[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE TRUTH ABOUT VETERANS' SUICIDES
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
MAY 6, 2008
__________
Serial No. 110-86
__________
Printed for the use of the Committee on Veterans' Affairs
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43-052 PDF WASHINGTON : 2008
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana VERN BUCHANAN, Florida
JERRY McNERNEY, California VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
May 6, 2008
Page
The Truth About Veterans' Suicides............................... 1
OPENING STATEMENTS
Chairman Bob Filner.............................................. 1
Prepared statement of Chairman Filner........................ 77
Hon. Steve Buyer, Ranking Republican Member...................... 5
Prepared statement of Congressman Buyer...................... 78
Hon. John J. Hall................................................ 7
Hon. Phil Hare................................................... 9
Hon. Ciro D. Rodriguez........................................... 10
Hon. Harry E. Mitchell........................................... 11
Prepared statement of Congressman Mitchell................... 79
Hon. James P. Moran.............................................. 12
Prepared statement of Congressman Moran...................... 82
Hon. John T. Salazar............................................. 14
Hon. Jerry McNerney.............................................. 14
Hon. Corrine Brown............................................... 15
Hon. Stephanie Herseth Sandlin, prepared statement of............ 80
Hon. Shelley Berkley, prepared statement of...................... 80
Hon. Jeff Miller, prepared statement of.......................... 80
Hon. Ginny Brown-Waite, prepared statement of.................... 81
Hon. Timothy J. Walz, prepared statement of...................... 81
WITNESSES
U.S. Department of Veterans Affairs:
Hon. James B. Peake, M.D., Secretary......................... 15
Prepared statement of Secretary Peake.................... 83
Michael Shepherd, M.D., Senior Physician, Office of
Healthcare Inspections, Office of Inspector General........ 69
Prepared statement of Dr. Shepherd....................... 107
______
Maris, Ronald William, Ph.D., Distinguished Professor Emeritus,
Past Director of Suicide Center, Adjunct Professor of
Psychiatry, and Adjunct Professor of Family Medicine,
University of South Carolina, School of Medicine, Columbia, SC. 53
Prepared statement of Dr. Maris.............................. 96
Rathbun, Stephen L., Ph.D., Interim Head and Associate Professor
of Biostatistics, Department of Epidemiology and Biostatistics,
University of Georgia, Athens, GA.............................. 55
Prepared statement of Dr. Rathbun............................ 102
Rudd, M. David, Ph.D., ABPP, Professor and Chair, Department of
Psychology, Texas Tech University, Lubbock, TX................. 57
Prepared statement of Dr. Rudd............................... 105
MATERIAL SUBMITTED FOR THE RECORD
Video Transcriptions:
Transcription of CBS News Video entitled, ``Suicide Epidemic
Among Veterans,'' aired November 13, 2007.................. 109
Transcription of CBS News Video entitled, ``VA Hid Suicide
Risk, Internal E-Mails Show,'' aired April 21, 2008........ 110
Reports:
CRS Report for Congress entitled, ``Suicide Prevention Among
Veterans,'' May 5, 2008, Order Code RL34471, by Ramya
Sundararaman, Sidath Viranga Panangala, and Sarah A.
Lister, Domestic Social Policy Division, Congressional
Research Service........................................... 111
Background Materials:
U.S. Department of Veterans Affairs Pamphlet entitled,
``Suicide Prevention, Men and Women Veterans, Knowing the
Warning Signs of Suicide,'' dated September 2007........... 120
U.S. Department of Veterans Affairs Pamphlet for VA Employees
entitled, ``Suicide Risk Assessment Guide,'' Issued by the
U.S. Department of Veterans Affairs, Employee Education
System..................................................... 121
Letters:
Hon. Michael J. Kussman, M.D., M.S., MACP, Under Secretary
for Health, U.S. Department of Veterans Affairs, sample of
outreach letter sent to veterans, informing veterans of the
National Suicide Prevention toll-free hotline number, 1-
800-273-TALK (8255), and pocket-sized card with VA Suicide
Crisis Hotline phone number/information, as well as a
Crisis Response Plan....................................... 122
Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking
Republican Member, Committee on Veterans' Affairs, to Rick
Kaplan, Executive Producer, CBS Evening News With Katie
Couric, letter dated December 21, 2007, and response letter
dated May 16, 2008, from Linda Mason, Senior Vice
President, Standards and Special Projects, CBS News........ 123
Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking
Republican Member, Committee on Veterans' Affairs, to Hon.
James B. Peake, M.D., Secretary, U.S. Department of
Veterans Affairs, letter dated December 21, 2007, and
response letter dated February 5, 2008, requesting
additional data on suicide rates among veterans............ 124
Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking
Republican Member, Committee on Veterans' Affairs, to Hon.
Robert M. Gates, Secretary, U.S. Department of Defense,
letter dated December 21, 2007, requesting the number of
active-duty suicides for each year from 1995 to 2006; Hon.
Robert M. Gates, Secretary, U.S. Department of Defense, to
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs,
providing preliminary response designating David Chu, Under
Secretary of Defense for Personnel and Readiness, to
address the matter, letter dated January 17, 2008; Followup
request letters from Chairman Filner, dated May 6 and 21,
2008, requesting DoD to provide response to original letter
dated December 21, 2007; Response letter from Secretary
Gates, designating David Chu, Under Secretary of Defense
for Personnel and Readiness, to address the matter, letter
dated June 3, 2008; and Followup request letter from
Chairman Filner, dated June 5, 2008, requesting DoD to
provide response to original letter dated December 21,
2007. [AS OF SEPTEMBER 25, 2008, THE U.S. DEPARTMENT OF
DEFENSE HAS REFUSED TO RESPOND TO THE COMMITTEE'S REQUEST
FOR INFORMATION REGARDING THE NUMBER OF ACTIVE-DUTY
SUICIDES FOR EACH YEAR FROM 1995 TO 2006.]................. 132
Materials Due from the U.S. Department of Veterans Affairs
Requested During the Hearing:
Hon. Michael J. Kussman, M.D., MS, MACP, Under Secretary for
Health, U.S. Department of Veterans Affairs, to Hon. James
B. Peake, Secretary, U.S. Department of Veterans Affairs,
Memorandum dated May 5, 2008, Regarding Blue Ribbon Work
Group on Suicide Prevention in the Veteran Population...... 134
Table entitled, ``Rates and Risk of Suicide and Other
Suicidal Behaviors Among U.S. Veterans,'' Updated April 30,
2008, Prepared by Joseph Francis, M.D., MPH, Acting Deputy
Chief Quality and Performance Officer, Office of Quality
and Performance, U.S. Department of Veterans Affairs....... 137
``The Comprehensive Veterans Health Administration Mental
Health Strategic Plan,'' (A Comprehensive VHA Strategic
Plan of Mental Health Services), dated July 2004........... 142
Table entitled, ``Crosswalking between the U.S. National
Strategy for Suicide Prevention, the VHA Comprehensive
Mental Health Strategic Plan and VHA's Suicide Prevention
Actions''.................................................. 188
Information Provided by the U.S. Department of Veterans
Affairs from Discussion with Secretary Peake during Post-
Hearing Meeting............................................ 189
Post-Hearing Questions and Responses for the Record:
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to
Hon. James B. Peake, M.D., Secretary, U.S. Department of
Veterans Affairs, letter dated May 21, 2008, and VA
Responses.................................................. 208
Attachments to Chairman Filner's Post-Hearing Questions and
Responses for the Record Retained in the Committee files
include the following: The Medical Inspector Final Report
#2008-D-654, entitled ``Quality of Care Review, Veterans
Affairs Medical Center (VAMC) Dallas, Texas, Veterans
Integrated Service Network 17,'' dated May 20, 2008; the
Course Script entitled, ``VA National Rules of Behavior,''
Developed by the U.S. Department of Veterans Affairs,
Office of Information and Technology, Cyber Security
Service; and Presentation entitled, ``VHA Privacy Policy
Training, FY 2008''
Hon. Stephanie Herseth Sandlin, Committee on Veterans'
Affairs, as forwarded by Hon. Bob Filner, Chairman,
Committee on Veterans' Affairs, to Hon. James B. Peake,
M.D., Secretary, U.S. Department of Veterans Affairs, and
VA Responses............................................... 236
Hon. John J. Hall, Committee on Veterans' Affairs, as
forwarded by Hon. Bob Filner, Chairman, Committee on
Veterans' Affairs, to Hon. James B. Peake, M.D., Secretary,
U.S. Department of Veterans Affairs, and VA Responses...... 238
Hon. Shelley Berkley, Committee on Veterans' Affairs, as
forwarded by Hon. Bob Filner, Chairman, Committee on
Veterans' Affairs, to Hon. James B. Peake, M.D., Secretary,
U.S. Department of Veterans Affairs, and VA Responses...... 240
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to
Michael Shepherd, M.D., Physician, Office of Healthcare
Inspections, Office of Inspector General, U.S. Department
of Veterans Affairs, letter dated May 21, 2008, forwarding
questions from Hon. Stephanie Herseth Sandlin, and response
letter dated July 2, 2008.................................. 245
THE TRUTH ABOUT VETERANS' SUICIDES
----------
TUESDAY, MAY 6, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:03 a.m., in
Room 334, Cannon House Office Building, Hon. Bob Filner
[Chairman of the Committee] presiding.
Present: Representatives Filner, Brown of Florida, Snyder,
Michaud, Herseth Sandlin, Mitchell, Hall, Hare, Berkley,
Salazar, Rodriguez, McNerney, Space, Walz, Buyer, Stearns,
Moran of Kansas, Brown of South Carolina, Miller, Boozman,
Brown-Waite, Turner, Lamborn, and Buchanan.
Also Present: Representatives Kennedy and Moran of
Virginia.
OPENING STATEMENT OF CHAIRMAN FILNER
The Chairman. Good morning. This meeting of the Committee
on Veterans' Affairs of the House of Representatives is now
called to order.
I ask unanimous consent that two of our colleagues, Mr.
Kennedy and Mr. Moran, be allowed to sit with us at the dais.
They have a longstanding interest in the issues that we will be
discussing today. Any objection?
Mr. Buyer. I have no objection. We should follow protocols
of the Committee.
The Chairman. Thank you, Mr. Buyer.
The hearing today is entitled, ``The Truth about Veterans'
Suicides.'' I hope we can get to that truth.
A few months ago, on December 12, 2007, this Committee held
a hearing that we entitled: ``Stopping Suicides: Mental Health
Challenges within the U.S. Department of Veterans Affairs
(VA).'' Nearly 5 months later, we are holding another hearing
on this tragic issue and what the VA is doing. But it is
brought to us because of data within the VA that seems to
dispute what we were told in a hearing in December.
Much of this was occasioned because last year, in November,
CBS News aired a story called ``Suicide Epidemic Among
Veterans,'' and recently, another story called ``VA Hid Suicide
Risk, Internal E-Mails Show.''
I want to just make sure everybody understands what we are
dealing with, and I would like to play two brief segments of
those newscasts on our new video system.
[Videos played.]
The Chairman. Mr. Buyer raised an interesting point now of
how we are going to refer to this in the record--a tape. We
have not exactly figured it out yet. We may have a transcript
or referral to a Web site. But before the transcript of this
hearing is done, we will work with you to figure out a way to
do this.
Mr. Buyer. Members, this is relatively new. Often we ask
unanimous consent to place letters in the record. This is a
first, that we actually watch a news program.
I am willing to work with the Chairman to do something new.
Either we refer to a Web site, whereby individuals could pull
that down from a record, actually view the video, because that
was how it was viewed in the Committee; or do we transcribe
what was just put in there and put that in the record?
We are going to work with the Chairman to figure out how we
handle this.
The Chairman. This is a 21st century problem.
Mr. Buyer. We will work through it.
Sorry, Mr. Secretary. Housekeeping.
[A transcription of both the November 2007 and April 2008
CBS News videos appear on pages 109 and 110. In addition, the
videos may be viewed at http://veteransaffairs.edgeboss.net/
wmedia/veteransaffairs/videos/cbs_suicide_part_1.wvx (November
2007) and http://veteransaffairs.edgeboss.net/wmedia/
veteransaffairs/videos/cbs_suicide_part_2.wvx (April 2008).]
The Chairman. I think we all know that the first step in
addressing a problem is to understand its full scope and
extent. In the case of the VA and the epidemic of veteran
suicides, either the VA has not adequately attempted to
determine the scope of the problem, which I think is an
indictment of the competence of the VA; or the VA knows the
extent of the problem, but has attempted to obfuscate and
minimize the problem to veterans, Congress, and the American
people. This is an indictment, I think you would all agree, of
the leadership of the entire Department.
In December, Dr. Katz' testimony before this Committee
stressed a low rate of veteran suicides, stating that: ``From
the beginning of the war through the end of 2005, there were
144 known suicides amongst these new veterans.'' In responding
to the figures that CBS News researched, Dr. Katz stated that:
``Their number for veteran suicides is not, in fact, an
accurate reflection of the rates of suicide.''
Either Dr. Katz knew that the CBS News figures were indeed
an accurate reflection of the rates of suicides at that hearing
or he had a sudden epiphany just 3 days later.
In an internal e-mail dated December 15, 2007, Dr. Kussman,
Under Secretary for Health in the Department, referred to a
newspaper article and wrote that: ``Eighteen veterans kill
themselves every day, and this is confirmed by the VA's own
statistics. Is that true? Sounds awful, but if one is
considering 24 million veterans.''
That same day, Dr. Katz responds, ``There are about 18
suicides a day among America's 25 million veterans. This
follows from CDC (Centers for Disease Control and Prevention)
findings that 20 percent of suicides are among veterans, and it
is supported by CBS numbers.''
Just this past February, Dr. Katz sends another e-mail that
starts with, ``S-h-h. Our suicide prevention coordinators are
identifying about 1,000 suicide attempts per month among the
veterans we see in our medical facilities. Is this something we
should carefully address ourselves in some sort of release
before someone stumbles on it?''
There was silence from the VA.
As you saw on the viedo, the chief investigative reporter
for CBS News, Armen Keteyian, characterized the VA's internal
e-mails as a ``paper trail of denial and deceit, a disservice
to all veterans and their families that has rightfully been
exposed.''
In April of this year, a Dallas Morning News editorial
describing a ``recent spike in suicides among the psychiatric
patients treated at the Dallas VA hospital,'' stated that
``descriptions of how four veterans committed suicide in 4
months, prompting the psychiatric ward to close, suggests that
patients went to conspicuous and time-consuming lengths to end
their own lives. There seemed to be ample time for staffers to
stop them, had they been doing their jobs better.''
The RAND Corporation, in a recently published study
entitled, ``Invisible Wounds of War,'' found that since October
of 2001, approximately 1.6 million U.S. troops have been
deployed, and more than a quarter of them have mental health
conditions.
I think it is higher than that. The study estimated that
approximately 300,000 of those deployed suffer from post
traumatic stress disorder (PTSD) or major depression. Among
those with PTSD or major depression, only half had seen a
mental health provider or physician to seek help in the past 12
months, and among those who sought help, just over half
received ``minimally adequate treatment.''
We saw a recent New York Times article that said up to one-
third of those diagnosed with PTSD of recent veterans had
committed felonies, of which 200 had been homicides, mainly
members of their own families.
Something is going on in America. The study that RAND did
found minimally adequate exposure to psychotherapy as
consisting of at least eight visits with a mental health
professional, such as a psychiatrist, psychologist, or
counselor in the past 12 months, with visits averaging at least
30 minutes.
I would like to know, how does the VA mental healthcare
treatment stack up against this definition of minimally
adequate care?
The RAND study also found that the VA faces challenges in
providing access to Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF) veterans, many of whom have difficulty
securing appointments, particularly in facilities that have
been resourced primarily to meet the new demands of older
veterans. Better projections of the amount and type of demand
among new veterans are needed to ensure the VA has the
appropriate resources to meet the potential demand. ``New
approaches of outreach would make facilities more acceptable to
OEF/OIF veterans,'' so says the RAND study.
I think many of us believe that the VA healthcare system
has been pushed to the edge in dealing with mental healthcare
needs of our veterans. I believe we are witnessing either an
inability to address this problem or a purposeful attempt to
minimize the problems faced by veterans and the VA, and sweep
this epidemic of suicides under the rug.
This morning we are going to attempt to get a better idea
of the scope of this epidemic and what the VA is doing to
respond to it. What specific steps has the VA taken since
December, steps not previously planned, to get a better idea of
the scope of what problem; and what has it done to begin to
address the problem?
Finally, I think we must seek real accountability from the
VA.
Mr. Secretary, we are looking to you to provide that.
[The prepared statement of Chairman Filner appears on p.
77.]
The Chairman. Let me just say, for the record, that was my
prepared, controlled statement. My uncontrolled statement goes
something like this, Mr. Secretary:
We should all be angry at what has gone on here, at what
looks like posturing before this Committee by not telling us
the truth and talking about how to deal with statistics without
informing this Committee. Our oversight function has to work,
and can only work, with mutual respect for each other. We both,
presumably, want to do the best job we can for veterans. We
have to have mutual respect for each other, and the facts; and,
I believe your staff exhibited neither.
If the testimony that Dr. Katz gave was wrong, being
questioned 3 days after we went through a back-and-forth that
was very difficult to do for both of us, why weren't we
notified? Why didn't you say, ``we found new statistics and
we're checking them out?'' You never told us anything after
your chief doctor in charge of mental health testified
differently.
What we see is a pattern, Mr. Secretary, a pattern that we
have seen going back to the days of atomic testing, through the
Agent Orange controversies of Vietnam, depleted uranium, and
more recently, Persian Gulf War Illness, PTSD, traumatic brain
injury (TBI), suicides, and homelessness. The same pattern that
really reveals a culture of a bureaucracy.
The pattern is deny, deny, deny. Then, when facts seemingly
come to disagree with a denial, you cover up, cover up, cover
up. When the cover-up falls apart, you admit a little bit of a
problem and underplay it: It's only a few people, only 1,000
veterans got exposed to that gas; Agent Orange didn't affect
very many; atomic testing, well, nobody knew what was going on.
Then, finally, maybe you admit it's a problem and then, way
after the fact, try to come to grips with it.
We have seen it again and again and again. It is not just
dealing with numbers, as your whole testimony does, Mr.
Secretary. You are talking about numbers as if that is all it
is. It is a bureaucratic situation.
This is not a bureaucratic situation with just numbers.
This is a matter of life and death for the veterans that we are
responsible for.
I think there is criminal negligence in the way this was
handled. If we do not admit, if we do not assume there are
problems, if we do not know what the problem is, then the
problem will continue, and people will die. If that is not
criminal negligence, I don't know what is.
Mr. Secretary, we had a discussion right after you were
confirmed. I came up to see you to congratulate you on your new
role as Secretary. I asked you a question. I said, Are you
going to just be a caretaker for the last year of this
administration, or are you going to do something real and have
a legacy? I said, I hope it is the latter, and I will help you
do that.
I will tell you how you deal with this issue will determine
how we see your role. There is clear evidence of a bureaucratic
cover-up here.
One of the people in the e-mails is Dr. Kussman and I don't
even see him here. I guess he had a previous engagement. He
ought to be here. I also don't see the public relations guy
that was one of the people in the other e-mail. They should be
here to talk about what happened.
I want to know, since I don't see it in your testimony and
I see only vague references to the e-mail, how are you going to
ensure accountability? Are you going to ask for the
resignations of Dr. Kussman, Dr. Katz, and anyone else who
participated in the cover-up of the data?
I want to know if you are going to really take your role
seriously and if there is going to be accountability for what
has gone on here. This is not just an abstract discussion, this
is not just a hearing to say, ``We got you.'' This is about our
veterans and whether they have a life ahead of them or not.
I will tell you I have talked to the Members of this
Committee and they are pretty angry with what is going on. I
think you need a better answer than your prepared statement,
which just goes into bureaucratic details.
Now, we will have opening statements.
Mr. Buyer, you are recognized.
OPENING STATEMENT OF HON. STEVE BUYER
Mr. Buyer. Thank you, Mr. Chairman. I think those of us who
have friends or family members that have committed suicide,
number one, are haunted by that experience because we then look
at that individual, and we reflect upon what could we have done
to have prevented it. What did we miss? What were those risk
factors?
And sometimes they are noticeable. Sometimes when they are
a friend and they are closest to you, you might be providing
counsel to them, you think it is a moment of just being a good
friend. Then, when they commit a foolish act and take their own
life, you are tortured for the rest of your life.
So this is a pretty powerful issue. Especially, it cuts
across the sections of our population, when you think of
suicide being the 11th leading cause of death in our society.
So it is just not within the veteran population, it is within
our population as a whole. When we don't have a national
surveillance system, it is very difficult for us to even gain a
better understanding.
But we do have defined abilities to come up with the proper
cohorts not only within U.S. Department of Defense (DoD), but
also in the VA, so we can better understand, and identify those
risk factors.
I think, Mr. Secretary, by looking at how many Members have
come here today, it sends a signal to you that the loss of a
single veteran is a tragedy to us. I am sure that every Member
of this Committee, in earnest, seeks to help you to identify
contributing factors and to do anything we possibly can to
prevent servicemembers or veterans from taking their own lives.
We recognize that many of the veterans that do take their
own lives, in fact, are inpatients and in psychiatric care. So
even though we can provide in a controlled environment and we
do everything we can, half of them that are inpatients are
committing suicide.
So it is one of those things where, even in a controlled
environment, we can come up with identifying factors and still
can't prevent someone from committing what we view as a very
foolish act.
So the challenge that you have is real.
I want to thank the Chairman for continuing these hearings
to discuss this important issue and to help those at risk. A
number of questions were raised during our hearing last
December regarding the validity of data on the number of
veteran suicides. Such information is vital to understanding
the scope of the problem, as well as identifying risk factors
and providing better prevention and treatment protocols.
Chairman Filner joined me in a letter I wrote to you, Mr.
Secretary--and to DoD and CBS News--requesting their respective
data on how it was formulated. For the record, CBS News failed
to respond to Mr. Filner's and my letter. DoD only acknowledged
the letter, and we are still waiting on their reply.
Mr. Secretary, you were the only one to respond to Mr.
Filner's and my letter. That letter included information and
worksheets on two separate studies that the VA is conducting.
So I appreciate the timeliness with which you responded to this
Committee's concerns.
These studies may provide some useful information, but they
are limited to data on suicide rates among veterans in the VA
healthcare system. VA must have a better method for the
systematic collection and tracking of veteran suicide data. It
is also important to find ways to reduce the stigma associated
with mental healthcare and encourage more servicemembers to
seek treatment when it is needed.
During our last hearing, I asked the VA to be proactive and
to reach out to soldiers and their families during
premobilization, and to start with the 76th Indiana Brigade
Combat Team as it prepared to deploy. Mr. Filner and I agreed
that we would proceed with that.
I want to thank you, Mr. Secretary. I am very pleased that
the VA came, as requested, and participated in such an
outreach.
I also recognize that you are operating outside the lines
of your jurisdiction. But you didn't say that. You didn't say,
``That is outside my jurisdiction; I am now dancing on DoD
turf.'' You said, ``I am going to embrace the counsel of the
Committee and we are going to see if we can follow this group.
We will identify ourselves with the family members. They are
the ones who are the closest to being able to identify
individual risk factors or if there is a change in my husband,
my brother, my loved one, that we could see.''
I stood with 3,400 Indiana soldiers, with Joe Donnelly at
the RCA Dome on January 2, for the formal send-off ceremony.
Along with about 20,000 friends and family members was VA staff
from the Indianapolis VA Medical Center, the regional office,
and the Vet Center. The VA reported about 1,700 families
received information regarding VA benefits and services,
including mental health services, Mr. Chairman, and information
on post traumatic stress disorder and suicide prevention.
The VA also followed up with subsequent briefings while the
brigade was at Fort Stewart, Georgia, for training. As the
brigade marched off to war, I believe they left with a clear
impression that the VA was available to provide support and
assistance to their families during their deployment, and that
you will be there when they return from Iraq.
There was very positive feedback regarding the VA's
presence at these events; so I want to thank you, Mr.
Secretary, for working with the Committee to be proactive and
to do something outside the norm.
Mr. Secretary, you have taken decisive action to meet these
increased needs. This month, for example, the VA contacted
nearly 570,000 recent combat veterans about VA medical care and
benefits. These veterans were either injured in Iraq or
Afghanistan or discharged from active duty but had yet been
contacted by the VA. So I want to thank you for your outreach.
It is something that Mr. Filner had also been expressing, and
had expressed that to you.
So, Mr. Chairman, I think we need to acknowledge when the
Secretary acts on something that you ask for, we need to
compliment him for it. The Secretary has also directed the
creation of an independent working group to assess VA's suicide
prevention programs.
I want to thank Secretary Peake and other witnesses for
their participation today, and I look forward to their
testimony. In the end, I hope this hearing will drive home the
message to our Nation's men and women who serve, and to their
families, that if you need help, care is available and
treatment works, and there is a road to recovery.
I yield back.
[The prepared statement of Congressman Buyer appears on
p. 78.]
The Chairman. Before the Secretary testifies, are there
opening remarks of any Members? I will call Members in the
order that we have.
Mr. Hall.
OPENING STATEMENT OF HON. JOHN J. HALL
Mr. Hall. Thank you, Mr. Chairman.
Just briefly, I would say that if we can prevent any single
suicide among our veterans, it is worth going to great lengths
to do that. I would ask you--I know you are wearing two
conflicting--and, sometimes--hats that are at cross-purposes
with the ``Honorable Secretary'' before your name and the
initials ``M.D.'' after it, and most of my questions will be
addressed toward the M.D. part of it.
It strikes me that minimally adequate treatment, as
described in our documents we have before us, of at least eight
visits in 1 year to a counselor, psychiatrist, or psychologist;
and we understand from testimony before this Committee that
that is not necessarily the same psychiatrist, psychologist or
counselor. It is hard for an individual servicemember or
veteran to strike up enough of a rapport with a doctor or
counselor who is treating them, if they are seeing somebody
different every time they go in and they have to kind of start
from scratch. We have heard that that is a problem.
Thirty minutes, anybody in this room who has been to
therapy for any kind of marital counseling or depression or
whatever can tell you that 30 minutes is just about enough to
get started and say goodbye and book the next visit. So I would
at least say that the definition of ``minimally adequate
treatment'' is not adequate.
I would also say that with the rates of bankruptcy and
divorce that we are seeing, which are records, we are told are
records among our veterans, that those two things--each of them
alone, not to mention bankruptcy and divorce taken together--
are enough to drive people, servicemembers or regular
civilians, to suicide. There are many stories during the Great
Depression of people jumping off of buildings because their
material wealth was gone, and they saw no hope.
So some of this is rocket science in the mental health
world; some of it is really just nuts and bolts and simple
common sense in taking care of our veterans.
I think that we should be as adaptable. Just as our
military adapts their strategy in combat, we have had to change
the course. For instance, in the war in Iraq we have had to
change our strategy several times, and the insurgents have
changed their strategy several times in response. They make a
bigger bomb, we make a more armored vehicle, et cetera. We need
to do the same thing, I think, on the VA side and constantly be
ready to change our strategy.
Lastly, we had a pair of parents before, I forget whether
it was the full Committee or Subcommittee on Disability
Assistance and Memorial Affairs, but two parents who were
courageous enough to come in, whose son had taken his own life.
They asked us for universal screening for PTSD for all veterans
so they don't have to self-identify.
I think that that is maybe one of the answers, because men
or women who are taught to be tough and are taught to handle
situations, and who also want to just get back to their
families and not be held over for extra questioning and not
have something on their record that might be a stigma in the
future for employment or for being able to be in law
enforcement or advance themselves in the Guard or Reserve or
what have you.
Their son, this couple's son, had not shown a sign that
they, the parents, saw that would tip them off that he was so
distressed that he was going to take his own life. So if
parents, people that are close to an individual, don't see the
change, and can't see it, I think we need the professionals to
be right on top of the case. That would probably call for
universal screening at some point after separation.
With that, I look forward to your testimony. Thank you very
much.
I yield back, Mr. Chairman.
The Chairman. Mr. Miller. Mr. Brown. Ms. Brown-Waite. Mr.
Turner.
Mr. Hare.
OPENING STATEMENT OF HON. PHIL HARE
Mr. Hare. Thank you, Mr. Chairman.
Thank you, Mr. Secretary, for appearing before the
Committee today. It is nice to see you again.
While I appreciate the amount of time and the effort and
thought the VA has put into veteran suicide prevention, which I
honestly believe has saved some lives, I have to say I was
shocked and very disturbed after reading the e-mails.
But this isn't about numbers or formulas or programming.
This is about people; this is about families, wives, husbands,
sons, daughters. This is about honoring those who serve this
country.
A few weeks ago I sat and talked with Mike and Kim Bowman
of Illinois, whose son, Tim, committed suicide. Tim was an
incredible young man who bravely served in Iraq and came home a
changed man, suffering from PTSD. His parents did their best to
try to help him, but they didn't know what signs to look for
and how to reach out to help him. They are rightly angry and
frustrated that, from their perspective, the VA didn't do more
to reach out to help their son.
I believe the first step in solving any problem is
admitting that you have one. If the VA, for some reason, isn't
being honest about the number of veterans committing suicide,
then that is stopping us or preventing us from giving you the
resources that you need to prevent them.
I have said many times at hearings, and I will continue to
say as long as I serve on this Committee, the question isn't,
``Can we afford to give the necessary funds out to help our
veterans?'' The question should be--the statement should be,
``We simply can't afford not to give you the funds we need.''
But we have to know how severe the problem is in order to be
able to help you on that.
I think, to be honest, this is more than a problem; I think
it is an epidemic among veterans if these numbers are remotely
close, to what is happening and I believe they are.
But we are all here today for the same reason, to find
solutions to stopping veteran suicides so that no family like
the Bowmans have to go through this. The RAND report found that
300,000 military servicemembers who have returned from Iraq and
Afghanistan report symptoms of PTSD or major depression, but
only slightly more than half have sought treatment for their
conditions.
Let me just echo the sentiments of my friend from New York,
Mr. Hall, when he said that screening all the veterans when
they come back is something that we need to do. It is something
that I think--clearly, they may not know that they have the
problem, their families don't know; then we need to monitor
them for some period of time down the road to make sure that if
there is a problem, we can bring them in and be able to help
them.
With mental health disorder being a significant precursor
to suicidal thoughts, it is clear to me that the VA has to do
more to proactively reach out to veterans.
As you know, Mr. Secretary, when we met--you know I come
from a rural district, and I am also interested--one of my
questions to you during the question period is going to be, How
do we reach out to those rural veterans that come back where
there may not be a VA hospital close to them? How do we get
them in quickly and timely in order to prevent what happened to
Mr. Bowman?
So I thank you for coming today.
I would yield back my time. Thank you, Mr. Chairman.
The Chairman. Thank you.
Mr. Rodriguez.
OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ
Mr. Rodriguez. Thank you, Mr. Chairman.
Let me, first of all, thank you, Mr. Secretary, for being
here today. And let me just add that some of us have extremely
high expectations for you--and I know that you are uniquely
situated because you served not only in our military as a
soldier, but also in the DoD--in terms of service there and the
VA, and the difficulty that we have had as a Committee in the
past to try to get both the DoD and the VA to work together.
With this situation, also I think that we are talking right
now about veterans committing suicide, but we have had a lot of
active-duty soldiers also committing suicide. Nothing is worse
than a soldier committing suicide in terms of how badly they
and their families are treated when they come home, even by
other veterans. They are treated as if they were cowards and
those kind of things. Those are the numbers that we also need
to seek out and get the right information for us to be able to
do the right thing. I think you can be helpful there.
Let me just add to what Chairman Bob Filner has said, we
are coming from a perspective, when I got on this Committee
some 12 years ago, I heard about Project 112, Project SHAD,
where the DoD was denying that it even existed. Later on, as
time went on--and 20 years have passed since the inception of
those projects--we identified some 35 projects that were out
there, that we did experimental things with our soldiers. Then
we found it was not 30, it was 40; then it went to 50. I think
the latest numbers were something like 60, where we
experimented with our own soldiers.
But it took us prying and pushing and tugging to be able to
get that information, when we really need to work together to
see how we can help address some of these situations--and
hopefully that is what we will do--to move quickly to try to
meet the needs of our soldiers and our families out there.
I want to also lay down the groundwork for that in terms of
how important it is, what do we do from now? We know we have a
serious situation in the VA. And I know we have a serious
situation in the DoD also, which I know you don't oversee, but
that is also another area that we need to deal with.
We have situations where--I just did an interview in San
Antonio regarding a VA patient that died; the accusations are
basically that he was killed because of presumed negligence on
the part of the doctors--and the importance of peer review in
the military, I mean in the VA, as it deals with doctors'
recommendations and those kinds of things.
So there are other areas that are very serious, and I am
hoping that we can make some inroads in those areas. As we move
forward on this testimony, I am hoping that we can come up with
some recommendations, and if you have recommendations for us as
to what you need to get it done.
And, I know that for the longest time we didn't provide the
resources that were needed, and we have a responsibility there.
But we also ask that we be given the information and the data
that is needed for us to be able to do that, and hopefully we
can respond to some of those needs.
Thank you very much. Thank you for being here, Mr.
Secretary.
[The following was subsequently received from the VA:]
1. Update on Dallas (not requested during hearing)
2. Noted patient died in San Antonio may be related to
negligence--importance of peer review--provide updates.
Response: The Office of Medical Inspector (OMI) conducted a site
visit to the Dallas VA Medical Center (VAMC) on April 16 through April
17, 2008. Its findings were presented to the Dallas VAMC leadership at
the conclusion of the site visit and to the Veterans Health
Administration (VHA) leadership on the OMI's return. The OMI identified
a number of environmental issues that needed to be addressed. The
Dallas VAMC reports that action to address environmental issues such as
removal of metal holders for linen hampers, geriatric chairs in the
showers, and replacement of unit doors that did not lock automatically
were completed by April 30, 2008.
The OMI recommendations currently under assessment or in progress
include increasing the amount of therapeutic patient activity,
replacing the suicide risk assessment tool, and changing the current
continuity of care model to an inpatient model of care. The Dallas VAMC
is addressing these issues.
On April 22, 2008, a team from VA's Office of Mental Health
Services visited the facility to evaluate the safety of its mental
health program. It identified additional environmental, organizational,
and programmatic issues that can improve the delivery of mental
healthcare. Actions on many of these environmental issues, such as
additional housekeeping staff, painting and repairs, installation of
new doors, and moving cameras and monitors have been completed or will
be in the near future. In addition to the actions noted, the Dallas
VAMC is reassessing the mixing of acuities on the Mental Health unit.
The report has not been cleared by OMI and is in the pre-decisional
stage. It is anticipated that it will be ready by the end of May.
San Antonio--An external Peer Review was completed in the second
quarter FY 2008. South Texas is in the process of reviewing the results
and developing professional practice evaluations.
The Chairman. Thank you.
Mr. Mitchell.
OPENING STATEMENT OF HON. HARRY E. MITCHELL
Mr. Mitchell. Thank you, Mr. Chairman.
In November, CBS News brought some shocking and critically
important information to light. Not just that those who served
in the military were more than twice as likely to take their
own life in 2005 than Americans who never served, or that
veterans aged 20 to 24 were killing themselves when they
returned home at rates between two-and-a-half to four times
higher than nonveterans the same age, but that the Department
of Veterans Affairs wasn't keeping track of veteran suicides
nationwide.
In December we had a hearing to find out why.
Mr. Chairman, I don't know if there is anyone here who
attended that hearing who will ever forget it. Mr. Hare
mentioned that we heard from Mike and Kim Bowman, whose 23-
year-old son, Tim, survived a year of duty in Iraq, only to
come home and take his own life. Mr. Bowman warned us that our
troops were coming home to an underfunded, understaffed,
underequipped VA mental health system that imposes so many
challenges that many are just giving up.
So when Dr. Katz insisted at that hearing, repeatedly, that
the VA had all the necessary resources to reach all veterans at
risk for suicide and make special treatment available to them,
I was skeptical. How could Dr. Katz be so sure that there
weren't any requests for additional resources sitting somewhere
within the vast VA system that have gone unfulfilled? Was he
absolutely certain that there were no pending requests for an
additional mental health counselor, for extra gas money to
enable a VA employee to drive somewhere to contact an outreach?
As Chairman of the Subcommittee on Oversight and
Investigations, I felt I had a responsibility to make sure, so
I asked the VA to double-check. I asked them to take a look at
their records and send us any documents relating to any request
for additional resources that had gone unfulfilled or
underfilled. My thought was, if we could find out what the VA
needs are to address this problem, we could get to work and
make sure they got it.
More than four months later, however, all I have gotten are
excuses, complaints, and most recently, a suggestion that I,
``Go file a Freedom of Information Act request.'' That is not
just an insult to me, it is an insult to this Committee and to
our veterans.
I have tried to be reasonable. I have tried to work with
Secretary Peake's office. But, Mr. Chairman, my patience is at
an end.
I have given the Department until Friday to finally produce
the documents I requested. If they do not, Mr. Chairman, I want
you to know that I will be asking you to pursue a subpoena.
I yield back.
[The prepared statement of Congressman Mitchell appears on
p. 79.]
The Chairman. Thank you, Mr. Mitchell.
Mr. Moran, we thank you for your interest. You have been
interested in this issue and have been a leader for many years,
and we thank you.
OPENING STATEMENT OF HON. JIM MORAN
Mr. Moran of Virginia. Thank you very much, Mr. Chairman
and Ranking Member Buyer and my friends and colleagues.
I want to mention, incidentally, with regard to the
recommendation for individual screening, in the Defense
Appropriations bill, when we put $900 million in for PTSD and
traumatic brain injury, we did require that everyone get an
individual face-to-face screening by the Pentagon. But the
problem is, that is when all they can think about is getting
home to their families, and it is oftentimes only after they
get home that evidence of emotional problems, whether it comes
out in domestic abuse or inability to hold on to a job and so
on, manifests itself.
The fact that 20 percent of our veterans from Iraq and
Afghanistan show signs and symptoms of PTSD, depression, and
anxiety is a compelling statistic. But even more so is the fact
that that number increases to 50 percent for soldiers with
multiple tours and inadequate time between deployments; and in
fact, that is becoming more and more the case.
One of the measures that I would suggest that this
Committee might consider is to create a stand-alone, 24-hour,
national, toll-free hotline to assist our veterans in times of
intense crisis. The key is that this hotline would be staffed
by veterans trained to appropriately and responsibly answer
calls from other veterans.
I understand that the Department of Veterans Affairs has
developed a veterans option off of the National Suicide
Hotline. While I applaud your effort to address this problem, I
believe that there are about three deficiencies in this
approach. First, oftentimes a veteran doesn't want to talk to a
doctor; he or she wants to talk to someone who has got a real-
life perspective on what is going on in their mind--cultural
competency, if you will. That is a term that has been used to
express that a fellow veteran can provide a real difference in
crisis counseling because they can better relate.
Secondly, soldiers with mental illnesses face social stigma
that is identified with seeking care through the VA. Research
from the Air Force's Suicide Prevention efforts suggests that
fear of the system, of an unfriendly mental health
establishment, and of potential job-related consequences do
keep many active-duty soldiers and recent veterans from seeking
the care that they need.
Thirdly, the VHA is already overburdened by a great many
healthcare responsibilities; and as a result, I think it is
ever more difficult to provide a topnotch hotline effort.
Stretched budgets, staffing shortages, they may not be able to
meet the challenges of so many returning veterans when our
Nation redeploys from Iraq in the future.
A nonprofit organization dedicated to suicide prevention
might be better able to provide focus, stability, and
commitment that the VA is particularly challenged in being able
to achieve.
So to conclude, our vets deserve as much support when they
return from combat as they receive while in battle, and I know
that this Committee is acutely aware of that fact. But too many
of our veterans are struggling to make the difficult adjustment
back to society, and they desperately need someone that they
can talk to, that they can relate to, someone that has walked a
mile in their shoes. So that is why I have offered legislation
that would do that.
I very respectfully suggest that this Committee consider
that legislation. I certainly applaud this Committee for your
efforts on behalf of veterans.
Mr. Buyer. Would the gentleman yield?
Mr. Moran of Virginia. I would be happy to.
Mr. Buyer. Mr. Moran, I want to thank you for your
leadership over the years. Your care and sincerity, it is real
and very evident to me, having known you over the years. So I
want to thank you for your leadership.
We debated your bill; and I like the idea of having
veterans, but not all veterans are trained in mental health. I
know that is your aspiration. But you have a good idea, and we
want to work through that.
We did have a conversation, Mr. Chairman, and I want to
caution my friends in the fourth branch of government who may
be covering this hearing, please do not refer to suicide as an
epidemic without saying that treatment is available. Because if
you say or you put on the air that suicide is an epidemic in
America, you are exacerbating the problem and you could
actually be moving people to suicide. So, please, if you write
that, say that treatment and care are available.
Thank you for your leadership.
Mr. Moran of Virginia. Thank you, Mr. Buyer.
If I could quickly respond, what we are suggesting is that
a nonprofit organization that would be available for veterans,
that would spread the word within the network of veterans and
give them training simply to be able to react to people on the
other side of the line. They don't need to be trained in mental
health counseling, just be able to know how to listen and to
talk and to calm down someone that is in a time of crisis. That
is what we are talking about.
It is just that sometimes when you have very large
institutions, it is difficult to accomplish what a nonprofit
group that is particularly committed and understanding of the
problem sometimes is able to provide with a lot less money.
That is all I am suggesting.
I thank you for your comments, Mr. Buyer.
And thank you very much, Mr. Chairman, for giving me this
opportunity.
[The prepared statement of Congressman Moran appears on
p. 82.]
The Chairman. Thank you, Mr. Moran. We will be looking
again at that legislation.
Mr. Salazar, any opening remarks?
OPENING STATEMENT OF HON. JOHN T. SALAZAR
Mr. Salazar. Mr. Chairman, I want to thank you for having
this important hearing. I agree with my colleagues, but the one
thing that I think we have to be very, very adamant about is
finding out whether there was a cover-up by the VA to push
these things under the carpet or was it something that they
need additional tools for. We are here to help. That is what we
are here for.
So with that, thank you, Mr. Chairman.
The Chairman. Ms. Berkley.
Ms. Berkley. I would like to submit my opening statement
for the record, if I may, so we can get to the witnesses.
[The prepared statement of Ms. Berkley appears on p. 79.]
The Chairman. So ordered. I would ask unanimous consent
that all Members can submit their statements for the record.
Hearing no objection, so ordered.
The Chairman. Mr. McNerney, any quick opening?
OPENING STATEMENT OF HON. JERRY McNERNEY
Mr. McNerney. Thank you, Mr. Chairman. It is clear that all
Members of the Committee are sincere in wanting to find the
bottom of this.
There is nothing that is more tragic than suicide. As Mr.
Buyer pointed out, it is a situation that haunts the family and
friends for years and years, especially when young men and
women who have served our country and have looked to this
country to help them when they have needs and, it appears, that
that may not have been followed through.
So it is our solemn responsibility to get to the bottom of
this and to find ways to move forward that will prevent this in
the future.
Thank you.
The Chairman. Ms. Brown.
OPENING STATEMENT OF HON. CORRINE BROWN
Ms. Brown of Florida. Thank you, Mr. Chairman, and I want
to thank you for holding this hearing today.
First of all, let me say, it is not just the veterans; it
is the veterans and their families that are faced with this
situation. I am looking forward to hearing from the Secretary
and also from Dr. Katz on how he came up with this analysis and
what can we do together to change this situation, because this
is a serious problem.
I have been on this Committee for 16 years, and this is a
serious situation. We have passed the largest VA budget in the
history of the United States, and I want to make sure that we
are properly funding that healthcare issue, and the money is
going where it needs to go.
So, thank you, Mr. Chairman, for holding this hearing.
The Chairman. Thank you.
Mr. Secretary, I appreciate you being here. I was hoping
that everybody who was associated with these e-mails would be
with you but since they are not, I hope you can speak to those
issues that we have raised.
You are recognized, sir, for your statement.
STATEMENT OF HON. JAMES B. PEAKE, M.D., SECRETARY, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY GERALD M. CROSS,
M.D., FAAFP, PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; AND IRA KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT CARE
SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Secretary Peake. Mr. Chairman, with your permission, I
would like to provide a written statement for the record.
The Chairman. So ordered.
Secretary Peake. Mr. Chairman, Congressman Buyer, Members
of this Committee, thank you for the opportunity to discuss the
issues of veteran suicides. I really do appreciate your holding
this hearing. It is a very important subject.
We will be talking quite a bit about the numbers in this
discussion. I will tell you, quite frankly, to me personally
the most important thing is that each suicide number represents
a soldier, a sailor, an airman, a Marine, a veteran who has
served this country in uniform; and each individually is a
tragedy and each deserves all that we can do to try to prevent
that tragedy.
While it is appropriate--and frankly, it is necessary--to
try to measure and understand variances from the norm in
trending and statistical significance, I want to assure you and
this Committee and, frankly, the American people that we are
not waiting on these numbers to focus the VA on addressing this
very important issue.
The title of today's hearing is, ``The Truth about Veteran
Suicides.'' My objective is to tell you as clearly as I can
what we do know about veteran suicides and the sources of the
information. Also, I will tell you what we don't know and what
I intend to do about that. I also will take this opportunity to
tell you what we have been doing to address the issue of
suicide directly, from a clinical perspective, and expanding
our outreach even as we seek better ways to measure.
