installations.
                 mandatory separation health assessment
    16. Senator Warren. Dr. Orvis and Captain Colston, as you assess 
trends in mental health care and suicide prevention, are there any 
improvements that you would recommend at this time to the mandatory 
separation health assessment?
    Dr. Orvis. The Department of Defense (DOD), the Department of 
Veterans Affairs (VA), and Department of Homeland Security are working 
together to ensure seamless access to mental health care and suicide 
prevention resources for transitioning servicemembers and recent 
veterans during the critical first year after leaving the military. The 
separation health assessment is a key tool in understanding the needs 
of our transitioning members. While I have no modifications as of now, 
we are always in close partnership to ensure as we learn more about the 
experiences of our transitioning members, we can adjust the assessments 
accordingly.
    Captain Colston. The DOD and VA continue to work together to 
complete a single, common Separation Health Assessment to streamline 
the transition of health care from DOD to VA; improve clinical 
documentation of health status at the time of separation; and improve 
the VA claims process for those separating servicemembers who apply for 
benefits delivery at discharge.
                                opioids
    17. Senator Warren. Dr. Orvis and Captain Colston, in your written 
testimony, you noted that medication is a commonly used method for 
attempting suicide and that ``DOD has an opiate overdose death rate 
that is one-fourth of the civilian rate'' due, in part, to efforts such 
as ``pharmacy controls for all opiate medications.'' Do these pharmacy 
controls include declining to fill an opioid prescription under certain 
circumstances or partially filling opioid prescriptions?
    Dr. Orvis. Based on the 2017 Department of Defense Suicide Event 
Report Annual Report, approximately 2.9 percent of suicide deaths 
across all Military Services involved the use of opioids at time of 
death; 3 percent of suicide attempts involved the use of opioids at the 
time of their attempt. Specifics on pharmacy controls fall under Health 
Affairs.
    Captain Colston. Yes, pharmacy controls can assist/support a 
pharmacist's decision in declining to fill a prescription.