First, to compare veterans with nonveterans, the gold
standard and source of the database is the National Death
Index. It is a product of the National Center for Health
Statistics, a U.S. Department of Health and Human Services
(HHS) function. The most current complete data set is from
2005. 2006 data should be released, we are told, sometime soon.
Looking at 2005 and back to 2001, the overall rate of
suicide was 14.1 per 100,000 in the general population. That is
not a percent; that is per 100,000. It is important to separate
the rate of men and women. Men have a higher rate of suicide
than women, and that is statistically significant. We must
separate by age group because there are significant differences
by age groupings.
The National Death Index does not identify those who are
veterans. To compare all veterans, not just those seen in the
VA system, would require matching the full list of all 24
million veterans against the National Death Index to see how
many of them had committed suicide. We do not have the
identifying information for all veterans to do this analysis.
We would love to be able to do it; we don't have that
information.
The VA does have the ability to compare veteran suicide
rates with the national average for groups of veterans who have
used the VA health system. We have matched that group against
the National Death Index by name to know the number of those
veterans who have used the VA, who have committed a suicide.
With that data, we can calculate a rate.
The National Death Index data that we have broken that data
into--first, men and women; let me just show you this is the
population, 2005. Men make up about 20 percent of the
population. Men veterans make up about 20 percent of the
overall population. Women veterans make up only about 1 percent
of the overall population, just to give you the perspective.
What this chart is showing is for 2005. The numbers in red
represent the numbers that are statistically higher than the
general population. This is for women. This is for men. You can
see that for 2005, in the older, but not in the younger, age
groups for veterans who use the VA health system, just those
veterans, the suicide rate was higher than the general
population.
Looking at this for each, from 2002, will give a more
complete picture. But here, just to say this is the general
suicide rate, this is the veterans'--again, those who have only
been seen in our system because we don't have all the
veterans--you can see that it is a bit higher than the general
population, and it is statistically significant.
Now, to show you the trending, this is the summary of data
from 2002, 2003, 2004, 2005, and you can see that the red is
the veteran population, again for age group 18 to 29, age group
30 to 64, and then the older age group. What you see, the
national population figure is here in terms of rates per
100,000.
The rates for veterans who are users of the VA, again, just
users of VA, have also been relatively stable over this period.
You can see that it is, again, stable. This is women, the
smaller group; and it is--what we are showing with these
brackets here are the statistical significance. So that this is
clearly statistically significant.
Looking at the veterans who have used the VA in this
period, male veterans commit suicide at a somewhat higher rate,
but with varying statistical significance by age over different
years. You can see that in the charts.
Within the group of male veterans there are differences in
age of suicide compared to what is seen in the general
population with a statistically higher middle-age group. So
statistically you can see this age group is generally higher
for veterans--above the national average.
Male veterans commit suicide at a higher rate than female
veterans. Within the group of female veterans--and that is what
this slide shows--by age group, there is nearly a twofold
increase over women in the general population. That is, again,
variably, statistically significant over years and by age. So
in this older age group in 2002, it was above the national
average statistically. Here, it was about the same, and here it
has bounced up again. I don't know what 2006 will show, but we
need to follow that and find out.
In 2002, to better understand the nature of violent deaths,
the CDC Violent National Death Reporting System was established
and gradually implemented, first in six States, then expanded
to 16 by 2005, to collect data on violent deaths, including
suicides. It gets information from a variety of sources,
including death certificates, police reports, medical
examiners, coroners, crime laboratories; and unlike the
National Death Index, coroner-reported veteran status is
included in the database. VA can get, at least for these 16
States, information on overall suicide rates among all
veterans.
This chart summarizes the 2005 data. What you see of note
is that, at least in these 16 States, there is a significantly
higher rate of suicide in the younger age group of veterans
compared to the general population. This is similar in both
veterans seen in the VA system and those who do not use the VA
system. This is for veterans who are really all veterans, and
these are veterans who actually use the VA system. You can see
these are relatively the same, but they are higher than the
national averages.
We intend to trend this information over each year of the
available data, going back as far as we can go to 2002. We
believe that some of these veterans' deaths in this data set
represent servicemembers who were actually on active duty when
they committed suicide. We will work with CDC and DoD to
understand this group, particularly, obviously, wanting to know
whether this represents OIF or OEF returnees.
Clearly, OIF and OEF returning servicemen and women
represent a group of particular interest to us today. We have a
sense of urgency to understand and intervene to prevent even a
single suicide. To better understand suicide in this particular
cohort, Dr. Kang, of the VA, conducted a study, which matched
servicemembers who had served in OIF and OEF theater and
separated between 2002 and 2005 against the National Death
Index. He found--just looking only at that group, he found that
144 out of 490,346 separated OIF and OEF servicemembers
committed suicide during that time, for an overall rate of 21.9
per 100,000.
Because there was some initial confusion around this study,
I want to clarify that these, unlike our concerns about the
last data that I presented, are deaths only of men and women
who had separated from the military and do not include any
deaths while a servicemember was on active duty.
To compare to other national norms, we looked at this
cohort against the national averages that I discussed earlier.
For OIF/OEF veterans who had deployed and separated from 2002
to 2005, the suicide rate was slightly higher than would be
expected in an age-, gender-, race-matched general population,
but the difference was not statistically significant except in
the young non-VA user age group. So these are folks that were
not seen in the VA, and again, it was only significant in the
age group of 18 to 29.
We have also examined this data for differences in suicide
rates between those who use the VA and those who have not used
the VA. We found that 17 per 100,000 OIF/OEF veterans who used
the VA for care took their own lives, compared to 24 of 100,000
OIF/OEF veterans who did not use the VA for care. Again, this
apparent advantage to VA care, though encouraging, is not
statistically significant. In this group, a slight but not
improved rate is also true for those who visited our Vet
Centers. There were only three women among the 144. So no
conclusions can really be drawn from that group.
Our medical statisticians have plumbed this data in
anticipation of follow-on studies when the updated National
Death Index information is available. Some of the insights that
we have taken from this look include that there is little
variation in suicide by branch of service. We also found that a
diagnosis of a mental disorder predicted a nearly 1.8 times
higher suicide risk than the general population. This is
consistent with what has been published regarding people in
general with mental health diagnoses, but emphasizes the
absolute importance of our mental health efforts.
Likewise, the use of firearms as a means of suicide in this
group is consistent with the higher rate of this modality of
suicide in all veterans compared to the general population.
I would reiterate that all of this data comes from national
data for suicide run against those who we know from our data
sources and DoD are veterans. We must use these national
numbers, because our clinical records do not capture in any
reliable or complete way such events as suicides or suicide
attempts. This national roll-up of information from the
coroners through the States offers the most complete
compilation of deaths and its causes, since we may well not
know of a death even if it occurs locally.
The information on deaths continues to be updated as the
reports come in over time, so our confidence in the
completeness of those numbers comes only after several years of
data collection. We are awaiting now, again, the release of the
National Death Index compilation for the year 2006 for further
analysis, and we will dig into that very deeply as soon as we
get it.
For this reason, and not satisfied with that data lag, Dr.
Katz, who led in the institution of a VA-wide system of 153
suicide-prevention coordinators whose prime function was
clinical in nature--taking care of patients, identifying and
closely following high-risk patients, educating staff on
suicide issues--he directed them, beginning in October of 2007,
to report specifically on suicide attempts.
This entailed getting a clear definition and reporting
standards for suicide attempts. When is a suicide attempt an
attempt? Does a cry for help with an overdose of a non-
threatening medication ingestion or a cut on the wrist so
slight as to not really risk serious injury, is that really an
attempt? Those are the kind of questions that we have to get
standardized across 153 different reporting entities.
On February 13, 2008, an internal e-mail from Dr. Katz
discussed what was the first 3 months of this reported
information. In his e-mail, he suggested that a thousand
veterans a month under VA care were being reported as
attempting suicide, and appropriately was concerned about
releasing information that was not validated and was so very
preliminary.
The data was clearly not accurate. Our suicide prevention
coordinators were new to their jobs. There was a great deal of
uncertainty over borderline calls, and many of them were just
beginning to make the community contacts that are essential in
making an accurate count of the number of suicides and suicide
attempts.
A number of States had suspiciously low reporting rates. We
are still not satisfied with the consistency of the reporting,
its accuracy or its completeness.
Let me show you this chart. And what this is is month by
month, facility by facility, and what you can just see is how
erratic the reporting is even now. The VA is addressing the
problem through regular review, educating coordinators with
questionable data, collaborating with our coordinators on
difficult calls, and encouraging them to meet the right people
in their communities to obtain additional data.
To be clear, VA had not reported on suicide attempts
previously, either to Congress or to the media. Though perhaps
we should have been looking at it earlier, we were not. The
number, 790 a year, was a CBS News number that they derived
from a Freedom of Information data request looking at clinical
records coding. I now understand, I think, the places in the
spreadsheets that they got under the Freedom of Information and
added together to get this number.
But for all the reasons noted earlier, this source of data
should not have been considered at all reliable if the purpose
of the count was to determine the total number of suicides and
attempts among veterans under our care. Some people who attempt
suicide, but do not die, go elsewhere for care. Others do not
admit that their injuries were due to suicide attempts, and may
not, even when a counselor discusses a situation with them. CBS
News' number, while arithmetically correct, is in actuality
misleading.
I can appreciate that the number of a thousand suicide
attempts a month might be shocking. But in a system as large as
ours, and with the numbers I have shown you nationally on
suicides, and consistent with the literature, we might well
expect a larger number of attempts than that because it's
somewhere between 8 and 25 attempts per suicide completed in
the national literature.
But what is really important is to identify them, because
people who attempt suicide are more likely to commit suicide
and are so, therefore, such an important target for our
interventions.
There's a large body of scientific literature on suicides,
and the VA has over the years, been a prime contributor to that
knowledge. In fact, I can submit this binder full of peer-
reviewed articles for the record.
It is where we have the basis for conclusions that target
our efforts, conclusions such as: Among veterans receiving care
from VA who died from suicide, almost 60 percent of those aged
under 65 have a mental health or substance abuse diagnosis, but
only 24 percent of those aged 65 and over have such a
diagnosis.
There is significant variability in suicide rates
geographically. In general, the rates are lowest in the
Northeast and highest in the West. I don't know exactly why.
For veterans who died from suicide, firearms are the most
common means, accounting for almost two-thirds of the deaths.
Among Vietnam veterans, there appears to have been an
increase in suicide rates in the first few years after veterans
returned home; however, after a few years, those rates became
comparable to the general population. There was no increase in
suicide rates among veterans who returned from the first Gulf
War. And those wounded, hospitalized and multiple wounds, have
had a higher risk of suicide.
You know, I have focused a lot on the numbers and what we
know and don't know. And while I am pushing our VA team to
explore these numbers in greater depth and expand our
understanding of them, I want to emphasize that we are not
waiting for perfect numbers to appreciate the importance of
extending our intervention and outreach. Whether veterans
suicides are at or above or below some national average, any
suicide--any suicide--in our view, is a tragic loss.
There is probably no system focusing on suicide and mental
health issues in as a comprehensive and far-reaching way as
your VA. And Dr. Katz here has been a key leader in that
effort.
Recognition of the problem by all who serve veterans is
important. So we have had two national VA Suicide Prevention
Awareness Days throughout our system to focus 200,000
healthcare employees on this issue. We have trained VA staff on
prevention resources, including the hotline and the roll of
suicide-prevention coordinators. We are incorporating special
training in suicide prevention for our case managers.
Two of our mental health education and research centers
focus on technical assistance across the VA for suicide
prevention. One is our Mental Health Center of Excellence in
Canandaigua, New York, with expertise in testing clinical and
public health intervention; the other in Denver with clinical
and neurobiological sciences, emphasizing suicide risk.
In July of 2007, a suicide hotline center was established
at Canandaigua. In the subsequent 10 months, the hotline has
fielded more than 37,000 calls, more than 16,000 from veterans.
Nearly 500 from active-duty servicemembers, and more than 2,000
from family members or friends, just as you all have pointed
out. These calls have led to more than 3,000 referrals to
suicide-prevention coordinators and 885 rescues involving
emergency services.
Let me introduce Dr. Jan Kemp, who is with us today, who
leads this effort on the ground up there in Canandaigua.
Jan, stand up. Thanks.
VA's hotline is staffed solely by mental health
professionals, 24/7/365. They are trained in crisis
intervention and issues such as traumatic brain injury and post
traumatic stress disorder. In emergencies, they contact local
emergency resources, police or ambulances. They can use the
veteran's electronic medical record during the call and link
directly with the medical center if they are one of our
patients. And they work with the local suicide-prevention
coordinators directly.
Cards, pamphlets, refrigerator magnets--I provided samples
that I believe are at your desks--are widely distributed. And
our suicide-prevention coordinators ensure at-risk veterans and
their family members get them.
[Samples of cards and pamphlets appear on pages 120 and
121. The refrigerator magnet will be retained in the Committee
files.]
This was pulled out by one of our veterans service
organizations (VSOs) who said, boy, we're using this all over
the place. Posters and hotline information such as these are
located throughout VA medical centers, clinics and Vet Centers.
Hotline stickers are on phones and by the doors in our
residential programs.
Far from hiding this issue, we are more public about it
than any organization that I know. I've mentioned the suicide-
prevention coordinators before. Their main function is
clinical, to educate staff and the veterans and the family
members and to carefully monitor those at higher risk. So they
maintain everyone's higher state of awareness and alertness to
suicide issues, as well as dealing with individual patients.
It was not primarily for epidemiologic purposes that they
were identifying suicide attempts, but rather because we know
that those who have attempted suicide are at the highest risk.
Under Dr. Katz's leadership and with the help of Congress, we
have grown our mental health program in a number of ways: more
than 3,800 new mental health employees hired in the past 3
years; incorporating mental health into primary care in our
medical centers and in our Community-Based Outpatient Clinics
(CBOCs); growing the number of both CBOCs and Vet Centers;
expanding our hours of operation for mental health clinics
beyond normal business hours; using telemental health to reach
more remote veterans; providing separate access for women
veterans with mental health, primary care and gynecologic care.
It recognizes their increasing proportion of the force and
their special needs and special desires for privacy. We are
doing this in each of our hospitals.
The standard for mental health access was tightened so that
patients with mental health issues are screened within 24
hours, provide urgent care immediately when needed--and if we
don't have it in our house, we will buy it--or provided a full
evaluation and a treatment plan within 14 days for those non-
emergent patients.
I have spoken to you before on our outreach efforts with
letters and participation in transition briefings for active
and reserved demobilization at both deployment health
reassessment sites and on bases and in military hospitals.
[A sample of an outreach letter to veterans from Hon.
Michael Kussman, M.D., MS, MACP, Under Secretary for Health,
U.S. Department of Veterans Affairs, appears on p. 122.]
On May 2nd, we began an outreach call center program to
contact nearly 570,000 combat veterans of the war on terror to
ensure that they know about our ability to provide them care.
Now we can do that up to 5 years after separation and to
provide them information on other benefits. The first of those
calls are going to veterans who were sick or injured while
serving in Iraq or Afghanistan. And if any of those 17,000 or
so veterans do not have a care manager, we will offer to
appoint them one.
All of these efforts support not only our general concerns
for our men and women veterans but to also directly address the
issue of suicide concern about which we are here today.
I am impressed by the quality of my people and the
dedication to this work, but I also appreciate the value of an
outside look. I have directed the creation of a blue-ribbon
work group of experts in suicide and its prevention to look at
all of our data, consult with our team and advise me on
different looks at our own data or new lines of inquiry that
they might recommend. The members will come from DoD, other
government agencies, and other nationally recognized treatment
research and public health experts on suicide and its
prevention, all from outside the VA. They will be given all of
the data that we have and access to all of our experts. I have
asked for a report 15 days from the completion of their meeting
to tell me how I can better approach suicide prevention and
suicide research.
You know, there is nothing more tragic than the loss of
even one of these great men and women who have served this
Nation. The VA is committed to doing all that we can to serve
the individual while we continue to try to understand a very
complicated problem that is also a national problem. We owe
this Committee, and the Nation, accurate information and
carefully studied, thoughtful conclusions while we provide the
best care anywhere to our veterans, and that's exactly what I
intend us to do.
Again, Mr. Chairman, I do appreciate you holding this
hearing, and I look forward to your questions.
[The prepared statement and slide presentation of Secretary
Peake appear on p. 83.]
The Chairman. Thank you, Mr. Secretary.
I don't doubt your commitment, but I will tell you, if
there is a book on how a bureaucratic response should be given
to an emotional problem, there should be a chapter in there
with your testimony. Because what you have done is make us all
look at these charts, which are almost impossible to read, and
all the things you're doing and, of course, the icing on the
cake, a blue-ribbon commission--it's always done to avoid an
issue--without us understanding what you need in terms of
resources from us and what we are missing. It sounds to me,
``Everything is fine, we have it under control, we are going to
study our data, we dug up all this data, but it is under
control.'' You don't ask for any additional resources, you
don't say what you could do, you don't say what mistakes you
have made; everything is fine.
[The following was subsequently received from VA:]
The Blue Ribbon Work Group on Suicide Prevention in the Veteran
Population provides advice and consultation to the Secretary on various
matters relating to research, education and program improvements
relevant to the prevention of suicide in the veteran population. The
Blue Ribbon Work Group on Suicide Prevention in the Veteran Population
will create a report, within 15 days of the completion of its meeting
with recommendations for improvements in VA's programs related to
suicide prevention, research, and education.
Recommendations will be directly related to the primary objective
of reducing risk of suicide in the veteran population. The attached
Memorandum from Hon. Michael J. Kussman, M.D., MS, MACP, Under
Secretary for Health, U.S. Department of Veterans Affairs, to Hon.
James B. Peake, Secretary, U.S. Department of Veterans Affairs, dated
May 5, 2008, Regarding Blue Ribbon Work Group on Suicide Prevention in
the Veteran Population, appears on p. 134.
The Chairman. And that is a standard answer to everything
we have done for years and years in this Committee. That is why
we are upset and impatient, because you are not focusing on
what we can do together to make sure that all the mental
illness issues that have been associated with combat: PTSD,
domestic violence, homelessness and suicides--we are not doing
the job. I don't care what your figures show. We have tens of
thousands of young people getting out of the military or the
Guard who have not been adequately diagnosed for either PTSD or
brain injury.
Every one of your statistics says, ``those who have come to
us,'' which is, you know, a small fraction of who is out there.
So we are not doing the job. And we can't do our job if you are
not honest with us.
And as I said before in my opening statement, we only came
into possession of certain e-mails--I don't know how many there
are out there, but we only have a few--brought to the public by
discovery in a legal case out on the West Coast.
So 3 days after the hearing in which we asked directly--and
Mr. Mitchell just said this--Dr. Katz, ``Do you need any help
from us? What resources do you need?'' And he said, ``No, we
have it taken care of, and here are our statistics, CBS News
was wrong, and you guys shouldn't worry about this.''
Three days after that, Dr. Kussman writes to Dr. Katz and
others that--I don't know if the e-mail is from home or work,
but the fact that you are all working Saturday, is good--18
veterans kill themselves every day. That is what the CBS News
report said. ``Sounds awful, but let's not worry too much if
you are considering 24 million veterans.''
Even in the first e-mail that we have--and I don't know
what else there is--nobody is saying, ``We are not doing the
job here.'' They are saying, ``Does this sound good? Does this
sound bad?'' And Dr. Katz says, yes, there are 18 suicides.
This is supported by the CBS News numbers.
Now, Dr. Katz, this contradicts what you told us in the
hearing 3 days earlier. Why didn't you just call us up or ask
for another hearing and say, ``You know, we are looking at
things differently. I misspoke. I want to talk to you some more
about the statistics.'' This looks like a cover-up, because you
didn't tell us anything. And this is contradictory to what you
said to our Committee in December.
Why shouldn't you go to court for perjury or resign because
you didn't tell us the truth?
Dr. Katz, I am asking you. You keep looking at the
Secretary, but I am asking you.
Dr. Katz. Thank you for asking.
In response to a question from Mr. Mitchell in the December
12th hearing, I and my colleague, Dr. Fred Blow, who
accompanied me to the hearing, did mention the 18-a-day for
suicides among all veterans. We mentioned the four to five a
day for suicides among those we cared for in VHA healthcare
services.
When I asked him to, Dr. Blow mentioned the fact that,
overall, veterans had a rate of suicide about 1.5 times that of
age- and sex-matched individuals from the general population.
And he mentioned the fact that, among women, the ratio of
suicides among veterans in our system to the general population
was about two.
That was mentioned in the hearing on December 12th. There
was no cover-up. This was mentioned.
The Chairman. Did you not say--and we saw the clips. Did
you not say that the CBS News data was wrong?
Dr. Katz. I was not referring to the entire data, but the
subset of data dealing with the youngest of veterans.
The Chairman. So the ``Mission accomplished'' should have
said, ``Mission accomplished only by those sailors who were
aboard this ship on those 2 days.'' We didn't see the fine
print.
We asked you several times, and you said several times that
the CBS News data was wrong. You never made any qualification
of that as far as I can remember. Your story was that they were
wrong, and you didn't need any help to deal with this issue. Is
that right? You were fine?
Why do you keep looking at the Secretary? I am asking you,
Dr. Katz.
Dr. Katz. Sir, I did speak about the suicide rates among
veterans on December 12th, and I continue to have concerns
about the CBS News reports about rates and standard mortality
ratios or ratios among the youngest veterans. I wish they would
present their data so we could review it.
The Chairman. Yes, but you are in charge. They are just
reporting. They asked for all this data, and you never gave it
to them, so they spent 6 months trying to find stuff that, Dr.
Peake said the VA didn't have. Well, they went out and found
it. So I assume somebody can go out and find it if you think
it's important enough.
Secretary Peake. Mr. Chairman, if I may, I don't disagree
with your premise that somebody should be able to go out and
find it. They did not provide it to us, even though we asked.
And so we have now gone out and asked for the same information.
I am very anxious to see what actually came back.
As I tried to explain, we are using the data from the
national sources, which is the gold standard that any
responsible statistician would be able to use for this.
I will tell you, I am worried that suicide in general in
this Nation is underreported, not just in the military, not
just in the VA.
The Chairman. But don't start that red herring. We are
talking about veterans right now. So don't tell me, ``Well, the
whole society is screwed up.'' We are going to do our job for
veterans.
So on the December 12th data, you don't see any difference,
Dr. Katz, between what you told us then and what you said a few
days later. You say you are consistent.
Dr. Katz. Again, the issue is the 18-a-day, the 4-to-5 a
day, the ratios of 1.5 and 2.0. And those were provided at the
December 12th hearing in response to a question from Mr.
Mitchell.
The Chairman. Now, on one, the February 13th e-mails you
said, ``Shh!'' what did you mean by that?
Dr. Katz. That was very unfortunate. I think the e-mail has
to be divided into the subject line and the content. I deeply
regret the subject line. It was an error, and I apologize for
it.
However, the content of the e-mail, the body of the e-mail
reflects an appropriate and healthy dialogue among members of
VA staff about when it is appropriate to disclose and make
public information early in the process of developing----
The Chairman. No. An appropriate e-mail would say, ``We are
not sure of this data. We will study it further. Maybe we
should inform the Committee.'' But what you said is, ``This is
something we should carefully address ourselves before someone
stumbles on it.''
I mean, that is what you are concerned about, not the
suicides, but somebody stumbling on this data.
Dr. Katz. No, sir, I am concerned about saving lives.
The Chairman. Well, but that is not what you suggest here.
Dr. Katz. Sir, that e-mail was in poor tone, but the
content was a dialogue about what we should do with new
information.
The Chairman. And did you tell Secretary Peake about all
this, about the new data or these thousand attempts per month?
Dr. Katz. The purpose of that e-mail was to open extensive
dialogue within VHA about this emerging data.
The Chairman. Did you tell Secretary Peake about that, that
you were showing a thousand suicide attempts per month?
Dr. Katz. I reported it to VHA's senior leadership.
The Chairman. That is not what we have in the e-mails. We
just have you talking to the PR guy.
Dr. Katz. We were opening a dialogue about what to do with
the new information.
The Chairman. Yes, and the first thing you do is talk to
your public relations guy instead of somebody who might know
how to treat suicide. It seems to me that what you were trying
to do was manage the data, not deal with the data.
Dr. Katz. Sir, there has been extensive conversation about
this with other suicide and mental health people.
The Chairman. I'm sorry? I didn't----
Dr. Katz. There was extensive conversation about the
thousand a month with other people----
The Chairman. Yes, but not in the information we have.
Dr. Katz. Not in that e-mail, no.
The Chairman. I would think that you would tell us about it
since we have a concern about the issue and we are the ones who
can help get you the money to deal with the issue.
All I have is what you provided to the court by discovery
motions, which I assume is as complete as you want it to be. If
you have more complete information, then you probably didn't
give enough information to the original requests. It appears to
me that your interest is in managing the data as opposed to
helping the veteran.
Dr. Katz. Sir, earlier at that same court, in a hearing, I
testified under oath to the thousand a month and talked about
how knowing about that number was so very important, because it
pointed to a thousand people a month where we really could do
something to dramatically decrease suicide risks.
The Chairman. Why didn't you just write us a letter, or set
up a meeting, or brief us? I mean, instead of managing the
data, why didn't you just talk to us about it and say, ``We are
on it, we are serious, we care about it, we want you to know
about it, and we need this much more money or not to do
something?''
Dr. Katz. Dr. Peake spoke to the fact that this wasn't data
yet. These were observations and measurements very much in the
state of development.
The Chairman. When do you expect that to be real data?
Another year, after your term is over?
It looks like this would never have come to our attention
unless there was the court case with discovery. You never had
any intention of talking to us, dealing with the data in an
open way, but you were trying to manage it from the inside. And
who knows when we would have heard about it.
Both the court case that got the data and the news media
that has been looking at this issue have done a far better job
than you have in keeping us informed.
Mr. Buyer, I took too much time. I apologize.
Mr. Buyer. I am trying to follow this. I was present at the
December 12th hearing. And I know we have ongoing litigation,
so I recognize, Mr. Secretary, you have to be careful if you
have ongoing litigation, yet we are also asking you questions
about data.
And it appears that, when this e-mail is released in
discovery in litigation, CBS News has created an impression now
in our country by their report that no one knew about this 18
per day until it was in discovery.
Now, when I look at the report on the December 12th
hearing--and I want to compliment my colleague, Mr. Mitchell.
You did a very good job here, when you look at the transcript.
I mean, you went right in on Dr. Katz, and you asked the
specific question to him.
You asked this: ``One last question really quick. Do you
believe that suicide is an epidemic?'' Dr. Katz: ``There is a
suicide epidemic in America.'' Mr. Mitchell then says, ``Among
veterans?'' Dr. Katz says, ``The number''--then parentheses,
(inaudible) end parens--``about 18 veterans kill themselves
each day in America. That is too many,'' Dr. Katz says. And Mr.
Mitchell then says, ``And?'' Dr. Katz's response is, ``About
four or five.'' There is cross-talk, inaudible. Mr. Mitchell
then: ``According to CBS News, it was 120 a week.'' Dr. Katz
says, ``About the same.'' Mr. Mitchell then says: ``That is not
higher than the general population?'' Dr. Katz says, ``It is
somewhat higher than the general population among veterans
because of demographics and risk factors.''
Mr. Mitchell, then you asked a really good question. You
said, ``I think one way we can find out about that is if you
have the data. I think that is one thing that people were
arguing about earlier, was the methodology of data that CBS
had.''
Now, see, when you asked that question, I homed right in on
it. And that is the reason that I wrote the letter, and that is
the reason Bob Filner joined me. And we sent this letter, with
regard to methodology and data, not only to the Secretary but
also to DoD and CBS News. CBS News has yet to share this with
us. So if you can get it, Mr. Mitchell, I hope you can.
But from what I recall from the hearing, Mr. Chairman, Dr.
Katz, this was in response to Mr. Mitchell's questions.
I have other questions for you, Mr. Secretary.
You have much in your toolbox. When you think about the
access that you have to great intellect in your research and
development and your abilities to study and define cohorts, I
would like to know, is there any epidemiological resource
analysis that is being done for the, quote, ``at-risk,'' end
quote, veterans from either Vietnam or the first Gulf War,
specifically looking at the mortality rates for in-theater
versus non-theater, veterans versus general population?
Obviously, we are trying to home in on, then, those who are
most susceptible, and so obviously you want to look at--and I
just mentioned this to the Chairman--those who may already show
trends in mental health, depression, PTSD, wounds or
disabilities, whether they occur in-theater or non-theater.
With that, I yield to you for a response.
Secretary Peake. Well, sir, in this gathering of documents
here that have been published on the Vietnam and Gulf Wars, it
addresses some of those specific issues in terms of the
epidemiology of suicide in those groups.
It is very clear that those with mental health disorders,
in some of our published literature just in the general veteran
population, those with depression have a higher suicide attempt
rate when you look at that as a group. And that gets better,
that rate gets smaller if they are on medications. At least one
of our studies has proved that.
So it starts to give us the opportunity to target the
individual groups. Those with suicide attempts clearly have a
higher rate. So, again, we are trying to target the individual
specific groups based on the science behind it in terms of what
we are actually finding as you really understand what groups
are at risk--those with wounds; we are looking at the TBI group
as a potential for specific intervention.
One of the reasons why I tried to emphasize in this call
center outreach is to make sure that we are going after those
who have returned who were injured, specifically to try to get
them into care management, and why we are training the care
managers on suicide intervention, because of just exactly that
nexus. So that is exactly the direction that we are trying to
go.
Mr. Buyer. Mr. Chairman, I think what would be helpful for
the Committee, the Secretary keeps referring to a binder that I
can see is pretty thick, and he refers to, quote, ``peer-
reviewed articles.''
I think it would be helpful to the Committee, Mr.
Secretary, if you would provide the Committee with and would
submit for the record a page of references----
Secretary Peake. Absolutely.
Mr. Buyer [continuing]. That would list the title, the
author, the publisher, dates, and/or if there are Web sites,
okay?
Secretary Peake. Very well. We will provide that for the
record.
Mr. Buyer. Thank you very much.
The Chairman. Mr. Michaud.
Mr. Buyer. Mr. Chairman, and we are doing this for the
record, it is being submitted for the record, their references
would be submitted for the record.
The Chairman. Yes, that is a fine idea, so ordered.
[The following was subsequently received from VA:]
In reference to the binder at the hearing, attached are research
articles published in peer-reviewed medical journals that have
relevance to the question of the rates and risk factors for suicide
among veterans. All demonstrate VA's investment in research and
epidemiology in providing scientifically evidenced understanding in
mental health conditions that impact veterans.
Articles are separated by whether the population studied was
population based (ie., representing the full spectrum of all veterans)
or a clinical cohort (ie., representing a sample of only those veterans
who sought care in VA). In cases where websites are available they are
cited.
Clinical cohorts cannot be used to estimate population-based rates and
risks.
Patients who seek and receive medical care differ from the general
population. For instance, they may be sicker, leading to higher
expected rates of death. Also, they may travel far from home to get
medical care, in which case it may be hard to calculate the
``denominator'' (see below) of total patients at risk.
Reported suicide rates in clinical cohorts are usually higher than
that of the general population. Therefore, for determining the rates
and risk factors for suicides among veterans overall, population-based
studies assume a higher priority. Insights from clinical cohorts,
however, are valuable for suggesting more effective ways to deliver
clinical care to veterans who use the VHA healthcare system.
References
Cypel Y, Kang H. Mortality patterns among women Vietnam-
era veterans: Results of a retrospective cohort study. Ann Epidemiol
2008; 18:244-252.
Herrell, R, Goldberg J., True, WR, Ramakrislman, V.,
Lyons, M., Eisen, S., Tsuang, MT. Sexual Orientation and Suicidality.
Arch General Psychiatry 1999; 56: 867-874.
Bullman TA, Kang HK. Risk of suicide among wounded
Vietnam veterans. Am J Public Health 1996;86:662-667.
Bullman TA, Mahan CM, Kang HK, Page WF. Mortality in U.S.
Army Gulf War veterans exposed to 1991 Khamisiyah chemical munitions
destruction. Am J Public Health 2005; 95:1382-1388.
Kang HK, Bullman TA. Mortality among U.S. veterans of the
Gulf War: 7-year follow up. Am J Epidemiol 2001; 154: 399-405.
Kang HK, Bullman TA. Mortality among U.S. veterans of the
Persian Gulf War. NEngl J Med 1996; 335:1498-1504.
Zivin, K., Kim, M., McCarthy, JF., Austin, KL., Hoggatt,
KJ., Walters, H., Valenstein, M. Suicide Mortality Among Individuals
Receiving Treatment for Depression in the Veterans Affairs Health
System: Associations with Patient and Treatment Setting
Characteristics. American Journal of Public Health 2007; 97 (12): 2193-
2198.
Desai, MM., Rosenbeck, RA., Desai, RA. Time Trends and
Predictors of Suicide Among Mental Health Outpatients in the Department
Veterans Affairs. Journal of Behavioral Health Services and Research
2007.
Gibbons, RD., Brown, CH., Hur, K., Marcus, SM., Bhaumik,
DK., Mann, JJ. Relationship Between Antidepressants and Suicide
Attempts: An Analysis of the Veterans Health Administration Data Sets.
American Journal Psychiatry 2007; 164:7: 1044-1049.
Tiet, QQ., Finney, JW., Moos, RH. Recent Sexual Abuse,
Physical Abuse, and Suicide Attempts Among Male Veterans Seeking
Psychiatric Treatment. Psychiatric Services 2006; 57(1): 107-113.
Desai, RA., Dausey, DJ., Rosenbeck, RA. Mental Health
Service Delivery and Suicide Risk: The Role of Individual Patient and
Facility Factors. American Journal of Psychiatry 2005; 162: 311-318.
Kausch, O. Suicide Attempts Among Veterans Seeking
Treatment for Pathological Gambling. Journal of Clinical Psychiatry
2003; 64(9): 1031-1038.
Desai, RA., Lui-Mares, W., Dausey, DJ., Rosenbeck, RA.
Suicidal Ideation and Suicide Attempts in a Sample of Homeless People
with Mental Illness. Journal of Nervous and Mental Disease 2003;
109(6): 365-371.
Thompson, R., Katz, I., Kane, V., Sayers, SL. Cause of
Death in Veterans Receiving General Medical and Mental Health Care.
Journal of Nervous and Mental Disease 2002; 190(11): 789-792.
Kausch, O, McCormick, RA. Suicide Prevalence in Chemical
Dependency Programs: Preliminary Data from a National Sample, and an
Examination of Risk Factors. Journal of Substance Abuse Treatment 2001;
22: 97-102.
Sernyak, MJ., Desai, R., Stolar, M., Rosenheck, R. Impact
of Clozapine on Completed Suicide. American Journal of Psychiatry 2001;
158(6): 931-937.
The attached table entitled, ``Rates and Risk of Suicide and Other
Suicidal Behaviors Among U.S. Veterans,'' Updated April 30, 2008,
Prepared by Joseph Francis, MD, MPH, Acting Deputy Chief Quality and
Performance Officer, Office of Quality and Performance, U.S. Department
of Veterans Affairs, appears on p. 137.
Mr. Michaud. Thank you, Mr. Chairman, Mr. Ranking Member,
for having this hearing today.
Mr. Secretary, just looking at some information--and,
actually, one of the panelists that is coming up, Dr. Stephen
Rathbun, who will be testifying later on today. CBS News
actually asked him to run a detailed analysis on the
information, the raw data that he obtained from the States.
In that raw data, it shows that, according to the doctor,
that it found that veterans are more than twice as likely to
commit suicide in 2005 than non-veterans. But it also goes on
to say that, between the age group of 20 and 24, that veterans
are two-to-four times higher likely to commit suicide than non-
veterans.
I don't know if you had a chance to look at that or if Dr.
Katz has. Is that analysis correct?
Secretary Peake. Sir, we have not seen that data.
But I would like to, if I could, and with your permission,
Mr. Chairman, put up that slide again on the 16 State material,
and it is on your screen now actually. This study of these
States under the National Violent Death Registry does give
coroners information to say if this person is or is not a
veteran. We understand it may also include active-duty people.
But you can see that the numbers there suggest that there is a
higher rate statistically in the younger servicemember--I'm
sorry, veteran or potential servicemember, both in those who
have been seen in the VA and those who are not.
So at least in these 16 States, which is not necessarily
representative of all of our States, it does give us that kind
of inference here. And we see that both in men and in women.
And so we take that very seriously, and that is why we are
pushing so hard and why I want this outreach. Because I believe
if you get these people in and get them into some kind of care,
if they are depressed and get on treatment, there is evidence
that we can mitigate some of this tragic loss in terms of
death.
So I can't speak to what was presented on data we haven't
seen, but this is data that is available, and we have run it
against what data we know for VA users, so we are comfortable
or confident in that data.
Mr. Michaud. And what role has the VA found that substance
abuse and the lack of treatment has played in a veteran's
suicide?
Secretary Peake. Sir, it is one of the clearly linked
conditions for suicide. Depression and the co-morbid conditions
do relate to an increased suicide risk.
Mr. Michaud. And you had mentioned outreach. And that is
one of the whole ideas behind the CARES process, is to get more
access points throughout the country for our veterans. And that
is probably part of the reason that we are seeing some of the
problems, particularly in rural areas.
You mentioned a lot of the programs that the VA is doing to
help our veterans deal with this problem that is out there. A
couple of years ago, when the Congress actually provided the VA
with about $300 million to take care of mental health needs, a
GAO report--came back and said that only about $100 million to
$150 million was used, and, out of that amount, they really
couldn't tell what it was used for. It was supposed to be used
specifically for mental health.
So my question to you, Mr. Secretary, is, number one, how
do you know that the money and the programs you are doing are
going to directly benefit our veterans?
And the second question is, have you seen a decrease in the
number of suicides since these programs and outreach have been
implemented?
Secretary Peake. Well, sir, first, I will tell you that--
and as we have talked about here--for 2009, we expect to
increase our expenditure on mental health to $3.9 billion. We
have hired 3,800 new mental health workers--we have about
17,000 mental health folks working in mental health across our
system.
Going to Mr. Moran's point, we have OEF and OIF people that
we have hired specifically to do the peer review and reach into
from our Vet Centers.
And so I do know that there is a history of the inability
to expend the money. And that is part of the difficulty of
hiring people and the slowness of it. I think we are up to
speed in terms of moving forward on that. And we will monitor
that very carefully to make sure that we are putting everything
that we need and that we have been given to use for mental
health into that process.
Mr. Michaud. The second question that I asked is, has there
been a decrease?
Secretary Peake. Sir, let me ask Dr. Katz.
As I look at these numbers, you know, I can see a decrease.
It is hard to say, well, that is the cause and effect. If you
can put up that other slide, you can see that, at least in the
one male in the slide that is up on the board now, in the
younger age group, there in 2005, at least. But this is old
data. And so the problem, sir, is being able to really get
accurate data to be able to give you an honest answer on that.
We are absolutely trying to plumb it and dig into it, but we
don't have perfect knowledge about that.
So that is part of why we are very interested in getting
our suicide coordinators out there, up to speed, in terms of
giving us as accurate a report as we can, not because that
number is exactly important, but because we want to be able to
intervene for those people.
And so I don't think I can actually give you an honest
answer about if we have seen a decrease in response to those
specific interventions.
And I would ask Dr. Katz, if you have any more comments on
that.
Dr. Katz. 2005 is the most recent year for which
information is available from the National Death Index. It is
just too early to evaluate the outcomes of the Mental Health
Strategic Plan (MHSP), whose implementation began in the
beginning of 2005.
We are looking toward this data with incredible intensity.
Just yesterday, I received data from the National Violent Death
Reporting System about early data from 2006 veteran deaths. It
is complex data; data like this always is.
The best way to summarize it is that, at this point, the
early data does not seem to show an increase in veteran suicide
rates from 2005 to 2006. This is very important, but it is very
early data. The numbers may change as late reports from State
medical examiners, and county coroners come in. It has to be
viewed as an evolving story.
The Chairman. Mr. Hall, you are recognized.
Mr. Hall. Thank you, Mr. Chairman.
And in my short 5 minutes, I just want to ask a couple of
practical questions.
Dr. Peake, if I may call you by that title, there is a
problem--currently, as I understand it, when a veteran gets a
prescription or has to order a refill, there is no way for a
doctor to expedite the delivery of the medication, which can
take 10 days sometimes. For a veteran needing an antianxiety or
antidepressant medication, it seems that he or she should be
able to get that refill sent quicker by allowing the doctor to
request overnight delivery.
Is that something you can do by rule or that you think that
is a problem that----
Secretary Peake. I would think that would be within my
purview. That has not been up to me, but I would be delighted
to look at it.
Mr. Hall. Well, it has now, and I just am asking you, if
you can, to make a ruling and send it down to all of the staff.
Because it is a drop--that is one of the ways in the general
population, as well as the veterans population, if you are on
an antianxiety/antidepressant drugs and you go off of them for
a period of days, it is not a good thing; ask any doctor.
Dr. Cross, you were going to say something?
Dr. Cross. There are some other options, as well. Many of
our facilities have pharmacies, like our medical centers, and
they can make an arrangement with the local commercial
pharmacy, if necessary, or they can pick it up there.
And I don't think it really takes ten days for the CBOC to
get the medicine out, but you raised an interesting issue. And
I agree with you, that continuity of providing that medication
is absolutely vital. And so I would like to look into that for
you.
[The information from VA was provided in response to Mr.
Hall's Post-Hearing Questions for the Record, which appears on
p. 238.]
Mr. Hall. Thank you.
And also, Dr. Peake, as far as your blue-ribbon Committee,
would you consider, or have you already, appointed any
representatives of veterans service organizations?
Secretary Peake. Sir, I will tell you, what I am going
after are people that have actually published and that are
recognized experts. I am not looking--I am trying to get at our
data. I mean, our veracity has been questioned. I think it is
reasonable to be questioned. We are America's VA, and we ought
to be transparent. What I want to get is some outside look at
it and see from a scientific clinical research and public
health perspective. And that is the kind of folks I am looking
at here.
Mr. Hall. I was concerned about, on one of your slides
here, the one showing--by the way, if you could provide the
Committee which 16 States you were looking at in the study,
that would be great.
Secretary Peake. Sir, this is the National Violent Death
Reporting, and it is on the bottom of the slide there.
[The information from VA was subsequently received:]
Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey,
North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
Virginia, Wisconsin, Kentucky, New Mexico, Utah and 4 counties in
California.
Mr. Hall. Oh, good. Okay, I'll find that. But, anyway, it
seems to show that the user-veteran suicide rate is higher than
the all-veteran suicide rate, which would indicate that the
VA's involvement may not actually be positive in these cases.
Am I reading that correctly?
Secretary Peake. Actually, what it shows is they are about
the same, because the comparison for statistical significance
is between the general population. So it is both the user and
the non-user that are in that younger age group, particularly
that are different from the general population. Between the
two, there is not a statistical significance--it is the same
whether you are in a VA or not in a VA.
Mr. Hall. So a four-point difference is not considered
statistically significant?
Secretary Peake. In that test, in this case, it is not.
Ira.
Dr. Katz. It really depends on the particular statistical
test that one does. We are dealing with a counterbalancing of
two complex effects----
Mr. Hall. Okay, thank you, Doctor. I have less than a
minute left. If I may, I appreciate your explanation, but I
wanted to ask two more questions.
One is, on the following slide, the non-user, 18- to 29-
year-old rate of 3.4, which you have illuminated in red, is of
concern. And that would seem to indicate a need for greater
outreach, and refrigerator magnets and handout cards may not be
doing it. I am curious, first of all, what you would propose?
Let me just ask a second question, and then you can answer
them both, if you will.
There are fewer females serving than men serving, as you
point out. However, the rate of suicide among female veterans
is approximately twice the rate of male veterans in your
testimony, if I am reading it correctly.
And I am curious if you think that is related to sexual
harassment or sexual abuse, which unfortunately occurs in our
bases as well as our academies, military academies, and it is a
problem that we are trying to deal with, I know at West Point,
in particular, where I serve on the board of visitors. And/or
is it due to a difference in the way women process their
experiences in battle and these things they have seen and
witnessed, do they have a different emotional reaction to it?
So those are a couple of questions, if you would.
Secretary Peake. Sir, first, the outreach. I agree with
you, we are looking for whatever way of outreach that we can
do. That is why I put this call center, outreaching call center
into effect, to try to get at those who haven't used us, those
who may finally be at a point where they had the teachable
moment to realize that we are there for them and to establish
that relationship. We have talked about putting signs on buses
and things like that, even, to try to do outreach.
In relation to women, sir, I would just like to correct, if
I misspoke before. The women's rate is higher than the national
average. Women, both veterans and non-veterans, are lower than
males across the board. But our women veterans are higher than
the general population.
And I think then it is fair to try to understand why. They
are about 14 percent of the DoD population now; they are about
14 percent of the force. And so an increasing number are
becoming veterans, and why we are pushing so hard to put
women's programs into a system that, really, for years, was
mostly an older men's service organization.
So we really are trying to address that and to try to
understand those issues of military sexual trauma. We are
seeing that. When I talk to our Vet Centers, they say that is
an issue that is very important. And so we are targeting that
group to try to make sure they get the counseling that they
need. We train our people specifically in that.
Mr. Hall. Thank you.
I yield back, Mr. Chairman.
The Chairman. Thank you, Mr. Hall.
Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman.
Mr. Secretary, I only have 5 minutes, so I will give you
the three questions and then--and, again, thank you for being
here today.
Why is there not more coordination between the DoD and the
VA with soldiers separated or discharged with either TBI or
PTSD? It would seem to me that more effort needs to be done to
reach out to veterans to bring them into the system rather than
wait for them to come to us.
The other question I have--and, again, it goes back to what
I think we talked about last week, with the rural areas--and
how do we, for veterans in rural areas who call the hotline--do
the suicide-prevention coordinator set them up with
appointments at the nearest clinic, VA clinic or hospital?
Because, you know, I've talked to veterans, and then asking
them to ride for a few hours in a van ride, a lot of times they
are just not going to do it. They just feel very uncomfortable
doing that.
And then my last question to you--it is probably and, I
understand, very broad-based--but what can we do from your
perspective for this Committee to be able to--is it, you know,
more money, which is something I think we can look at, or what
is it that we can do to help you with whatever we need to do on
our end? If you were to say to us, ``Listen, this is what I
need from you folks, to help me move down the road with this
and to be able to bring more people in,'' is it hiring more
people? Is it a combination of a number of things?
And so, I hate to load you with three like that, but with
only 5 minutes I thought I would try to get all three in.
Secretary Peake. Sir, let me start first at the top, with
DoD coordination. There is a general roster steering Committee
on the 15th of May. We have been invited to be a part of that.
Dr. Katz works closely with DoD. I spoke to the DoD psych
consultant this morning, who used to work for me. So I think we
have good relationships going on. We have a VA deputy now for
General Sutton who is going to be running that PTSD/TBI effort
for DoD to make sure that we are linked.
I think the issue of outreach is important. So we do go to
the Post Deployment Health Reassessments (PDHRAs), we do do the
Transition Assistance Program (TAP) debriefings, to try to get
that message out, as Mr. Hall was talking about, to make sure
people, wherever we can get them--part of it is trying to get
them when they are really ready to listen finally--the hotline.
If you have an emergency, we go to the police, we go to the
fire station, we go to whoever can make the intervention. And
we have had 885 rescues. We follow up a week later or 24--I
guess 48 hours a week and then 2 weeks later to track them
down. We work directly with the treating facility. If they are
active-duty--and we have had nearly 500 active-duty people call
our hotline--we have the relationships with DoD to get them
back in the DoD system, if that is what they need.
So, you know, I think we are very pleased, and we continue
to monitor and learn from it.
What can we do? You know, the Chairman brought up the issue
of family members. I think we need to do a better job of being
able to reach family members. They can be the canary in the
cage, if you will, when you have a servicemember or a veteran
who isn't just quite acting right and may not even recognize
it.
I do appreciate the issue of stigma, and we need to
continue to fight that down. I was very pleased to see what
Secretary Gates did this last week about taking, you know, that
question off the security questionnaires and so forth. I mean,
it is those kinds of things that will help us down the road.
But it is more than stigma, I think, that keeps people from
coming to us. I think some of these folks, it is a lack of
realization that something is wrong, that they are not quite
right. They just don't appreciate it until, sometimes, it is
too late. And if we can get family members and employers to
really understand that this is treatable, if you get them in,
we can help them, it will make a difference.
And so for helping us to find ways and the authorities to
reach out and do that would be something that would be
positive.
Mr. Hare. Thank you, Mr. Secretary.
Just one last thing on the rural areas. In terms of, if
somebody calls, a veteran who lives in a rural community, and
they call the hotline, do you try to get them into the VA
hospital?
Secretary Peake. Sir, we will get them wherever the care is
required and where we can get it. Unfortunately, some rural
areas, it is a long way, whether you are a veteran or not. And
that is a different kind of issue, but it is, again, part of
that national issue that we were talking about before. But it
is not, well, if you can't get to the VA, we are not going to
take care of you.
Mr. Buyer. Will the gentleman yield?
Mr. Hare. I certainly will be happy to.
Mr. Buyer. You just asked a very insightful question.
So say, for example, you have Montana or Kansas, and they
are not close to a Vet Center or an outpatient clinic. Do you
contract care, or how do you fill the gap, Mr. Secretary?
I think that is what the gentleman is trying to ask.
Secretary Peake. Sir, in Montana, we do contract with
centers around Montana. I have had a chance to visit both
Billings and Helena, because I am concerned about rural America
and access to care for our veterans that live in those areas.
But the fact is we do fee-based care, as you know, sir, and
we are willing to go out and we do go out and purchase the care
if it is not available and it is needed.
Mr. Buyer. Mr. Secretary, I would just ask you to work with
Mr. Hare. He's got a rural district in Illinois, and he has a
gap in coverage. Please work with him to make sure that gets
covered.
Secretary Peake. I absolutely will.
Mr. Hare. Thank you, sir.
The Chairman. Mr. Rodriguez.
Mr. Rodriguez. Thank you, Mr. Chairman. And, once again,
thank you for holding and conducting this hearing.
Good seeing you again, Mr. Secretary.
You know, I indicated earlier I think you are ideally
situated, because we have been working for the longest time to
try to establish a seamless transition from DoD to the VA. And
I wanted to ask you, and I know there has been some questions
on that, if we have made any gains in terms of where we are at
on that, of trying to transition that soldier to the VA.
Because there are going to be more soldiers coming in, and
there are going to be some that are really going to be hurting,
and the numbers might go up you know before they go down. And I
understand that. And so I wanted for you to respond to that.
Secondly, based on the Congressional Research Service (CRS)
report that we have and you have also and Dr. Katz has
mentioned it, that we don't have a hold on the actual suicides
and attempts. We don't have a good hold on that.
[The CRS Report entitled, ``Suicide Prevention Among
Veterans,'' May 5, 2008, appears on p. 111.]
Mr. Rodriguez. What else do we need to do besides possible
recommendations later on where we can start getting and
compiling that data in a way that makes sense where we will be
able to see if we can make any inroads there?
And thirdly, what do we do now, and maybe Dr. Katz can help
on this, what do we do now to provide the services that are
needed that we are not doing in reaching out?
And I know that people are hurting out there. They are
probably not the ones that will come out. And I know Mr. Moran
had some recommendation in terms of utilizing some of those
veterans organizations to reach out for those veterans that
find themselves underneath the bridges throughout our country
and those individuals out there.
So if you might respond to those three questions.
Secretary Peake. Yes, sir. First, on the issue of
transition, I've been talking lately about the notion that
there is ``transition'' with a big T and ``transition'' with a
little T, if you will; that, you know, for these servicemembers
that are coming out of our military treatment facilities and so
forth that are wounded and injured, with the Federal recovery
coordinators that we are starting to get into place and
expanding that program, I think that will go a long way to
helping them for a long-term transition.
And that really is important, because these are folks that
are wounded and, therefore, you know, appropriate to our
discussion today, have a higher risk for suicide. So having a
care manager is important.
What we are in the process right now--and on the 15th of
May, I should get my next report on it--is going back and re-
reviewing every soldier that we know that has been in our
system to understand, okay, what is their current status on
case management, who has been in touch with them recently, and
to ensure that we have the follow-up that I believe we owe
them. And so we are pushing very hard on that.
Then there is the other issue of the transition. Sir, there
has been a million and a half people who have deployed, a
little bit more now. About 800,000 have separated from the
service. About 300,000, a little more now, have come in to VHA
for care. When they come into care, they do get screened for
PTSD and TBI and suicidal tendencies. And so, you know, we have
that relationship with them.
Is it perfect? No. In fact, the people that--the national
preventive task force basically says there is no real good
evidence to prove about screening. We believe in it, though.
And so we are doing it every single time.
There is that other group out there, however, that 500,000
that haven't come to see us, that we will be part of this big
outreach effort that we are doing now to try to help them if
they need that help in transition. So we just want to make sure
they have that relationship with the VA, that they know that we
are there for them.
I will tell you, I know that trying to get at the data is
hard. The military is looking at how to really study every
single suicide. We get an in-depth review of any suicide that
we know of from one of our patients, because we can try to
plumb it to understand what the factors are, so that we can
learn from it. So it really becomes an individual case study
for each one of these, as well.
The problem is, as I say, sometimes we don't know if one of
our veterans has gone out somewhere else and it has not been
reported to us. And so we do want to stay in touch with the
national data.
Mr. Rodriguez. I would hope that we would establish and
start looking at some system that would give us information,
not only from the 16 States, but all of them as much as
possible.
And then, finally, the last recommendation in terms of what
do we do now, even if it is an initial phase to try to reach
out there, and maybe even utilizing existing veterans
organizations to work with some of our veterans. And I know
they are not trained in this area, but they are definitely
trained at reaching out and dialogueuing with them and maybe
getting them to come back in.
Secretary Peake. You know, I, kind of, made the point that
when I was talking--I meet with the veterans service
organizations regularly. And when I was talking to them, they
pulled it out and said, ``Oh, look, this is a great tool.''
This is what they are using to pass out; it is a VA product.
And so we are linked with the veterans service
organizations. We agree with you, sir, that they are an
important ally and an important partner. And we share the same
concerns with them about trying to do this kind of outreach.
Mr. Rodriguez. And before I know I ran out of time, and I
don't know how I can overemphasize it, let us know if we need
do more--but when it comes to these issues in terms of working
with a family. Because I know the VA, for a long time--you
know, only in certain situations have they worked with the
family. But I think when it comes to these situations, we need
to really stress that and the importance of that and how we do
that in different ways.
Secretary Peake. Thank you, sir.
The Chairman. Thank you.
Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman.
And thank you, Mr. Secretary, for being here. I truly
appreciate what you do and appreciate your service. And as the
members of the military medical community say, you are one of
them, and that is a very important thing.
And you and I have talked. You know as well as I do all of
us are here to serve our veterans, first and foremost. I have
been your strongest supporter in whatever we can do for the VA,
but because of that commitment I am also the biggest critic.
And, Dr. Katz, I will have to say, your term--using
``unfortunate'' for that e-mail--that is very correct. And I
say this, I am not a judge of your medical professionalism, I
am not a judge on the things you are doing there. What I am a
judge on is oversight, and perception of our veterans, and they
are losing faith in the system because of instances like this.
So it is very unfortunate, because they believe the system will
fail them. And that is something we are fighting hard to
overcome. I believe we have made great progress. And those
types of unfortunate slip-ups or whatever or these beliefs are
very, very damaging to what we are going to do.
So I am deeply sorry that this incident happened. But I can
tell you, today's tone is much different than when you came in
December. And that troubles me, in terms of restoring that
faith.
The one thing I would say, my ultimate goal--and I was just
speaking with the Ranking Member--is how do we implement this
plan to make sure that it is successful. I know that gathering
this data is very difficult. But I know some of the new data we
are seeing from the CDC, is actually--I think, Dr. Katz, when
you get a chance to look at it, and we looked at it this
morning, tables 5 and 6 show a fairly significant increase in
18- to 29-year-old males. And I think we are going to see
somewhat of a trend.
The problem here was we didn't start looking at this until
2005. We didn't have an Inspector General (IG) report and
recommendations on this until May of 2007, and here we sit in
2008. This should have been planned for, and prepared for, when
we went into these conflicts. The VA knew these types of
situations arose after Vietnam, and yet we weren't prepared to
deal with them. That is very troubling to me.
So when those of us try and gather data or try and
implement this, I can tell you, I went to the Veterans
Integrated Services Network (VISN) 23, asked for data on
Minnesota, they promptly replied--I was speaking with them, and
they said they sent it through your office, and your office,
Mr. Secretary, delivered it to me 1 hour before this hearing.
I have nothing but the best interests of the VA at heart. I
wanted to have this data so I could ask the appropriate
questions as it deals with my constituents. And I have to
believe--why was that held up?
And I hear a Subcommittee Chairman say he has to use the
Freedom of Information Act to get information from the VA? His
concerns is for the veterans. He is on the Oversight and
Investigation Committee. Why does he have to use the Freedom of
Information Act? And why am I waiting until the hour before the
hearing?
Those types of things trouble me, because the issue here--
and I think all of us understand--the key is identifying and
preventing suicides. That is the ultimate key. The key to doing
that is making sure these people see the proper people.
Now, I had a proposal that I sent over, and I discussed it
with you personally, Mr. Secretary, about this inability when a
person transitions from the DoD to get his DD-214 into the
hands of people who can help him.
We, in Minnesota, have County Veterans Service Officers in
all of our counties. Those County Veterans Service Officers are
veterans who are professionals in navigating the system.
Because of the support of our Governor, the Director of
Veterans Affairs in Minnesota, all of the veterans service
organizations, and our nationally recognized Beyond the Yellow
Ribbon campaign, our National Guard members, 99-plus percent of
them are enrolled in the VA system; 36 percent are regular
soldiers.
As one young veteran told me as he came back, ``We come
back in ones and twos and fall between the cracks,'' as he sat
beside his father who lost his leg in Vietnam.
When we have asked, I get put off and, quite honestly, get
the run around from the VA. ``It can't happen because we can't
trust the County Veterans Service Officers because they are not
employees of the VA.'' That's what they tell me. They may lose
data. I asked them to provide me a single case of a County
Veterans Service Officers breaching confidentiality, and they
couldn't do it. I need not remind you who lost the 26 million
names.
This issue of not wanting to cooperate on the State level,
of not trying to get it on the front end--if we had every DD-
214 assigned and put out, you would have a success rate like we
have in Minnesota of 99 percent compliance, and you would have
them identified. Maybe we wouldn't need bus stickers as much.
Maybe we wouldn't need those types of things. We would have
them identified, we would know who they are.
My County Veterans Service Officers tell me this, and I
tell you today--and I am going to find out, because I am not
loose with facts, as you well know, Mr. Secretary. The front
page of my hometown newspaper in Mankato today says, ``Standoff
and Tragedy Averted; Iraqi War Veteran Takes Hostages.'' His
complaint was he couldn't access the system.
Now, I don't know if that is true or not. I don't know if
he is even an Iraqi veteran. And I don't know if he tried to
access the system, because wild claims have been made in the
past that were not true about that.
The VA does a wonderful job. They do a great job of caring
for our veterans. We simply have improvements to be made.
So my question is, why the resistance on allowing us to
register the DD-214s? Why not allow us to make the necessary
changes? I understand privacy, I understand the HIPAA
regulations. But why, in this case, when the least we could do
is at least say, you have a veteran living here and you need to
at least make contact with him.
I would like to see, and I will find out, if this young man
was ever talked to, or why he slipped through the cracks.
[The following was subsequently received from VA:]
DoD controls form DD-214, Certificate of Release or Discharge from
Active Duty. The military service mails Copy 3 of the DD-214 to VA. If
a military member elects to do so and specifies a State, Copy 6 of the
DD-2314 is sent to the State Director of Veterans Affairs. We have
provided your staff with a point of contact at DoD (Lori Howes, 703-
697-4491; [email protected]).
State Benefits Seamless Transition Program (for seriously injured):
Currently forty-three states, including Minnesota, participate in the
State Benefits Seamless Transition Program. To date, 350 veterans have
signed the consent form authorizing VA to notify their local State
Department of Veterans Affairs of their return to their home state.
The initiative involves VA staff located at the following
Department of Defense medical facilities:
Walter Reed Army Medical Center, Washington DC
National Naval Medical Center, Bethesda
Brooke Army Medical Center, San Antonio, TX
Darnall Army Medical Center, Ft. Hood, TX
Madigan Army Medical Center, Puget Sounds, WA
Eisenhower Army Medical Center, Augusta, GA
Evans Army Community Hospital, Ft. Carson, CO
Naval Medical Center, San Diego, CA
Womack Army Medical Center, Ft. Bragg, NC
Naval Hospital, Camp Pendleton, CA
Naval Hospital, Camp Lejeune, NC
Under the program, wounded veterans returning to their home States
can elect to be contacted by their local State Department of Veterans
Affairs about State benefits available to them and their families. VHA
Liaisons for Healthcare identify injured military members who will be
transferred to VA facilities, inform them about the program, and obtain
a signed consent form from veterans electing to participate. The State
offices, in turn, contact the veterans to inform them of available
State benefits.
In order to participate in the program, State Departments of
Veterans Affairs must provide a point of contact and dedicate a fax
machine in a private, locked office to receive the release of
information forms. VA asked States to participate in the program in
February 2007 when it was expanded beyond the Florida pilot program.
Transition for non-seriously injured: In order to ensure that OIF/
OEF combat veterans receive high quality healthcare and coordinated VA
services and benefits as they transition from the DoD system to VA, VA
and the National Guard developed a creative partnership. Late in 2005,
following the signing of a MOU between the National Guard and VA, the
National Guard (NG) hired 54 (now 60) National Guard Transition
Assistance Advisors (TAAs) to serve as VA/NG Liaisons in the field at
the State level to assist NG servicemembers and their families and
provide access to VA benefits and services. In February 2006, the newly
hired National Guard/VA TAAs were trained by VA faculty experts about
VA benefits and services at the VBA Academy in Baltimore. The purpose
of the training was to enhance the outreach skills of the TAAs by
learning about VA benefits and services and to connect them with VA
resources and staff members in the field at the VA Medical Center
(VAMC) and the Regional Office (RO). This new knowledge assisted them
to help Guard members to access VA medical and benefits and address
access issues in the 54 States and territories for returning Guard/
Reserve members. Annual refresher training was held in January 2007 and
2008 in conjunction with the National Guard Family Program Conference.
The TAAs have been the critical link in facilitating access to VA by
National Guard/Reserves returning combat troops in each of the 50
States and 4 territories of Puerto Rico, Virgin Islands, Guam and
District of Columbia and providing VA with critical information on
numbers of returning troops, location, homecoming and reintegration
events. TAAs also facilitate enrollment into VHA care for returning
troops and families.
The TAA program continues to be a funded National Guard Program and
is presently expanding this program with a goal of 2 TAAs per each
State with large number of deployed troops. VHA OEF/OIF Outreach Office
staff continues to be linked with the 60 TAAs by providing access and
collaboration at monthly teleconferences, quarterly newsletters, and
monthly identification of success stories and best practices in the
States. Outreach staff work with VA experts at annual training events
to ensure they are updated on changes in VA services/benefits. TAAs
facilitate the development and maintenance of State coalitions
utilizing the State Triad Leadership of the Adjutant General, State
Director of Veterans Affairs (DVA) and VA leadership to integrate and
coordinate the delivery of VA services and benefits to those Guard and
Reservists in each State when providing needed outreach programs. Over
47 States have developed State Memorandum of Understandings (MOUs)
through the Leadership Triad of the State Director VA, Adjutant General
and VA Leadership from the VISN, VAMC and RO. These State partnerships
are the foundation for State coalitions with participation by community
and State organizations to address the coming home needs of the Guard
and the Reserve members.
Outreach: On May 2, 2008, VA began contacting nearly 570,000 combat
veterans of the Global War on Terror to ensure they know about VA
medical services and other benefits. The Department will reach out and
touch every veteran of the war to let them know it is here for them.
The first of those calls are going to an estimated 17,000 veterans who
were sick or injured while serving in Iraq or Afghanistan. If any of
these 17,000 veterans do not now have a care manager to work with them
to ensure they get appropriate healthcare, VA will offer to appoint one
for them.
Mr. Buyer. Will the gentleman yield?
Mr. Walz. Yes.
Mr. Buyer. Mr. Walz, when you referred to ``the plan,''
``why aren't you implementing the plan,'' were you referring to
the Mental Health Strategic Plan?
Mr. Walz. Yes. And the Ranking Member has brought up a
great point on this. In the IG's report of May 2007, we have
never heard where you are at on that or what the timeline is or
where you are going with that. And, as I referenced earlier, I
would like to have seen that put into place before our troops
landed in Iraq. But that being the case, I am most concerned
that it actually gets done now, and I am wondering where it is
at.
So I thank you.
Secretary Peake. I think that it is absolutely the right
thing to ask for both things, in terms of getting our returning
servicemembers into our system is what we want to get done. And
I will circle back and work with you.
I would like to apologize to you and to Mr. Mitchell for
what may seem like recalcitrance. I have seen your letter, sir.
I tried to call you last night, actually, because I wanted to
get some clarification. I think I have some things for you. But
I am interested in increasing the transparency of the VA. And,
as I said, we are America's VA, and our intent is to be
forthcoming. If we have something to hide, we shouldn't be
hiding it, we should be doing something about it. So I will
just put that on the table.
In terms of the Mental Health Strategic Plan, actually,
when I looked at the IG report, it looks like we are moving
ahead. I mean, it is a complicated and a big plan. And maybe I
can come back, for the record, to give you the specific metrics
about each one of the milestones. But I do know that we are
moving forward on it. And, as I say, the complexity of it is
such that I can't give you a clear summary of it right now. But
I have looked at it. I have had that same discussion with Dr.
Kussman and Dr. Katz. It was one of the first things that I
asked him to brief me on, was the strategic plan.
It has lots of pieces. I will tell you that, like any plan,
it never survives first contact with the enemy. So we don't
want to be just resting on our laurels that we have a plan and
that it is moving along, but that it is continuing to be
relevant to the needs of our servicemen and women that are
returning as veterans. And that includes finding these issues,
if you have a younger group that we need to refocus some of our
efforts and our resources on.
And I will just tell you that we will continue to be
vigilant and look for the issues so that we become more
proactive rather than just reactive.
Mr. Buyer. Will the gentleman yield?
When the Secretary answers that question--Mr. Secretary, I
think you will be helpful to us if you will also take the plan
and compare to it HHS, and the National Strategy for Suicide
Prevention. So when you do the comparability between the two
agencies, it will become helpful to us.
Mr. Walz, you asked a great question. And I yield back.
[The following was subsequently received from the VA:]
The Comprehensive VHA Mental Health Strategic Plan, which describes
initiatives and current status, appears on p. 142. A crosswalk between
the U.S. National Strategy for Suicide Prevention, the VHA
Comprehensive Mental Health Strategic Plan and VHA's Suicide Prevention
Actions comparing the three programs, also appears on p. 188.
[GRAPHIC] [TIFF OMITTED] 43052A.001
Mr. Walz. Well, I thank you, Mr. Secretary. And I think
today, again, we can't make it any clearer that this Committee
is here to serve our veterans. And I represent the Mayo Clinic
area, and their mantra is: What is good for the patient is
good. What is good for our veterans is good. And whatever we
can do to deliver that, we are here as partners for that.
I know it is a difficult job you have taken. I know much of
this has happened before you were at the helm. Many of us are
very, very optimistic that you are the man to do it. Anything
unfortunate needs to be swept and cleaned and put out in the
public eye and let sunshine heal it and get moving forward.
So, thank you.
The Chairman. Mr. Mitchell.
Mr. Mitchell. Thank you, Mr. Chairman.
Thank you, Mr. Secretary, for being here.
I mentioned in my opening statement about the testimony at
the December hearing of Mr. and Mrs. Bowman, Mike and Kim
Bowman, who lost their son to suicide. Mr. Bowman, at that
hearing, warned us--and I want to quote this--that, ``Our
troops are coming home to an understaffed, underfunded,
underequipped VA mental health system.''
So, as a result of that, I asked the question to Dr. Katz,
do we have the resources necessary to find these veterans and
to treat these veterans, and the answer was yes. I said, do you
have, again, enough resources, and the answer was yes.
As you know, I have been trying to assess what kind of
additional resources your Department may need in order to make
sure that we can provide these resources. We need to make sure
that we conduct an outreach to veterans who are at risk of
suicide, to treat veterans who are at risk of suicide, to track
veterans who commit suicide. We need that information.
In light of what CBS News reported--in fact, it is
important that in Arizona--and I don't know if Arizona is one
of the 16 States listed on this chart that you had, but the
suicide rates among veterans in Arizona has increased 39
percent since 2003. They make up nearly a quarter of all
suicides in the State. So I thought I had a responsibility to
go and double-check to see if you do have all the resources
necessary.
In my last letter that was sent to your office on April
24th I asked, ``To review documents relating to requests for
additional resources within the Department that were denied,
unanswered or responded to with less than the amount of
additional resources requested.''
I think it is important that we know if you are being
provided with enough resources to make sure that the VA is not
understaffed, not underfunded, not underequipped. That is what
our goal is here.
So I want to ask you three questions in response to this.
First of all, do you feel that, ``Go file a Freedom of
Information Act,'' is an appropriate response to a Member of
this Committee seeking additional information about testimony
offered by the VA at one of our hearings?
The next question, do you think there is something
inappropriate about the Chairman of the Oversight and
Investigations Subcommittee to ask to review records kept by
the Department about an issue that has been the subject of one
of our hearings?
And, finally, will you be producing the documents I
requested by Friday?
Secretary Peake. First, I am saddened to hear that somebody
would tell you to go file a Freedom of Information Act. I don't
know where that came from. I will tell you that I don't think
it is appropriate. The issue is--actually, you could file that.
I mean, this is information you would be given.
If there is a concern about or a question about what you
are asking for, I owe you a phone call, which is what I tried
to do last night, to say I am not sure what you are really
after and I want to make sure we have it. I think we ought to
give you that information, because I agree with you that we
share the same goal, in terms of helping veterans.
So, as I say, I will close the loop back with you before
Friday to give you what I think that you are asking for.
Mr. Mitchell. Well, and let me just repeat, Mr. Secretary.
I asked for any documents relating to a request for additional
resources within the Department that were denied, unanswered,
or responded to with less than the amount of additional
resources requested.
What we are trying to find out is, you know, we want to
make sure that you are funded right, you are staffed right, you
have the equipment. We can't do that unless--and there may be
somebody, and I want you to be absolutely certain, that, yes,
there was somebody in Montana, or wherever they may be, who
asked for something and we said we didn't have the resources or
we gave them less than they needed.
We just need to know what it is that we can do to make sure
that our veterans are coming back and getting everything that
they deserve and were promised.
Thank you.
[Congressman Mitchell received the information.]
Secretary Peake. Thank you, sir.
The Chairman. Dr. Snyder.
Dr. Snyder. Thank you, Mr. Chairman.
Good to see you again, General Peake. I appreciate you
being here.
Dr. Katz, I want to be a bit of an advocate for you, at
least a little bit, because I want to be sure I understand. In
the first--well, Mr. Chairman, I think Mr. Buyer brought this
out, too--that one point of attack on you has been today that,
in this exchange of e-mails in which Dr. Kussman sends you an
e-mail back in December that says, the McClatchy newspaper
article says these statistics, and you confirm those
statistics. But, in fact, two or three days before, you had
given those same numbers here. I mean, it is in the transcript.
So, while there are a lot of reasons to be critical, I
think, of those e-mails referring to ``Shh,'' you know, that
kind of business, that was not what happened back in December.
Is that correct? I mean, you gave those exact same numbers that
you confirmed to Dr. Kussman. You did it here at the hearing,
and then you did it--it was in response to Mr. Mitchell's
question.
Dr. Katz. Yes, sir.
Dr. Snyder. The second thing is, with regard to the facts
in the second set of e-mails, the one that you have apologized
for in terms of the subject line, in fact, you instigated an e-
mail going to your communications person that says, we are now
identifying 1,000 suicide attempts per month, and you're asking
the question, essentially, ``Is this something we need to
release after we sort it out?''
But what you all are saying, I think, today, if I am
hearing you right, is you think that 1,000 number is a pretty
loosey-goosey number. There is a lot of variation of reporting
that you are trying to nail down.
Is that a fair statement, Secretary Peake.
Secretary Peake. Yes, sir, I do. And we are concerned that
it is underreporting, probably.
Dr. Snyder. Maybe underreporting.
So your conversation, there, Dr. Katz, is an effort to say,
we have some new information but it may not be accurate yet.
But you are, in fact, instigating an inquiry about, should we
be releasing this. And I can understand that.
Where I would part company, I think, with you on this, Dr.
Katz, is--and, Secretary Peake, you may want to address this,
because, in response to somebody's question, you talked about
how you want to have increased transparency. I have never
trusted the press operations coming out of, I guess I have to
say, this administration. And it appears to me you got bad
advice. Here you, Dr. Katz, are saying, ``We have new
information. We think it needs to get out there.'' You didn't
write it very artfully. ``We think it needs to get out there,
because this is a small town and people have a way of stumbling
on stuff.'' And your press office comes back and says, ``Oh,
no, let's figure out how to spin it.'' I mean, that is what
that response is. Is this the fact--we are stopping them.
Somebody is trying to get you to spin it. In fact, what you are
trying to do is, ``We have new information; let's get it out
there.''
And my advice is you have a communications department. You
ought to figure out what you want to communicate, and then
communicate it. Tell them, ``Here, get this information out
there.'' But don't let people tell you how to spin information
that you think is new. I don't think you are well-served.
Dr. Katz. Sir, could I respond?
Dr. Snyder. Go ahead and respond.
Dr. Katz. The e-mail was only part of the communication.
Dr. Snyder. Oh, I am sure that is right. Every one of us
have bad e-mails----
Dr. Katz. The other part of the communication from VHA's
senior leadership was, make sure everything is done to address
the increased risk in these thousand people a month.
The Chairman. Was that response in writing?
Dr. Katz. No, it was in conversation.
Dr. Snyder. A specific question I wanted to ask, Secretary
Peake, is one of the folks on the second panel suggests that,
because of the way some of the CBOCs are set up, that people
who are coming in for treatment may be getting psychotherapy
and counseling but not an appropriate level of antidepressants
and pharmacological therapy.
Do you agree with that? Is that a concern that you have
had?
Secretary Peake. I really don't have data to address that,
but I would take a look at it.
[The following was subsequently received from the VA:]
No. To promote a consistent and portable prescription benefit, VA
uses a single National Formulary (VANF) at all points of service,
including CBOCs. The VANF provides access to a very broad array of
medications used to treat mental health conditions and with few
exceptions, these medications are available to CBOC mental health
providers. If a CBOC mental health provider is not licensed to
prescribe medications (ie., Licensed Clinical Social Worker or
Psychologist), the CBOC primary care provider can prescribe them and if
necessary, he or she has remote access to a VA Psychiatrist for mental
health medication consultation.
At present, of CBOCs serving more than 1,500 unique patients, 452
(97%) have a meaningful mental health presence as defined by having at
least 10% of the total number of visits coded as mental health visits.
For those serving less than 1500 unique veterans, mental health
visits represent at least 10% of the total visits in 109 (58%) CBOCs.*
In other facilities, mental health services are provided by primary
care clinicians, or they are available by referral. The major
difference between mental health services in medical centers or CBOCs
is not the presence or absence of general mental healthcare, but
difficulties in making specialty mental health services available in
CBOCs, especially smaller and more rural ones. Historically, VA's
approach to this has been to refer patients when necessary to specialty
mental health programs in VA or non-VA sites. However, over the past
few years, there has been increasing use of telemental health
technologies to provide these services. Currently, telemental health is
available in 196 (40%) of CBOCs serving more than 1,500 unique veterans
and in 48 (21%) of smaller ones.**
Vet Centers will refer veterans to the local VAMC for medical care
and follow up of prescriptions if needed. In the mental health mental
status evaluation, any indicators of need for medical psychiatric or
primary care are automatically referred to the medical center. If
veterans are on medications and have challenges in getting
prescriptions filled, they are referred to the local VAMC or CBOC.
*Data source is adapted from VSSC website, Past Performance
Measures, Mental Health at CBOCs Performance Measure, FY 2008, Quarter
1.
**Telemental health data is from the Office of Care Coordination,
March 08. All Telemental health visits are coded as MH visits and are
not separated in the data base summary. These data include specific fee
basis visits at some sites.
Dr. Snyder. When you talk about the issue of trying to sort
out veterans from active component--you may have addressed this
with Mr. Walz--how are Reserve component members who come back
from active duty and entitled to come to the VA for a period of
time--are they counted as a veteran or an active component?
Secretary Peake. Sir, we count them as veterans.
Dr. Snyder. As veterans.
Secretary Peake. Yes, sir. They do have DD-214s that they
have then demobilized.
Dr. Snyder. Well, I appreciate you being here.
I think a lot of this could have been avoided, Dr. Katz,
by, as you pointed out, some more artfully written e-mails.
Because we are all here in the spirit of trying to solve these
problems. And unfortunately, you take snippets of this, and it
does not provide a very good picture of what was going on at
the time. It appears to be a department under siege.
And I don't think that has ever been your style
professionally, Secretary Peake. I think you are one of the
ones to solve problems. You may want to address that with your
communications department and let them work for you rather than
vice versa.
Thank you, Mr. Chairman.
The Chairman. Thank you, Mr. Snyder.
Mr. McNerney, any questions?
Mr. McNerney. Thank you, Mr. Chairman.
Dr. Katz, last November you attacked a CBS News report
which claimed that there were 6,200 suicides in 2005 among
those who had served in the U.S. military, by saying, and I
quote, ``Their number is not, in fact, an accurate reflection
of the rate.'' But then, just 3 days later, you wrote an e-mail
admitting there were about 18 suicides per day among America's
25 million veterans. That is about 6,570 a year.
Did you intentionally withhold information from CBS News?
Dr. Katz. From CBS News?
Mr. McNerney. Well, you attacked the CBS News report, and
then you admitted that their numbers were not only right but
they were low. And then you didn't----
Dr. Katz. I was concerned about their findings with respect
to very young veterans, not the entire veteran population.
Mr. McNerney. So was information withheld at that point?
Dr. Katz. Sir, I was not asked for information from CBS
News. I was merely asked to react to their information. I was
given a piece of paper, and it had ratios of veteran and non-
veteran suicides, and asked if I was shocked by that. I was not
shocked by the overall number of veteran suicides, and I think
their four-to-one ratio for the youngest of veterans may not
hold up. You saw a different ratio earlier.
If you are interested in whether there is an epidemic
related to the war, you would also want to see what the rates
were before the war. CBS News never addressed that. I have
concerns about the CBS News report. Those concerns were what I
have been referring to. I have never had concern about their
overall estimate for numbers of veteran suicides.
Mr. McNerney. After the VA provided CBS News with the 790
number as the annual number of veteran suicide attempts, you
wrote an e-mail to your media advisor again, because you were
concerned that there might be as high as 12,000 per year, is
that correct?
Dr. Katz. Sir, it may be even higher than that, in terms of
suicide attempts. And we could speak to that.
As I recall, the number 790 came from information sent to
CBS News when they asked for information about attempts or
completed suicides from the medical records. And from that
information, they extracted the number 790 as the count of
attempted suicides or deaths from suicide in 2005.
The estimate of a thousand a month came from the
tabulations done by the suicide-prevention coordinators, which,
because it was information and methods under development, were
not yet in the medical records.
Mr. McNerney. Well, in the same e-mail, you question
whether or not you should release the information before
someone else stumbles upon it. So it seems to me that
information on suicide statistics was either withheld or wrong
numbers were released.
My real concern here is that that would have prevented
procedures that could have saved precious lives, lives of young
soldiers who served our country and depended on us to help them
when they needed it.
How can you assure this Committee that that behavior
doesn't constitute wanton disregard of your duties and
responsibilities and that that will change and that we will see
procedures put in place that will prevent this?
Secretary Peake. Sir, let me try to address that.
First of all, I would tell you, as I tried to comment in my
opening remarks, that the numbers are important for trending
and all of those kinds of things. What is important is making
sure that we are doing the kinds of things that we are doing to
try to intervene in this, what we know, is a high risk group,
those with suicide attempts, to intervene with that younger age
group that we demonstrated have a higher level of suicide risk.
And, you know, that is full bore out, to try to work those
issues.
Trying to get the right numbers and making sure that we
give valid numbers is important, and I think that we owe
appropriate, validated numbers to this Committee and to people
that ask for that information.
So I can't tell you more, except to say that we are
absolutely committed to trying to do the right thing by all of
our servicemembers, our veterans, and not worry as much about
whether this is a little above or a little below some national
average, but to focus on doing the clinical right thing.
Mr. McNerney. Mr. Secretary, the Joshua Omvig Suicide
Prevention Act requires that you submit recommendations for
further legislation and administrative action that the
Secretary considers appropriate to improve suicide-prevention
programs within the Department of the Veterans Affairs.
Do you have recommendations for us today, or do you have
recommendations in general to meet the requirements of that
act?
Secretary Peake. Sir, I don't have those to present to you
today. But, as that may be required by the act, I will provide
those.
[The following was subsequently received from the VA:]
The Comprehensive Program for Suicide Prevention Among Veterans
report for P.L. 110-110 was submitted to Congress in February 2008 and
is attached for your review. In the report we stated that we are able
to monitor risk and needs and respond to them under existing legal
authority. VA did not recommend further legislative action and remains
with this position. Since the report was released, VA has the following
updated information:
Requirement: Designation of Suicide Prevention Counselors--To
support the identification of patients at high risk, the Suicide
Prevention Coordinators have been integrating information from
providers, other staff, and community contacts about veterans who have
survived suicide attempts. In preliminary findings, we have identified
approximately a thousand attempts per month. To address the increased
needs for these vulnerable veterans, VA has implemented standardized
approaches to enhancing care while, at the same time, encouraging
innovation and creativity.
Further developments in process at this time include tests of the
Coordinators inter-rater reliability and their sensitivity in the
identification of suicide attempts. Both will be necessary before the
number of attempts (or reattempts) in a facility can be used as a
measure for epidemiological or quality improvement purposes.
Requirement: Hotline--From the time the veterans' Hotline was
established in July, 2007 until the end of April, 2008, we received
43,294 calls. From the start of 2008 until the end of April we received
33,915 calls, with 16,414 confirmed as coming from veterans and 2,125
from family members or friends. These led to 2,725 referrals to the
Suicide Prevention Coordinators at VA facilities and 746 ``rescues''
requiring emergency services.
The ``Report to Congress for Public Law 110-110, Comprehensive
Program for Suicide Prevention Among Veterans,'' dated February 2008,
appears as an attachment to the response to Ms. Berkley's Post-Hearing
Questions for the Record, which appears on p. 240.
Mr. McNerney. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Ms. Brown.
Ms. Brown of Florida. Thank you.
Mr. Secretary, a couple of quick questions.
One, we have talked a lot today about the veterans. And I
mentioned the families earlier. What are we doing to work with
the families, the outreach to prevent suicide?
Secretary Peake. Well, first of all, within our Vet
Centers, they can do family counseling, and we really encourage
that. When a servicemember is within our care, providing
counseling to the family member is deemed part of that care,
that we can provide that kind of counseling as well.
As I was talking with Mr. Hare, one of the things I would
like to find a way to do is to reach out and touch family
members in a more specific way. So, as we go to the TAP
briefings, you know, it is possible to have family members
there, but, in all honesty, we are not seeing them available.
I think that what the Ranking Member brought up, in terms
of being able to participate in those kinds of events, are
things that we need to expand on. But I think it is an area
that we need to come up with an action plan. And I will be
happy to do that and report back to this Committee on that
action plan.
[The following was subsequently received from VA:]
The Secretary has asked that assistance to families be a VA
priority. Since 1979, the Vet Center program has been authorized to
provide family services as it relates to the readjustment of the
veteran. When an individual is reactivated, they shift from veteran
status to active military status. The servicemember and dependents then
revert to Department of Defense protocol. Once they complete their tour
and demobilize, they are once again veterans and they and their family
members are eligible for Vet Center services.
In FY 2007, Readjustment Counseling Service provided 1,055,186
visits to 164,228 total veterans. Cumulatively since the beginning of
the War, Readjustment Counseling Service has provided services to
288,594 OEF/OIF veterans (through 1st Quarter FY 2008). 216,172 were
provided outreach services and 72,422 received readjustment counseling
in the Vet Center.
Cumulatively, since 2003, (bereavement counseling authorization)
Readjustment Counseling Service has provided bereavement services to
the families of 1,238 fallen servicemembers, 876 of which were in
theater casualties in Iraq and Afghanistan.
Ms. Brown of Florida. The other thing is the women--I am
very concerned that women veterans are one of the fastest-
growing groups and one of the most underserved groups. Have you
thought about having a task force just for women vets and
trying to come up with how we can be more supportive and what
we can do just targeting that group?
Not to take anything away from veterans in general, but I
think women are unique and they have unique needs. And in a lot
of our VA centers, their needs have not been addressed.
Secretary Peake. You know, ma'am, I have not only a Federal
Advisory Committee Act (FACA) that looks at those kind of
issues for women, but also an office that focuses on women's
issues, with Dr. Irene Trowell-Harris as my lead.
We continue to ask this issue every time we get into it:
Now, are we taking care of the women veterans? Because, in
fact, we have been historically a male service organization, in
a way.
Ms. Brown of Florida. It still is, sir.
Secretary Peake. And I have been traveling a lot and, every
time, have asked to see the women's health unit. I have been
impressed with some of the things we are doing.
But it is very important to understand that they want to be
able to have a single portal where they can go in and get
women's healthcare, primary care, and mental healthcare without
being labeled. And so we are making sure that that is in there.
But I think we must continue to monitor very closely and
make sure that we have consistency across the whole VA when we
do those kinds of programs.
Ms. Brown of Florida. What can the Committee do
legislatively to assist, to widen your scope?
Secretary Peake. As we look at being able to provide access
and assistance to a family member, there may be ways that we
need to work together to find a road ahead there.
If a spouse, as an example, is depressed with their
servicemember or veteran spouse who may have a physical
disability or mental disability or TBI or something like that,
it would be nice to be able to ensure that they have the care
to include medications, if that is necessary, to help them
through that, even if for the short term. And so we are looking
at ways to try to get that kind of an authority.
Ms. Brown of Florida. You mentioned the Vet Centers, and I
do think it is a great delivery service. But, in some cases,
they have been cut or underfunded. Maybe we can think about how
we can rev up those Centers. Because it is going to be
comprehensive. It is going to be jobs, it is going to be
healthcare, it is a whole list of things. A lot of these
veterans come back, their jobs are no longer there. So it is
comprehensive.
Secretary Peake. Yes, ma'am. To my knowledge, we have not
had--I mean, I have asked specifically, and I am told that we
have not cut Vet Centers, and we are funding them as they have
requested. I will go back and check on that.
I do agree with you about the jobs issue. And, frankly, you
have young men and women who have gone overseas and have done
something that they feel in their life is really meaningful,
and they don't necessarily want to go back to that old job that
they had before. We do need to increase our efforts in that
regard, as well.
[The following was subsequently received from VA:]
Vet Centers are fully funded. Their funding levels:
2004 $87 million (206 Vet Centers)
2005 $94 million (207 Vet Centers)
2006 $100 million (209 Vet Centers)
2007 $113 million (215 Vet Centers)
2008 $153 million (232 Vet Centers)
The FY 2008 budget represents a 50% increase from 2006 through
2008.
Vet Centers provide individual and group counseling, marital and
family counseling for combat service related issues, military sexual
trauma counseling and referral, bereavement counseling for the families
of fallen servicemembers who die while on active duty, demobilization
outreach and direct service, substance abuse assessment and referral,
employment services, Veterans Health Administration and Veterans
Benefits Administration referral, and veteran community outreach and
education.
Twenty-two new Vet Centers have been approved.
Ms. Brown of Florida. Well, thank you.
And thank you, Mr. Chairman. I yield back the rest of my
time.
The Chairman. I am trying to decide if there are additional
questions. Do you want the Secretary to be back, Mr. Boozman,
Mr. Lamborn, Mr. Kennedy? We have three votes. Do you want to
talk to the Secretary when we return?
Mr. Lamborn. I don't need to.
The Chairman. We will get to Mr. Kennedy when we return.
And I hope you will respond to these general questions,
Secretary Peake. A half-dozen Members of Congress asked you
very specifically, what do you want us to do, how can we help?
You didn't ask us for one thing, one piece of legislation, one
dollar of funds. Who is better at outreach than we are? That is
our job. Have you ever asked a Member of Congress to help on
the outreach? Nobody has ever asked me.
We know the people. We talk to the people. We are in touch
with them every day. Otherwise, we wouldn't be here. Use us.
But you never mentioned one thing you wanted us to do.
Second, although I guess Dr. Katz is a doctor and not a
lawyer, your rhetoric still bothers me, and I am not sure you
are performing your job in an effective way, given the
unfortunate e-mails.
But in answer to one question, Dr. Katz, you said, ``CBS
News asked me for medical records.'' Why don't you say, ``Here
are the medical records.'' But if you really wanted to get that
information, you should ask for the number of attempts that our
coordinators are coming up with.
You are not very helpful in transparency--you are not
helping. You are supposed to be the expert. If we are not
asking the right questions, if the press is not asking the
right questions, help us ask the right questions. You are just
sitting there with all this data, ``Well, he asked for this; I
will give him this,'' or, ``I am not sure that is accurate, so
we won't give him that.''
The data is only important to reflect--it is a symptom of a
major problem with our current veterans and previous veterans.
The problem is inadequate mental health treatment. Suicide is
the ultimate symptom--the tragic symptom--but PTSD is a
symptom, homicides are a symptom, homelessness is a symptom,
marital difficulties are a symptom, domestic violence is a
symptom. We have to be focused on all the symptoms and we are
not doing the job.
I don't care what data you have, or what programs you are
starting; if you have a thousand--and you said it could be more
suicide attempts per month, we have some real difficult issues.
And you never asked us for anything to help you deal with it.
It is as if you have it under control. You don't have it under
control.
I talked to you, as I said, in our first conversation,
Secretary Peake. I said the one thing that is the most
important, that is missing from the mental health problem, is a
mandatory evaluation by competent medical personnel. I said I
had the concept of a Heroes Homecoming Camp that I thought we
could use. It was never followed up on.
We are letting tens of thousands of young men and women out
of the service, out of the National Guard, without adequate
diagnosis. You keep saying, well, everybody that comes to us,
we screen.
Is that screen, by the way, just a questionnaire, or is
that an hour interview with a psychiatrist? How do you screen?
You said it several times today. How do we screen?
Secretary Peake. It is a reminder to the primary care
physician to ask specific questions and to create the dialogue
with the patient. It is not an hour-long diagnostic session
with a psychiatrist.
The Chairman. So we don't adequately diagnosis anybody,
unless they ask for it? Then we have to make that mandatory for
every young man and woman who leaves combat so there is no
stigma. I suggest that you do it in cooperation as part of
their active duty service with the Army, Marines, et cetera,
with their family there, and with their company of soldiers
there. Let's get everybody the support system they need and get
that mandatory diagnosis.
If they are coming in, psychiatrists tell me and people
have testified to us, that you need competent medical
personnel--and there is minimally adequate treatment here that
the VA is not giving. We are not giving adequate diagnosis or
treatment to these hundreds of thousands of young people who
are getting out. That is the problem.
Until you tell us what you need to solve the problem, all
this data is meaningless. The data is only, as you said, a way
to understand the issue. But we have to get to the issue.
We have these kids in active duty. All I have to do is say,
visit the psychiatrist. This is not a hard thing to do.
Mr. Kennedy.
Mr. Kennedy. The evidence is so clear, and adherence to
medical advice averts hospitalizations over and over and over
again. And the same thing adheres to behavioral medicine and
mental health.
If we had people who called back and stayed on top of these
soldiers after they got out of the military and stayed in touch
with them with care management--not just the ones that were
grievously injured, as you pointed, that are at high risk for
suicide, but all the soldiers. Because we want to stay in touch
with the ones that are at modest risk, because we don't know
which ones may have had an exposure to trauma. Or the trauma
that they were exposed to they might not have the resiliency to
that that other soldiers had.
And so if we stayed in touch with all of them, and that is
not a huge expense, because we don't want them to become the
severe cases later on. So this is an investment in prevention
for us. So if we stayed in touch with all of them, that is an
investment in keeping them out of the hospital, and prevention.
We can put this in place as a preventive measure and employ
these new technologies in keeping in touch and preventive
medicine. And I think that is one of the recommendations in
prevention you ought to put forward.
The Chairman. Mr. Kennedy, I thank you for your leadership
and being a part of this.
I will make it real simple, Secretary Peake. Get us a plan
with the Secretary of Defense and the VA to evaluate--not
screen, not quiz, not give self-questionnaires--to diagnosis
with competent medical personnel for every soldier for brain
injury and for PTSD. We will make it that simple. You will
bring down every single one of these figures. You will not have
to start with ``Shh,'' ``Shh,'' ``Shh.'' We will come to grips
with this. Come back with a plan, which I already gave to you,
in a week or two. I will bet you that every single issue we
talked about today comes under control.
Mr. Secretary, you have been generous with your time.
We have three votes. We are going to come back in about 20
minutes. The first panel is excused, and we will go to the
second and third.
[Recess.]
The Chairman. Dr. Maris, thank you for joining us. The
other Members of the Committee will be following.
I know you have to catch a plane. I would like to introduce
you as a Distinguished Professor Emeritus at the University of
South Carolina, past director of the Suicide Center at the
University of South Carolina, and you have an extensive
background in research on suicidal behaviors.
I believe you will testify as to the problem of suicide
among veterans, whether or not it is an epidemic, and what you
think the VA is doing about it.
Let me thank you for taking the time to be here with us.
STATEMENTS OF RONALD WILLIAM MARIS, PH.D., DISTINGUISHED
PROFESSOR EMERITUS, PAST DIRECTOR OF SUICIDE CENTER, ADJUNCT
PROFESSOR OF PSYCHIATRY, AND ADJUNCT PROFESSOR OF FAMILY
MEDICINE, UNIVERSITY OF SOUTH CAROLINA, SCHOOL OF MEDICINE,
COLUMBIA, SC; STEPHEN L. RATHBUN, PH.D., INTERIM HEAD AND
ASSOCIATE PROFESSOR OF BIOSTATISTICS, DEPARTMENT OF
EPIDEMIOLOGY AND BIOSTATISTICS, UNIVERSITY OF GEORGIA, ATHENS,
GA; AND M. DAVID RUDD, PH.D., ABPP, PROFESSOR AND CHAIR,
DEPARTMENT OF PSYCHOLOGY, TEXAS TECH UNIVERSITY, LUBBOCK, TX
STATEMENT OF RONALD WILLIAM MARIS, PH.D.
Dr. Maris. Thank you, Mr. Chairman, Committee Members,
ladies and gentlemen.
Just for the record, I was a plaintiff expert in the Vets
v. Peake trial in San Francisco. So I am coming at this partly
with a plaintiff perspective.
In my written report, I want to highlight that suicide is
more than one outcome; it is a multidimensional outcome. And
for the Committee's sake, I would hope they would look not just
at completed suicides, but suicide attempts and other kinds of
collateral damage, partially self-destructive behaviors,
depression, alcohol, domestic violence, PTSD.
Secondly, I have also identified some risk factors, and I
list those in my written report, starting off, of course, with
depression and affective disorders, alcohol and substance
abuse. My point is that I think all these 15 risk factors that
have been shown to be related to suicide outcomes ought to be
asked of all vets. And I will come back to that in just a
minute. What the VA does is they ask two simple questions; they
don't ask all the risk factors for everybody.
I was asked whether or not we could talk about what causes
veteran suicide. And I want to say that part of the problem is
the Department of Veterans Affairs has not provided me or the
courts with crucial data that are needed. Every time there is a
military death, suicide attempt or serious incident, the VA
produces something called an incident brief, which summarily
decides the suicide or suicide attempt. Then, about 45 days
later, each incident goes through what is called a root-cause
analysis, and a three-page report is generated.
When I was an expert in San Francisco in the Vets v. Peake
trial, I was given only 170 of the somewhat estimated 15,000
incident briefs and none of the root-cause analyses. My point
being that such crucial documents would help clarify how many
vet suicides there are and what the VA itself thinks causes
them.
One of the documents in that trial was a document by
William Feeley, a Deputy Under Secretary for Health Care. And
he said in his deposition, I quote, ``Suicide occurs like
cancer.'' That is wrong. We all have to die, some by cancer,
some by heart disease, but no one needs to suicide. It seemed
to me that that comment suggested that the VA seems to think
there are a certain number of vet suicide deaths that are
inevitable and there is not a lot we can do about them.
The VA has a number of suicide coordinators. Interestingly,
I think the Committee should remember none of these suicide
coordinators are in what they call their CBOCs, their 875
outpatient clinics. They are all at the VA medical centers. So
the vast majority of treatment is at these outpatient clinics,
which I understand do not have suicide coordinators and do not
have people who can write prescriptions for antidepressant
medications.
When they measure suicide risk in the VA, they have
something called the suicide template, and that just has two
simple questions. Those questions have to do with whether or
not the patient felt hopeless, whether or not they felt
depressed, and whether or not they were thinking about suicide.
If you answer ``no'' to either of those two questions on the
so-called suicide template, you are not asked any more
questions, even though there are a number of other risk factors
that I have outlined in the first part of my written report and
that the VA itself actually states in their suicide template
the vets do not get asked those important questions.
So they are simply asking about self-reports of suicide
ideation and hopelessness or depression. They don't even
measure depression and hopelessness using standardized clinical
scales like the Beck or the Hamilton scales. So I have some
problems with how they measure these important variables and
the kinds of questions that they ask.
There is surprisingly little in the VA healthcare policies
about treating depressive disorders psychopharmacologically.
One of the backbones of the standard of care for suicidal
depression is to get somebody diagnosed appropriately and, if
they need it, to put them on some sort of psychopharmacological
treatment. I am not sure why this is not a major part of the
documents that I have read.
There are serious questions about these suicide
coordinators: Who are they? What do they do? Are they really
trained as well as they claim they are trained?
And then, finally, there are some questions about delays in
treatment. To even get mental health treatment for 2 years, a
vet has to fill out a 23-page application, which can be hard to
do if you have PTSD, and then receive a disability rating from
zero to 100 percent from a compensation and pension
examination. If the disability is denied or too low, found not
to be related to military service, then the appeal process can
be long and drawn out and sometimes----
The Chairman. Dr. Maris, I hate to interrupt you, and I
apologize. There is another procedural vote that was just
called and I have to run over and vote. I apologize again.
We will recess for a few minutes and hopefully return right
away.
[Recess.]
Mr. Hall [presiding]. The hearing will resume and come to
order. We do have a couple of Members here, so there is a
quorum. And I will, at the request of Counsel, sit in as
Chairman until Chairman Filner returns.
And, Dr. Maris, you were testifying. If you would be so
kind as to----
Dr. Maris. Yes, I have one sentence left.
Mr. Hall. Is that all? Well, feel free to add one or two
more if you would like.
Dr. Maris. Defense expert Alan Berman in the Peake v. Vets
trial testified that it could take up to 10 years for the 2007
MHSP plan to be implemented. One wonders how many vets are
going to die in the interim due to lack of assessment and
intervention.
[The prepared statement of Dr. Maris appears on p. 96.]
Mr. Hall. Thank you, Dr. Maris.
Dr. Rathbun, your statement has been entered in full into
the record, and you are recognized for 5 minutes.
STATEMENT OF STEPHEN L. RATHBUN, PH.D.
Dr. Rathbun. Thank you, Mr. Substitute Chairman, I guess.
The Chairman is out. I have never done this before, so you will
have to excuse me if I am not quite on protocol.
I got involved in this when Pia Malbran from CBS News
contacted me last fall. I believe it was some time in August.
The Chairman [presiding]. I apologize again for----
Dr. Rathbun. Sure.
The Chairman. I wonder, Dr. Maris, for the people who
weren't here, if you could repeat the two points you made on
the 15 risk factors versus two questions and CBOCs without
suicide coordinators.
Dr. Maris. Sure. The VA suicide risk assessment has
something called a suicide template. They ask two questions to
vets at any particular time, either at deployment or clinic
visits. Those questions are: In the last 2 weeks, have you felt
hopeless or depressed? Number two, in the last 2 weeks, have
you thought about harming yourself?
If the vet answers no, actually, to the second question,
they are asked no more risk factors. And my point is that is
way below the standard, to leave it at that. There are many
reasons why somebody would not answer yes to those questions,
many of which have been discussed earlier today: fear of career
advancement, you know, kind of, being a tough guy. So that you
need to ask all of those risk factors on their template or my
15 risk factors on my written report of all vets.
The CBOC question is that there is 154 VA medical centers;
that is where the suicide coordinators are located. They also
have most of their service delivered by the CBOCs, community-
based outpatient clinics. None of the suicide coordinators are
in those 875 outpatient clinics.
As I understand it, most of those outpatient clinics do not
have licensed physicians who are capable of prescribing
antidepressants. So it concerns me that the vast majority
structurally of the treatment is being given at the outpatient
clinics and that the suicide coordinators actually aren't even
there.
The Chairman. Thank you. I think those are two very
important points for us to keep in mind.
Dr. Stephen Rathbun is the Interim Head and Associate
Professor of Biostatistics at the Department of Epidemiology
and Biostatistics at the University of Georgia. Dr. Rathbun has
performed statistical analysis of veteran suicide data for the
CBS News and will talk about that analysis.
I, again, apologize for breaking in on you.
Dr. Rathbun. Okay. No problem. I will just start all over.
It wasn't really made clear exactly what I should be
talking about today, but I think I can go over a little bit of
the history of how I came to do the data analysis and some of
the results that I found.
I was approached originally back in August by Pia Malbran
from CBS News to assist them with the analysis of veteran
suicide data. After being approached, I agreed to do so,
essentially as a statistical consultant. I am a biostatistician
and not an expert on veteran suicides. I consulted with her on
the format that the data needed to come in, and she eventually
did provide the data in that format.
One of the important things when analyzing data of an
observational nature, as these data are--these are not the
results of experimental manipulations of study subjects--the
statistical protocol should be specified in advance. So, prior
to actually receiving the data, I determined what type of
analysis should be carried out on the data. And in the interest
of keeping things simple, which is usually a good idea, I tried
to keep it the most straightforward analysis, standard data
analysis as possible.
What Pia actually asked me to do was estimate rates of
veteran and non-veteran suicides over the general population
and broken down by gender and age, among other things. And when
making these estimates, it is important to adjust for the fact
that veterans are not representative of the general population.
Veterans tend to be more male, and their representation in
different age groups are different according to, I suppose, how
many, you know--what the current state of the world affairs
are. Certainly, in World War II, there were a lot higher
percentage of veterans than there are currently.
So I carried out the analysis using standard statistical
methods, and those analyses were reported on CBS News on
November 13. And the general findings were that veteran
suicides were about roughly double of the non-veteran suicides.
The comparisons I am making here are veterans versus non-
veterans. The results that you saw earlier were veterans versus
the general population. Since the general population includes
veterans, that can have an impact of reducing the magnitude of
the effects somewhat. So that can explain some of the
differences between my results and the results that the
Veterans Administration might be presenting.
But, in general, the veterans had about double, roughly
double, the suicide rates as the non-veterans. If you break it
down by gender, you find a similar pattern of higher rates
among males than females. And within both genders, you also
have higher rates of suicides among veterans than non-veterans,
roughly about double the rates of non-veterans in both genders.
One of the things I was asked to look at was the breakdown
by age. And in our story, we broke it down by 5-year age
classes: 20 to 24, 25 to 29, and so on. And when looking at
those ages, in this case gender-adjusted rates for each of the
ages, the thing that stood out to me the most was the higher
relative rate of veteran suicides among the 20- to 24-year-
olds. Here those rates were estimated between about 24 to 36
per 100,000 veterans compared to about eight per 100,000
nonveterans.
Higher rates also can be found among the 40-year-olds, but
the non-veterans in that group also have higher rates, so it is
not quite as striking there.
In the interest of brevity, I guess I can leave it up for
questions right now.
[The prepared statement of Dr. Rathbun appears on p. 102.]
The Chairman. Let me just make sure I understand what you
said. The charts that we saw earlier included the veterans back
into the general population?
Dr. Rathbun. Yeah, the figures were general population
numbers.
The Chairman. So that is a real distorting aspect?
Dr. Rathbun. I don't know how much a distortion it is. I
would have to have the actual numbers on the numbers of
veterans in each of the age groups to get some idea of exactly
how big an effect.
The Chairman. But it could be?
Dr. Rathbun. Some. I think it is only just the relative
magnitude that would be affected. The general story, I think,
will be the same.
You might not get--if you had different ages--if you have
in different age groups of our population differential veteran
representation, then that can cause some pattern in the
relative rates when comparing veterans to non-veterans, if you
were to do that direct comparison instead.
To defend what they did, however, I think the records, the
national death records were very readily obtained from the CDC,
I think it is where they come from. And it is the viable thing
to do, but you really have to understand what is going on with
those numbers. And it can be a little bit misleading if you
don't understand the numbers.
The Chairman. You know, I see Dr. Katz is still here, but I
don't see the expertise in the VA that you are showing here to
analyze the data. So maybe we could talk about that again of
who should be questioning whom.
Dr. David Rudd is the Professor and Chairman of the
Department of Psychology at Texas Tech University. He is a
former Army psychologist with a background as a practicing
psychologist in clinical research whose work focuses on the
assessment, management and treatment of suicide. He will
highlight the scope of the problem of suicide and some steps
that might be taken by the VA.
Thank you again for taking the time to be here with us.
STATEMENT OF M. DAVID RUDD, PH.D.
Dr. Rudd. Thank you, Mr. Chairman. You have my testimony,
and it has been entered into the record. Rather than repeat
much of what has been shared this morning and some of what Dr.
Maris shared, I would like to highlight a couple of points that
I think are important to consider when you look at the context
for this problem.
If you look at the issue of veterans being treated for
depression, estimates are that the suicide rate is seven to
eight times greater than the general adult population. In order
to understand the context for that, it is important to look at
comparable civilian data. And I have offered some of that in
the written testimony, but I will highlight a few things for
you along those lines.
The suicide prevalence rate for major depression and
affective disorders in general is actually lower than is
oftentimes quoted, but seems to depend on the apparent severity
of the illness, with the outpatient suicide prevalence rate
being 2 percent in contrast to 6 percent for those previously
hospitalized for suicidal symptoms and 4 percent for those
hospitalized for other reasons. Basically, that is a function
of severity. The more likely someone is to be hospitalized, the
more severe the illness, and the higher the risk over the
course of a lifetime.
If you are looking at estimates in terms of suicide attempt
rates, it is estimated that 24 percent of those suffering major
depression make a suicide attempt during the course of the
illness. It is estimated that up to 50 percent of individuals
with bipolar disorder will make a suicide attempt, and up to 80
percent will manifest suicidal symptoms of some sort during the
course of the illness.
Standardized mortality ratios for major depression and
bipolar disorder paint a very stark picture. Those with major
depression evidence a 20-fold increase for risk of death by
suicide relative to the general population; and those with
bipolar disorder, a 15-fold increase. There are data available
for other disorders, but the take-home message is a simple one:
that suicide risk is considerable for a number of mental
illnesses, and ultimately the mental illness, untreated,
unrecognized or undertreated, can be fatal.
It is also important to consider the expected rates of
adverse events during treatment. And this actually is something
that gets very little attention in terms of the literature,
particularly looking at suicide attempt rates. Data are now
available from a number of randomized clinical trials. We
actually have 53 randomized clinical trials that can be
considered and reviewed. Estimates indicate that as many as 40
to 47 percent of those in treatment, meaning psychotherapy and/
or medication, make a suicide attempt during the first year of
treatment. Once they have made one suicide attempt, it is
estimated that they will make an average of approximately 2.5
during the course of treatment. I think it is important to
consider that in terms of providing the context.
Standardized mortality ratios for men and women recently
discharged from the hospital for suicidal behavior range from
100 to 350 across several studies. These are tragically high
numbers. And what those numbers indicate is that the death rate
is remarkably high for people that are discharged from a
hospital. And the rate varies within the first week of
discharge relative to the first month of discharge as well.
I think you take those couple of points, in addition to
what Dr. Maris shared, as well as what was shared this morning,
and there are a number of possible conclusions.
First, as was outlined nicely in the RAND study, there are
high rates of psychiatric illness following combat exposure,
and that includes both direct and vicarious exposure. Multiple
deployments for Operation Iraqi Freedom and Operation Enduring
Freedom likely compound the situation because of repeated
combat exposure, sometimes after the initial emergence of
symptoms. The VA is faced with assessing and treating very
large numbers of seriously ill veterans.
Second, the overall rates of both suicide and suicide
attempts are tragic but consistent with the general trends for
the types and observed rates of psychiatric illness that
present.
Third, an effective response requires effective resources.
And, finally, there is an element of this problem that is
likely to be enduring and potentially chronic in nature. And,
actually, that is one of the things that I would emphasize, is
my concern that this is going to be a chronic issue, much like
we saw with some of the Vietnam veterans over time.
If you look at the treatment literature in general, I would
encourage you that, ultimately, the treatment literature says
some very basic things about treating and addressing
suicidality, that very simple things work. Making sure people
have access to emergency services when they need them--that
works; that will save lives. Making sure that somebody gets
into the system quickly after the emergence of significant
symptomatology works and can save lives. Very simple things
like managing crises effectively, in terms of the removal of
method or access to method, works and can save lives.
So I think, ultimately, if you take the data that is
available elsewhere, it provides considerable information that
helps inform a response to this problem in terms of the
veteran-specific population.
Thank you, Mr. Chairman. I am happy to respond to any
questions.
[The prepared statement of Dr. Rudd appears on p. 105.]
The Chairman. Thank you so much.
Mr. Hall, do you have any questions for the panel?
Mr. Hall. If the Ranking Member has none.
The Chairman. No, I am just going to call them, and then we
can conclude.
Mr. Hall. Oh, okay.
I would like to ask Dr. Rudd, in your written testimony,
you state that, ``Delays in evaluating the escalating numbers
of service-connected disability claims can be one of the
barriers to effective care being provided.''
And just to make a point that we voted out of this
Committee a bill last week, which would help to remove some of
those barriers and allow earlier decisions for service-
connected disability claims.
And also to ask you--and I guess this would be to both you
and Dr. Rathbun--about the standard for care of a minimum of 8
at-least-30-minute sessions per year with either a psychiatrist
or psychologist or a counselor, which does not have to be the
same psychiatrist, psychologist or counselor.
As a professional mental health expert, what is your
opinion of that standard?
Dr. Rudd. Well, I would think that it could be potentially
problematic for a number of reasons. I think one of the things
that we know from the treatment outcome literature is that
there is a portion of this problem that will be enduring and
chronic in nature. And that amount of care may not be adequate
to address the problem. There will be some chronicity. It will
take more visits and probably for a longer period of time than
many people expect.
Mr. Hall. And how much weight or how much credibility or
belief should we put in treatment by medication versus
treatment by psychotherapy?
Dr. Rudd. Well, I think both have been proven very
effective. It really depends on the nature of the disorder. But
both have been proven very effective. And, for many disorders,
doing both simultaneously has actually been evidenced to be the
most effective intervention and the most effective treatment.
Mr. Hall. I wanted to ask Dr. Rathbun about, under your
statistical page here, you show what we saw earlier in the
charts from the VA, that the younger veteran seems to be having
a much harder time coping, and the suicide rates are higher
among the 20-24-year old rate.
Obviously, we know, as was testified to earlier, that there
are more males than females serving, and young men are
notoriously slower to mature than young women. I am a father of
a daughter, so I have witnessed, you know, the other side of
it.
But I am wondering if maybe we shouldn't be trying to
provide a slightly different type of treatment or screening for
younger veterans who, for whatever reasons, are not either
processing their experience in combat as well or are not
reaching out for help as well.
Dr. Rathbun. Well, I can only address the numbers
themselves. I am not an expert on suicide and/or its treatment.
I am a biostatistician, mainly trained in analysis of numerical
data, numerical information. And I do have some background in
other disciplines, but it is primarily ecology, the environment
and environmental health, rather than the suicide issue. This
is my first real exposure to suicide.
Mr. Hall. Well, maybe we should ask Dr. Rudd then.
Dr. Rathbun. I think his comments would have a little more
knowledge than mine would.
Dr. Rudd. Well, I would tell you that we do know
scientifically that there are some treatments that work. We
actually did a large-scale study with Army individuals on
active duty a number of years ago, more than a decade ago, and
had some efficacy in terms of response with those individuals
that were all suicidal. That was one of the criteria to get
into the study.
I think that there are issues in terms of barriers that are
critical. And this is just anecdotal; I can't give you
scientific evidence for it. But having served as an Army
psychologist, I can tell you there is great concern among young
people about issues of confidentiality, about the impact of
receiving mental health, psychiatric, psychological care on
their future prospects for their employment either inside the
military or outside the military. Much of that is myth. I think
targeting that very specifically becomes critical, helping
people understand the importance of care early in the cycle of
the problem.
Part of my personal concern about this is that you have
young people who return from combat who have the emergence of
symptoms and then are hesitant to get care because they worry
about the impact on their status, the potential for promotion
and success in the military, don't get care, symptoms become
much more complicated, they develop comorbid disorders, in
terms of substance abuse and other problems, which makes it
much more difficult to treat later on.
And so I think there is a piece of this that very much is a
misunderstanding about the importance of getting care and that
it is not going to impact your future, it is not going to
impact your promotion and status in the military. There seems
to be a considerable misunderstanding about that.
Mr. Hall. Thank you.
And I would just point out before I yield back, Mr.
Chairman, that the parents of one of the veterans who took his
own life who testified before us suggested that the name or the
initials be changed from ``PTSD'' to ``post traumatic stress
injury'' or ``syndrome'' or something else, because
``disorder'' suggested a malady, like there is something wrong
with you as a person, whereas what you are really having is a
reaction to an experience that is not normal.
Dr. Rudd. Absolutely.
Mr. Hall. And that the stigma should be removed somehow.
Whether a name change can do that alone, I doubt. But I
appreciate your comments on removing the stigma and trying to
reach our veterans as early as possible.
Thank you, Mr. Chairman. I yield back.
The Chairman. Thank you.
Mr. Rodriguez, any questions?
Mr. Rodriguez. Let me just follow up on the same comments.
Because I know we have struggled with trying to pick them up as
quickly as possible and talked about maybe providing services
to them automatically and maybe not to label them at that point
in time. And I don't know if you might have some comments as it
relates to that, because it would be just in terms of maybe for
6 months or a year to provide services automatically. That way,
every soldier that has gone into a combat would automatically
go through that without the stigma of being labeled having one
thing or another and getting some degree of access to some
services beforehand.
I was wondering if you want to make some comments on that.
Dr. Rudd. Sure. I think it would be interesting to look at
that as an option.
I think you can look at other areas of the literature, and
specifically you can look at suicide-prevention programs that
have been in school systems, you can look at stress debriefings
that have been done for firefighters and other individuals. And
what that literature seems to suggest is that universal kinds
of intervention usually don't work very well, that they don't
tend to reach the people that are at highest risk. And I think
that what they suggest is that we need to be more creative
about what we do and how we reach individuals.
When I think about that, I will tell you very simple things
make a difference. Simply reminding people of the availability
of a service actually has an impact on suicidality. There was a
wonderful study done decades ago where they simply sent a
reminder letter to people who were at suicide risk from the Los
Angeles Suicide Prevention Resource Center. They sent them
periodic reminders on an annual basis. And the people who got
the letters actually committed suicide at markedly lower rates
than those who did not get the letters. So just an expression
of care and expression of concern to let someone know that you
are available can go a long way.
But I am not sure that universal intervention programs
would be received well and work well, I think, just from an
anecdotal experience when I was in the service.
Mr. Rodriguez. Doctor, you also talked about the ones who
were hospitalized and their health. I guess it jumped from 2 to
4 to 6 percent in terms of actual suicide.
Are there certain programs that could be triggered
automatically because there are those stressors? Any thoughts
on that?
Dr. Rudd. I think speculation suggests that when somebody
is hospitalized for an episode of suicidality and they are
discharged, that one of the things that happens is they are
returned to the environment that was stressful for them to
begin with, and so risk is elevated.
I think that data suggests very simple things need to be
done. When somebody is discharged from the hospital, they need
to follow up very quickly with an outpatient provider. That
doesn't always happen. Sometimes that takes weeks for someone
to follow up.
Those sorts of interventions, I would hypothesize, would
save lives. Making sure that somebody follows up within a day
to 2 days after discharge from a hospital with an outpatient
provider and make that something that is routine as a part of
care. That is something that might well save lives.
Mr. Rodriguez. And, Dr. Rathbun, your data basically, if I
can summarize, let me know if I am--you indicated that veterans
are twice as likely to commit suicide than the general public?
Is that what it is?
Dr. Rathbun. Yes, it is roughly about that. I can give you
a little bit more precise ratios.
Mr. Rodriguez. Okay. And on the data on the young soldier,
that was a little higher?
Dr. Rathbun. For the young veterans, the range that I gave
in my report is on the order of about three to four times the
non-veteran.
Mr. Rodriguez. Okay. Thank you very much.
Thank you.
The Chairman. Mr. Buyer.
Mr. Buyer. Mr. Rathbun, I want to focus on your--I want to
become clear. Your testimony is that, based upon your
statistical analysis of the data, that there is approximately a
2-to-1 ratio of more veterans committing suicide than those in
the general population?
Dr. Rathbun. That is right.
Mr. Buyer. Okay. Of the non-veterans, okay. So what that
CBS News story, then, is attempting to do is challenge the
credibility of the VA, right?
Dr. Rathbun. No, that is not the intent here.
Mr. Buyer. Pardon?
Dr. Rathbun. My role in this was as a statistical
consultant, just to provide the estimates that are given here.
Mr. Buyer. All right. I understand. You are not a health
clinician. You are a statistician.
Dr. Rathbun. Yes, I am a statistician.
Mr. Buyer. And what CBS News did with your analysis was
their own business and how they used it and created a story
with it, that is CBS News' business, correct?
Dr. Rathbun. Well, I do care how they use the information.
Mr. Buyer. Well, I not only care how it is used, I care
about how you came to your conclusions.
Dr. Rathbun. I didn't----
Mr. Buyer. Wait a second.
Dr. Rathbun. Okay, sure.
Mr. Buyer. I care because the credibility of the VA, then,
has been placed at stake with the American people.
Now, I have a series of questions for you, okay?
Dr. Rathbun. Okay.
Mr. Buyer. One, I would like to know--first of all, I would
ask unanimous consent that the letter that Chairman Filner and
I sent to Rick Kaplan, the Executive Producer of CBS Evening
News With Katie Couric, dated December 21, 2007, be entered
into the record.
The Chairman. Without objection.
[The letter to Rick Kaplan, Executive Director, CBS Evening
News With Katie Couric, dated December 21, 2007, and the
response from Linda Mason, Senior Vice President, Standards and
Special Projects, CBS News, dated May 16, 2008, appears on p.
123.]
Mr. Buyer. I would also ask that the letters that you and
I, Mr. Chairman, had sent to Secretary Peake, along with his
responses, be entered into the record.
The Chairman. Without objection.
[The letter to Hon. James B. Peake, M.D., Secretary, U.S.
Department of Veterans Affairs, letter dated December 21, 2007,
and response letter dated February 5, 2008, requesting
additional data on suicide rates among veterans, appears on p.
122.]
Mr. Buyer. I also ask that the responses from the
Department of Defense regarding not only our letter to DoD and
their response be entered into the record.
The Chairman. Without objection.
[Chairman Filner and Congressman Buyer wrote to Hon. Robert
M. Gates, Secretary, U.S. Department of Defense, on December
21, 2007, requesting the number of active-duty suicides for
each year from 1995 to 2006. On January 17, 2008, Secretary
Gates responded designating David Chu, Under Secretary of
Defense for Personnel and Readiness to provide information to
the Committee. Chairman Filner again wrote to Secretary Gates
on May 6 and May 21, 2008, requesting the information. On June
3, 2008, Secretary Gates again responded that he was
designating David Chu, Under Secretary of Defense for Personnel
and Readiness to provide information to the Committee. On June
5, 2008, Chairman Filner again wrote Secretary Gates requesting
the information. As of September 25, 2008, the U.S. Department
of Defense has refused to respond to the Committee's request
for information regarding the number of active-duty suicides
for each year from 1995 to 2006. The referenced letters appear
on p. 123.]
Mr. Buyer. With letter that the Chairman and I had sent to
CBS News, we had asked CBS News to share with us the data on
suicide among veterans with the Committee.
Given your written statement, obviously CBS News is unable
to do that because you destroyed the data. Is that not correct?
Dr. Rathbun. CBS News retains a copy of the data, I
thought. I am not certain if they do or not. But they had asked
me to not keep a copy. They were concerned about the
confidentiality of some of the veterans, mainly in the smaller
States.
Mr. Buyer. So, is your belief that CBS News still has the
data?
Dr. Rathbun. I don't know one way or the other, actually.
Mr. Buyer. But they had asked for you to destroy the data?
Dr. Rathbun. Yes.
Mr. Buyer. Okay. Did you conduct a blind analysis to
improve the integrity of your tests?
Dr. Rathbun. A blind analysis? You mean--I am not knowing
what you are referring to. I am not an epidemiologist, so it
is----
Mr. Buyer. A blind analysis, meaning anybody else have an
opportunity to look at the data? Is it peer-reviewed?
Dr. Rathbun. No, this is not peer-reviewed.
Mr. Buyer. It was not peer-reviewed and you destroyed the
data?
Dr. Rathbun. Yeah. That makes me feel----
Mr. Buyer. Then thereby we are to embrace with great trust
that what you did in your work was correct?
Dr. Rathbun. I have to say that, for the record, I have
been very uneasy about this aspect of it, given that this is
going beyond the story.
Mr. Buyer. I would think so. You are a professor?
Dr. Rathbun. Yes, I am.
Mr. Buyer. Would you advocate that of your students?
Dr. Rathbun. Not at all.
Mr. Buyer. As a methodology in normal business practice?
Dr. Rathbun. That is why I have been very uneasy.
Mr. Buyer. Sir, would you advocate that to your students?
Dr. Rathbun. No, I would not.
Mr. Buyer. No, you would not. Now, you said that you were
not paid by CBS News; you got a baseball cap.
Dr. Rathbun. I did get a baseball cap.
Mr. Buyer. Do you know whether or not the parent company of
CBS News made any forms of contribution to the University of
Georgia?
Dr. Rathbun. I have no information on that.
Mr. Buyer. Viacom, is that who owns CBS News? You have no
knowledge whether or not they made any contributions on
research or anything?
Dr. Rathbun. I am not aware of what the University receives
in terms of those contributions.
Mr. Buyer. Then let me ask this. If you are uncomfortable
and you would never advise your students to destroy data and
not permit a peer-review process with regard to the results,
why?
Dr. Rathbun. This was not intended as a scientific
investigation. I was asked as a consultant to do a data
analysis.
What I am really uncomfortable with is having it gone
beyond the story and being asked to testify in court about it
and, actually, quite frankly, in this group, given that I no
longer had the data to back up the numbers.
Mr. Buyer. Yes, I think CBS News put you, as a
professional, in a very, very uncomfortable position. I think
the best thing, Professor, coming out of this that you can
always do now is use this as an example for your students here
and ever after as to why you should never do something like
this. Because it is being used and manipulated and it brings
things into question, and it makes it challenging for us.
Dr. Rathbun. I am comfortable with the results that I
found, but I am uncomfortable in presenting them beyond their
original intent, which was just that story.
Mr. Buyer. But, professionally, you would even be more
comfortable if it were peer-reviewed and one of your peers
objectively confirms your findings, would you not?
Dr. Rathbun. Of course. Sure. I had never--since I do not
do my work in suicide, my work is really far outside that
discipline, I would have been unlikely to publish this kind of
results anyway. It is just not my priority, at the moment.
Mr. Buyer. Well, I want to thank you for coming. I want to
thank you for being very honest and forward with us. Because we
have a new Secretary in the VA, who is a doctor himself, who
spent 40 years in the Army, and he cares a lot about the men
and women who wear the uniform, and I think he embraces this
issue with great sincerity.
And I know the Chairman has challenged the Secretary here
today and members of his staff. But when I am faced with a
story that CBS News put out there, when, in fact, we can't gain
access to the data, the data was destroyed, and a process that
was not peer-reviewed, and the last thing, Mr. Chairman, I
would like to conclude with is, when we look at the CRS Report
for Congress, ``Suicide Prevention Among Veterans,'' the CRS
report on page five said, quote, ``It is tempting to make
comparisons between studies and with information about suicide
in the general population. Such comparisons are often made, but
they are not necessarily valid. Among other things, data about
suicides in the general population includes suicides among
veterans, information about suicides in groups that exclude
veterans, is scant, and is information about the extent for
which data for veterans may skew the data for the general
population, if at all.''
CRS, Mr. Chairman, did a pretty good report, they are
pretty concerned, and they laid out that there is much work for
us to do to build a database nationally for us to be able to
track this kind of thing.
But I do appreciate you coming here today.
And I would note to the Secretary, your time is very
valuable, sir, and I, with deep respect, appreciate you being
here to listen to this. But I think we are going to have to
place great trust and confidence in your analysis and what you
are going to have to do, Mr. Secretary, if this is what has
been done out in the population generally.
I yield back.
The Chairman. Thank you, Mr. Buyer.
What we heard today is that the VA data basically confirms
the CBS News data.
Dr. Rathbun, when Dr. Katz was with us a few months ago, he
said something about VA controlled for gender but in a strange
way.
Do you know what he is talking about? Or how did you
control for gender?
Dr. Rathbun. I have no idea about what that would mean.
The Chairman. You don't know?
Dr. Rathbun. I used, I think, very standard methodology
adjusting for gender and age.
The Chairman. Dr. Katz, you said something about your
objection to the data for younger veterans. You clarified that
today. What was your problem with the way the data dealt with
younger veterans? Can you just repeat that for us?
Dr. Katz. I was much less concerned with what Dr. Rathbun
did to the data than the data that was given to Dr. Rathbun.
Mr. Stearns. Point of order, Mr. Chairman.
Dr. Katz. When the coroner----
The Chairman. Can you just come to the microphone?
Mr. Stearns. Point of order, Mr. Chairman. I think what you
should do is bring this person up and identify who he is for
the record, so we know.
The Chairman. Dr. Katz, can you come forward, please?
Dr. Katz testified earlier today.
Mr. Stearns. Okay.
The Chairman. I was trying to clarify what I took as your
general condemnation of the CBS News data. Today, you clarified
that you were concerned with younger veterans. If you want to
make that more clear, you have the opportunity.
Dr. Katz. Well, in the spirit of attribution and review, I
want to acknowledge that it was Dr. Cross who pointed out this
issue to me.
When coroners and medical examiners check or don't check
the veteran status box on a standardized death certificate,
they don't distinguish between active duty and veterans.
Someone may have died while in active duty in the community and
be evaluated for cause of death by a coroner or medical
examiner, and that coroner or medical examiner would check off
``yes'' for a veteran, because that person was, in the past, a
service man or woman.
So that the States' death certificates tabulation of
veteran status will include veterans as evaluated by the
coroner or funeral director. It will also perhaps include some
people who are active-duty personnel who took their lives while
on active duty.
The Chairman. But----
Dr. Katz. So that the number of suicides tabulated will
include both active duty and veterans.
The denominator, the evaluation of the number of people at
risk, given your data source, includes only veterans. An
extended numerator with a focused denominator will lead to an
inflated rate. That will be a greater problem in the younger
veterans, for which the mathematical contribution from active-
duty personnel would be greater. And that is why I have
concerns about the younger veterans.
The Chairman. I understand your concern.
Dr. Katz. Thank you.
The Chairman. Thank you for coming back.
Dr. Rathbun, do you have any response to that?
Dr. Rathbun. Yes, I do have some response.
CBS News, after the original taping and before they
actually broadcast the story on November 13th, approached me
with additional numbers which were active-duty suicide numbers,
and asked me to subtract those from the data on the veteran
suicides. And that is, actually, why the data on the veterans
is given as a range rather than as a single number. It is
really one--the lower number reflects the subtraction of those
observations that were of some question. Pia Malbran expressed
concern that some of the active duty may have been counted as
veterans.
The Chairman. So, I mean, this was figured out before any
actual----
Dr. Rathbun. I am not really certain where she came up with
those numbers. I really can't talk to the quality of those
particular numbers. We didn't discuss them at any great length.
The Chairman. But the concept was understood?
Dr. Rathbun. Yes.
The Chairman. Dr. Rudd, I missed what you were saying. When
a question was asked by Mr. Hall, you said universal prevention
was problematical. Did I understand you correctly?
You heard what I said earlier about universal diagnosis of
everybody who is discharged or even after combat. That is a
universal process that I believe can be done.
Did you say that was not a good thing to do or wasn't
effective?
Dr. Rudd. No, no, that is not what I was saying. Actually,
let me be a little more specific around that.
Universal prevention programs where there is a targeted
intervention for everyone, where everyone gets an intervention
regardless of whether or not--and those are usually
psychoeducational programs that have been done in the school
system.
The Chairman. But you wouldn't object to universal
diagnosis?
Dr. Rudd. No, not coming out of a combat zone.
The Chairman. All right. Counsel wanted me to ask, again,
it was along the same lines as Mr. Hall; the RAND report
defined minimally adequate treatment, eight visits in the past
12 months, averaging at least 30 minutes.
I forget what Mr. Hall asked about that, but is that an
adequate standard?
Dr. Rudd. It won't be an adequate standard for a portion of
those that are diagnosed and identified as ill.
The Chairman. I remember now. Thank you. You clarified
that.
In looking back at this over the years, it seems to me
that, a big problem is the vast number of both National Guard
and active-duty troops who do not get adequately diagnosed.
Everybody knows what they have to check on a form to get
home quickly. We have had reports of commanding officers
telling their troops, ``Don't check that box, because that will
keep you here,'' or lead to further security problems, which
has been clarified recently, or possible denial of law
enforcement jobs. There is a self-denial. There is an ethos
that says don't admit mental illness. And there may be a true
lack of symptoms, which might not be seen right away.
When that soldier returns to civilian society they don't
always have the support mechanisms they had while on active
duty. They are often without the understanding of their family,
the community and their employer. By the way, I want to invite
the VA--and I appreciate you staying here.
Tomorrow at four o'clock, the Sesame Street people are
going to roll out the DVD they just finished for young children
under the age of five. There are more than a million children
of those currently deployed in Iraq, those who have returned,
or those who will be deployed. Sesame Street has done a DVD on
how to deal with situations when Dad or Mom come back injured,
or perhaps, with an amputation or PTSD. They rotate their
puppets of Elmo and Rosita with real-life situations. For
instance, they have a young child, four or five, bringing a
prosthetic leg to Dad and making it look natural and that it is
something not to fear.
They are doing outreach, which I think is incredible. They
are going to distribute this DVD free of charge to all the
families who request it. That is the kind of knowledge
everybody needs to have.
If you let people out of the military without diagnosis or
having that knowledge, it is going to be pretty hard to deal
with, which is why we have the problem we have now.
So, my plan is for soldiers to be given treatment while on
active duty within a company-size of fellow soldiers to keep
that camaraderie there, along with their families who help in
both diagnosis and treatment. I call it a Heroes Homecoming
Camp. It is like a ``de-boot camp'' or a boot camp just before
discharge where you can decompress and get an understanding of
what went on and then get an adequate diagnosis and early
treatment.
It seems to me that it would do a lot to remedying all the
symptoms that we have seen in our society. You can't catch
everybody, and you can't prevent every suicide. You would have
to do followup at 3 months, 6 months or a year later. It seems
to me we can help a lot of soliders before they are allowed out
of active duty.
And I don't know if you want to comment on that as a
concept.
Dr. Rudd. I think the one comment that I would offer is
that the Air Force actually has had a model suicide-prevention
program for a number of years and were able to significantly
reduce suicide rates across several years.
And a part of that program is very much similar to what you
are talking about, which is a universal change in how we think
about mental illness, how we think about suicide prevention, an
acceptance of the risk of mental illness from the very top and
changing the community psyche about how we think about issues
of illness and getting treatment when it is needed.
And that program could serve as a model and a very
effective one.
The Chairman. I hope that Secretary Peake heard that.
Secretary Peake, you were the surgeon general of the Army.
I just met with the current surgeon general and he was saying
something about doing some education. I asked why he didn't
promote or bring out in public the generals or colonels who
have had PTSD and have dealt with it to show in a public way,
that they can be promoted to general. Show that they have been
successful in the military, even having dealt with PTSD. That
would be the way to take away the stigma and to give soldiers
the confidence that it is okay. I mean, I would call it combat
stress injury and get the whole ``disorder'' out of the name.
But that would be a real good example for soldiers, which
would be faster than anything the Army or Marines are doing now
to say, hey, it is okay because General X or General Petraeus
says, ``I have had PTSD, and it is okay.''
I assume that would be a good thing for soldiers to see?
Dr. Rudd. Well, I think, actually, that is one of the
things that the Air Force program did. They talked about these
issues from the very top, about the importance and
significance. It was emphasized from the top all the way
through the system. And the focus shifted, and there is greater
acceptability.
And when you have that, you have people willing to talk
about their own personal issues, I think, with greater
frequency. And that, sort of, demystifies and, to some degree,
helps destigmatize the problem.
The Chairman. Thank you.
I appreciate you all spending the time, Dr. Rathbun and Dr.
Rudd. You have helped us understand this, and we appreciate it
very much. Thank you so much.
Our last panel is Dr. Michael Shepherd from the Office of
Inspector General at the Department of Veterans Affairs. Dr.
Shepherd is a physician with the Office of Health Care
Inspections that will discuss the need for VA to continue
moving forward with full implementation of the suicide-
prevention initiatives from the Mental Health Strategic Plan.
Thank you, again, for taking the time.
STATEMENT OF MICHAEL SHEPHERD, M.D., SENIOR PHYSICIAN, OFFICE
OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Dr. Shepherd. Mr. Chairman and Members of the Committee,
thank you for the opportunity to testify on suicide prevention
and the Office of the Inspector General report, ``Implementing
VHA's Mental Health Strategic Plan Initiatives for Suicide
Prevention.''
My statement today is based on that report, as well as
individual cases that the IG has reviewed and reported on
involving veteran suicides and accompanying mental health
issues.
In the process of these inspections, clinicians in our
office have had the opportunity to meet with and listen to the
concerns of surviving family members and to witness the
devastating impact that veteran mental health issues and
suicide have had on their lives.
In prior testimony, we have stressed the importance of the
need for VA to continue moving forward toward full
implementation of suicide-prevention initiatives from the
strategic plan. In terms of some additional changes VA could
make, we would offer the following observations.
Number one, community-based outreach. In our report, we
noted that, while several facilities had implemented
innovative, community-based suicide-prevention outreach
programs, the majority of facilities did not report community
linkages aimed at suicide prevention. Although facilities would
need to tailor strategies to consider local demographics and
resources, a system-wide effort at community outreach appears
prudent.
Number two, timeliness from referral to mental health
evaluation. In our report, we noted that, while most facilities
reported at least three-fourths of those patients with moderate
depression referred by primary care providers are seen within 2
weeks of referral, approximately 5 percent reported a 4- to 8-
week wait. Because these patients are at risk of progression of
symptom severity and development of suicidal ideation, VISN
leadership should work with facility directors to ensure that,
once referred, patients with moderate depression and those
recently discharged from the hospital are seen in a timely
manner at all VA medical centers.
Number three, co-occurring combat stress-related illness
and substance use. Substance use may contribute to the severity
of a concurrent mental health condition, such as major
depression. The presence of alcohol may exacerbate impulsivity,
and acute alcohol use is associated with suicide. Quality of
life becomes duly impacted by anxiety and depressive symptoms
and comorbid substance use issues. Augmenting services to
equally address combat stress and comorbid substance use
should, therefore, be given due consideration for inclusion in
a comprehensive program aimed at suicide prevention.
Number four, enhanced access to mental healthcare.
Treatments for mental health problems may necessitate multiple
visits over time and may entail multiple modalities, including
individual and group therapy, medication management and/or
readjustment counseling. Therefore, efforts of enhanced patient
access to appropriate treatment may help facilitate both
patient engagement and the potential for treatment benefit.
For example, improved availability of mental health
services at CBOCs may help mitigate vocational and logistical
challenges facing some veterans residing in rural areas who
otherwise may have to travel longer distances to appointments.
In certain locations, availability of care during off-tour
hours may increase the ability for some transitioning veterans
to access mental health treatment while minimizing interference
with occupational and educational obligations, and would be
consistent with the recovery model for mental health treatment,
which emphasizes not only symptom reduction, but also
restoration of function.
Number five, facilitating early family involvement. Mental
health symptoms can have a significant and disruptive impact on
family and domestic relationships. Relational discord has been
cited as one factor associated with suicide in active-duty
military and returning veterans. The VA should consider efforts
to bolster early family participation in patient treatment.
Lastly, coordination between VHA and non-VA providers. When
patients receive mental health treatment from both VA and non-
VHA providers, communication becomes an increasingly complex
challenge. Fragmentation of care is particularly worrisome in
periods of patient destabilization or following hospital
discharge.
The Office of Mental Health Services should consider
development of innovative methods to facilitate flow of
information for patients receiving simultaneous treatment from
VA and non-VA providers within the constraints of relevant
privacy statutes.
In addition, the Readjustment Counseling Service and Office
of Patient Care Services should pursue further efforts to
foster communication for patients receiving treatment services
at Vet Centers and VAMCs or CBOCs.
Mr. Chairman, thank you again for the opportunity to
testify. I would be pleased to answer any questions that you or
other Members of the Committee may have.
[The prepared statement of Dr. Shepherd appears on p. 107.]
The Chairman. Thank you, Dr. Shepherd.
Mr. Rodriguez, do you have any questions?
Mr. Rodriguez. On those five recommendations that you have
made, do you know how the VA ranks in those areas?
Dr. Shepherd. Well, in terms of number one and number two--
--
Mr. Rodriguez. Excuse me, six recommendations.
Dr. Shepherd. You mean from this statement?
Mr. Rodriguez. Yes, from the statement. You mentioned
community-based outreach, also timely referrals, between
referrals. You mentioned enhancing mental healthcare. You
mentioned family involvement in the last one, in terms of
coordination with others.
Do you know how the VA might rank?
Dr. Shepherd. Sure. In terms of community-based outreach in
the Mental Health Strategic Plan implementation report, we
found that a minority of facilities were engaged in community
linkages or use of the chaplaincy for community-based outreach.
In terms of timeliness from referral to mental health
evaluation, rather than considering all waiting times, we
focused on patients with moderate depression. Those with severe
depression you would expect to be referred quickly. Those with
minor, it would be debatable. And those with moderate
depression or those who recently have been hospitalized and
discharged, you would think of as a group that is an at-risk
subpopulation that you would really want to hone in on. So we
looked at their reporting on that, which showed that most did
do a timely job in referring. But, in our view, even a small
percent means there is more work to be done on that.
In terms of the other items, those reflect our observations
from a series of cases involving individual patients that we
have looked at.
Mr. Rodriguez. Okay. Thank you.
The Chairman. Thank you.
Mr. Stearns, any questions?
Mr. Stearns. Thank you, Mr. Chairman.
Dr. Shepherd, as mentioned, there are six recommendations
here. So you say if these six recommendations were implemented,
the problem would be totally solved, partially solved, would
move to a better conclusion? What is your feeling?
Dr. Shepherd. I am not saying the problem would be solved.
I am saying that it is our feeling that these recommendations
would help move the ball forward, in terms of additional
considerations that may help with suicide prevention.
Mr. Stearns. Additional considerations that would help with
suicide prevention.
Dr. Shepherd. Right.
Mr. Stearns. Who asked you to do the survey? I wasn't
clear.
Dr. Shepherd. Originally, we were asked by this Committee.
Specifically, we were asked by Congressman Michaud.
Mr. Stearns. Okay. How long ago?
Dr. Shepherd. The report came out in May 2007. The request
was in the late fall of 2006.
Mr. Stearns. 2006, okay. So it took you, what, 2 years to
do this?
Dr. Shepherd. No, about 6 months.
Mr. Stearns. 6 months, okay. And were you the prime person,
or were there other people?
Dr. Shepherd. I was the prime person, and then there were a
couple other people.
Mr. Stearns. Did it ever occur to you while you were doing
this that DoD has a component of this? That is, at the point
the DoD has the soldier, if they don't do anything, and then
the soldier comes to the VA, perhaps it might be too late,
because the soldier will not be as obligatory as he was still
in the Department of Defense and still in regular duty. Had
that ever occurred to you during this study?
Dr. Shepherd. Yes. And I would agree with that sentiment,
we don't, obviously, provide oversight to the DoD, but
maximizing intervention in both DoD and VA would be ideal.
Mr. Stearns. I know you didn't look and you weren't
requested to look at DoD. But if you did the study, you are
saying when you came up with your six recommendations, it
occurred to you that there is responsibility for the Department
of Defense here?
Dr. Shepherd. Yes. Again, I think that it is a joint
effort.
Mr. Stearns. It is a joint effort. And would you say that
is 50/50 or maybe the predominance of this initial, shall we
say, solution to the problem would be at the Department of
Defense?
Dr. Shepherd. I honestly don't know how I would partition
that.
Mr. Stearns. Dr. Shepherd, would you describe in detail the
actions that the VA has taken to address the recommendations
made by the May 10, 2007, IG report and perhaps what challenge
exists?
Dr. Shepherd. Sure.
One of our recommendations in the original report was
basically making arrangements for 24-hour crisis mental
healthcare availability. And one of the responses to the
report, VA did establish a suicide-prevention hotline based out
of Canandaigua, New York. And I have visited that hotline in
person and seen the folks working there in action, and have to
applaud the work they are doing up there.
We suggested that they needed to develop education for non-
clinical first-exposure personnel, such as clerks, on suicide
prevention. VA subsequently developed a CD and training module,
which they began, I believe, in December to disseminate.
We asked them to develop a similar module for clinicians.
My understanding is that module and development has not
occurred yet.
We had recommended that sustained sobriety should not be a
barrier to treatment in specialized mental health programs for
returning combat veterans. And subsequent to our report, the
Deputy Under Secretary for Health Operations and Management did
put out a directive basically stating--I am going to put this
in my words--that substance use issues should not keep people
from getting appropriate mental healthcare. Because, in the
past, there were instances where people would say, well,
someone needs to be completely sober before we can treat them.
And so that directive did occur to address that.
Mr. Stearns. So would you say four of the six have been
implemented, it sounds like?
Dr. Shepherd. Yes, four of the six have been implemented.
Mr. Stearns. Okay. And have you seen any appreciable
difference since that, or has there been any feedback to say,
okay, these six recommendations, we have done four of them,
which is four out of six, is two-thirds, 67 percent have been
done, and we have noticed a dramatic difference? Have you heard
anything?
Dr. Shepherd. I haven't, but it is also too early a time
horizon to tell. I think when you are----
Mr. Stearns. Well, it has been a year.
Dr. Shepherd. It has been a year. And we have heard, again,
very good feedback about the number of veterans calling the
suicide hotline.
Mr. Stearns. So when you are making these recommendations,
you put in place so that you get feedback and know how it is
working on your recommendations?
Dr. Shepherd. Yes. We have gotten feedback that a lot of
the veterans are obviously calling the hotline and utilizing
that as an outreach tool.
In terms of ultimate impact, because of numbers in terms of
suicide, really would take a longer time horizon to fully
appreciate.
Mr. Stearns. Well, I can just tell you, in the private
sector, if recommendations came that we all agreed upon, they
would be put in place about a year, and everybody would move on
and have a measurement, a metric to determine how well they had
been implemented.
So the fact--you are saying that two of them have not been
implemented, right?
Dr. Shepherd. Right, and that is concerning to us. And as I
have stated earlier, we continue and have continued to ask them
to move forward.
Mr. Stearns. Okay. My time has expired.
Do you think it is because of lack of money, or why haven't
these two been implemented?
Dr. Shepherd. I am not sure why they haven't been
implemented.
Mr. Stearns. Do you want to venture a guess?
Dr. Shepherd. It would be a pure guess.
Mr. Stearns. No one has come back to you and said, this is
a problem why haven't we done these?
Dr. Shepherd. No.
The Chairman. I am sorry, which two?
Mr. Stearns. The last two.
All right. Well, I think my time has expired, Mr. Chairman.
But I think the point is, it has been a year since the
recommendations. Two of them have not been implemented. We
can't even find out whether it is because of money or because
of personnel. Dr. Shepherd can't even give us an idea----
The Chairman. What are you trying to get at? What is your
conclusion?
Mr. Stearns. Well, I am not a witness here today, Mr.
Chairman, but I sure am here to try to find out. And I am just
a little concerned, after a year, why these two haven't been
implemented. And I would think that the IG could tell us that
the feedback they get--they don't have the money, the
personnel, or is it just a low priority?
The Chairman. Let me ask you the procedure on these
reports. Do you have to get another request to report on the
follow-up?
Dr. Shepherd. No. We----
The Chairman. Or do you follow it up automatically? Is the
VA given a certain amount of time to respond?
Dr. Shepherd. The VA is given a certain amount of time to
respond to the initial report. And then, subsequent to the
response, I believe it is quarterly, we have an office within
the IG that requests further follow-up. The next one is due
mid-June. And then I look at the responses that are sent to
that office, in terms of whether I think they are legitimate
responses or not.
In addition, since the issuance of this report, I have had
subsequent conversations with various people, for instance, I
met with someone from Ann Arbor about 2 months ago, wanting to
know where things are at in terms of one of the initiatives
they were working on. And I have visited Canandaigua.
So, as a process, quarterly, we have an office that does do
follow-up. And that is passed through me to make sure that if
they say, we are going to do it and we are going to do it by
blank, then I think that is reasonable, or I may say I don't
think that is reasonable.
[The following was subsequently received from VHA:]
The Office of Inspector General re-opened the following
recommendations:
Recommendation 2: The Acting Under Secretary for Health should
ensure that VISN directors ensure that facility directors ensure that
all non-clinical staff who interact with veterans receive mandatory
training about responding to crisis situations involving at-risk
veterans; this should include suicide protocols for first contact
personnel.
VHA Update 8/2007: Planning for facility based training in suicide
prevention for clinical and non-clinical staff is proceeding with full
rollout anticipated for no later than October 31, 2007. Suicide
Prevention Coordinators have been identified at each VA Medical Center
to support the implementation of these educational efforts locally. In
addition to monthly conference calls, these providers attended a
special training conference August 21-23, 2007. This Conference
included a protocol for Guide Training to assist nonclinical personnel
in appropriate identification and management of veterans who present
with suicidal ideation or behavior. VA will hold a national Suicide
Prevention Awareness Week (September 9-15, 2007) that will feature
educational presentations for clinical and non-clinical staff from VACO
and the Canandaigua Center of Excellence in Suicide Prevention.
Update 3/6/2008: The National Suicide Prevention Center of
Excellence in Canandaigua has developed and distributed a standard
suicide awareness training package to the field through the facility
Suicide Prevention Coordinators. A memo from the Under Secretary for
Health has been drafted, and is concurrent for release through the
office of the Deputy Under Secretary for Health for Operations and
Management, that will task each facility with developing their own
ongoing training, awareness and communication plan that includes
appropriate procedures/suicide protocols, and community resources for
all first contact personnel in both clinical and non-clinical
personnel. It is expected that all frontline staff complete the
training by September 1, 2008. Facility Suicide Prevention Coordinators
are required to report compliance with this training monthly to the
National Suicide Prevention Coordinator.
Update 5/9/2008: Mandatory training for non-clinical staff is in
place. Monitoring of the training and documentation of compliance is
currently through forwarding of sign-in sheets to the National Suicide
Prevention Coordinator. Processes for use of the Learning Management
System for documentation are being developed.
Recommendation 3: The Acting Under Secretary for Health should
ensure that VISN directors ensure that facility directors ensure that
all healthcare providers receive mandatory education about suicide
risks and ways to address these risks.
VHA Update 8/2007: Educational protocols for clinicians as well as
non-clinicians are under development for implementation no later than
October 30, 2007, and full compliance by April 30, 2008. The facility
Suicide Prevention Coordinators will be critical in ensuring
implementation and compliance across the system.
Update 3/6/2008: A ``State of the Art'' conference on Suicide
Awareness and Intervention Training was held in Canandaigua on March 5
and 6, 2008 to finalize the content used in development of a mandatory
``Suicide Risk and Treatment'' training program for VHA clinicians.
Final program content will be forwarded to the Employee Education
System (EES) by April 1, 2008, who expect to complete development of
the on-line standardized training program by September 30, 2008. Once
the program has been fully implemented, clinicians will be given 120
days to complete. Full compliance with the training requirement is
expected to be completed by January 31, 2009.
Update 5/9/08: Training activities are in place. The remaining
issue is to ensure accountability of participation of all healthcare
providers. A Directive to this effect is in the concurrence process;
monitoring of completion will be accomplished through VA's Learning
Management System (LMS).
The Chairman. Thank you.
The first thing you did mention was the National Call
Center and the Secretary provided us with the pamphlet
advertising this. It sounds like a lot of people are calling. I
don't know if Mr. Stearns was here when Mr. Moran from Virginia
was talking about the concern of many veterans dealing with the
Federal Government.
I know, Mr. Stearns, that you always say, ``Well, the
Federal Government can't do this, and besides, people aren't
worried about it.'' Mr. Moran made the point that many veterans
may not want to interact with the Federal Government, as
represented by the VA, and that this kind of advertisement may
work with a certain percentage but it is probably also turning
off a certain percentage.
He was arguing--and I think we need to look at his bill--
for a hotline to be run by peers especially, but probably
working with a nonprofit, for both privacy and the
understanding that they don't want to deal with the Federal
Government anymore. They don't trust them. I think there is a
point there.
I don't know if there is a way to even look at that. Have
you been trying to make any study about people who would call
the hotline center? Of course, you can't ask anybody who
committed suicide, but maybe the veterans who have attempted
suicide.
Dr. Shepherd. No, I haven't looked at or studied who the
callers are. I do think that Congressman Moran's suggestion and
the existing hotline are not necessarily mutually exclusive,
and maybe there could be a way to combine ideas.
The Chairman. Exactly. I think you are right. Mr. Moran
stimulated me to read this, and I know Mr. Stearns would use
this in another context sometime, but, ``Pick up the phone if
you are experiencing an emotional crisis and need to talk to a
trained VA professional.''
I mean, there are a lot of folks where that would be the
last thing they would do. You are dealing with, again, a
bureaucracy or the Government, and I don't think that kind of
appeal would work.
Dr. Shepherd. And, again, talking about combining ideas, I
believe Morris Armstrong is a veteran who started the Vet-to-
Vet model in New Haven, which I believe is a program that
follows a Vet-to-Vet model. But he does work with VAMCs and VA
facilities. And so, following that model of a joint non-VA and
VA venture, perhaps is a way to think about it.
The Chairman. I think you are right; they are not mutually
exclusive. I was hearing from the VA that this is their
outreach; however, we need to look at it from the point of view
of someone who, by their very problem, is suspicious of an
organized bureaucracy.
Dr. Shepherd. Sure. And that is why also as I said in my
statement, we would encourage all forms of aggressive outreach,
including, for instance, one center invites local clergy in and
gives them information about the facility and what the services
are, so that if a parishioner or relative comes up to the
reverend and says, ``My son is having trouble,'' they know
where to refer them or how to get them help. And I think
innovative outreach ideas like that should continue to be
pursued.
The Chairman. Well, again, thank you very much.
Remind me, on the quarterly reports, are they automatically
sent to Congress?
Dr. Shepherd. No, I don't believe they are. But that is a
statement out of ignorance, so I will have to check on that.
The Chairman. I hope they are. I think we have talked about
this with the IG before, that the reports should come to us, we
should not have to ask about what is going on.
We thank you for your contribution, and we look forward to
your continuing oversight.
[The Chairman and the Ranking Member are provided quarterly
updates on the status of open recommendations. The Committee
receives copies of Office of Inspector General reports as they
are released.]
Dr. Shepherd. Thank you, Mr. Chairman.
The Chairman. And unless there are further questions, this
hearing is adjourned.
[Whereupon, at 2:58 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Honorable Bob Filner,
Chairman, Full Committee on Veterans' Affairs
Good morning and welcome to the Committee on Veterans' Affairs'
hearing on ``The Truth about Veterans' Suicides.''
On December 12, 2007, this Committee held a hearing entitled
``Stopping Suicides: Mental Health Challenges within the Department of
Veterans Affairs.'' Nearly five months later, we are again holding a
hearing on the tragic issue of suicide among our veterans and what the
VA is doing to address what is clearly an epidemic. In November of last
year, CBS News aired a story entitled ``Suicide Epidemic Among
Veterans.'' On April 21, 2008, CBS News aired a story ``VA Hid Suicide
Risk, Internal E-Mails Show.''
The first step in addressing a problem is to understand the scope
and extent of the problem. In the case of the VA and the epidemic of
veteran suicides, either the VA has not adequately attempted to
determine the scope of the problem, which is an indictment of the VA's
basic competence, or the VA knows the extent of the problem, but has
attempted to obfuscate and minimize the problem to veterans, Congress,
and the American people, which is an indictment of the leadership of
the entire Department.
In December, Dr. Katz, in testimony before this Committee, stressed
a low-rate of veteran suicide, stating that ``from the beginning of the
war through the end of 2005 there were 144 known suicides among these
new veterans.'' In responding to the figures used by CBS, Dr. Katz
stated that ``their number for veteran suicides is not, in fact, an
accurate reflection of the rates of suicide.''
Either Dr. Katz knew that the CBS figures were indeed an accurate
reflection of the rates of suicide at that hearing or had a sudden
epiphany only days later.
In an internal email, Dr. Kussman, on December 15, 2007, referring
to a newspaper article, writes that ``18 veterans kill themselves every
day and this is confirmed by the VA's own statistics. Is that true?
Sounds awful but if one is considering 24 million veterans.'' That same
day, Dr. Katz responds: ``There are about 18 suicides per day among
America's 25 million veterans. This follows from CDC findings that 20%
of suicides are among veterans it is supported by CBS numbers.''
In February of this year Dr. Katz sends an email stating ``Shh!--
Our suicide prevention coordinators are identifying about 1000 suicide
attempts per month among the veterans we see in our medical facilities.
Is this something we should (carefully) address ourselves in some sort
of release before someone stumbles on it?''
There was silence from the VA.
Armen Keteyian, Chief Investigative Reporter for CBS News,
characterized the VA's internal emails as ``a paper trail of denial and
deceit--a disservice to all veterans and their families--[that] has
rightfully been exposed.''
In an April 24, 2008, newspaper article, a VA spokeswoman stated
that ``there are an estimated 1,000 suicide attempts per month among
the 7.8 million veterans treated by Veterans Affairs, she said.''
The VA spokeswoman may have misspoke, or this could be yet another
example of the VA's attempt to hide the true magnitude of the problem.
In the VA's most recent budget submission, the VA claims it will treat
5.2 million veterans this year, and 5.3 million next year--2.5 million
fewer veterans than the 7.8 million quoted in the newspaper article.
In April, a Dallas Morning News editorial, describing a ``recent
spike in suicides among psychiatric patients treated at the Dallas VA
hospital'' stated that ``descriptions of how four veterans committed
suicide in four months--prompting the psychiatric ward to close--
suggest that patients went to conspicuous and time-consuming lengths to
end their own lives. There seemed to be ample time for staffers to stop
them had they been doing their jobs better.''
The RAND Corporation, in a recently published study entitled the
``Invisible Wounds of War,'' found that since October 2001,
approximately 1.6 million U.S. troops have deployed, and that ``upward
of 26 percent of returning troops may have mental health conditions.''
The study estimated that approximately 300,000 of those deployed suffer
from PTSD or major depression. Among those with PTSD or major
depression, only half had seen a mental health provider or physician to
seek help in the past 12 months, and among those who had sought help,
``just over half received minimally adequate treatment.''
The study defined minimally adequate exposure to psychotherapy as
consisting of at least eight visits with a mental health professional
such as a psychiatrist, psychologist or counselor in the past 12
months, with visits averaging at least 30 minutes. How does VA mental
health care treatment stack up against this definition of minimally
adequate care?
The RAND study also found that ``the VA too faces challenges in
providing access to OEF/OIF veterans, many of whom have difficulty
securing appointments, particularly in facilities that have been
resourced primarily to meet the demands of older veterans.
``Better projections of the amount and type of demand among newer
veterans are needed to ensure that the VA has the appropriate resources
to meet the potential demand. New approaches of outreach could make
facilities more acceptable to OEF/OIF veterans.''
I think many of us believe that the VA health care system has been
pushed to the edge in dealing with the mental health care needs of our
veterans. And, I believe that we are witnessing either an inability to
address this problem, or a purposeful attempt to minimize the problems
faced by veterans and the VA and sweep the epidemic of veteran
suicides, and the mental health care needs of our returning
servicemembers, under the rug.
So this morning we are going to attempt to get a better idea of the
scope of this epidemic, and what the VA is doing to respond to it. What
specific steps has the VA taken since December, steps not previously
planned before December, to get a better idea of the scope of the
problem, and what has it done to begin to address the problem?
Finally, I believe we must also seek real accountability from the
VA, and, Mr. Secretary, we look to you to provide that accountability.
Prepared Statement of Honorable Steve Buyer,
Ranking Repubican Member, Full Committee on Veteran's Affairs
Thank you Mr. Chairman.
The loss of a single veteran to suicide is a tragedy.
I am sure that like me, every member of this committee seeks to
identify and eliminate contributing factors, and to prevent one more
service-member or veteran from taking his or her own life. I want to
thank Chairman Filner for continuing hearings to discuss this issue and
to help those at risk.
A number of questions were raised during our hearing last December
regarding the validity of data on the number of veteran suicides. Such
information is vital to understanding the scope of the problem, as well
as identifying risk factors and providing better prevention and
treatment protocols.
Chairman Filner joined with me in a letter I wrote to VA, DoD, and
CBS requesting their respective data and how it was formulated. CBS
failed to respond.
DoD acknowledged the letter, yet I am still awaiting a further
reply.
Secretary Peake was the only one to provide a thorough response,
which was about two separate studies VA is conducting.
These studies may provide some useful information, but they are
limited to data on suicide rates among veterans in the VA health care
system. VA must have a better method for the systematic collection and
tracking of veteran suicide data. It is also important to find ways to
reduce the stigma associated with mental health care and encourage more
servicemembers to seek treatment when it is needed.
During our last hearing, I asked VA to be proactive and reach out
to soldiers and their families during pre-mobilization--and to start
with the 76th Indiana Brigade Combat Team as it prepared to deploy to
Iraq. I was very pleased that VA came as requested and participated in
the outreach event.
I stood with 3,400 Indiana soldiers at the RCA dome on January 2
for the formal send-off ceremony. Along with about 20,000 friends and
family members was VA staff from the Indianapolis VA Medical Center,
Regional Office, and Vet Center.
VA reported that about 1,700 families received information
regarding VA benefits and services, including mental health services
and Information on Post Traumatic Stress Disorder (PTSD) and Suicide
Prevention.
VA also followed-up with subsequent briefings while the Brigade was
at Ft. Stewart, Georgia for training.
As the Brigade marched to war, I believe they left with a clear
impression that VA will be available to provide support and assistance
to their family during their deployment and will be there when they
return from Iraq. There was very positive feedback regarding the VA
presence at these events.
Secretary Peake has taken decisive actions to meet the increased
needs for mental health services. For example, on May 1st, VA began
contacting nearly 570,000 recent combat veterans about VA medical care
and benefits.
These veterans were either injured in Iraq or Afghanistan or
discharged from active duty, but have not yet contacted VA.
The Secretary has also directed the creation of an independent
workgroup to assess VA's suicide prevention programs.
I want to thank Secretary Peake and the other witnesses for their
participation today and I look forward to their testimony.
In the end, I hope that this hearing will drive home the message to
our Nation's men and women who serve, and to their families, that if
you are in need of help, care is available, treatment works and there
is a road to recovery.
Prepared Statement of Honorable Harry E. Mitchell
Thank you Mr. Chairman.
In November, CBS News brought some shocking, and critically
important information to light. Not just that those who served in the
military were more than twice as likely to take their own life in 2005
than Americans who never served . . . or that Veterans aged 20-24 were
killing themselves when they returned home at rates between two-and-a-
half to four times higher than non-vets the same age, but that the
Department of Veterans Affairs wasn't keeping track of veteran suicides
nationwide.
In December, we held a hearing to find out why.
And, Mr. Chairman, I don't think there is anyone who attended that
hearing who will ever forget it.
We heard from Mike and Kim Bowman, whose 23-year-old son, Tim,
survived a year of duty in Iraq, only to come home and take his own
life.
Mr. Bowman warned us that our troops are coming home to an,
``understaffed, under-funded, under-equipped VA mental health system''
that imposes so many challenges, many are just giving up.
And so, when Dr. Katz insisted at that hearing, repeatedly, that
the VA had all the necessary resources to reach all veterans at risk
for suicide and make treatment available to them, I was skeptical.
How could Dr. Katz be so sure that there weren't any requests for
additional resources sitting somewhere, within the vast VA system, that
had gone unfulfilled? Was he absolutely certain that there were no
pending request for an additional mental health counselor? Or for extra
gas money to enable a VA employee to drive somewhere to conduct
outreach?
As Chairman of the Subcommittee on Oversight and Investigations, I
felt I had a responsibility to make sure.
So I asked the VA to double-check.
I asked them take a look at their records, and send us any
documents relating to any requests for additional resources that had
gone unfulfilled or under-fulfilled.
My thought was, if we could find out what the VA needs to address
this problem, we could get to work make sure they get it.
More than 4 months later, however, all I've gotten are excuses,
complaints, and, most recently, a suggestion that I, ``go file a
Freedom of Information Act request.''
That's not just an insult to me, it is an insult to this Committee,
and to our veterans.
I've tried to be reasonable. I've tried to work with Secretary
Peake's office. But, Mr. Chairman, my patience is at an end.
I've given the Department until Friday to finally produce the
documents I requested. If they do not, Mr. Chairman, I want you to know
that I will be asking you to pursue a subpoena.
I yield back.
Prepared Statement of Honorable Stephanie Herseth Sandlin
Thank you to everyone for being here. I congratulate Chairman
Filner and Ranking Member Buyer for holding today's hearing to examine
and identify mental health challenges within the Department of Veterans
Affairs healthcare system and the problem of suicides among veterans.
As the wars in Iraq and Afghanistan continue to produce a new
generation of veterans, it is important that Congress evaluate the
impact of these conflicts on the mental well-being of returning
servicemembers. We must closely evaluate the ability of the VA to meet
the mental healthcare demands placed upon it.
While the VA offers a wide array of mental health programs, there
continues to be room for improvement. In particular, I believe we must
do more to meet the mental healthcare needs of our rural veterans--who
often must travel long distances to reach VA healthcare services.
I am pleased that we have the opportunity to hear from today's
panelists and am grateful to have the opportunity to hear their
suggestions and answers to the critical issues involved. I look forward
to hearing their testimonies.
Again, I want to thank everyone for taking the time to be here and
discuss these important matters.
Prepared Statement of Hon. Shelley Berkley
Mr. Chairman,
I am extremely discouraged that we are here today holding a hearing
on the VA's cover-up of veterans' suicide attempts. I find it
absolutely appalling that anyone would try to conceal these numbers--
preventing us from addressing the root of the issue of suicide among
veterans. We must provide sufficient mental health services to our
veterans in order to address the needs facing our servicemembers
returning from Iraq and Afghanistan.
Nationally, one in five veterans returning from Iraq and
Afghanistan suffers from PTSD. Twenty-three percent of members of the
Armed Forces on active duty acknowledge a significant problem with
alcohol use. It is vital that our veterans receive the help they need
to deal with these conditions.
The effects of substance abuse are wide ranging, including
significantly increased risk of suicide, exacerbation of mental and
physical health disorders, breakdown of family support, and increased
risk of unemployment and homelessness. Veterans suffering from a mental
health issue are at an increased risk for developing a substance abuse
disorder.
As servicemembers return from combat, it becomes increasingly
important to provide them with the mental health services they need to
readjust to society and deal with the invisible wounds of war.
A constituent of mine, Army Pfc. Travis Virgadamo returned home
from Iraq on leave. During this trip, he told his family he had been so
frightened, he had sought and received psychiatric counseling from the
military in Iraq. He also received additional counseling during that
trip home in late July. The Army's response was to treat him with
Prozac. After returning to Iraq, Virgadamo was placed on suicide watch
and the bolt from his rifle was taken away, making the weapon useless.
He was also given a desk job. After Virgadamo was cleared for combat
again, they gave him back the bolt to his rifle. Hours later, he killed
himself.
Even though he was still on active duty (placing him under DoD
jurisdiction), this incident only reinforces the fact that we need to
place more emphasis on mental health of servicemembers in or returning
from combat.
Prepared Statement of Honorable Jeff Miller
Thank you, Mr. Chairman.
There is no doubt that suicide under any condition is a tragedy.
Suicide that could have been prevented is even more so, and we here on
this Committee have a duty to provide the best services for a targeted
group: our Nation's veterans. These brave men and women spend countless
hours, days, and years defending liberty for us here at home, and it is
imperative that we provide them the best services upon their return
from combat.
As we learn more each day about mental health, it is imperative
that we apply these findings toward helping those who suffer,
especially when it comes to preventing suicide. To be sure, veterans
have a unique set of factors that may lead to an increased suicide
rate. None of us here doubt the extreme rigors of combat and the toll
it can take on a person. However, with no single factor causing
suicide, it is a difficult and ongoing process to identify those most
at risk and those most likely to attempt suicide.
While this Committee cannot identify and eliminate every factor
that may contribute to suicide risk, especially those arising from the
civilian world, we certainly can work toward addressing those arising
from service, including PTSD and substance abuse. I look forward to
hearing what steps have been implemented by VA, what progress has been
made, and what steps they will take in the future. Our soldiers gave
too much to not receive the best treatment across all fronts upon their
return home. A smooth transition to civilian life and easy access to
care must be ensured for them, and this can be aided with a proactive
approach by the VA to see that they have everything they need before it
is too late.
I yield back.
Prepared Statement of Honorable Ginny Brown-Waite
Thank you Mr. Chairman.
It is no secret that the Department of Veterans Affairs is seeing
an increase in cases of Traumatic Brain Injury and Post Traumatic
Stress Disorder among OEF/OIF veterans. While these conditions may not
be as visible as an amputated leg or gun shot wound, they can be just
as debilitating. Left untreated, these conditions may lead to the
veteran committing suicide.
To address these growing concerns, this Committee approved and the
President signed into law the Joshua Omvig Veterans Suicide Prevention
Act. The act requires the VA to establish a comprehensive program for
suicide prevention among veterans. Signed into law in November 2007,
this act will dramatically affect the way the VA handles veterans with
suicidal tendencies.
Unfortunately, a majority of veterans with conditions that lead to
suicide do not seek help for these conditions. That is why the outreach
section of the Joshua Omvig Veterans Suicide Prevention Act is so
important. The VA must reach out to veterans, their families and the
organizations that help veterans to ensure this nation's veterans
receive the care they deserve.
I look forward to hearing from all of the witnesses here today
about what is being done and what still needs to be done to minimize
the number of veteran suicides. Specifically, I look forward to hearing
from Secretary Peake as to the implementation of the programs contained
in the Joshua Omvig Veterans Suicide Prevention Act and the impact they
have made thus far.
Thank you, Mr. Chairman.
Prepared Statement of Honorable Timothy J. Walz
Mr. Chairman, Ranking Member Buyer, Members of the Committee, thank
you for the opportunity to speak. And thank you to the witnesses who
are here today.
I have been troubled by recent, credible allegations that the U.S.
Department of Veterans Affairs has been withholding important
information about the rates of suicides and suicide attempts among
America's veterans. I wrote to Chairman Filner requesting a hearing,
and I am very pleased that we are having one. We must reach out to our
veterans--young and old--to make sure they know where they should go
for help if they are feeling suicidal. The VA should get all of the
resources and tools it needs to care for our veterans. The reason I
called for an investigation is so that we can get our facts straight,
and from there, we'll have a better sense of whether new legislation is
needed to address this problem . . . or just new leadership on these
issues. The VA must be forthcoming about what it knows about suicide
attempts among veterans in the VA system and overall, as well as about
suicides. Only if we have accurate information can we act decisively to
address this troubling trend among veterans.
I have been very pleased to work with the fine people at the VA in
Minnesota to ensure that our veterans continue to receive world-class
healthcare at VA facilities. When the latest information about the VA
was disclosed, I wrote to the head of VISN 23 requesting information on
mental healthcare for Minnesota's veterans and statistics on suicide
and suicide attempts among them. He and his staff have worked
diligently to gather the facts that I had requested, and I appreciate
that. I have not yet seen the information, as it came back from VA in
Washington only this morning, right before this hearing began, but I
look forward to reviewing it carefully so the people of the First
District and all of Minnesota can be sure that we are doing all we can
to help Minnesota's veterans.
I commend CBS News for bringing important facts to light,
fulfilling the press' duty to the public and its right to know.
Internal VA e-mails obtained by CBS show a concerted effort by Dr. Katz
and others at the VA to minimize the extent to which the public would
learn facts unflattering to the VA and its ability to serve veterans in
need of mental health assistance. In February of this year, Dr. Katz
sent an e-mail to Ev Chasen, VA's Chief Communications Officer, with
the subject: ``Not for the CBS News Interview Request.'' In the e-mail
exchange, Dr. Katz and Ev Chasen discussed how to deal with the VA's
own data showing alarming rates of suicide attempts--1000 per month--
among veterans in the VA medical system itself. They were clearly
trying to minimize the publicity the information might receive. The
spirit of Dr. Katz's e-mail was characterized by its first line,
stating, ``Shhh!''
In December of 2007, the House Veterans' Affairs Committee held a
hearing on the topic at which Dr. Katz testified. At that hearing, he
at times sought to cast doubt on a recent CBS report about the numbers
of suicides among veterans. At other times in the hearing, he appeared
to confirm the numbers CBS was reporting, but did so in a way that was
not clear, parsing words and numbers. In an e-mail just three days
after that hearing, also published by CBS, Dr. Katz wrote an e-mail to
a colleague at the VA which made clear that VA's own numbers on the
rate of suicide among veterans were in line with the CBS report.
Reviewing that transcript is a disturbing experience, because Dr. Katz
and others seemed more interested in distracting from the issue at hand
by bashing the news media, than in informing the Committee, the press
and the public about this very important matter so that we can address
it in as effective a way as possible.
I am pleased that we are having this follow up hearing today, so
that we may gain all the facts and thereby work to prevent suicide
among our veterans.
Prepared Statement of Honorable James P. Moran,
a Representative in Congress from the State of Virginia
Mr. Chairman, Members of the Committee, I thank you for
holding this important hearing and I commend your work that you've
already undertaken on behalf of our Nation's veterans.
Most of us understand from the media reports and
anecdotal accounts from our constituents that suicide among our
veterans is one of the most pressing issues that we should address.
We know that the new generation of returning soldiers is
more vulnerable to the immediate psychological wounds of war that lead
to suicide. 20 percent of our veterans from Iraq and Afghanistan show
signs and symptoms of PTSD, depression and anxiety. This number
increases to 50 percent for soldiers with multiple tours or inadequate
time between deployments.
One of the measures that we can take to prevent suicide
is to provide a voice of understanding in their time of need. The
``Veterans Suicide Prevention Hotline Act'' would create a stand-alone
24-hour National toll-free hotline to assist our Nation's veterans in
crisis.
The key is that this hotline would be staffed by
veterans, trained to appropriately and responsibly answer calls from
other veterans. These volunteers would be trained in active listening
and crisis de-escalation respond to a variety of crisis calls.
I understand that the Department of Veterans' Affairs has
developed a veterans' option off of the National Suicide Hotline. While
I applaud their effort to finally address this problem, I believe that
there are key differences in the approach.
Sometimes a veteran doesn't want to talk to a doctor--he
or she wants to talk to someone who's got a real-life perspective of
what's happening. This ``cultural competency'' that a fellow veteran
provides can make a real difference in crisis counseling.
Moreover, soldiers with mental illnesses face societal
stigma associated with seeking care through the VA. Research from the
Air Force's suicide prevention efforts suggest that fear of ``the
system'', of an unfriendly mental health establishment, and of
potential job-related consequences keep many active duty soldiers and
recent veterans from seeking the care they need.
I am also concerned that the VHA is already overburdened
by their many healthcare responsibilities to provide a top-notch
hotline effort. Stretched budgets and staffing shortages may not be
able to meet the challenges of many returning veterans as our Nation
redeploys from Iraq in the future. A non-profit organization dedicated
to suicide prevention would be able to provide focus, stability and
commitment that the VA may not.
To conclude, our vets deserve as much support when they
return from combat as they receive while in battle. Too many of our
veterans are struggling to make the difficult adjustment back to
society and need someone they can talk to, someone who's walked a mile
in their shoes. This legislation will offer that caring voice at the
end of the line.
I applaud the Committee for their work on this effort.
Prepared Statement of Honorable James B. Peake, M.D.,
Secretary, U.S. Department of Veterans Affairs
1. ISSUES RELATED TO COLLECTING SUICIDE DATA
The purpose of this testimony is to provide information on the
issues related to veterans suicide: what VA knows, including the
sources of information we use; what we do not know, and what we intend
to do about that problem; and what we have been doing to directly
address the issues of suicide from a clinical perspective, and how we
are expanding our outreach, even as we seek better ways to measure the
problem.
The language used to talk about suicide is complex. Suicidal
behavior exists along a continuum; from thinking about ending one's
life, to developing a plan to do so, to non-fatal suicidal behavior, to
actually ending one's own life. The Centers for Disease Control (CDC)
has come up with some definitions of suicidal behavior which the
Department of Veterans Affairs (VA) has adopted.
CDC has defined suicidal ideation as having thoughts of harming or
killing oneself; a suicide attempt is a non-fatal, self-inflicted
destructive act in which a person has either an explicit or an inferred
intent to die; self-inflicted injuries are suicidal and non-suicidal
behaviors such as self mutilation; and suicide itself refers to a fatal
self-inflicted destructive act in which there is an explicit or an
inferred intent to die.
Suicide is a relatively infrequent act. Although suicide is the
11th leading cause of death among Americans of all ages,
when studying any group over short periods of time the number of actual
suicides will be low. Only very large studies conducted over long
periods of time allow the accumulation of enough observations to make
meaningful comparisons.
Suicide risks vary by age, gender and other factors. For Americans
in general, the highest rates of suicide are among older men, but
middle-aged veterans appear to take their own lives in greater
proportions than their elders.
Suicides often occur in close proximity, especially after media
attention. This kind of behavior is called ``copycat behavior,'' or the
``Werther effect,'' after a wave of suicides in 18th century
Europe following the publication of a book by Goethe. It can be
difficult to tell when a cluster represents a temporary trend, or a
sustained trend.
Official suicide rates based on death certificate data can be
incomplete. There are regional differences in how suicides are defined;
how ambiguous cases are classified; and how thoroughly coroners or
medical examiners investigate causes of death. In some areas religious
traditions, life insurance policies, or legal sanctions may lead to
underreporting. The increased awareness of the relationship between
mental illness and suicide may cause an apparent increase in the
reported number of suicides--without the rates actually differing.
And finally, reconstructing the events leading up to a death is
difficult. Death certificates provide only a limited amount of
information about actual causes of death, so researchers need to
contact those closest to the victim to understand the true
circumstances of death, and the factors that contributed to a death.
Family members and others can often provide inaccurate or incomplete
information.
The way researchers determine incidences for suicide is to express
the number of suicides in a population per hundred thousand people per
year. Because suicide rates vary by age, with both older and younger
people at higher risk, any rates that attempt to make comparisons
across different populations by year must be adjusted to allow for
accurate comparisons. One way to do so is to look at age specific rates
of suicides and compare them to the U.S. population as distributed by
age. CDC uses the U.S. population census figures for 2000 to do this.
Another method of adjustment is called the standardized mortality
ratio. This ratio compares the number of observed deaths in a defined
group with the number of deaths that would be expected if that group
had the same age-specific rates as a standard population.
Finally, there are sophisticated statistical techniques which can
be used to derive a relative risk that take into account multiple
characteristics of individuals, such as gender, race and ethnicity,
medical conditions and other factors.
Each of these methods of adjustment has their strengths and their
weaknesses. Each is potentially misleading when comparing populations
with very different age or gender distributions. A careful analysis of
suicide rates that is age and gender specific is both necessary and
appropriate.
Because of this, VA has long subjected its own data, that of the
Department of Defense, and data from nationally accepted statistical
sources to careful and painstaking analysis to obtain the truth about
veterans' suicide.
A suicide rate is normally calculated by describing the number of
cases occurring in a defined group over a specific period of time.
These are called incidences of suicide, and to avoid expressing
incidences as very small fractions, suicide rate is typically expressed
in terms of the number of suicides per 100,000 persons per year.
To make accurate comparisons of suicide rates, such as trends over
time or comparisons among veterans and non-veterans, three important
elements are needed. First is an accurate count of events for both
groups, called the numerator. Second is an accurate estimate of the
total population at risk, called the denominator. And third, as already
mentioned, there needs to be an adjustment for age and gender
differences between populations.
2. HOW VA COLLECTS SUICIDE DATA
VA relies on multiple sources of information to identify deaths
that are potentially due to suicide. This includes VA's own Beneficiary
Identification and Records Locator Subsystem, called BIRLS; records
from the Social Security Administration; and data compiled by the
National Center for Health Statistics in its National Death Index.
This is a painstaking and difficult process for VA and for others,
best illustrated by the fact that suicide data from the Centers for
Disease Control and Prevention are available only through 2005.
Calculating suicide rates specifically for veterans is made even more
difficult by the fact that the National Death Index does not include
information about whether a deceased individual is a veteran or not.
The National Death Index is simply a central computerized index of
death record information on file in the vital statistics offices of
every state. The Index is compiled from computer files submitted by
State vital statistics offices. Death records are added to the file
annually, about twelve months after the end of a calendar year. CDC
uses this data to compile its statistics on American death rates.
Given that the NDI does not indicate veteran status, VA regularly
submits requests for information to NDI. Because the system contains a
list of all Americans who have died, and because of the capabilities of
its Electronic Health Record system, VA is able to send NDI a list of
all patients who have not been treated at any VA medical centers in the
past twelve months and before, to see if they are still among the
living.
NDI checks this list against their records, and tells VA which
veterans have died, and the cause of their death as listed on the
veterans' death certificates. From this information, VA is able to
learn the approximate number of veterans under its care who have died
of suicide, and to use that information to make comparisons on rates of
suicide among those veterans and all other Americans.
This information tells VA about the suicide rates among veterans
under its care, but says nothing about the rates of suicide among
veterans who are not currently in the system. For those veterans, an
even more complicated process has to be followed in order to estimate
rates. VA obtains regular updates from the Department of Defense's
Defense Manpower Data Center on soldiers separating from the military.
Those new veterans immediately become part of total population and
suicide calculations.
In 2002, the CDC established the National Violent Death Reporting
System, or NVDRS. NVDRS today is fully implemented in 16 states, and
collects data on violent deaths, including suicides. NVDRS collects
data on violent deaths from a variety of sources, including death
certificates, police reports, medical examiner and coroner reports, and
crime laboratories. Veteran status is included in the database.
Together, these sources offer a comprehensive picture of the
circumstances surrounding homicides and suicides. This, too, is a time-
consuming and difficult task, and standard reports from NVDRS are
available only through 2005.
Because NVDRS is a comprehensive source of data, and because it
indicates whether or not a coroner has indicated that the deceased is a
veteran, VA is able to obtain counts of the number of suicides among
all veterans in the sixteen stats that have fully implemented this
system, broken down by sex, age, race and state. To summarize,
determining suicide rates among veterans is a challenging puzzle.
Multiple data sources must be used, and data must be carefully checked
and rechecked. Each system helps obtain a piece of the complicated
puzzle that constitutes the process of accurately estimating rates of
veteran suicides.
These are time-consuming processes--but they are the best ways VA
knows to obtain aggregate data on suicide. The weaknesses inherent in
this method are clear.
First, the CDC's manual for completion of death certificates states
that the determination of whether or not someone is a veteran should
usually be done by funeral directors. The information available to
directors is limited, and their willingness to investigate the question
of veteran status varies. Generally, these directors allow families to
self-certify their response to the question of whether their loved one
was a veteran; an approach fraught with pitfalls. In addition, funeral
directors may not be clear on whether a young person died on active
duty, or shortly after leaving the service.
Second, the classification of a death as suicide is dependent on
the work of coroner's offices throughout America. This paper has
already discussed issues related to coroner determinations: regional
differences in definitions; the manner in which ambiguous cases are
classified; the level of investigative determination; religious
traditions, and legal sanctions all create difficulties in data
reliability.
And third, data takes a very long time to assemble. Neither NDI nor
NVDRS has released reports of data newer than 2005--and it is midway
through 2008 at present.
There are actions VA can take, and is taking, to improve the
reliability and the speed of the data the Department is obtaining and
providing to Congress. First, VA has begun negotiations with NVDRS
staff that will provide information from all of NVDRS' sources (death
certificates, police reports, medical examiner and coroner reports, and
crime laboratories) on a monthly and quarterly basis, as they are
received by NVDRS.
VA will not be able to determine when there is sufficient
information to provide full and publishable data--only NVDRS can do
that--but will be able to examine and analyze these reports in a way
that will allow the Department to spot suicide trends by age, sex and
even region more quickly and to take action in those areas.
The Department will also systematically assess its efforts to
inform funeral directors about the importance of determining whether or
not a person who has died of suicide is or is not a veteran, and what
sorts of information to consider in making that determination.
VA will also investigate working directly with state vital records
offices, as the NDI does, to obtain information on veteran suicides
directly from them.
And finally, VA has a new way of obtaining information on both
suicides and suicide attempts: the Department's suicide prevention
coordinators.
Until VA committed itself last year to providing full time suicide
prevention coordinators at each of its 153 hospitals, it could provide
no useful number of attempted suicides among patients. Last October, a
standardized definition of suicide attempts was developed and
coordinators were asked to begin to count the number of such attempts
of which they were aware.
VA's definition of a suicide attempt included any behaviors that
might have potentially allowed veterans to injure themselves, when
there was evidence that the veteran had the intent to kill himself or
herself--whether or not he or she was actually injured. The definition
also included events in which a veteran was rescued, an attempt
thwarted, or a veteran changed his or her mind after taking an initial
action.
On February 13, 2008, an internal email from VA's Deputy Chief of
Patient Care Services for Mental Health discussed the existence of this
information. In this email, he suggested 1,000 veterans a month under
VA care were being reported as attempting suicide, and was concerned
about disclosing the information.
The data was not sent to CBS because of his concerns.
The number of attempts referenced was based on only three months
worth of data, too short a time period to determine if it was reliable.
The data was demonstrably not accurate. Even now, six months after
collecting data began, the reports indicate that a number of states
have suspiciously low reporting rates--and there is remarkable
variability among individual VA facilities throughout the United
States, due either to regional variability in suicide rates,
differences in the manner in which individual suicide coordinators
reported data, or both.
VA's suicide prevention coordinators were new to their jobs, and
new to their tasks. There was a great deal of uncertainty over
``borderline calls,'' and many of them were just beginning to make the
community and in-hospital contacts that are essential in making an
accurate count of the number of suicide attempts among patients.
VA is addressing the problem of the accuracy of suicide
coordinators' data in a number of important ways; by regularly
reviewing the data the Department receives, and educating coordinators
on the proper way to collect and report this information;
And VA is regularly reviewing difficult ``calls'' with its suicide
coordinators--and encouraging them to meet the right people in their
communities to obtain additional data.
In the near future, the Department intends to ask suicide
prevention coordinators for the names of all those in their facility
who have attempted suicide. This will allow further refinement of this
data by checking the electronic medical records of individual veterans
whose names have been reported as having attempted suicide. VA will
learn how this information has been entered into the health record, and
how practitioners have incorporated this information into the treatment
plan for the individual whose record is being reviewed--with important
implications for preventing suicide throughout VA's system.
VA's suicide coordinators are providing another important service;
they are providing an additional source of data on the number of
completed suicides at their facilities. This data, too, has significant
problems: while VA can tell with considerable accuracy how many
veterans commit suicide within its facilities, suicide coordinators
have both limited time and contacts among coroners and funeral
directors to provide accurate counts of the numbers who have died of
suicide in the community.
While coordinators will be encouraged to continue to make those
contacts, and to attempt to refine the accuracy of the numbers of dead
they submit, VA believes that the focus of suicide prevention
coordinators must be on preventing suicide among the living.
Epidemiologists and researchers, using the data sources described
above, will be the ones to learn more from those who have been lost.
Before turning to the actual data, here is a brief explanation of
some data which has been widely attributed to VA, but which, in fact,
is not the Department's. On March 20, 2008, CBS aired a story on
veterans' suicide which included a statement in which the network said
it had ``obtained from VA'' the information that there had been 790
attempted suicides among veterans under the Department's care in all of
2007.
VA has since reviewed its records to try to understand where CBS
might have gotten their information, and believes the number stemmed
from a response to a Freedom of Information Act Request CBS made to the
Veterans Health Administration's Freedom of Information Act Officer on
December 20, 2007; a request that was subsequently modified on January
29, 2008. VA provided CBS with the information they asked for--
information in the Department's National Patient Care Data base for the
years 2000 through 2007, broken down by year, state, age group, gender
and race.
This data provides a breakdown of why veterans were seen in VA's
hospitals and clinics by International Classification of Diseases code.
Once such code is ``Suicide and other Self-Inflicted Injuries.'' CBS
apparently counted the total number of veterans for whom that code was
entered--and came up with 790 attempts for 2007.
That number, unfortunately, is not at all useful if the purpose of
the count is to determine the total number of suicides and attempts
among veterans under VA's care. Some people who attempt suicide, but do
not die, do not then present directly to VA for care. Others do not
admit that their injuries were due to suicide attempts until a
counselor discusses their situation with them. And still others treat
their own wounds without seeing a clinician; the attempt is only
revealed later, during counseling. CBS's number, while arithmetically
correct, is actually misleading.
3. VA' S DATA ON SUICIDES AND ATTEMPTS
To review what we do know specifically, let us compare veterans'
rates of suicide to non-veterans rates. The source of the base data is
the National Death Index, a product of the National Center for Health
Statistics of the Department of Health and Human Services. The most
current complete data in this area is from 2005; 2006 data should be
released soon. The overall rates of suicide for men and women from 2001
through 2005 are shown in Tables 1 and 2. It is important to separate
the rates for men and women. By doing so, we see that men have a higher
rate of suicide than women; a rate that is statistically significant.
It is also important to separate these figures by age groupings,
because there are significant differences in that area as well. These
tables provide that information as well.
Table 1: Suicide Rates Per 100,000 Male U.S. Citizens by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
All men 23.18 23.63 23.20 23.20 23.19
----------------------------------------------------------------------------------------------------------------
18-29 20.14 20.08 19.38 20.21 19.35
----------------------------------------------------------------------------------------------------------------
30-64 22.45 23.10 23.13 23.00 23.19
----------------------------------------------------------------------------------------------------------------
65+ 31.42 31.81 29.76 29.01 29.53
----------------------------------------------------------------------------------------------------------------
Table 2: Suicide Rates Per 100,000 Female U.S. Citizens by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
All women 5.22 5.44 5.42 5.81 5.65
----------------------------------------------------------------------------------------------------------------
18-29 3.40 3.67 3.56 3.91 3.90
----------------------------------------------------------------------------------------------------------------
30-64 6.28 6.47 6.57 7.09 6.78
----------------------------------------------------------------------------------------------------------------
65+ 3.88 4.09 3.79 3.79 3.99
----------------------------------------------------------------------------------------------------------------
Source: CDC's WISQARS Injury Reporting System and CDC's National Center for Health Statistics' National Death
Index
Tables 3 and 4 provide overall rates of suicide for male and female
Veteran VA users, broken down into three age groups: 18 to 29; 30 to
64; and 65 and older.
Table 3: Suicide Rates Per 100,000 Male Veteran VA Users by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
All Male VA users 36.49 41.58 32.92 35.40 37.19
----------------------------------------------------------------------------------------------------------------
18-29 27.75 36.54 35.64 42.54 26.94
----------------------------------------------------------------------------------------------------------------
30-64 41.37 46.32 39.57 38.44 40.66
----------------------------------------------------------------------------------------------------------------
65+ 32.03 37.03 26.77 32.09 34.27
----------------------------------------------------------------------------------------------------------------
Table 4: Suicide Rates Per 100,000 Female Veteran VA Users by Fiscal Year and Age
----------------------------------------------------------------------------------------------------------------
2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
All Female VA users 9.87 12.49 9.00 12.28 13.59
----------------------------------------------------------------------------------------------------------------
18-29 2.12 15.75 5.93 7.41 7.81
----------------------------------------------------------------------------------------------------------------
30-64 11.99 11.17 10.76 14.88 13.96
----------------------------------------------------------------------------------------------------------------
65+ 6.58 15.66 3.95 4.31 17.60
----------------------------------------------------------------------------------------------------------------
Source: CDC's National Center For Health Statistics' National Death Index
These tables show that men, whether or not they are veterans, have
a higher rate of suicide than women, in numbers that can be considered
statistically significant. In addition, there are significant
differences by age groupings. VA is able to make these comparisons,
because it is able to match the names of veterans under our care whom
we have not recently seen against the National Death Index. The Death
Index then provides information on which of these men and women have
died, and the cause of their death, including suicide.
What cannot be learned from this table is how the rates of suicide
compare among all veterans, not only those in the VA system, to the
general population. Doing so would require matching the full list of
24.5 million veterans against the National Death Index to see how many
of them have committed suicide. That currently is not possible.
However, VA has matched up general population rates of suicide in the
sixteen states reporting to NVDRS in 2005 against the rate of veteran
suicide in those states.
Table 5: Suicide Rates per 100,000 in 16 States Among General
Population vs. Veteran Population (Males) in 2005
------------------------------------------------------------------------
18-29 30-64 65+
------------------------------------------------------------------------
All male VA users 53.18 36.85 36.00
------------------------------------------------------------------------
All male veterans 44.99 25.60 31.52
------------------------------------------------------------------------
All men 20.36 23.28 30.51
------------------------------------------------------------------------
Table 6: Suicide Rates per 100,000 in 16 States Among General
Population vs. Veteran Population (Women) in 2005
------------------------------------------------------------------------
18-29 30-64 65+
------------------------------------------------------------------------
All female VA users 25.02 15.81 ---
------------------------------------------------------------------------
All female veterans 15.35 11.41 3.66
------------------------------------------------------------------------
All women 4.35 7.04 3.63
------------------------------------------------------------------------
Sources:
General Population: CDC's Web-based Injury Statistics Query and
Reporting System
OEF/OIF: DoD's Defense Manpower Data Center
Suicide Data: CDC's National Center for Health Statistics National Death
Index and CDC's National Violent Death Reporting System
At this time, there is no firm explanation of the reason for the
disparity in rates between VA's patients and other Americans. However,
the veterans VA serves--as opposed to the overall population of
American veterans--are older, sicker, and poorer than the general
population of the United States. VA researchers believe this may
account for at least some of the apparent differences.
VA's summary of this data from 2001 through 2005 yields the
following hypotheses:
Male veterans commit suicide at a somewhat higher rate
than other men, but with varying statistical significance by age and
over different years.
Within the group of male veterans there are differences
in the age at which veterans die of suicide compared to what is seen in
the general population--especially in the ages between 30 and 64, at
which ages veterans have a statistically significant higher rate. This
finding is reproducible over time.
Male veterans commit suicide at a higher rate than female
veterans.
Within the group of female veterans, there is nearly a
twofold increase over the rate of suicide for women in the general
population, which is also variably statistically significant over the
years and by age.
Clearly, returning service men and women represent a group of
particular interest to the Nation. VA has a particular sense of urgency
to understand why these men and women might be taking their own lives--
and to intervene to prevent even a single suicide. To better understand
suicide in this particular cohort, Dr. Han Kang of VA's Environmental
Epidemiological Service conducted a study that matched those
servicemembers who had served in the theater of operations, and who
separated from service between 2002 and 2005 against the National Death
Index.
Using this method, Dr. Kang found that 144 out of 490,346 separated
OEF/OIF servicemembers committed suicide during that time, for an
overall rate of 21.9 per 100,000. These are deaths only of men and
women who separated from the military, and the data does not include
any suicides while a servicemember was on active duty.
To compare this to other national norms, Dr. Kang looked at this
cohort against the national averages discussed above. For OIF/OEF
veterans who had deployed and separated from 2002-2005, the rate was
slightly higher than would be expected in an age, gender and race
matched general population, but not by a statistically significant
amount. (Standardized mortality Ratio of 1.15 (p >.05.)
Dr. Kang also examined this data for differences in suicide rates
between those who have used VA for care and those who have not. He
found that 17.0 of every 100,000 OEF/OIF veterans who use VA for care
take their own lives, compared to 24.0 of every 100,000 OEF/OIF
veterans who do not use VA for care. This apparent advantage of VA
care, though encouraging, is not statistically significant. In this
group, the same is true for vet center users.
Male veterans 18-29 who used VA care took their own lives at a rate
of 21.0 per 100,000, compared to veterans of that age who did not use
VA for care, a group which died of suicide at a rate of 30.4 per
100,000--a statistically significant difference. Male veterans aged 30-
64 who used VA for care died of suicide at a rate of 17.5 per 100,000,
compared to a rate of 22.8 per 100,000 for their fellow veterans who
did not use VA for care--not a statistically significant difference.
Since only 3 women OEF/OIF veterans died of suicide through 2005,
accurate rates within age groups cannot be calculated.
VA statisticians have worked with this now-older data in
anticipation of follow-on data when the updated National Death Index
information is available. Some of the insights they have found include
the knowledge that there appears to be little variation in suicide risk
by branch of service. Statisticians also found that a diagnosis of a
mental disorder predicted a nearly 1.8 times higher suicide risk than
the general population. This is consistent with what has been published
in research journals regarding the non-veteran population, and
emphasizes the importance of the Department's mental health efforts.
All of this data comes from national data for suicide against those
who are known, from VA's data sources or from Department of Defense
records, to be veterans. These national numbers must be used because
VA's clinical records do not capture, in any reliable or complete way,
such events as suicides or suicide attempts.
The National Death Index, a national roll-up of information from
coroners through the states, offers the most complete compilation of
deaths among veterans and their causes--since VA may not know of a
death even if it occurs in an area in which the Department has a
facility. Because information on deaths continues to be updated as
reports come in over time, confidence in the completeness of those
numbers only comes after several years of data collection. VA is
awaiting at this time the release of National Death Index compilations
for 2006 for further analysis.
Regarding inpatient deaths: from 2000 through 2007, exactly 50 VA
inpatients took their own lives while under the Department's care,
based on root cause analyses of the deaths received by VA's Office of
Patient Safety. That number varies from a high of 14 such suicides in
2002, to a low of 2 in 2007, when Veterans Health Administration
officials demanded that all facilities pay special attention to
improving their environment of care to reduce opportunities for
suicide.
4. VA' S SUICIDE PREVENTION EFFORTS
The steps VA is taking to prevent suicide among veterans are
important and significant. All VA employees have been given the message
that even strong and resilient people can develop mental health
conditions; care for those conditions is readily available and should
be immediately provided; and treatment works.
VA has held two National VA Suicide Prevention Awareness Days
throughout its system to focus all 200,000 health care employees on
this issue. The first event focused on enhancing overall awareness of
the issue. The second coincided with National Suicide Prevention
Awareness Week. During that week, VA staff was trained on how to work
with available prevention resources, including the hotline and the
suicide prevention coordinators. VA will continue participating in
Suicide Prevention Awareness Week activities every year, with a special
focus on veterans and ways VA can continually improve its suicide
prevention efforts.
The Department is in the process of adding 23 new vet centers
throughout the Nation to provide more individual, group and family
counseling to veterans of all wars who have served in combat zones,
bringing the total number of vet centers to 232.
VA's suicide prevention program includes two centers that conduct
research and provide technical assistance in this area to all locations
of care. One is the Mental Health Center of Excellence in Canandaigua,
New York, which focuses in developing and testing clinical and public
health intervention related to suicide risk and prevention. The other
is the VISN 19 Mental Illness Research Education and Clinical Center in
Denver, which focuses on research in the clinical and neurobiological
sciences with special emphasis on issues related to suicide risk.
VA's system of care also includes a suicide prevention call center,
also located in Canandaigua, and the suicide prevention coordinators
previously discussed, who are located at each of VA's 153 hospitals.
Altogether, VA has more than 200 mental health providers whose jobs are
specifically devoted to preventing suicide among veterans.
To develop the suicide prevention call center, the Department has
partnered with the Lifeline Program of the Substance Abuse and Mental
Health Services Administration. Those who call 1-800-273-TALK are asked
to press ``1'' if they are a veteran, or are calling about a veteran.
Unlike other such hotlines, VA's hotline is staffed solely by
mental health professionals--24 hours a day, seven days a week. Hotline
staff is trained in both crisis intervention strategies, and in issues
relating specifically to veterans, such as traumatic brain injury and
post traumatic stress disorder. In emergencies, the hotline contacts
local emergency resources such as police or ambulance services to
ensure an immediate response.
Cards, pamphlets and posters--even refrigerator magnets--bearing
the number are distributed by suicide prevention coordinators to at-
risk veterans and their family members.
In addition, posters with hotline information are located
throughout VA medical centers and clinics, and in all residential
rehabilitation programs there are stickers on phones and by doors with
the hotline number. Vet Centers also make this information available.
If the caller is a veteran enrolled with VA for care, the hotline
staff is able to use the veteran's electronic medical record during the
call, if the veteran is a VA patient and willing to identify himself or
herself. These records provide information that is invaluable during a
crisis, including information on medications; the patient's treatment
plan; and who to contact during this emergency.
Staff can talk directly to the facility that is treating the
veteran. They can place consults in the patient's medical record, and
are able to make arrangements to directly refer veterans to a Medical
Center or Community-based outpatient clinic to be seen if that's
appropriate.
And hotline staff follows up on these referrals. They check
patient's records to see if consultations were completed; actions are
taken; and followups are ongoing. If the record does not show this
information, the suicide prevention coordinator is called, ensuring
that no referral is lost in the process.
From its beginnings in July, 2007 through the end of April, 16, 414
calls have come to the hotline from veterans and 2125 family members or
friends have called. These calls have led to 3464 referrals to suicide
prevention coordinators and 885 rescues involving emergency services.
493 active duty servicemembers have also called.
Besides keeping track of veterans who have tried to take their own
lives, suicide prevention coordinators receive referrals of those at
risk for suicide from both the hotline and from providers in their
facilities. They also ensure that care for these veterans is
appropriate for their situations.
Coordinators educate their colleagues, veterans and families about
risks for suicide. They provide enhanced treatment monitoring for
veterans at risk and ensure that any missed appointments are followed
up on. The coordinators work with the entire staff of their medical
centers to maintain awareness of those who have previously attempted
suicide, and ensure their care is enhanced to reduce the risk of
renewed attempts.
They also work with patient safety officers to conduct quarterly
safety inspections of inpatient psychiatry units, and coordinate staff
education programs about suicide prevention. These coordinators are in
the process of organizing a system of flags in the electronic medical
record system to alert providers about those at high risk. They are
also conducting training for community members who have frequent
contact with veterans to help them recognize those at risk and
encourage them to seek treatment.
There is a large body of scientific literature on suicide. Over the
years, VA has been a prime contributor to the knowledge that has been
developed in the scientific community on this issue. Our research has
helped us target our efforts to reduce suicide. Some of the information
our researchers have developed includes:
Among veterans receiving care from VA who died from
suicide, almost 60% of those under age 65 had a mental health or
substance abuse diagnosis on their medical records--but only 24% of
those 65 or over had such a diagnosis.
There is significant variability in suicide rates among
veterans by geography. In general, rates are lowest in the Northeast
and highest in the West.
Firearms are the most common means used by veterans who
died of suicide, accounting for nearly two-thirds of all deaths.
There appears to have been an increase in suicide rates
among Vietnam veterans during the first two years after these veterans
returned home. After a few years, however, Vietnam veterans' rates of
suicide were comparable to those of the general population.
There was no increase in suicide rates among veterans who
returned from the first Gulf War.
Those veterans who are wounded in combat are at higher
risk of suicide.
5. FUTURE ACTIVITIES
In the near future, the Department will continue to educate its
employees; through additional Suicide Prevention Days; through posters
identifying the warning signs of suicide; and through its continuing
Employee Education process to identify those at possible risk of
suicide to ensure they get proper care. As new data on suicide rates,
risk factors for suicide and regional variations become available, VA
will use that data to refine its programs, and to better evaluate their
level of success.
VA will increasingly reach out to the newest generation of
veterans, by using communications outlets familiar to them. VA now has
a virtual office on ``Second Life;'' and recently collaborated with MTV
on a video on readjustment issues for returning veterans that can be
found on their Web site.
VA will continue its efforts to meet the mandate of the President's
New Freedom Commission to reduce the stigma that surrounds mental
illness.
VA will also continue the expansion of its mental health program
that has enabled the Department to hire more than 3800 new mental
health employees in the past three years, and expand hours of operation
for mental health clinics beyond normal business hours. These efforts
to better identify and treat mental illness will help prevent
contemplation of suicide and suicide attempts--and will help ensure
that veterans in crisis are already involved in VA's system and have
somewhere to turn when they need help.
The Department will aggressively follow up on patients in mental
health and substance abuse programs who miss appointments to ensure
they are not lost to follow up care. VA will also monitor the standards
the Veterans Health Administration has set for itself: to provide
initial evaluations of all patients with mental health issues within 24
hours, provide urgent care immediately when that evaluation indicates
it is needed, and to complete a full evaluation and initiate a
treatment plan within 14 days for those not needing immediate crisis
care.
On May 2, VA began contacting nearly 570,000 combat veterans of the
Global War on Terror to ensure they know about VA medical services and
other benefits. The Department will reach out and touch every veteran
of the war to let them know it is here for them. The first of those
calls are going to an estimated 17,000 veterans who were sick or
injured while serving in Iraq or Afghanistan. If any of these 17,000
veterans do not now have a care manager to work with them to ensure
they get appropriate healthcare, VA will offer to appoint one for them.
All case managers for OEF/OIF veterans will be trained in suicide
risk recognition and management for their patients, and encouraged to
establish a personal relationship with those veterans to support their
healthcare needs.
I have also directed the creation of a work group on suicide
prevention in the veteran population. This work group will look at all
matters relating to VA's ability to prevent suicide among veterans.
They will be given all the data VA has, and access to the best experts
VA knows.
The work group will be asked to provide a report within fifteen
days of the completion of their meeting on how VA can better approach
suicide prevention, suicide research, and suicide education.
All work group members will come from outside the Department of
Veterans Affairs. Some will be DoD specialists; others will be from
other government agencies. Nationally recognized clinical treatment,
research and public health experts on suicide and suicide prevention
will augment them. The work group will provide an additional level of
advice and oversight to all the issues described above.
There is nothing more tragic than the loss of even one of those
great men or women who have served this nation. The VA is committed to
doing all that we can to serve the individual while we continue to try
to understand a very complicated problem that is also a national
problem. We owe this committee and the nation accurate information and
carefully studied, thoughtful conclusions while we provide the ``best
care anywhere'' to our Veterans.
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Statement of Ronald William Maris, Ph.D.,
Distinguished Professor Emeritus, Past Director of Suicide Center,
Adjunct Professor of Psychiatry,
and Adjunct Professor of Family Medicine,
University of South Carolina, School of Medicine, Columbia, SC
What Causes Suicide? Suicide is not one thing, but is a
multidimensional outcome (including a continuum of self-destruction
from unintentional self-harm, partially self-destructive behaviors,
ideas about suicide, plans to suicide, lethal and non-fatal suicide
attempts, and finally, to suicide completions; which themselves can be
escape, revenge, altruistic, and/or risk-taking) resulting from several
risk factors interacting over time (what I call a ``suicidal career,''
Maris, 1981). Risk factors for suicide include relatively chronic
vulnerabilities (like being an aging male, owning a gun, having a
history of depressive disorder, being an alcoholic, etc.) and more
acute stressors (like post-traumatic stress disorder, recent losses,
pharmacological crises [such as serotonergic dysfunctions], inability
to get effective healthcare, etc.).
From my case-control surveys I have derived about 15 evidence-based
risk factors for suicide outcomes (the following list includes
statistically significant risk factors compared to controls of nonfatal
suicide attempts and natural death in a random sample of 2,153 suicides
(Maris, 1969 and 2002). There could be more than just fifteen risk
factors for suicide (See Maris, 2000, Chapter 17) and the list below is
not necessarily ranked (although factors 1 and 2 tend to be the most
prevalent in suicides). The factors that cause most suicides are (See
Maris et al., 2000:80; Maris, 2002; Maris, 2007):
Depressive and affective disorders, schizophrenia
Alcohol and substance abuse
Suicide ideas, plans, preparations
Prior suicide attempts (caveat: many white males die
after one attempt)
Available lethal methods (especially, firearms)
Social isolation, loss of social support
Hopelessness (Beck claims hopelessness is more predictive
of a suicide outcome than depression is; See Maris et al., 1992)
Being an older white male (generally the older, the more
likely suicide is)
History of suicide or mental disorder in one's first
degree relatives
Work problems, unemployment, lower SES, homelessness
Marital problems & discord, separation, divorce,
widowhood
Stress, PTSD, negative life events, traumas
Feelings of anger, aggression, impulsivity, serotonergic
dysfunction
Physical illnesses; like spinal cord, brain injury,
epilepsy, arthritis, ulcers
Repetition and co-morbidity of above risk factors;
``suicidal careers''
Obviously, what causes veteran suicides has both common and unique
factors compared to the general population in the United States. Murphy
and Robins (1970, 1981) found in St. Louis county that about 47% of all
suicides had an affective disorder and 25% had alcohol problems. Rates
of depression, alcohol abuse, having a firearm, isolation, marital
disruption, and trained aggression are all more prevalent in veteran
populations. Zivin (12/7/07 @ 2193) estimated that veteran depression
symptoms are 2 to 5 times higher than those in the general population.
Kang (12/11/07) states that as of 9/2007 among vets in healthcare
at the VA, 40% had major depression diagnoses and 20% had diagnoses of
PTSD (DSM IV code 309.81).
Post-traumatic stress disorder is extremely important among combat
veterans (about 33% of female veterans experience sexual trauma, which
can also cause PTSD) because it is common (15 to 50% of vets have PTSD;
See Vets for Common Sense et al. v. Peake et al. Complaint, 7/23/07 @
18-69) and it is interactively related to other suicide risk factors.
CBS (11/13/07) reports that 28.3 percent of Iraq vets had mental health
problems. Kang (12/11/07 @ 445) claims that of the approximately 1.6
million troops deployed in Afghanistan and Iraq 3,444 (now over 4,000)
have been killed and 90% have been ``traumatized.''
PTSD was first stated as a psychiatric anxiety diagnosis in 1980 in
the DSM-III (code 309.81). It involved the following symptoms or
criteria:
Being exposed to a traumatic event where death or serious
injury occurs accompanied by feeling of intense fear and helplessness.
The event is persistently re-experienced.
The victim avoids trauma-associated stimuli.
The victim experiences symptoms of increased arousal.
The symptoms last one month or more (acute v. chronic)
and are characterized by social and occupation dysfunction
PTSD is one of the unique suicidogenic factors among veterans and
interactively raises other suicide risk factors. Note, too that the
percentage of all USA general population deaths that are suicides is
2.1% (AAS, 1/24/08). But among 15 to 24 year-olds 12.3% of all death
are by suicide. Kang reminds us that the median vet suicide age is 20
to 29 (12/11/07 @ 441) and 18-24 year-old soldier suicides make up 26.3
% of all suicide [about twice that of the non-soldier population].
Thus, obviously, the prompt and accurate diagnosis and treatment of vet
PTSD (and related depressive and substance abuse disorders) is a major
condition for veteran suicide prevention.
One reason I cannot answer definitely about what causes veteran
suicides is that the Office of Veteran Affairs has not provided me or
the courts crucial data that are needed. For example, each time there
is a military death, suicide attempt, or other serious incident, the VA
produces a short ``incident brief'' which summarily describes the
suicide or suicide attempt (Feeley, 4/9/08 @ 158). Then about 45 days
later each incident undergoes what is called a ``root cause analysis''
and a 3-page report is generated (Feeley @ 160). On April 22, 2008,
when I was an expert for the Plaintiff in the Veterans . . . v. Peake
trial in San Francisco, I was given only 170 of the estimated 15,000
incident briefs and none of the root cause analyses. Clearly these VA
documents could go a long way in establishing what causes veteran
suicides and whether or not there is an ``epidemic'' (Dr. Katz denies
that there is an epidemic, 11/13/07). It seems that these personal,
clinical documents could be redacted, with patients' names and other
identifying information removed, and then supplied to independent
scientific investigators, like myself. Clearly such crucial documents
would help clarify how many vet suicides there are and what the VA
thinks causes them (i.e., what are the root causes).
How High is the Veteran Suicide Rate and Is It An ``Epidemic''?
Virtually everyone agrees that the Iraq & Afghan vet suicide rates are
higher than those of the general USA population. One problem in getting
a consistent answer to our question is that there are shifting veteran
populations (all vets, WWII, Korea, Viet Nam, Gulf War, Afghanistan,
and Iraq), shifting times frames (e.g., yearly, 01-05, 06-08, etc.) and
various samples based on different data sets (e.g., incident briefs,
death certificates from the U.S. Department of Vital Statistics,
Department of Defense data, etc. Consequently there is a very wide
range of estimates of vet suicides.
Nevertheless, there is consensus that the vet suicide rates
(especially in OEF/OIF veterans; viz., Afghan and Iraq vets) are higher
than those of the general population; high enough to constitute a
serious national problem that demands resolution (Katz, 11/13/07).
Some of the estimates of veteran suicides rates and how much higher
they are than those of the general population are:
Katz (VA Deputy Chief of Patient Care Services) (2/21/08)
says 3.2 times higher (suicide rate of 34.6 /11, N = 8,218, VHA
patients from 2001-2005).
OIG Mental Health Strategic Plan for Suicide Prevention
(5/10/07) says 7.5 times higher (viz., 83/100,000/11), page 8.
Rathbun/CBS (2/28/08) says 1.8 to 2.3 times higher (6,256
vets of any war surveyed in 45 states = about 120 vet suicides per
week).
Zivin (12/7/07 @ page 2194) says 1683 of 807,694 vets
suicided = 208/100,000 or about 19 times higher than the general
population.
Katz (2/13/08 in an e-mail to Ev. Chasen) says that ``VA
suicide prevention coordinators are identifying about 1,000 suicide
attempts per month among vets seen in VA medical facilities (note:
usually suicide attempts exceed completed suicides about ten to twenty-
five times [AAS, 1/24/08]).
Katz (e-mail to Kussman [Under Secretary for Health] on
12/15/07) reports 18 suicides per day out of 25,000,000 total vets.
Kang (12/11/07) simply says ``the risk of death for vets
from suicide and motor vehicle accidents is higher that for the general
population'' (page 444, N = 144, 01-05, OIF/OEF vets only).
How high is a high enough vet suicide rate to merit national
concern? From one perspective even one suicide is too many, since
suicide is one of the leading causes of unnecessary death (See Maris et
al. 2000). William Feeley, Deputy Under Secretary for Health Care
Operations at the VA, said in a deposition (4/9/08, p. 38): ``Suicide
occurs like cancer occurs.'' Wrong! We all have to die (some by cancer,
some by heart disease, etc.), but no one needs to suicide. The VA seems
to think that a certain number of vet suicide deaths are inevitable and
that there is not much we can do about them.
When I consulted with Columbia University and the FDA to determine
if 9 antidepressant medications caused child and adolescent suicide,
the FDA decided that a relative risk of 2.1 or higher was sufficient to
require a Black Box warning be put in the drug's package insert and in
the Physician's Desk Reference. While there is no arbitrary bright line
for danger, note that almost all of the relative risks for vet suicide
are above 2.0.
Webster says an ``epidemic'' means prevalent and spreading rapidly
among many people in a community (like the U.S. military) at the same
time.'' Although we often reserve the concept of epidemic for extreme
cases like the plague, smallpox, influenza, polio, etc. It does seem
that veteran suicides are the product of a disease process and are
increasing. For example, Kang (12/11/07 @ 441) claims the following
percentages for vet suicides (OIF/OEF) from 2002 to 2006:
2002 = 7%
2003 = 21%
2004 = 48%
2005 = 68%
This looks a little like an epidemic to me (although one would need
to control for the numbers of vets and calculate rates).
The Office of the Inspector General's Mental Health Strategic Plan
for Suicide Prevention (by John Daigh, Jr., M.D., Assistant Inspector
General. 5/10/07). The purpose of this ambitious document is to assess
implementation of action pertaining to suicide prevention in the VHA's
mental health strategic plan (p. 1). Overall I found this plan to be a
systematic, well-organized survey, but in fact it points out many of
the VA's shortcomings in suicide assessment and prevention. For the
record in the VA there are (1) 21 regions (``VISNs''), (2) 154
hospitals or medical centers, (3) 875 outpatient clinics or ``CBOCs'',
and (4) 136 nursing homes (Feeley, 4/9/08 @ 45).
In the plan overview (@ iv) it indicates that ``at present the MHSP
initiatives for suicide prevention are only partially implemented.''
For example, on page 21 there is a chart summarizing the findings for
six major objectives:
Areas:
Findings:
A. Crisis intervention
24 hour mental health services in 94.5% of
facilities
B. Screening
98% screen for depression, major suicide risk
factor
C. Assessment
70% do not have tracking system
D. Interventions
61.8% do not target special groups
E. Databases
See SMITREC (data not available)
F. Education
61.4% of facilities did not make information
on suicide risks mandatory
The document (Cf., ``Suicide Risk Assessment Guide, Reference
Manual,'' VA 001510 in Vets . . . v. Peake, 5/21/08, p. 1, no date)
argues that suicide attempts are a major risk factor for suicide in
vets (p. 1). The problem with this finding is that about 90% of older
white males only make one suicide attempt (usually because they shoot
themselves in the head; See Maris, 1981). Thus, for most vet suicides,
a prior suicide attempt cannot be used to prevent their suicides. It is
too late already.
Later (p. 16) the MHSP document argues that the ``VA strategy for
suicide prevention should include universal screening designed to
activate the system for suicide prevention.'' In fact (See ``Suicide
Template,'' below) universal screening for vet suicide prevention
includes asking only two questions (viz., ``Have you felt depressed or
hopeless in the last two weeks?'', and ``Have you thought about
hurting/harming yourself in the last two weeks?'' If the vet answers
``No'' to question # two, no further suicide screening is done (Cf.,
Marcus Nemuth deposition, 3/25/08, VA staff psychiatrist in Seattle
area). Asking one or two suicide questions, which could easily be
denied, misunderstood, misrepresented, etc., is not a suicide screen up
to the standard of care. Probably self-destruction is under-counted by
the VA with such perfunctory screens.
Importantly, when the VA measures the crucial suicide risk factors
of depression and hopelessness, as far as I could determine, they just
use self-reporting; not short, reliable and valid scales, like:
The Hamilton Rating Scale for Depression (1960)
The Beck Depression Inventory (1967; Cf., Maris et al.,
2000: 84)
Beck Hopelessness Scale (1974; Maris et al., 2000, Figure
3.5, p. 85)
Beck Suicide Intent Scale (1990)
All of these scales are relatively short (17-20 questions), have
the advantage of indirection (i.e., the vet is not sure what they
measure), have known validity and reliability, and could be done in 15
to 30 minutes. Since hopelessness and depression are key suicide risk
factors, they should be measured systematically, not by subjective
self-reporting. Finally, some vets may not even know if they are
depressed, hopeless, or suicidal.
On page 36 of the MHSP we are told ``90.9% of the VA facilities do
not have suicide case managers.'' Why identify vets with suicide risk,
if no one follows them? Recently, I have been told that in fact there
are ``suicide coordinators'' in all 21 VA VISNs in the 154 medical
centers (but none at the 875 CBOCs). However, it is unclear (to me) who
these people are, what their suicide prevention training is, what their
exact job descriptions are, and how effective they are. There is also a
question about the quality of staffing of CBOCs, most of which have
LPNs, RNs, MSWs, and MA psychologists, and not psychiatrists.
We know that two psychiatric drugs have proven very effective in
reducing suicidality in patient populations. One of these medications
is lithium (See Baldessarini in Simon and Hales, 2006) for depressed
and bipolar I patients even get lithium (@ p. 41). Likewise with
suicidal schizophrenic patients, the drug Clozaril has been shown to be
effective in clinical trials in reducing the suicide rate (See MHSP @
42). In the vast majority of VA clinics (90.7%) fewer than 10% of their
schizophrenic patients are on Clozaril.
Thus, most of the MHSP initiatives are only partially implemented
after several years (about four years) and some of the operational
definitions of key risk factors are below the standard of care.
Measuring Suicide Risk Factors and the Suicide Template. There is
no reason why all veterans could not have all significant suicide risk
factors measured at least at deployment, discharge, or at other crucial
clinic visits (see my list of 15 suicide risk factors on page 1,
above). The VA's ``Suicide Risk Screening and Comprehensive Suicide
Risk Assessment'' form (aka ``Suicide Template'' or ``Suicide Risk
Assessment Pocket Card'') is woefully inadequate to detect suicidality.
As I said above, just asking if the vet felt (1) hopeless or depressed
in the last two weeks or (2) thought about harming themselves in any
way does not measure suicidality.
The vet could easily deny depression or suicide ideation
(especially if they thought it might affect their promotions or
military career, or were ashamed of their mental health issues). When I
worked for the U.S. Army in Berlin, Germany, doing suicide prevention
training, the staff psychiatrist there told me he had little to do,
because especially male soldiers would not admit to any mental health
problems for various career reasons. Many males do not seek mental
health treatment. Other soldiers may not even realize they are
depressed or self-destructive.
In short, all the questions on the suicide template need to be
asked and answered and put in objective formats that do not make it
obvious what is being measured. The suicide pocket assessment card has
questions about (1) a suicide plan, (2) whether the plan includes
firearms, (3) what psychiatric symptoms the vet is having, if any, (4)
lack of social support, (5) the age, sex, race and family history of
suicide of the vet, (6) whether or not there have been any prior
suicide attempts, (7) levels of impulsivity, (8) past psychiatric
diagnoses or treatment, (9) chronic pain, (10) protective factors like
religion, (11) additional risk factors, (12) quantification of suicide
risk level, and (13) immediate actions and treatment needed. Every vet
should have every risk factor assessed, not just one or two of them,
and asked in a manner that is effective.
Systematic Healthcare Deficiencies as Reflected in the VA Incident
Briefs.
Although I was provided only 170 of the estimated 15,000 incident
briefs in which VA patients' suicides and suicide attempts were
described, nonetheless they provide a sample of suggested systematic
healthcare and treatment deficiencies identified by the VA itself.
Below are some of the highlighted treatment failures of the VA in
assessing and managing suicidal veterans (all documents were provided
in the Vets v. Peake trial in San Francisco, California and were Bates-
stamped for that trial; obviously, they have been redacted to protect
individual patients; in each bullet item one could add ``and the vet
suicided or attempted suicide,'' etc. Since these documents are
``protected,'' I have removed the VA Bates-stamped numbers):
Treatment was delayed.
Patient with suicide ideation not evaluated for suicide
risk (violates template, criterion # 2).
No coordination of patient's care (even though there are
s. coordinators).
Vet should have been admitted but was not.
Inadequate response to vet's expressed wish-to-die.
VA needs a suicide hotline (Note: VA now has a hotline,
but research shows that a very small percentage of suicides [perhaps <
1%] even call the hotline; Feeley @ 51; I am not persuaded that male
soldiers are likely to call a hotline).
No referral for severe antisocial behavior of vet.
No psychiatric evaluation of vet was done in the ER.
Suicide assessment policies and procedures were not
followed.
Hopeless vet not identified as such.
Vet not rescheduled for appointment within one week per
policy.
Suicide risk assessment was negative, but patient
suicided anyway.
Patient denied access to VA hospital and then suicided.
Doctor at VA fired for inadequate treatment of soldier
found dead.
Inadequate healthcare for homeless vet with suicide
ideation and threat.
VA not meeting the needs of suicidal vet.
Feeley says of this vet's suicide: ``VHA not meeting
standard that we are after.''
Vet actually shoots self on the grounds of the VA
outpatient clinic.
These bulleted items reflect the VA's own admissions of healthcare
problems or failures in treating suicidal vets. One can only imagine
how much more investigators could have learned about assessment and
treatment failures of suicidal vets, had they been given all of the
redacted incident briefs and root cause analyses. Since this hearing is
entitled ``The Truth About Veterans' Suicides,'' it only makes sense
that all incidents be made public, after removing references to
individual vets.
William Feeley, VA Deputy Under Secretary for Health Operations and
Management (He reports to Dr. Kussman and Kussman reports to Secretary
Peake; the following facts are reported in Mr. Feeley's deposition of
April 9, 2008 in the Vets v. Peake legal suit). Feeley said that
although he was 3rd in the chain of command, and when it came to vet
healthcare, ``the buck stops here'' (although later on Feeley tried to
pass the buck to Dr. Katz and others at the VA).
Feeley said (@ 19) that the 21 VISN directors all report
to him at least once a week, but when asked about vet suicide rates, he
said he did not talk to directors about their suicide rates (why not,
if this is a ``major problem''?). As Feeley put it (@ 35): ``Suicide
rates are not a metric we are measuring.''
When asked about implementing the MHS Plan of 7/2004, his
reply was (@ 64): ``I did not read the plan from cover to cover.''
When asked between 2004 and 2008 if there were a national
systematic program for suicide prevention, Feeley answered ``No.''
One of the policies that have been supposedly fully
implemented in the MHSP of 2007 was 24-hour VA healthcare. @ 97 Feeley
was asked to name that policy. His answer: ``I don't know that
policy.''
@ 100 Feeley was asked, (well) ``where are these
policies?'' Answer: ``I don't know where they are.''
Question @ 104: ``Has the idea of screening every service
person coming back from Iraq or Afghanistan for PTSD been a subject of
discussion?'' Answer: ``I really could not give you an answer on
that.''
Question @ 105: ``Is there a national screening program
for every returning serviceman or woman to meet with a mental health
professional?'' Answer: ``I don't know the answer to that.''
The MHSP (7/20/04) @ A-14 says that every military person
. . . will meet individually with a mental health professional as part
of post-deployment and separation. Question: ``Has that happened?''
Answer: ``I don't believe it has.''
Question @ 141-142: ``Have you read the national strategy
for suicide prevention and the Institute of Medicine's report Reducing
Suicide (2002)?'' Answer: ``No.''
Question @ 147: ``What methods are there for tracking at-
risk (for suicide) veterans?'' Answer: `` I'm not sure, sorry.'' What
are suicide coordinators for?
Question @ 171: ``Is there any relationship between the
number of times a vet is deployed and suicide?'' Answer: ``Don't
know.''
One could easily conclude that if the ``suicidal buck'' stops with
Mr. Feeley, then the VA is in serious trouble when it comes to
assessing and preventing veteran suicides. Mr. Feeley is singularly and
dramatically uninformed about suicide. But maybe that is when Feeley
passes the buck to Dr. Katz?
Leftovers and Loose Ends. There are a few other important issues
that at least deserve mention.
First, it is possible that soldiers become suicidal in part due to
conditions pre-dating their military recruitment. If so, their baseline
vulnerabilities (See the concept of ``stress-diathesis'' in Maris et
al., 1992, Chapter 27) may interact with the stressors of combat to
exacerbate their suicidality. One example on this might be the DSM
diagnosis of antisocial personality disorder among young males (@ least
18 years old; DSM code 301.7). There is some evidence (See Vets v.
Peake Complaint, 7/23/07 @ 8-24) that some soldiers may have been
induced to accept a discharge diagnosis of antisocial personality
disorder, rather than (say) PTSD. Importantly, a diagnosis of
personality disorder precludes the veteran from receiving disability
benefits, since the psychopathology was presumed to be present prior to
the recruitment. Nevertheless, even if true, the Department of Defense
needs to improve its recruitment screening procedures to keep such
recruits out of the military in the first place.
Second, there is surprisingly little mention in the VA mental
healthcare policies and procedures documents about treating the
depressive disorders psycho-pharmacologically. It is axiomatic in
suicide prevention that much of the treatment of suicidality requires
prompt and precise diagnosis of depressive disorders, followed by
appropriate specific pharmacological treatment of the patient with one
or more of the SSRI antidepressants (e.g., Lexapro, Prozac, Zoloft,
Paxil, Louvox, Celexa, etc.), SNRIs (e.g., Cymbalta or Effexor, etc.),
anxiolytics (such as the benzodiazepines like Xanax, Klonopin, Traxene,
Ativan or non BZs, like Buspar, etc.), perhaps a major tranquilizer
(like Risperdal or Zyprexa, etc.), and even electroconvulsive therapy
in some cases. Note that many of the VA's 875 outpatient clinics or
``CBOCs'' often do not even have a physician on staff, who can write
critical prescriptions that suicidal vets may need. Since there are 875
CBOCs but only 154 VA hospitals or medical centers, structurally (given
the VA healthcare system) a depressed vet is likely to get only
psychotherapy, rather than both pharmacotherapy and psychotherapy.
Third, the VA takes pride that they now have ``suicide
coordinators'' in their medical centers (See Feeley, 4/9/08 @ 88).
However, serious questions remain about these suicide coordinators.
Only the 154 medical center hospitals even have suicide coordinators;
none of the 875 CBOCs do. Thus, the vast majority of VA facilities in
fact do not have suicide coordinators. Several questions remain: (a)
What do these coordinators do, exactly (job descriptions)? (b) How are
they trained to do suicide assessment and prevention (Berman addressed
this issue in Vets v. Peake)? (c) What are their professional
credentials and licensing (LPN, RN, SW, MA psychologist, MH techs,
etc)? (d) Who supervises these suicide coordinators? (e) Do suicide
coordinators interact directly with suicidal vets in clinical care of
the VA patients? (f) What exactly are they ``coordinating'' (data,
people, policies and procedures, etc.)?
Finally, there is a whole set of issues concerning diagnosis,
treatment, and benefit delays in VA mental healthcare, which I have not
yet commented on (See Vets v. Peake, 4/21/08, Federal trial in San
Francisco). To even get mental health treatment for up to two years the
veteran must fill out a 23-page application form (which can be very
hard to do, if you in fact do have PTSD) and then receive a disability
rate from 0 to 100% from a ``Compensation and Pension'' examination
(Complaint, 25-98). If the disability is denied or too low, found not
to be related to military service; then the appeal process can be long
and drawn-out (some vets die during the appeal process), which can
encourage a suicidal resolution of the vet's problems. Note, too, that
most of the VA suicide prevention initiatives (See OIG, MHSP, 5/10/07)
have only been partially implemented after four years. Defense expert
Alan Berman in the Vets v. Peake trial, testified that it could take up
to 10 years for the MHSP to be implemented. One wonders how many vets
are going to die in the interim due to lack of assessment and
treatment?
References
American Association of Suicidology. 1/17/08. USA Suicide. 2005
Official Final Data.
American Psychiatric Association. 2000. DSM-IV-TR. Washington, DC:
American Psychiatric Press.
CBS/Stephen Rathbun. 1/19/08 & 2/22/08 Declaration.
Beck, A.T. 1967. Depression. New York: Harper.
Beck et al. 1974. The measurement of pessimism: the hopelessness
scale. J. Consulting & Clinical Psychology 42: 861-865.
Beck, A.T. 1990. Suicide intent scale in Blumenthal, S. & Kupfer,
D. (eds.). Suicide over the Life-Cycle. Washington, DC: American
Psychiatric Press.
Beck, A.T. et al. 1999. Suicide ideation at its worst point. . . .
Suicide and Life-threatening Behavior 29: 1-9.
Feeley, William. 4/9/08 deposition in Vets. v. Peake trial in
Federal court in San Francisco, 4/21/08.
Goldsmith, S.K. et al. (eds) 2002. Reducing Suicide: a National
Imperative. Washington, DC: National Academies Press.
Hamilton, M. 1960. A rating scale for depression. Journal of
Neurology, Neurosurgery, and Psychiatry 23:56-61.
Hoge, C. W. et al. 2004. Combat duty in Iraq and Afghanistan,
mental health problems, and barriers to care. The New England Journal
of Medicine 351: 13-22.
Kang, H.K. & Bullman, T.A. 12/11/07. The risk of suicide . . .
among vets of OIF and OEF (unpublished).
Katz, Ira. 2/21/08. Suicide study (unpublished).
Maris, R.W. 1969. Social Forces in Urban Suicide. Homewood, IL:
Dorsey Press.
Maris, R.W. 1981. Pathways to Suicide. Baltimore: Johns Hopkins
University Press.
Maris, R.W. et al. 1992. Assessment and Prediction of Suicide. NY:
Guilford Press.
Maris, R.W. et al. 2000. Comprehensive Textbook of Suicidology. NY:
Guilford Press.
Maris, R.W. 2002. Suicide. The Lancet. Vol 360: 219-226.
Maris, R.W. 2007. Foreword to Cutliffe & Stevenson. Care of the
Suicidal Person. Edinburgh, Elsevier.
Office of the Inspector General. 5/10/07. Mental Health Strategic
Plan for Suicide Prevention. John Daigh, Jr. VA Office of the Inspector
General. Pages 1071.
Robins, E. (with Murphy, G.). 1981. The Final Months. NY: Oxford
Press.
Nemuth, M. 3/25/08. Deposition in Vets v. Peake.
Simon, R.I & Hales, R.E. 2006. Textbook of Suicide Assessment and
Management. Washington, DC: American Psychiatric Press.
Veterans for Common Sense et al. v. Peake et al. Trial commencing
4/21/08 in Federal Court, San Francisco, CA. Judge Samuel Conti.
Zivin, K. et al. 2007. Suicide mortality among individuals
receiving treatment for depression in the VA health system. American
Journal of Public Health, 2193-2197.
Prepared Statement of Stephen L. Rathbun, Ph.D.,
Interim Head and Associate Professor of Biostatistics,
Department of Epidemiology and Biostatistics, University of Georgia,
Athens, GA
Summary
In the fall of 2007, I was asked to perform a statistical analysis
of veterans' suicide data collected by CBS News for a story that was
broadcast on November 13, 2007. I agreed to do so, and was not
compensated for my contributions. For 2004 and 2005, CBS provided data
on numbers of veteran and non-veteran suicides and veteran and non-
veteran population sizes, cross-tabulated by state, gender and age
class. Suicide data were obtained from state death records and
population sizes from the U.S. Census. These data are the property of
CBS News and were erased from my computer following the broadcast on
November 13, 2007. To avoid investigator biases, methods of statistical
analyses were specified prior to receiving the data. Standard
statistical procedures were used to analyze the data; estimated suicide
rates adjusted for age and gender. Veteran suicide rates were estimated
to be approximately double those of non-veterans. This pattern of
higher estimated veteran suicide risk was observed for both genders and
all age classes. The most striking pattern was an especially high risk
ratio for 20-24 year old veterans; in this age class, veteran suicide
rates were estimated to be about 3 times those of non-veterans.
Introduction
This statement concerns the analyses of veterans' suicide data
conducted at the request of CBS News during the fall of 2007, the
results of which were broadcast during CBS Evening News on November 13,
2007. The following will describe my relationship with CBS News, the
data that were analyzed, the method of statistical data analyses, and
the results of those analyses.
Before proceeding, please note the following:
1. I am an expert in biostatistics, but not an expert on veterans'
suicides. Although I have a 18-year record of teaching and research in
biostatistics, I have not had any prior experience with suicide data.
While I can comment on the methods of data analyses, estimated suicide
rates and limits of statistical inference regarding the data analysis,
I cannot make expert comments regarding what causes the observed
patterns of suicide rates.
2. The suicide data are a property of CBS News and at the request
of CBS News, my copy was erased following the November 13, 2007
broadcast. This was done to comply with agreements made between CBS
News and States to ensure the confidentiality of sensitive human-
subjects data.
3. On March 4, 2008 I testified on behalf of the plaintiffs in the
case of Veterans for Common Sense and Veterans United for Truth, Inc.
vs. Gordon H. Mansfield, Acting Secretary of Veterans Affairs (U.S.
District Court, Northern District of California, San Francisco
Division, Case No. C-07-3758-SC). No compensation was received from the
plaintiffs for this testimony. I had no prior relation with either
party in this action.
Relationship with CBS News
I had no prior relationship with CBS News before Pia Malbran,
producer of the veterans' suicide news story, contacted me in August
2007 asking me to analyze veterans' suicide data. Aside from the gift
of a CBS News baseball cap (valued at less than 20), I was not paid by
CBS News for the work that I have done. I understand from Pia Malbran,
producer of the veterans' suicide news story, that I was contacted
because I had no relationship with the Veterans Administration,
veterans groups, or involvement with advocacy related to veterans'
issues.
Data Collection
During my initial consultations, Pia Malbran discussed the sources
of the data, and I advised her regarding the format in which the data
should be provided for data analysis. Ms. Malbran requested that
suicide rates be adjusted for age, gender, and race. She obtained
population totals from the U.S. Census, and population totals for
veterans from the Veterans Administration. The states provided her
information on the number of veteran suicides and total number of
suicides. Veteran status was to be ascertained from state death records
indicating that suicide was the cause of death, and including a check
box indicating whether or not the subject was a veteran. In a few
cases, veteran status was not available in the death records. Data were
to be provided for 2004 and 2005. Death records after 2005 were not
available at the time that the news story was prepared.
In response to Pia Malbran's description of the available data, I
indicated that an excel spreadsheet should be prepared including
columns for state, age class, gender, race, number of veteran suicides,
number of suicides with unknown veteran status, total number of
suicides, number of veterans, and population total. Suicides with
unknown veteran status were allocated to veterans and non-veterans in
numbers proportional to the respective sizes of veteran and non-veteran
populations. For example, if 10% of all 25-29 year old males in a given
state were veterans, then 10% of the suicides of unknown veteran status
in that group would be allocated to veterans, while the remaining 90%
of suicides in that group would be allocated to non-veterans. This
proportional allocation results in conservative estimates, under-
estimating the differences between veteran and non-veteran suicide
rates.
Preliminary data analysis indicated that states and the Veterans
Administration had different definitions of race with respect to the
classification of black Hispanic-Americans. So, race was dropped from
the data collection efforts. Thus, the data can be cross-classified by
state, age class, gender, veteran status, and population size for data
analysis. A total of 45 states provided data for 2004 and 2005.
For states with small populations of veterans, the cross
classification of veterans by age, gender and suicide status may
suffice to identify individual subjects. For that reason, CBS News had
to agree that data be kept confidential before data were released to
CBS News. To ensure this confidentiality, I was asked to erase the data
immediately following the November 13, 2007 broadcast of the veterans'
suicides news story. This was done as requested.
Data Analysis
To avoid investigator bias, the methods of statistical data
analyses were specified before data were received from CBS News. The
specific choice of methods was based on the type of data collected, and
the specific estimates that Pia Malbran requested in her memo of
October 1, 2007:
1. What is the overall rate of suicide (per 100,000--age and
gender adjusted) for veterans verses non-veterans nationwide?
2. What is rate (per 100,000--age and gender adjusted) of suicide
for veterans verses non-veterans state by state ranked highest to
lowest?
3. What is the overall rate of suicide (per 100,000) for veteran
males (all ages) verses non-veteran males nationwide?
4. What is the rate of suicide (per 100,000) among male veterans,
65 or older? And, how does that compare with male non-veterans, 65 or
older?
5 What is the rate of suicide (per 100,000) among veterans (both
genders) aged 20 to 34?
A logistic regression model was fit to the data from each year
(2004 and 2005), including main effects for age-class, gender, and
veteran status, as well as two-way interactions among pairs of these
explanatory variables. Logistic regression is the standard statistical
method for modeling binary responses such as suicide status; a person
has either committed suicide or not committed suicide. The inclusion of
interactions allows the effect of veteran status on suicide risk to
depend on gender and age. As per the pre-specified protocol for data
analysis, the three-way interaction among age, gender and veteran
status was dropped from the model since it was not statistically
significant.
All estimated suicide rates were adjusted for the impact of age and
gender. This was done because suicide rates depend on age and gender.
For example, suicide rates are higher among males and than among
females. Moreover, males are over-represented among veterans since
males are more likely to serve in the military than females. Given the
higher suicide rates among males, and the over-representation of males
in veteran populations, failure to adjust for gender will result in
over-estimates of veteran suicide rates. Similar arguments can be made
for the impact of age.
Initial data analysis was completed before my portion of the story
was taped by CBS News on October 3, 2007. On October 16, Pia Malbran
contacted me with data on the numbers of active-duty soldiers
committing suicide in 2004 and 2005, cross-classified by age and
gender. She expressed concern that some of these soldiers may have been
mistakenly classified as veterans in the state death records, and asked
me to re-analyze the data subtracting these cases from the veteran
suicide counts. Thus, two estimates of veteran suicide rates will be
presented. The higher estimate is based on the original analysis, while
the lower estimate was obtained after these active-duty suicides were
subtracted.
All analyses were carried out using SAS. Analyses using this
statistical software involve written code documenting exactly how the
analyses are carried out. This is as opposed to other statistical
software packages that rely on point-and-click menu-driving procedures
for data analysis that leave no record documenting the method of
analysis. SAS code used for my data analysis was provided to Ira Katz
following the November 13 CBS News broadcast.
Results
The estimated suicide risk is higher among veterans than non-
veterans. Table 1 presents the age- and gender-adjusted estimates of
suicide rates by veteran status for each of the two years. The suicide
risk among veterans was estimated to be 1.86-2.32 times the risk among
non-veterans in 2004, and 2.10-2.34 times the risk among non-veterans
in 2005. These risk ratios were computed by dividing the suicide rates
among veterans by the suicide rates among non-veterans.
Table 1. Estimates of overall suicide rates adjusted for age and
gender. All rates are expressed as numbers of suicides per 100,000
people.
------------------------------------------------------------------------
Veteran Status 2004 2005
------------------------------------------------------------------------
Veterans 17.5-21.8 18.7-20.8
------------------------------------------------------------------------
Non-Veterans 9.4 8.9
------------------------------------------------------------------------
Table 2 presents the age-adjusted estimates of suicide rates for
males and females by veteran status for each of the two years. For both
veterans and non-veterans, suicide rates were higher among males than
among females. Among males, the suicide risk for veterans was estimated
to be 1.67-2.09 times the risk among non-veterans in 2004, and 1.79-
2.01 times the risk among non-veterans in 2005. Among females, the
suicide risk for veterans was estimated to be 2.08-2.60 times the risk
among non-veterans, and 2.47-2.73 times the risk among non-veterans in
2005.
Table 2. Estimates of suicide rates by gender adjusted for age. All rates are expressed as numbers of suicides
per 100,000 people.
----------------------------------------------------------------------------------------------------------------
Gender Veteran Status 2004 2005
----------------------------------------------------------------------------------------------------------------
Males Veterans 30.6-38.3 31.5-35.3
----------------------------------------------------------------------------------------------------------------
Non-Veterans 18.3 17.6
----------------------------------------------------------------------------------------------------------------
Females Veterans 10.0-12.5 11.1-12.3
----------------------------------------------------------------------------------------------------------------
Non-Veterans 14.8 4.5
----------------------------------------------------------------------------------------------------------------
Table 3 presents the gender-adjusted estimates of suicide rates for
the various age-classes by veteran status. The most striking result is
the high relative risk of suicide among 20-24 year old veterans when
compared to non-veterans. For this group of young veterans, the suicide
risk is estimated to be 2.81-4.31 times the risk among non-veterans in
2004, and 2.75-3.84 times the risk among non-veterans in 2005. Veterans
in their forties also had high estimated suicide rates, but the risk of
suicide among non-veterans in their forties was also estimated to be
high. Consequently, the risk ratio did not exceed 1.73 in this age
group.
Table 3. Estimates of suicide rates by age adjusted for gender. All rates are expressed as numbers of suicides
per 100,000 people.
----------------------------------------------------------------------------------------------------------------
Age Class Veteran Status 2004 2005
----------------------------------------------------------------------------------------------------------------
20-24 Veteran 23.3-35.8 22.9-31.9
----------------------------------------------------------------------------------------------------------------
Non-Veteran 8.3 8.3
----------------------------------------------------------------------------------------------------------------
25-29 Veteran 12.8-15.5 13.1-16.1
----------------------------------------------------------------------------------------------------------------
Non-Veteran 9.0 8.3
----------------------------------------------------------------------------------------------------------------
30-34 Veteran 14.1-14.7 16.1-17.7
----------------------------------------------------------------------------------------------------------------
Non-Veteran 10.2 9.9
----------------------------------------------------------------------------------------------------------------
35-39 Veteran 16.4-17.8 16.1-16.5
----------------------------------------------------------------------------------------------------------------
Non-Veteran 11.4 10.5
----------------------------------------------------------------------------------------------------------------
40-44 Veteran 20.4-20.6 19.4-19.7
----------------------------------------------------------------------------------------------------------------
Non-Veteran 13.4 12.6
----------------------------------------------------------------------------------------------------------------
45-49 Veteran 22.4-22.5 23.4
----------------------------------------------------------------------------------------------------------------
Non-Veteran 14.4 13.5
----------------------------------------------------------------------------------------------------------------
50-54 Veteran 20.3 21.0
----------------------------------------------------------------------------------------------------------------
Non-Veteran 13.4 12.9
----------------------------------------------------------------------------------------------------------------
55-59 Veteran 15.3-15.4 16.0-16.1
----------------------------------------------------------------------------------------------------------------
Non-Veteran 11.4 11.0
----------------------------------------------------------------------------------------------------------------
60-64 Veteran 14.3-14.4 13.6
----------------------------------------------------------------------------------------------------------------
Non-Veteran 10.3 10.5
----------------------------------------------------------------------------------------------------------------
65+ Veteran 11.8 14.9-15.0
----------------------------------------------------------------------------------------------------------------
Non-Veteran 9.6 9.7
----------------------------------------------------------------------------------------------------------------
Prepared Statement of M. David Rudd, Ph.D., ABPP,
Professor and Chair, Department of Psychology,
Texas Tech University, Lubbock, TX
Mr. Chairman and Members of the Committee, thank you for the
invitation and opportunity to join you here today and discuss the
tragic, but important problem of suicide among our Nation's veterans. I
am honored to be here. My scientific and clinical opinions are
influenced by a diverse background as a practicing psychologist,
clinical researcher whose work focuses on the assessment, management
and treatment of suicidality, along with the fact that I'm a veteran.
Having served previously as an Army psychologist, I'm keenly aware of
the complexity and challenge of clinical decisionmaking during wartime,
the competing demands juggled by military mental health providers, and
the arduous task of managing soldiers at risk for suicide both during
active duty and after discharge. As a researcher, I understand suicide
is most often the end outcome of a complex web of variables, several
easily identified but not so easily treated. As a veteran, I have some
understanding of what it means to serve our country, the personal and
professional sacrifices that are made, and the potential consequences,
but only a fraction compared to those that return from war struggling
with injuries both visible and invisible.
The tragic increase in both active duty and veteran suicide rates
since the beginning of Operation Iraqi Freedom and Operation Enduring
Freedom (OIF/OEF) underscore a seldom recognized but very real fact
about mental illness; that it can be fatal. Data are now available from
multiple sources, including the Department of Veterans Affairs (VA),
the recently released RAND Corporation study, along with the existing
literature indicating that anywhere from a quarter to a third of
previously deployed veterans present with a mental health problem
following discharge. Most prominent among the problems are major
depression, post-traumatic stress disorder (PTSD), traumatic brain
injury (TBI), and substance abuse. Data available prior to the most
recent military conflicts (OIF/OEF) indicated heightened suicide risk
among the general veteran population, with estimates indicating that
veterans are twice as likely to die by suicide, regardless of whether
or not they were affiliated with the VA. More recent data indicate a
marked increase in suicide risk among veterans being treated for
depression, with the risk being 7-8 times greater than that for the
general adult population in the United States. Similarly, recent
revelations about suicide and suicide attempt rates among veterans have
been alarming, with estimates as high as 18 suicides a day. Recent data
on TBI are also of concern, indicating suicide rates in the range of 3-
4 times the general population and lifetime suicide attempt rates of
8%, along with significant rates of suicidal ideation (23%). At this
point, the relationship between brain injury and suicidality is not
well understood.
An accurate and meaningful interpretation of these data requires a
look at and consideration of comparable civilian data. Although it is
certainly difficult to accurately estimate suicide rates for those in
and out of treatment, there is some data for comparison. The suicide
prevalence rate for major depression and affective disorders in general
(i.e. major depression, bipolar disorder I and II and affective
psychosis) is actually lower than often quoted. Rates differ depending
on the apparent severity of the illness, with the outpatient suicide
prevalence rate being 2%, in contrast to 6% for those previously
hospitalized for suicidal symptoms and 4% for those hospitalized for
other reasons. Rates of suicide attempts are much higher. It is
estimated that as many 24% of those suffering major depression make a
suicide attempt during the course of the illness. It is estimated that
up to 50% of individuals with bipolar disorder will make a suicide
attempt and up to 80% will manifest suicidal symptoms of some sort.
Standardized mortality ratios (ratio of observed deaths to expected
deaths) for major depression and bipolar disorder paint a stark
picture; those with major depression evidence a twentyfold increased
risk for death by suicide relative to the general population and those
with bipolar disorder a fifteenfold increase in risk. There are data
available regarding other disorders, but the take home message is that
the risk for suicide is considerable for a number of mental illnesses.
Mental illness can be fatal, particularly if unrecognized, untreated or
under-treated.
It is also important to consider the expected rates of adverse
events during treatment, in particular, suicide attempt rates. Data are
available from randomized clinical trials targeting suicidal behavior
(irrespective of diagnosis). Estimates indicate that as many as 40-47%
of those receiving treatment (psychotherapy and medications) make
suicide attempts during the first year of treatment. If an attempt is
made during the first year, the average is approximately 2.5 attempts.
This is what routinely happens during treatment. We also know that an
individual making multiple suicide attempts will likely struggle with
suicidality for many years, if not a lifetime. These data, coupled with
data about recent discharge from the hospital, indicate that risk for
suicide (in the context of mental illness) is not only potent but
enduring. Standardized mortality ratios (ratio of observed deaths to
expected deaths) for men and women recently discharged from the
hospital range from 100 to 350 across several studies. These are
tragically high numbers. The VA experience is not markedly different
than its civilian counterpart when it comes to the presentation of
high-risk suicidal patients.
There are several possible conclusions. First, as outlined nicely
in the RAND study, there are high rates of psychiatric illness
following combat exposure, including both direct and vicarious
exposure. Multiple deployments for OIF/OEF likely compound the
situation because of repeated combat exposure, sometimes after the
initial emergence of symptoms. The VA is faced with assessing and
treating large numbers of seriously ill veterans. Second, the overall
rates of both suicide and suicide attempts are tragic but consistent
with general trends for the types and observed rates of psychiatric
illness. Third, an effective response requires effective resources.
Finally, there is an element of this problem that is likely to be
enduring and potentially chronic in nature.
The VA has already moved toward increasing recognition and
treatment of suicidal veterans, implementing a telephone hotline and
making available training on recognizing and responding to suicide
warning signs. Treatment outcome studies targeting suicidality have
confirmed that simple things work and can save lives. Limiting and
removing access to the suspected method can save lives. Removing
barriers to emergency care can save lives. Patient tracking and
effective followup for treatment non-compliance can save lives.
Evidence-based treatments for depression, bipolar disorder, PTSD are
effective and can save lives. Despite the fact that treatment is
effective, it's estimated that only about half of those at risk pursue
care.
The military and VA system face unique barriers to providing
effective care, including issues of confidentiality, delays in
evaluating the escalating numbers of service-connected disability
claims, and misconceptions about the nature and effectiveness of mental
healthcare. The FDA warning label for antidepressants is but one
example of how misunderstanding of the scientific data can lead to
fewer people expressing a willingness to seek care, with potentially
tragic results. Science, clinical experience, and common sense converge
when it comes to suicidality. Improving our ability to both recognize
and respond quickly to those at risk can save lives. Removing barriers
to care, particularly emergency care, can and will save lives. Those
that have served our Nation deserve no less. It is tragic and
heartbreaking when a soldier that has survived the trauma of war
returns home to die by his or her own hand, especially when treatment
is an option.
Thank you, I appreciate the opportunity to speak with you today and
welcome the chance to respond to questions.
Prepared Statement of Michael Shepherd, M.D.,
Senior Physician, Office of Healthcare Inspections,
Office of Inspector General, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify today on suicide prevention and the Office of
Inspector General (OIG) report, Implementing the VHA's Mental Health
Strategic Plan Initiatives for Suicide Prevention. My statement today
is based on that report as well as individual cases that the OIG has
reviewed and reported on involving veteran suicides and accompanying
mental health issues. In the process of these inspections, clinicians
in our office have had the opportunity to meet with and listen to the
concerns of surviving family members, and to witness the devastating
impact that veteran mental health issues and suicide have had on their
lives.
The May 2007 OIG report reviewed initiatives from the Veterans
Health Administration's (VHA) mental health strategic plan pertaining
to suicide prevention and assessed the extent to which these
initiatives had been implemented. In prior testimony, we have stressed
the importance of the need for VA to continue moving forward toward
full implementation of suicide prevention initiatives from the mental
health strategic plan. In terms of other changes VA could make, we
would offer the following observations:
Community Based Outreach--In our report, we noted that while
several facilities had implemented innovative community based suicide
prevention outreach programs, (e.g., facility presentations to New York
City Police Department officers who are Operation Iraqi Freedom/
Operation Enduring Freedom (OIF/OEF) veterans, participation by mental
health staff in local Spanish radio and television shows) the majority
of facilities did not report community based linkages and outreach
aimed at suicide prevention. In addition, less than 20 percent of
facilities reported utilizing the Chaplain service for liaison and
outreach to faith-based organizations in the community (e.g., inviting
faith-based organizations in the area to a community meeting at a VA
Medical Center (VAMC) to explain VHA services available, having a VA
Chaplain accompany the OIF/OEF coordinator to post-deployment events in
the community). Although facilities would need to tailor strategies to
consider local demographics and resources, a system-wide effort at
community based outreach appears prudent.
Timeliness from Referral to Mental Health Evaluation--In our report
we noted that while most facilities self-reported that three-fourths or
more of those patients with a moderate level of depression referred by
primary care providers are seen within 2 weeks of referral,
approximately 5 percent reported a significant 4-8 week wait. Because
these patients are at risk for progression of symptom severity and
possible development of suicidal ideation, Veterans Integrated Service
Network leadership should work with facility directors to ensure that
once referred, patients with a moderate level of depression and those
recently discharged following hospitalization are seen in a timely
manner at all VAMCs and Community Based Outpatient Clinics (CBOCs).
Co-Occurring Combat Stress Related Illness and Substance Use--
Substance use may contribute to the severity of a concurrent or
underlying mental health condition such as major depression. The
presence of alcohol may cause or exacerbate impulsivity and acute
alcohol use is associated with completed suicide. In a recent study
published in the Journal of the American Medical Association (JAMA),
Longitudinal Assessment of Mental Health Problems Among Active and
Reserve Component Soldiers Returning from the Iraq War, Milliken et
al., found that soldiers frequently reported alcohol concerns on the
Post Deployment Health Assessment and Reassessments ``yet very few were
referred to alcohol treatment.''
Regardless of why a patient begins to abuse alcohol, with frequent
and/or excessive use, physiologic and psychologic drives develop until
alcohol misuse ultimately takes on a life of its own that is
independent of patient history and circumstance. Functional ability and
quality of life become dually impacted by both underlying anxiety and
depressive symptoms and co-morbid substance use issues. For patients
with concurrent conditions, an effective treatment paradigm may require
addressing the primacy of not only anxiety/depressive conditions but
also of co-morbid substance use disorders. VA should consider
augmenting services that address substance use disorders co-morbid with
combat stress related illness for inclusion in a comprehensive program
aimed at suicide prevention.
Enhanced Access to Mental Health Care--Treatments for mental health
problems may take time to show effect. For example, antidepressant
medication, when indicated, may take several weeks to several months to
effect symptom reduction or remission. For some patients, treatment may
necessitate multiple visits that occur consistently over time and may
entail multiple modalities including individual and/or group evidence
based psychotherapy, medication management, and/or readjustment
counseling. Therefore, efforts that enhance patient access to
appropriate treatment may help facilitate both patient engagement and
the potential for treatment benefit.
For example, ongoing enhancements in the availability of mental
health services at CBOCs may help mitigate vocational and logistical
challenges facing some veterans residing in more rural areas who
otherwise may have to travel longer distances to appointments at the
parent VAMC.
In certain locations, the VA may want to consider expanding care
during off-tour hours to increase the ability for some transitioning
OIF/OEF veterans to access mental health treatment while minimizing
interference with occupational, and/or educational obligations. This
would be consistent with the recovery model for mental health treatment
which emphasizes not only symptom reduction but also promotion and
return to functional status.
Facilitating Early Family Involvement--Mental health symptoms can
have a significant and disruptive impact on family and domestic
relationships. Relational discord has been cited as one factor
associated with suicide in active duty military and returning veterans.
In addition, some studies indicate that family involvement in a
patient's treatment may enhance the ability for some patients to
maintain treatment adherence. VA should consider efforts to bolster
early family participation in patient treatment.
Coordination between VHA and Non-VHA Providers--When patients
receive mental health treatment from both VHA and non-VHA providers,
seamless communication becomes an increasingly complex challenge. This
fragmentation of care is particularly worrisome in periods of patient
destabilization or following discharge from a hospital or residential
mental health program. VA's Office of Mental Health Services should
consider development of innovative methods or procedures to facilitate
flow of information for patients receiving simultaneous treatment from
VA and non-VA providers while adhering to relevant privacy statutes. In
addition, VA's Readjustment Counseling Service and VA's Office of
Patient Care Services should pursue further efforts to heighten
communication and record sharing for patients receiving both counseling
at Vet Centers and treatment at VAMCs and/or affiliated CBOCs.
Mr. Chairman, thank you again for this opportunity to testify. I
would be pleased to answer any questions that you or other Members of
the Committee may have.
CBS News
Suicide Epidemic Among Veterans
NEW YORK, Nov. 13, 2007
(CBS) They are the casualties of wars you don't often hear about--
soldiers who die of self-inflicted wounds. Little is known about the
true scope of suicides among those who have served in the military.
But a 5-month CBS News investigation discovered data that shows a
startling rate of suicide, what some call a hidden epidemic, Chief
Investigative Reporter Armen Keteyian reports exclusively.
``I just felt like this silent scream inside of me,'' said Jessica
Harrell, the sister of a soldier who took his own life.
``I opened up the door and there he was,'' recalled Mike Bowman,
the father of an Army reservist.
``I saw the hose double looped around his neck,'' said Kevin Lucey,
another military father.
``He was gone,'' said Mia Sagahon, whose soldier boyfriend
committed suicide.
Keteyian spoke with the families of five former soldiers who each
served in Iraq--only to die battling an enemy they could not conquer.
Their loved ones are now speaking out in their names.
They survived the hell that's Iraq and then they come home only to
lose their life.
Twenty-three-year-old Marine Reservist Jeff Lucey hanged himself
with a garden hose in the cellar of this parents' home--where his
father, Kevin, found him.
``There's a crisis going on and people are just turning the other
way,'' Kevin Lucey said.
Kim and Mike Bowman's son Tim was an Army reservist who patrolled
one of the most dangerous places in Baghdad, known as Airport Road.
``His eyes when he came back were just dead. The light wasn't there
anymore,'' Kim Bowman said.
Eight months later, on Thanksgiving Day, Tim shot himself. He was
23.
Diana Henderson's son, Derek, served three tours of duty in Iraq.
He died jumping off a bridge at 27.
``Going to that morgue and seeing my baby . . . my life will never
be the same,'' she said.
Beyond the individual loss, it turns out little information exists
about how widespread suicides are among these who have served in the
military. There have been some studies, but no one has ever counted the
numbers nationwide.
``Nobody wants to tally it up in the form of a government total,''
Bowman said.
Why do the families think that is?
``Because they don't want the true numbers of casualties to really
be known,'' Lucey said.
Sen. Patty Murray, D-Wash., is a Member of the Veterans' Affairs
Committee.
``If you're just looking at the overall number of veterans
themselves who've committed suicide, we have not been able to get the
numbers,'' Murray said.
CBS News' investigative unit wanted the numbers, so it submitted a
Freedom of Information Act request to the Department of Defense asking
for the numbers of suicides among all servicemembers for the past 12
years.
Four months later, they sent CBS News a document, showing that
between 1995 and 2007, there were almost 2,200 suicides. That's 188
last year alone. But these numbers included only ``active duty''
soldiers.
CBS News went to the Department of Veterans Affairs, where Dr. Ira
Katz is head of mental health.
``There is no epidemic in suicide in the VA, but suicide is a major
problem,'' he said.
Why hasn't the VA done a national study seeking national data on
how many veterans have committed suicide in this country?
``That research is ongoing,'' he said.
So CBS News did an investigation--asking all 50 states for their
suicide data, based on death records, for veterans and non-veterans,
dating back to 1995. Forty-five states sent what turned out to be a
mountain of information.
And what it revealed was stunning.
In 2005, for example, in just those 45 states, there were at least
6,256 suicides among those who served in the armed forces. That's 120
each and every week, in just one year.
Dr. Steve Rathbun is the acting head of the Epidemiology and
Biostatistics Department at the University of Georgia. CBS News asked
him to run a detailed analysis of the raw numbers that we obtained from
state authorities for 2004 and 2005.
It found that veterans were more than twice as likely to commit
suicide in 2005 than non-vets. (Veterans committed suicide at the rate
of between 18.7 to 20.8 per 100,000, compared to other Americans, who
did so at the rate of 8.9 per 100,000.)
One age group stood out. Veterans aged 20 through 24, those who
have served during the war on terror. They had the highest suicide rate
among all veterans, estimated between two and four times higher than
civilians the same age. (The suicide rate for non-veterans is 8.3 per
100,000, while the rate for veterans was found to be between 22.9 and
31.9 per 100,000.)
``Wow! Those are devastating,'' said Paul Sullivan, a former VA
analyst who is now an advocate for veterans rights from the group
Veterans For Common Sense.
``Those numbers clearly show an epidemic of mental health
problems,'' he said.
``We are determined to decrease veteran suicides,'' Dr. Katz said.
``One hundred and twenty a week. Is that a problem?'' Keteyian
asked.
``You bet it's a problem,'' he said.
Is it an epidemic?
``Suicide in America is an epidemic, and that includes veterans,''
Katz said.
Sen. Murray said the numbers CBS News uncovered are significant:
``These statistics tell me we've really failed people that served our
country.''
Do these numbers serve as a wake-up call for this country?
``If these numbers don't wake up this country, nothing will,'' she
said. ``We each have a responsibility to the men and women who serve us
aren't lost when they come home.''
CBS News
VA Hid Suicide Risk, Internal E-Mails Show
April 21, 2008
(CBS) The Department of Veterans Affairs came under fire again
Monday, this time in California Federal court where it's facing a
national lawsuit by veterans rights groups accusing the agency of not
doing enough to stem a looming mental health crisis among veterans. As
part of the lawsuit, internal e-mails raise questions as to whether top
officials deliberately deceived the American public about the number of
veterans attempting and committing suicide. CBS News chief
investigative correspondent Armen Keteyian reports.
In San Francisco Federal court Monday, attorneys for veterans'
rights groups accused the U.S. Department of Veteran's Affairs of
nothing less than a cover-up--deliberately concealing the real risk of
suicide among veterans.
``The system is in crisis and unfortunately the VA is in denial,''
said veterans rights attorney Gordon Erspamer.
The charges were backed by internal e-mails written by Dr. Ira
Katz, the VA's head of Mental Health.
In the past, Katz has repeatedly insisted while the risk of suicide
among veterans is serious, it's not outside the norm.
``There is no epidemic in suicide in VA,'' Katz told Keteyian in
November.
But in this e-mail to his top media adviser, written two months
ago, Katz appears to be saying something very different, stating: ``Our
suicide prevention coordinators are identifying about 1,000 suicide
attempts per month among veterans we see in our medical facilities.''
Katz's e-mail was written shortly after the VA provided CBS News
data showing there were only 790 attempted suicides in all 2007--a
fraction of Katz's estimate.
``This 12,000 attempted suicides per year shows clearly, without a
doubt, that there is an epidemic of suicide among veterans,'' said Paul
Sullivan of Veterans for Common Sense.
And it appears that Katz went out of his way to conceal these
numbers.
First, he titled his e-mail: ``Not for the CBS News Interview
Request.''
He opened it with ``Shh!''--as in keep it quiet--before ending with
``Is this something we should (carefully) address--before someone
stumbles on it?''
On Monday, CBS News showed the e-mail to Rep. Bob Filner, D-Calif.,
who chairs the House Committee on Veterans Affairs.
``This is disgraceful. This is a crime against our Nation, our
Nation's veterans,'' Filner told CBS News. ``They do not want to come
to grips with the reality, with the truth.''
And that's not all.
Last November when CBS News exposed an epidemic of more than 6,200
suicides in 2005 among those who had served in the military, Katz
attacked our report.
``Their number is not, in fact, an accurate reflection of the
rate,'' he said last November.
But it turns out they were, as Katz admitted in this e-mail, just
three days later.
He wrote: there ``are about 18 suicides per day among America's 25
million veterans.''
That works out to about 6,570 per year, which Katz admits in the
same e-mail, ``is supported by the CBS numbers.''
In an e-mail late Monday to CBS News, Katz wrote that the reason
the numbers were not released was due to questions about the
consistency and reliability of the findings--and that there was no
public cover up involved.
CRS REPORT TO CONGRESS
Suicide Prevention Among Veterans
May 5, 2008
Order Code RL34471
By Ramya Sundararaman, Sidath Viranga Panangala, and Sarah A.
Lister
Domestic Social Policy Division, Congressional Research
Service
CONTENTS
Summary
Introduction
Data and Data Systems for Tracking Suicide
Suicide in the U.S. General Population
Incidence of Suicide
Risk and Protective Factors
Suicide Among Veterans
Incidence of Suicide
Risk and Protective Factors
The Effects of PTSD, TBI, and Depression on Suicide
Risk
Congressional Action
VA's Suicide Prevention Efforts
Mental Health Strategic Plan
Mental Health Research
Suicide Awareness
Screening
Suicide Prevention Hotline
Funding for Suicide Prevention
Conclusion
List of Tables
Table 1. U.S. Death Rates for Suicide, by Age, 2004
Summary
Numerous news stories in the popular print and electronic media
have documented suicides among servicemembers and veterans returning
from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom
(OEF). In the United States, there are more than 30,000 suicides
annually. Suicides among veterans are included in this number, but it
is not known in what proportion. There is no nationwide system for
surveillance of suicide specifically among veterans. Recent data show
that about 20% of suicide deaths nationwide could be among veterans. It
is not known what proportion of these deaths are among OIF/OEF
veterans.
Veterans have a number of risk factors that increase their chance
of attempting suicide. These risk factors include combat exposure,
post-traumatic stress disorder (PTSD) and other mental health problems,
traumatic brain injury (TBI), poor social support structures, and
access to lethal means.
Several bills addressing suicide in veterans have been introduced
in the 110th Congress. On November 5, 2007, the Joshua Omvig Veterans
Suicide Prevention Act (P.L. 110-110) was signed into law, requiring
the Department of Veterans Affairs (VA) to establish a comprehensive
program for suicide prevention among veterans. More recently, the
Veterans Suicide Study Act (S. 2899) was introduced. This bill would
require the VA to conduct a study, and report to Congress, regarding
suicides among veterans since 1997.
The VA has carried out a number of suicide prevention initiatives,
including establishing a national suicide prevention hotline for
veterans, conducting awareness events at VA medical centers, and
screening and assessing veterans for suicide risk.
This report discusses data sources and systems that can provide
information about suicides in the general population and among
veterans, and known risk and protective factors associated with suicide
in each group. It also discusses suicide prevention efforts by the VA.
It does not discuss Department of Defense (DoD) activities, or VA's
treatment of risk factors for suicide, such as depression, PTSD, and
substance abuse.
This report will be updated when legislative activity warrants.
----------
Introduction
Considerable public attention has been drawn toward the mental
healthcare needs of veterans, especially those returning from combat in
Iraq and Afghanistan. Numerous news stories in the popular print and
electronic media have documented suicides among servicemembers and
veterans returning from Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF).\1\ Some veterans advocacy groups have filed a
class-action lawsuit claiming that the Department of Veterans Affairs
(VA) is not providing adequate and timely access to mental healthcare,
and that this has led to an ``epidemic of suicides.'' \2\
---------------------------------------------------------------------------
\1\ Ken Fuson and Jennifer Jacobs, ``Iowans Lauded for Anti-suicide
Efforts,'' The Des Moines Register, January 26, 2008; Dana Priest,
``Soldier Suicides at Record Level,'' Washington Post, January 31,
2008, Page A01; ``Soldier, After Bipolar Treatment and Suicide
Attempts, Sent Back to War Zone,'' Editor & Publisher, February 11,
2008; ``Suicide Epidemic Among Veterans--A CBS News Investigation
Uncovers a Suicide Rate for Veterans Twice That of Other Americans,''
aired November 13, 2007. OEF, which began in October 2001, conducts
combat operations in Afghanistan and other locations. OIF, which began
in March 2003, conducts combat operations in Iraq and other locations.
\2\ Veterans for Common Sense and Veterans United for Truth, Inc.,
v. James B. Peake, Secretary of Veterans Affairs, et al., Plaintiffs
Trial Brief, Case No. C-07-3758-SC, filed April 17, 2008.
---------------------------------------------------------------------------
However, most often the data cited in these press reports do not
differentiate between suicides among veterans and active duty
servicemembers.\3\ It is important to make this distinction, because
two separate healthcare systems--at the VA and the Department of
Defense (DoD), respectively--are responsible for providing mental
healthcare to these two distinct populations. This report explains the
difficulties in determining the incidence of suicide among veterans,
summarizes what is known about suicides in the general population and
among veterans, and discusses known risk and protective factors
associated with suicide in each group. It also discusses recent
congressional action to address suicide among veterans, and suicide
prevention efforts by the VA. The report does not discuss DoD
activities, or VA's treatment of risk factors for suicide, such as
depression, post-traumatic stress disorder (PTSD), and substance abuse.
---------------------------------------------------------------------------
\3\ Within the context of the VA, a veteran is defined as a
``person who served in the active military, naval, or air service, and
who was discharged or released there from under conditions other than
dishonorable.'' [38 USC Sec. 101(2); 38 CFR Sec. 3.1(d)]. The VA
largely bases its determination of veteran status upon military
department service records.
---------------------------------------------------------------------------
Data and Data Systems for Tracking Suicide
Suicide is the act of intentionally ending one's life, attempted
suicide is an effort that does not have a fatal outcome, and suicidal
ideation is thinking about or wanting to end one's life. Because
completed (versus attempted) suicide results in death, national
statistics on suicide come from death certificate data.\4\ These data
are collected by state and territorial health officials, under their
authority, and are voluntarily reported to the Centers for Disease
Control and Prevention's (CDC's) National Vital Statistics System. The
CDC analyzes the data and publishes information on numbers and rates of
death, and important trends, in the United States.\5\ The CDC also
publishes a U.S. standard death certificate, which states and
territories can modify. Most U.S. deaths are not investigated by
government officials. Possible suicides may be investigated, however,
pursuant to state and territorial authorities. To the extent that a
death is recognized as a suicide, the standard death certificate
provides the means to report suicide as the manner of death, but it has
limited options for noting other information that may be relevant to
the suicide.
---------------------------------------------------------------------------
\4\ In reference to fatal suicides, the public health community
prefers to use the term ``completed,'' rather than ``committed'' or
``successful,'' to recognize the frequent association of suicide with
mental illness, and reduce the accompanying stigma.
\5\ For more information, see Centers for Disease Control and
Prevention (CDC), Mortality Data from the National Vital Statistics
System, at http://www.cdc.gov/nchs/deaths.htm, visited May 2, 2008.
---------------------------------------------------------------------------
In 2003, CDC launched the National Violent Death Reporting System
(NVDRS), an active surveillance system that provides detailed
information about the circumstances of violent deaths, including
suicide.\6\ The NVDRS augments death certificate data by linking it to
death investigation reports filed by coroners, medical examiners, and
law enforcement officials. These added layers of information allow the
NVDRS to identify suicide risk factors, such as depression; to gather
additional information, such as toxicology results; and to more
reliably capture information that could have been, but was not,
completed on the standard death certificate. At this time, the NVDRS is
not in operation nationwide, but only in 17 states, and NVDRS data
might not be generalizable to the entire U.S. population. Also, because
protocols for death investigation vary from one state to the next,
NVDRS data might not be comparable between those states in which it is
in operation. CDC's goal is to expand the system to all 50 states, all
U.S. territories, and the District of Columbia, and to continue efforts
to standardize data collection and analysis across states.
---------------------------------------------------------------------------
\6\ See CDC, National Violent Death Reporting System, at http://
www.cdc.gov/ncipc/profiles/nvdrs/default.htm.
---------------------------------------------------------------------------
At this time, there is no nationwide system for surveillance (i.e.,
tracking) of suicide among all veterans. As with all suicides in
civilian jurisdiction, suicides among veterans may be investigated, and
the death certificates completed, by state and territorial authorities.
Unless a veteran's suicide occurs in a VA facility, opportunities for
the VA to become aware of the incident may be limited. Three approaches
are being used to track the incidence of suicide among veterans, though
each of them has serious shortcomings.
First, CDC's standard death certificate allows officials to note if
a decedent has ever served \7\ in the U.S. Armed Forces. However, the
fact that a decedent is a veteran is not always known when the
certificate is completed. Although suicides among veterans are a part
of total national suicide statistics, it is not known what proportion
of that total is made up of veterans.
---------------------------------------------------------------------------
\7\ This definition captures current and former U.S. military
servicemembers.
---------------------------------------------------------------------------
Second, VA data may be linked to CDC's vital statistics data
through the National Death Index (NDI). This CDC data system allows
authorized researchers to link national death data to other data
systems, identifying the fact that an individual had died of suicide,
and that a death certificate has been filed.\8\ This would allow the VA
to identify suicide deaths among its enrollees. (Subsequent research
steps are cumbersome. For example, researchers typically must contact
state officials to access the actual death certificates.) The NDI is
not an ongoing data linkage that would constitute surveillance for
suicide. It can be used, however, to support special studies by linking
specific data sets. For example, researchers from the VA and the
University of Michigan conducted a study in which they linked data from
VA's National Registry for Depression (NARDEP) to the NDI, allowing VA
to match its patient registry to certified suicide deaths even when the
decedent's veteran status had not been noted on the death
certificate.\9\ However, because only about one-third of veterans
receive their healthcare from the VA, using VA health systems data for
linkage would not capture the complete experience of suicide among
veterans.
---------------------------------------------------------------------------
\8\ See CDC, National Death Index, at http://www.cdc.gov/nchs/
ndi.htm.
\9\ Zivin et al., ``Suicide Mortality among Individuals Receiving
Treatment for Depression in the Veterans Affairs Health System:
Associations with Patient and Treatment Setting Characteristics,''
American Journal of Public Health, Vol. 97, No. 12, pp. 2193-8,
December 2007, hereafter referred to as Zivin et al., study of
depression and suicide in veterans.
---------------------------------------------------------------------------
Third, the NVDRS resolves many of the problems discussed above.
Through ongoing active surveillance, NVDRS substantially improves the
likelihood that a suicide victim's veteran status will be captured, and
it provides additional useful information about suicide incidents. But
NVDRS is in operation in only 17 states. Though CDC intends it to
become a nationwide system, expansion would depend on appropriations.
Congress first provided funding for NVDRS in FY 2002 and has expressed
support for the program in annual appropriations report language. The
program has not received a specified appropriation in recent years, but
rather is funded through CDC's budget for intentional injury prevention
and control.
Suicide in the U.S. General Population
There are risk factors that increase the likelihood that someone
will attempt suicide, and protective factors that decrease that
likelihood. This section provides some context for suicide among
veterans by discussing the incidence, and risk and protective factors,
for suicide in the U.S. general population.\10\
---------------------------------------------------------------------------
\10\ Unless otherwise noted, information in this section is drawn
from CDC: ``Suicide, Facts at a Glance,'' Summer 2007, and
``Understanding Suicide, Fact Sheet,'' 2006, at http://www.cdc.gov/
ncipc/dvp/suicide/; and ``Surveillance for Violent Deaths--National
Violent Death Reporting System, 16 States, 2005,'' MMWR, vol. 57(SS03),
April 11, 2008, hereafter referred to as NVDRS 2005 report, at http://
www.cdc.gov/mmwr/preview/mmwrhtml/ss5703a1.htm.
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Incidence of Suicide
Suicide is a serious public health problem in the United States.
According to CDC, there were more than 32,000 suicide deaths in the
United States in 2004, making it the 11th leading cause of death that
year. On average, there are four suicides among males for each one
among females. Use of firearms is the most common method of suicide
among males, while poisoning is the most common method among females.
Suicide is the second leading cause of death among 25-34 year olds, and
the third leading cause of death among 15-24 year olds. Although
suicide is a leading cause of death in younger adults, the rate of
suicide (number of suicides within the age group per 100,000 resident
population in the age group) is actually highest in individuals aged 45
or older. Table 1 presents suicide rates across age groups in the
United States for 2004, as published by CDC. It is important to note
that except in the youngest age group, these rates may, and probably
do, include suicides among veterans, though in proportions that are not
known.
Table 1. U.S. Death Rates for Suicide, by Age, 2004
----------------------------------------------------------------------------------------------------------------
15-24 25-44 45-64 65 years All age
Age Group 5-14 years years years years and over groupsa
----------------------------------------------------------------------------------------------------------------
Suicide rate 0.7 10.3 13.9 15.4 14.3 10.9
----------------------------------------------------------------------------------------------------------------
ASource: CDC, death rates for suicide, according to sex, race, Hispanic origin, and age: selected years, 1950-
2004, ``Health, United States, 2007,'' Table 46, at http://www.cdc.gov/nchs/data/hus/hus07.pdf.
ANotes: CDC does not calculate rates based on small numbers of suicides among those younger than five years of
age, as such rates are not statistically reliable. In the source above, CDC also published rates for sub-
intervals of the age intervals presented here (e.g., for those aged 25-34 years and 35-44 years).
Aa. This rate is age-adjusted, calculated using the year 2000 standard population.
There are no official national statistics on attempted suicide
(i.e., attempts that were not fatal), but it is generally estimated
that there are 25 attempts for each death by suicide. Also, it is
reported that there are three suicide attempts among females for every
one among males.
Risk and Protective Factors
No single cause or factor leads to suicide. It is a ``final common
outcome with multiple potential antecedents, precipitants, and
underlying causes.'' \11\ A number of factors are known to increase or
decrease the likelihood that an individual will attempt suicide.
Factors that increase this likelihood are called risk factors. Risk
factors exist at multiple levels, involving individual, family,
community, and societal factors. Conversely, factors that decrease a
person's inclination to attempt suicide are called protective factors,
which also exist at multiple levels. It is important to note that none
of these factors in isolation is known to cause or prevent suicide.
---------------------------------------------------------------------------
\11\ Testimony of Michael Shepherd, M.D., Office of Healthcare
Inspections, Office of Inspector General, Department of Veterans
Affairs, in U.S. Congress, House Committee on Veterans' Affairs,
hearing on Stopping Suicides: Mental Health Challenges Within the
Department of Veterans Affairs, December 12, 2007.
---------------------------------------------------------------------------
The single best predictor of an increased risk of suicide is a
history of a prior suicide attempt. Other risk factors for suicide in
the general population include certain mental illnesses such as
depression, alcohol and substance abuse, history of trauma or abuse,
family history of suicide, job or financial stress, the stigma
associated with seeking mental healthcare, barriers to healthcare
access, and easy access to lethal means. Protective factors include
strong family or community connections; accessible and effective
clinical care; skills in problem solving, conflict resolution, and
nonviolent handling of disputes; and cultural and religious beliefs
that discourage suicide.\12\
---------------------------------------------------------------------------
\12\ Suicide Prevention Resource Center, ``Risk and Protective
Factors for Suicide,'' at http://www.sprc.org/library/srisk.pdf,
visited April 30, 2008.
---------------------------------------------------------------------------
Suicide Among Veterans
In the absence of national surveillance for suicide among veterans,
information is limited to the findings of special epidemiological
studies and surveys. These vary considerably in their design and in the
sub-population of veterans studied, and they often yield conflicting
results.
It is tempting to make comparisons between these studies, and with
information about suicide in the general population. Such comparisons
are often made, but they are not necessarily valid. Among other things,
data about suicides in the general population includes suicides among
veterans. Information about suicide in groups that exclude veterans is
scant, as is information about the extent to which data for veterans
may skew the data for the general population, if at all. An additional
problem in interpreting the findings of these special studies is that
they are often conducted on populations of veterans who are receiving
treatment for suicide risk factors. On the one hand, this makes it
difficult to determine whether study findings reflect the effects of
risk factors, or the effects of interventions. On the other hand, it
indicates that efforts to develop systematic surveillance of suicide
among veterans may, with careful attention to design, also provide the
means to evaluate the effectiveness of prevention and treatment
programs. This section discusses the findings of some key studies of
suicide among veterans.
Incidence of Suicide
The true incidence of suicide among veterans is not known. This
section discusses information from two recent published studies that
yield a partial picture of the burden of suicide in this group.
In 2005, the NVDRS identified 1,821 suicides among former or
current military personnel, comprising 20% of all suicides, in the 16
states in which the system was operational that year.\13\ CDC's
published findings about these 1,821 decedents include the following:
---------------------------------------------------------------------------
\13\ NVDRS 2005 report. The definition ``current and former
military personnel'' is likely to include both current military
personnel and veterans, but the publication does not provide
information about each group separately, or about whether such separate
information is available.
1,765 (96.9%) were male.
1,415 (77.7%) were 45 years of age or older.
The most common method used was firearms (67.9%),
followed by poisoning (12.7%), and hanging/strangulation/suffocation
(11.5%).
47.2% were married, 25.0% were divorced, 13.0% were
widowed, and 14.0% were never married.\14\
---------------------------------------------------------------------------
\14\ The remaining small number of decedents were ``married but
separated,'' ``single, not otherwise specified,'' or their marital
status was not known. These findings were not cross-tabulated by age.
Researchers from the VA and the University of Michigan conducted a
cohort study of 807,694 veterans who were diagnosed with depression in
the VA health system, and registered in the VA's National Registry for
Depression (NARDEP), between 1999 and 2004.\15\ During the study
period, 1,683 (0.21%) of the veterans in this high-risk group committed
suicide. The researchers calculated a rate of 88.25 suicides per
100,000 person-years in this group, seven to eight times higher than
the rate in the general population for the same time period. They noted
that this rate was similar, though, to a more relevant comparison,
namely, to suicides among those in the general population who were
depressed.\16\ They also found the rate among the group of veterans
studied to be highest among those who were younger than 45 years of
age, in contrast with the age trend in the general population.
---------------------------------------------------------------------------
\15\ Zivin et al., study of depression and suicide in veterans. The
authors used CDC's National Death Index to link NARDEP registrants with
death certificate data, in order to identify registrants who had died,
and determine that they died of suicide, during the study period.
\16\ The authors cited only one study on which to base this
comparison, though, which likely reflects the limited availability of
studies in groups that are meaningful for comparison. It is not clear
whether the comparison group included or excluded veterans.
---------------------------------------------------------------------------
In December 2007, VA testified that it had identified 144 known
suicides among OIF/OEF veterans from the time the conflicts began
through the end of 2005, and that this number translated into a rate
that is not statistically different from the rate for age, sex, and
race matched individuals from the general population. These data have
not been published.\17\
---------------------------------------------------------------------------
\17\ Testimony of Ira Katz, M.D., Ph.D., Deputy Chief Patient Care
Services Officer, Office of Mental Health, Veterans Health
Administration, Department of Veterans Affairs in U.S. Congress, House
Committee on Veterans' Affairs, Stopping Suicides: Mental Health
Challenges Within the U.S. Department of Veterans Affairs, hearings,
110th Cong., 1st sess., December 12, 2007.
---------------------------------------------------------------------------
Risk and Protective Factors
While there have been a number of studies to identify risk and
protective factors for suicide in the general population, few studies
have looked at factors specific to veterans. In the general population,
suicide risk factors include male gender; older age; diminished psycho-
social support (e.g., homelessness or unmarried status); availability
and knowledge of firearms; and the co-existence of medical and
psychiatric conditions. This profile describes a large portion of the
veteran patient population, making suicide risk management particularly
challenging in the VA healthcare system.\18\ A study that screened 703
patients from a general medical outpatient clinic at a VA hospital
found that 7.3% of the patients had suicidal ideation.\19\ Younger and
white patients were found to be at increased risk. The risk was higher
in patients with self-described fair or poor mental health, a history
of mental health treatment, and fair or poor perceived physical health.
When major depression was controlled for, anxiety and substance abuse
disorders continued to show an association with suicidal ideation.
---------------------------------------------------------------------------
\18\ Lambert et al., ``Suicide Risk Factors among Veterans: Risk
Management in the Changing Culture of the Department of Veterans
Affairs,'' Journal of Mental Health Administration, Vol. 24, No. 3, pp.
350-8, Summer 1997.
\19\ Lish et al., ``Suicide Screening in a Primary Care Setting at
a Veterans Affairs Medical Center,'' Psychosomatics, Vol. 37, No. 5,
pp. 413-24, 1996.
---------------------------------------------------------------------------
CDC's NVDRS data identified the following associated circumstances
among a group of 1,622 former or current military personnel who died by
suicide in 2005: \20\
---------------------------------------------------------------------------
\20\ NVDRS 2005 report. This group is a subset of the 1,821 former
or current military personnel whose suicides were recorded in NVDRS in
2005, for whom these additional types of information were collected.
Although almost half of them (47.2%) were depressed at
the time of death, only about a fourth (26.7%) were receiving mental
health treatment.
17.2% had an alcohol problem, and 7.7% had a problem with
other substances.
24.5% had a problem with an intimate partner.
38.4% had a physical health problem.
28.0% had experienced an acute crisis during the prior
two weeks.
33.9% had left a suicide note, 13.3% had made a previous
suicide attempt, and 29.0% had disclosed their intent to commit suicide
with enough time for someone to have intervened.
The VA/University of Michigan study of suicide among veterans with
depression found that having a service-connected disability was
associated with a lower risk of suicide in this group.\21\ The authors
suggest that greater access to VA health facilities and regular
compensation payments may explain the protective effect.
---------------------------------------------------------------------------
\21\ Zivin et al., study of depression and suicide in veterans.
---------------------------------------------------------------------------
The Effects of PTSD, TBI, and Depression on Suicide Risk
This section describes three suicide risk factors that are common
among veterans: Post-traumatic Stress Disorder (PTSD), Traumatic Brain
Injury (TBI), and depression. PTSD and TBI are common consequences of
war, with distinct symptoms, treatment modalities, and long-term
effects. PTSD has been recognized in various forms throughout military
history. It is an anxiety disorder, with symptoms of varying severity,
that can occur following experiences, such as military combat, in which
grave physical injury occurred or was threatened. People who suffer
from PTSD often relive the experience through nightmares and
flashbacks, have difficulty sleeping, and feel detached or estranged.
TBI occurs when a sudden physical trauma causes damage to the brain.
Improvised explosive devices (IEDs), which have been used extensively
in the current conflict in Iraq, can cause TBI, sometimes in the
absence of obvious external signs of injury. Symptoms of TBI can be
mild, moderate, or severe, depending on the extent of the brain injury.
When symptoms of TBI or PTSD are mild, they may go undiagnosed, or be
confused with conditions with similar symptoms, such as other mental
illnesses, including depression, or substance use disorders. Either
PTSD or TBI may co-occur with depression or substance abuse. Finally,
some veterans have both a TBI and PTSD.
In April 2008, the RAND Corporation published a study of mental
health problems in servicemembers and veterans.\22\ From their review
of the literature, the authors found that in the general population,
depression, PTSD, and TBI are each independent risk factors for
suicide. More limited information from studies of servicemembers or
veterans generally shows the same effect of these three risk factors in
specific groups that were studied. This information also typically
shows trends comparable to those in the general population with respect
to other risk factors for suicide, though the demonstrated effects of
interactions of these factors with depression, PTSD and TBI may differ.
For example, studies have found that while males are at greater risk of
death from suicide than are females, the effects that depression, PTSD
and TBI have on increasing this risk is greater in females. Among the
general population, substance abuse, prior nonfatal suicide attempts,
severity of PTSD symptoms, and certain types of TBI are more predictive
for suicide, and may signal areas of greater suicide risk among
military and veterans populations as well. Researchers also found that
combat exposure increases the risk of suicide, as well as the
likelihood of PTSD, which itself also increases the risk of suicide.
---------------------------------------------------------------------------
\22\ Tanelian and Jaycox, ``Invisible Wounds of War,'' RAND, 2008,
at http://RAND.org/pubs/monographs/2008/RAND_MG720.1.pdf, visited April
28, 2008.
---------------------------------------------------------------------------
The VA/University of Michigan study of suicide among veterans with
depression found that PTSD was associated with a lower risk of suicide
in this group.\23\ The authors suggest that this unexpected finding may
reflect the effect of treatment for PTSD, rather than a protective
effect of PTSD itself.
---------------------------------------------------------------------------
\23\ Zivin et al., study of depression and suicide in veterans.
---------------------------------------------------------------------------
Congressional Action
In the 109th Congress, two measures (H.R. 5771 and S. 3808) were
introduced regarding the prevention of suicide among veterans. However,
these bills did not see further legislative action.
In the 110th Congress, the Joshua Omvig Veterans Suicide Prevention
Act (H.R. 327) was introduced in the House, and a companion version (S.
479) was introduced in the Senate.\24\ The House passed H.R. 327 on
March 21, 2007, and the Senate passed the House measure with an
amendment on September 27. The bill was signed into law (P.L. 110-110)
on November 5, 2007.\25\ The act, among other things, requires the VA
to establish a comprehensive program for suicide prevention among
veterans. In carrying out this comprehensive program, the VA must
designate a suicide prevention counselor at each VA medical facility.
Each counselor is required to work with local emergency rooms, police
departments, mental health organizations, and veterans service
organizations to engage in outreach to veterans. The act also requires
the VA to provide for research on best practices for suicide prevention
among veterans, and requires the VA Secretary to provide for outreach
and education for veterans and their families, with special emphasis on
providing information to veterans of OIF and OEF. The act requires VA
to provide for the availability of 24-hour mental healthcare for
veterans and to establish a 24-hour hotline for veterans to call if
needed.
---------------------------------------------------------------------------
\24\ The Joshua Omvig Veterans Suicide Prevention Act is named for
a veteran who completed suicide on December 22, 2005.
\25\ Codified at 38 USC Sec. 1720F. For a detailed legislative
history of PL 110-110, see H.Rept. 110-55 and S.Rept. 110-132.
---------------------------------------------------------------------------
Also in the 110th Congress, the National Defense Authorization Act
for Fiscal Year 2008 (P.L. 110-181) requires the Secretaries of DoD and
VA to develop a comprehensive care and transition policy for
servicemembers who are recovering from serious injuries or illnesses
related to their military service, and to specifically address the risk
of suicide among these individuals in developing the required
policy.\26\
---------------------------------------------------------------------------
\26\ See CRS Report RL34371, ``Wounded Warrior'' and Veterans
Provisions in the FY 2008 National Defense Authorization Act, by Sarah
A. Lister, Sidath Viranga Panangala, and Christine Scott.
---------------------------------------------------------------------------
More recently, the Veterans Suicide Study Act (S. 2899) was
introduced. This measure would require the VA to study and report to
Congress regarding suicides that have occurred among veterans since
1997. In carrying out this study, the VA Secretary would have to
coordinate with the Secretary of Defense, Veterans Service
Organizations, the CDC, and state public health offices and veterans
agencies.
VA's Suicide Prevention Efforts \27\
In response to legislation and congressional oversight, the VA has
initiated several suicide prevention activities. Following is a summary
of major activities.
---------------------------------------------------------------------------
\27\ Drawn from the Department of Veterans Affairs, Report to
Congress, P.L. 110-110, Comprehensive Program for Suicide Prevention
Among Veterans, February 2008.
---------------------------------------------------------------------------
Mental Health Strategic Plan
In 2004, the VA developed the Mental Health Strategic Plan (MHSP),
which aimed to present a new approach to mental healthcare, to focus on
recovery rather than pathology, and to integrate mental healthcare into
overall healthcare for veteran patients. This 5-year action plan, with
more than 200 initiatives, includes timetables and responsible offices
identified for each action item. A number of these action items are
specifically aimed at the prevention of suicide. In 2006, following a
request by the House Committee on Veterans Affairs, the VA's Inspector
General (IG) undertook an assessment of VA's progress in implementing
the MHSP initiatives for suicide prevention, and provided
recommendations.\28\ The IG's findings revealed that MHSP initiatives
pertaining to 24-hour crisis availability, outreach, referral, and
development of methods for tracking veterans at risk have been
implemented in multiple facilities, but not yet systemwide. Initiatives
focused on the development of methods for screening, assessment of
veterans at risk, emerging best practice treatment interventions,
education of VA health providers, and an electronic suicide prevention
database have been piloted or are in the process of being piloted at
selected facilities.
---------------------------------------------------------------------------
\28\ Department of Veterans Affairs, Office of Inspector General,
``Implementing VHA's Mental Health Strategic Plan Initiatives for
Suicide Prevention,'' Report No. 06-03706-126, 2007.
---------------------------------------------------------------------------
Mental Health Research
VA's Mental Illness Research, Education and Clinical Center
(MIRECC) at Denver, Colorado, and the Center of Excellence in Mental
Health and PTSD at Canandaigua, New York, have been specifically
focusing on research related to suicide prevention. According to the
VA, ongoing studies at these centers are studying suicide risk factors,
validation of suicide ideation screening instruments, quality of mental
healthcare and its relationship to suicide prevention, and risk factors
for suicide as it relates to depression.
Suicide Awareness
In April 2007, VA held its first Suicide Prevention Awareness Day
at all VA medical centers (VAMCs). The program included recognizing
risk factors for suicide, and proper protocols for responding to crisis
situations. VA held its second Suicide Prevention Awareness Day in
September 2007. The program consisted of required training for all
staff on general principles of suicide prevention, and the use of the
national VA Suicide Prevention Hotline (see below).
VA has also appointed Suicide Prevention Coordinators who are
located at each VA medical center. They were appointed in response to
P.L. 110-110, which required VA to appoint suicide prevention
counselors in each VA medical facility. The primary function of these
coordinators is to support the identification of patients at high risk
for suicide, and to ensure that their monitoring and care are
intensified. Furthermore, they are involved in training and education,
both within the VA and in the community. All the coordinators are
licensed mental health professionals.
Screening
A screening program aims to identify individuals who have mental or
emotional problems that increase their risk for suicide.\29\ VA has
implemented a policy to screen all OEF/OIF veterans for depression,
PTSD, and alcohol abuse upon their initial visit to VA medical centers
or clinics. Furthermore, screening for depression and alcohol abuse is
required on an annual basis for all veterans, and screening for PTSD is
required annually for the first five years after enrollment, and every
five years thereafter. Veterans who screen positive for one of these
conditions are required to receive a follow-up clinical evaluation that
considers both the condition(s) related to the positive screen, and the
risk of suicide. When this process confirms the presence of a mental
disorder or suicide risk, veterans are offered mental health treatment.
When there is a referral or request for mental health services,
veterans must receive an initial evaluation within 24 hours. If this
evaluation identifies an urgent need, treatment is to be provided
immediately. Otherwise, veterans must receive a full diagnostic and
treatment planning evaluation and the initiation of care within two
weeks.
---------------------------------------------------------------------------
\29\ For more information on screening tools and their
effectiveness, see CRS Report RS22647, Screening for Youth Suicide
Prevention, by Ramya Sundararaman.
---------------------------------------------------------------------------
In addition, the DoD administers a post-deployment health
reassessment (PDHRA) 90-180 days after a servicemember's return from
deployment, to identify health concerns, with an emphasis placed on
screening for mental health conditions that may have emerged since
returning home. Information gathered during this assessment helps DoD
identify servicemembers who require referrals for further
evaluation.\30\ The Government Accountability Office (GAO) has stated
that DoD shares information gathered through the PDHRA with the VA.
According to GAO, ``VA officials obtain PDHRA information about
servicemembers referred to VA and individual servicemembers' [PDHRA]
when they access VA healthcare. Each month, VA receives a report that
provides monthly and cumulative totals of servicemembers referred,
including servicemembers referred to VA facilities.'' \31\ However, it
is unclear at this time if VA uses this information to specifically
screen those who may be potentially at risk of suicide.
---------------------------------------------------------------------------
\30\ The PDHRA (DD Form 2900) includes questions about feeling
down, depressed, or hopeless, the occurrence of nightmares,
relationship issues with family and friends, and increased alcohol use.
\31\ U.S. Government Accountability Office (GAO), DoD's Post-
Deployment Health Reassessment, GAO-08-181R, January 25, 2008, p.7.
---------------------------------------------------------------------------
Suicide Prevention Hotline
The VA has also partnered with the Lifeline Program, a grantee of
the Substance Abuse and Mental Health Services Administration (SAMHSA),
of the Department of Health and Human Services (HHS), to develop a VA
suicide prevention hotline. Those who call 1-800-273-TALK are asked to
press ``1'' if they are a veteran, or are calling about a veteran.\32\
When they do so, they are connected directly to VA's hotline call
center, where they speak to a VA mental health professional with real-
time access to the veteran's medical records. The responders at the VA
suicide prevention hotline have received American Association of
Suicidology (AAS) credentialing and certification.
---------------------------------------------------------------------------
\32\ VA is using the national suicide prevention hotline to provide
this service to veterans.
---------------------------------------------------------------------------
In emergencies, the hotline contacts local emergency resources such
as police or ambulance services to ensure an immediate response. In
other cases, after providing support and counseling, the hotline
transfers care to the suicide prevention coordinator at the nearest
VAMC for follow-up care.
From October 7 to November 10, 2007, 1,636 veterans and 311 family
members or friends called the VA suicide prevention hotline. These
calls led to 363 referrals to suicide prevention coordinators and 93
rescues involving emergency services.\33\
---------------------------------------------------------------------------
\33\ Testimony of Ira Katz, M.D., Ph.D., Deputy Chief Patient Care
Services Officer, Office of Mental Health, Veterans Health
Administration, Department of Veterans Affairs in U.S. Congress, House
Committee on Veterans' Affairs, Stopping Suicides: Mental Health
Challenges Within the U.S. Department of Veterans Affairs, hearings,
110th Cong., 1st sess., December 12, 2007.
---------------------------------------------------------------------------
Funding for Suicide Prevention
According to VA estimates, in FY 2008, spending for the suicide
prevention program will include $970,000 to establish the suicide
prevention hotline; $1.97 million for the Center of Excellence in
Canandaigua, New York; $2.20 million for the Mental Illness Research,
Education and Clinical Center in Denver, Colorado; $90,000 for the
Serious Mental Illness Research, Education and Clinical Center for
monitoring of suicide rates and risk factors; and $14.32 million for
Suicide Prevention Coordinators.\34\
---------------------------------------------------------------------------
\34\ Department of Veterans Affairs, Report to Congress, P.L. 110-
110, Comprehensive Program for Suicide Prevention Among Veterans, p. 7,
February 2008.
---------------------------------------------------------------------------
Conclusion
There has been considerable recent interest in the burden of
suicide among veterans, in particular those who have recently returned
from military service in Operation Iraqi Freedom and Operation Enduring
Freedom. This interest has thrown a spotlight on the fact that there is
not, at this time, a system of surveillance for suicide among veterans.
Despite recent interest in comparing suicide rates between veterans
and the general population, this may not be the most useful comparison.
In numerous ways that affect their suicide risk, veterans are not like
the general population. Also, the VA has an interest in decreasing the
burden of suicide among veterans, whether this burden exceeds that of
the general population or not. What may be more meaningful, and more
important to achieve, is the establishment of data systems that support
a more robust and reliable understanding of suicide among veterans. The
ideal systems would describe a clear baseline, and provide a means to
track changes going forward--with respect to such things as risk and
protective factors, and the effects of treatment--in order to know
which interventions work, and where to target them.
[GRAPHIC] [TIFF OMITTED] 43052A.009
[GRAPHIC] [TIFF OMITTED] 43052A.010
[GRAPHIC] [TIFF OMITTED] 43052A.011
[GRAPHIC] [TIFF OMITTED] 43052A.012
Department of Veterans Affairs
Under Secretary for HealthAddress
Washington, DC.
In Reply Refer To:
Dear Veteran,
If you're experiencing an emotional crisis and need to talk with a
trained VA professional, the National Suicide Prevention toll-free
hotline number, 1-800-273-TALK (8255), is now available 24 hours a day,
seven days a week. You will be immediately connected with a qualified
and caring provider who can help.
Here are some suicide warning signs:
1. Threatening to hurt or kill yourself
2. Looking for ways to kill yourself
3. Seeking access to pills, weapons or other self destructive
behavior
4 Talking about death, dying or suicide
The presence of these signs requires immediate attention. If you or
a veteran you care about has been showing any of these signs, do not
hesitate to call and ask for help!
Additional warning signs may include:
1. Hopelessness
2. Rage, anger, seeking revenge
3. Acting reckless or engaging in risky activities, seemingly
without thinking
4. Increasing alcohol or drug abuse
5. Feeling trapped--like there's no way out
6. Withdrawing from friends and family
7. Anxiety, agitation, inability to sleep--or, excessive
sleepiness
8. Dramatic mood swings
9. Feeling there is no reason for living, no sense of purpose in
life
Please call the toll-free hotline number, 1-800-273-TALK (8255) if
you experience any of these warning signs. We'll get you the help and
assistance you need right away!
Sincerely yours,
Michael J. Kussman, MD, MS, MACP
----------
VA Suicide Crisis Hotline (1-800-273 TALK)
Who Should Call?
Anyone, but especially those who feel sad, hopeless, or
suicidal
Family and friends who are concerned about a loved one
who may be having these feelings.
Anyone interested in suicide prevention, treatment and
service
1-800-273 TALK
The service is free and confidential
The hotline is staffed by trained counselors
We are available 24 hours a day, 7 days a week
We have information about support services that can help
you.
Crisis Response Plan
When thinking about suicide, I agree to do the following:
Step 1: Try to identify my thoughts and specifically what's
upsetting me
Step 2: Write out and review more reasonable responses to my
suicidal thoughts
Step 3: Do things that help me feel better for about 30 min (e.g.,
taking a bath, listening to music, going for a walk)
Step 4: If your suicidal thoughts persist, call 1-800-273-TALK
Step 5: If the thoughts continue, get specific, and I find myself
preparing to do something, call 911
Step 6: If I'm still feeling suicidal and don't feel like I can
control my behavior, I go to the emergency room
REMEMBER: The VA Suicide Hot Line is 1-800-273-TALK
Get Mental Health Follow-Up 1-202-745-8267 for an APPOINTMENT
Committee on Veterans' Affairs
Washington, DC.
December 21, 2007
Mr. Rick Kaplan
Executive Producer
CBS Evening News With Katie Couric
524 West 57th Street
New York, NY 10019
Dear Mr. Kaplan:
On December 12, 2007, the House Committee on Veterans' Affairs held
a hearing to assess the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide. This
hearing raised concerns regarding the discrepancy between the numbers
of veteran suicides reported by VA as compared to those reported by CBS
News on November 13, 2007.
Accurate data is crucial in identifying risk factors and providing
better treatment and suicide prevention programs. For this reason, we
respectfully request that CBS News share their data on suicide among
veterans with the Committee.
Specifically, we request data on the number of veteran and non-
veteran suicides for each year from 1995 through 2005 reported by State
with year of death, age, race, gender and manner of suicide.
Additionally, request the data that CBS News used to define the at-risk
populations (e.g., veterans/non-veterans, men/women) by age group.
Undoubtedly, you and the entire CBS Evening News staff, share our
desire to ensure that every possible measure is taken to prevent those
who have worn the uniform from succumbing to the tragedy of suicide. As
such, we would greatly appreciate your willingness to share the
information you have accumulated with the Committee.
Thank you for your prompt consideration and attention to this
request. Should you have any questions, please feel free to contact
either Committee Staff Director, Malcom Shorter, at 202-225-9756 or
Republican Staff Director, Jim Lariviere, at 202-225-3527.
Sincerely,
Bob Filner
Chairman
Steve Buyer
Ranking Member
CW/mh
----------
CBS News
New York, NY.
May 16, 2008
Honorable Bob Filner, Chairman
Committee on Veterans' Affairs
United States House of Representatives
One Hundred Tenth Congress
335 Cannon House Office Building
Washington, DC 20515
Dear Congressmen Filner:
This is in reply to your letter of last December to Rick Kaplan,
Executive Producer of the CBS Evening News. It appears that your letter
was originally lost within CBS and only came to light when a copy of it
was given to Armen Keteyian, CBS News' Chief Investigative
Correspondent, at last week's hearing of the House Committee on
Veterans' Affairs. I apologize for the delay.
In your letter you request that CBS News provide ``data on numbers
the veteran and non-veteran suicides for each year from 1995 through
2005 reported by. . . . [and] data that CBS News used to define the at-
risk populations (e.g., veterans/non-veterans, men/women) by age
group.''
You are quite right, Congressmen, in stating that we at CBS News
share your desire to ensure that every possible measure is taken to
prevent veteran suicide. We believe, however, that the respect in which
we are best able to serve the interests of veterans and of all other
segments of the American public is to preserve our ability to do
effective news reporting; and that to be effective reporters, we must
maintain our journalistic independence. For that reason we must
respectfully decline to provide the data you request.
Insofar as the Committee's request derives from its need for the
raw data on which CBS News based its reporting, that data is readily
available to the Committee from State agencies, which are public. If
the Committee's goal is to review the editorial process by which we
arrived at our reports' content, we respectfully urge that it would be
quite wrong of CBS News to submit voluntarily to such governmental
oversight. Indeed, doing so would fundamentally compromise the
editorial independence on which we and all news organizations depend.
I should also point out that obtaining suicide data from the
various States involved more than just a basic public records request.
Initially, several States refused to provide their data to CBS News out
of a concern for the privacy of the veterans involved and their
families. These States believed that the suicide numbers in some
categories are small enough so that individuals could be identified and
their privacy compromised. In order to obtain the data, CBS News had to
give these States our assurance that we would keep the raw data
confidential. Some States insisted upon written agreements to this
effect. Accordingly, we are constrained not only by principle, but by
these specific undertakings, from providing the Committee with the data
you have requested.
I hope you will appreciate Congressmen, that we take the work of
the House Committee on Veterans' Affairs very seriously and that we
withhold our cooperation only out of deference to our own
responsibilities as journalists.
Respectfully,
Linda Mason
Senior Vice President
Standards and Special Projects
cc Rick Kaplan
Armen Keteyian
Committee on Veterans' Affairs
Washington, DC.
December 21, 2007
The Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
On December 12, 2007, the House Committee on Veterans' Affairs held
a hearing to assess the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide. This
hearing raised concerns regarding the discrepancy between the numbers
of veteran suicides reported by VA as compared to those reported by CBS
News on November 13, 2007.
Accurate data is crucial in identifying risk factors and providing
better treatment and suicide prevention programs. For this reason, we
respectfully request that the Department of Veterans Affairs share
their data on suicide among veterans with the Committee.
Specifically, we request to have the number of veteran suicides for
each year from 1995 through 2006, reported by year of death, age, race,
gender and manner of suicide. Additionally, we ask for the methodology
the Department uses to collect data on veteran suicides.
Undoubtedly, you share our desire to ensure that every measure is
taken to prevent our Nation's veterans from committing suicide. We
would greatly appreciate your willingness to share any information you
may have regarding this issue with the Committee.
Thank you for your prompt consideration and attention to this
request. Should you have any questions, please feel free to contact
either Committee Staff Director, Malcom Shorter, at 202-225-9756 or
Republican Staff Director, Jim Lariviere, at 202-225-3527.
Sincerely,
Bob Filner
Chairman
Steve Buyer
Ranking Member
----------
The Secretary of Veterans Affairs
Washington, DC.
February 5, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
This is in response to your letter requesting data on suicide rates
among veterans and the methodologies used by the Department of Veterans
Affairs (VA) to collect data on veteran suicides.
The enclosed information and worksheet contains data on veteran
suicides from two separate projects. One is an ongoing study of
mortality in Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) veterans being conducted by VA's Office of Environmental
Epidemiology. Identification of veterans is based on information from
the Department of Defense and includes all OEF/OIF servicemembers who
were separated from active duty including National Guard and Reserve
personnel. The second project is an ongoing study of suicide in
veterans who have used Veterans Health Administration services from
2000 onward and who were alive at the start of 2001. The study includes
veterans of all eras.
For both projects, information about the time and causes of death
was derived from the National Death Index. Information contained in
data files on causes of death from the National Death Index is only
available through the end of 2005. I have also enclosed the methodology
used for both projects.
Your interest in our Nation's veterans is appreciated. A similar
letter is being sent to Congressman Steve Buyer.
Sincerely yours,
James B. Peake, M.D.
Enclosures
----------
Study of Operation Enduring Freedom/Operation Iraqi Freedom Veterans
Methodology
Population: As part of our mortality study of veterans who served
in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF),
the Department of Veterans Affairs (VA) obtained the identities of
490,346 OEF/OIF veterans who served as part of either OEF or OIF and
were separated or deactivated from military service between October
2001 and December 2005. This study will assess both overall mortality
risk as well as cause-specific mortality risk. Among the cause specific
mortality of particular interest are deaths due to motor vehicle
accidents and suicides.
Data Sources: The identities of the 490,346 OEF/OIF veterans,
military service characteristics, and various demographic data were
provided to VA by the Department of Defense Manpower Data Center. Vital
statistics data pertaining to OEF/OIF veterans was determined by using
VA's database, Beneficiary Identification and Records Locator
Subsystem, and deaths reported to the Social Security Administration
Death Master File. The Beneficiary Identification and Records Locator
Subsystem file has the identities of all veterans who have applied for
VA benefits (including death benefits), and the Social Security
Administration Death Master File includes all deaths reported to that
agency. All veterans were matched against the Beneficiary
Identification and Records Locator Subsystem and Social Security
Administration files using Social Security numbers. Cause of death data
was obtained from the National Death Index. Since 1979, the Office of
Vital Statistics in each State has reported deaths, including cause of
death data to the National Center for Health Statistics, where the
National Death Index is compiled. Causes of death were recorded using
International Classification of Diseases codes 10th Revision (ICD-10).
For traumatic deaths, including suicide, part of the ICD-10 codes
records the method of injury. For suicides, the ICD-10 codes report the
method of suicide. At the time this study began, the National Death
Index had cause of death data through December 31, 2005. Using the
aforementioned databases, VA identified a total of 818 deaths to
include 144 suicides.
The attached table has demographic and military service
characteristics as well as death certificate data and method of suicide
for the 144 suicides identified in this study.
CHARACTERISTICS OF 144 SUICIDES AMONG OEF/OIF* VETERANS THROUGH 2005
----------------------------------------------------------------------------------------------------------------
Characteristic Frequency Percentage
----------------------------------------------------------------------------------------------------------------
Age at death
----------------------------------------------------------------------------------------------------------------
20-29 78 54.1
----------------------------------------------------------------------------------------------------------------
30-39 39 27.1
----------------------------------------------------------------------------------------------------------------
40-49 14 9.7
----------------------------------------------------------------------------------------------------------------
50-59 13 9.1
----------------------------------------------------------------------------------------------------------------
Year of death
----------------------------------------------------------------------------------------------------------------
2002 7 4.9
----------------------------------------------------------------------------------------------------------------
2003 21 14.6
----------------------------------------------------------------------------------------------------------------
2004 48 33.3
----------------------------------------------------------------------------------------------------------------
2005 68 47.2
----------------------------------------------------------------------------------------------------------------
Method of suicide
----------------------------------------------------------------------------------------------------------------
Poisoning 7 4.9
----------------------------------------------------------------------------------------------------------------
Hanging 30 20.8
----------------------------------------------------------------------------------------------------------------
Firearm 105 72.9
----------------------------------------------------------------------------------------------------------------
Jumping 1 .7
----------------------------------------------------------------------------------------------------------------
Sharp Object 1 .7
----------------------------------------------------------------------------------------------------------------
Sex
----------------------------------------------------------------------------------------------------------------
Male 141 97.9
----------------------------------------------------------------------------------------------------------------
Female 3 2.1
----------------------------------------------------------------------------------------------------------------
Race
----------------------------------------------------------------------------------------------------------------
White 118 81.9
----------------------------------------------------------------------------------------------------------------
Non-White 26 18.1
----------------------------------------------------------------------------------------------------------------
Ever seen at VAMC
----------------------------------------------------------------------------------------------------------------
Yes 33 22.9
----------------------------------------------------------------------------------------------------------------
Branch of service
----------------------------------------------------------------------------------------------------------------
Army 73 50.7
----------------------------------------------------------------------------------------------------------------
Marines 15 10.4
----------------------------------------------------------------------------------------------------------------
Air Force 33 22.9
----------------------------------------------------------------------------------------------------------------
Navy 23 16.0
----------------------------------------------------------------------------------------------------------------
Rank
----------------------------------------------------------------------------------------------------------------
Officer 8 5.6
----------------------------------------------------------------------------------------------------------------
Warrant Officer 1 0.7
----------------------------------------------------------------------------------------------------------------
Enlisted 135 93.7
----------------------------------------------------------------------------------------------------------------
Unit component
----------------------------------------------------------------------------------------------------------------
Active 68 47.2
----------------------------------------------------------------------------------------------------------------
Reserve 35 24.3
----------------------------------------------------------------------------------------------------------------
National Guard 41 28.5
----------------------------------------------------------------------------------------------------------------
* These suicides were identified among a cohort of 490,346 OEF/OIF veterans selected for mortality follow-up
through 2005.
Study of Veterans Using Veterans Health Administration
Methodology
Population: The Veterans Health Administration defined the
population of VA patients at risk for suicide in each fiscal year as
those who were alive at the start of the year, and who had received VA
services during either that year or the prior one. This approach to
identifying VA's patient population was developed in consultation with
VA mental health leadership and assumes that patients seen in VA
settings in the prior year would still be considered to be in active VA
care and part of the at-risk patient population in the following year.
Data Sources: This study used data from VA's National Patient Care
Database to identify all veterans with inpatient or outpatient services
utilization in any VA facility during the relevant years. Measures of
vital status and cause of death were based on information from the
National Death Index. The National Death Index is considered the ``gold
standard'' for mortality assessment information and includes national
data regarding dates and causes of death for all U.S. residents. This
information is derived from death certificates filed in the Office of
Vital Statistics for each State. National Death Index searches were
performed for cohorts of VA patients who received any VA services
during the relevant years, and who had no subsequent VA services
through June 2006. This cost-efficient method for conducting National
Death Index searches enables comprehensive assessment of vital
statistics and cause of death among all veterans in the VA patient
population. The National Death Index data request included Social
Security number, last name, first name, middle initial, date of birth,
race and ethnicity, sex, and State of residence. National Death Index
search results often include multiple records that are potential
matches. ``True matches'' were identified based on established
procedures.
Veterans' age and gender were identified from VA administrative
files included in the National Patient Care Database. Age at the start
of Fiscal Year 2001 was categorized as being either less than 30, 30 to
39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, or greater than or equal to
80 years. Information regarding race and ethnicity was not consistently
available in the National Patient Care Database for all VA patients. VA
identified dates and causes of death using National Death Index data.
Suicide deaths were identified using International Classification of
Diseases codes X60 through X84, and Y87.0 (World Health Organization
2004).
VA is conducting a comprehensive program for preventing veteran
suicides, and is conducting ongoing research to guide its prevention
strategies. The VA Office of Mental Health staff is available to
provide additional briefings to the Committee on rates, risks factors
and strategies.
----------------------------------------------------------------------------------------------------------------
Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005
-----------------------------------------------------------------------------------------------------------------
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
Characteristic --------------------------------------------------------------------------
N % N % N % N % N %
----------------------------------------------------------------------------------------------------------------
Total* 1403 100 1737 100.0 1600 100.0 1702 100.0 1784 100.0
----------------------------------------------------------------------------------------------------------------
Total, age 20 and over 1401 100 1734 100.0 1598 100.0 1701 100.0 1781 100.0
----------------------------------------------------------------------------------------------------------------
Sex
----------------------------------------------------------------------------------------------------------------
Male 1360 97.1 1682 97.0 1559 97.6 1647 96.8 1720 96.6
----------------------------------------------------------------------------------------------------------------
Female 41 2.9 52 3.0 39 2.4 54 3.2 61 3.4
----------------------------------------------------------------------------------------------------------------
Age Group
----------------------------------------------------------------------------------------------------------------
20-29 yrs 26 1.9 44 2.5 38 2.4 50 2.9 38 2.1
----------------------------------------------------------------------------------------------------------------
30-39 yrs 108 7.7 119 6.9 111 6.9 105 6.2 105 5.9
----------------------------------------------------------------------------------------------------------------
40-49 yrs 240 17.1 283 16.3 272 17.0 256 15.0 254 14.3
----------------------------------------------------------------------------------------------------------------
50-59 yrs 359 25.6 437 25.2 407 25.5 424 24.9 470 26.4
----------------------------------------------------------------------------------------------------------------
60-69 yrs 202 14.4 261 15.1 264 16.5 272 16.0 291 16.3
----------------------------------------------------------------------------------------------------------------
70-79 yrs 320 22.8 393 22.7 345 21.6 381 22.4 380 21.3
----------------------------------------------------------------------------------------------------------------
80+ yrs 146 10.4 197 11.4 161 10.1 213 12.5 243 13.6
----------------------------------------------------------------------------------------------------------------
Race
----------------------------------------------------------------------------------------------------------------
White Hispanic 30 2.1 25 1.4 32 2.0 24 1.4 29 1.6
----------------------------------------------------------------------------------------------------------------
Black Hispanic 2 0.1 1 0.1 1 0.1 2 0.1 2 0.1
----------------------------------------------------------------------------------------------------------------
Native American 2 0.1 6 0.3 3 0.2 2 0.1 7 0.4
----------------------------------------------------------------------------------------------------------------
African American 55 3.9 80 4.6 47 2.9 62 3.6 78 4.4
----------------------------------------------------------------------------------------------------------------
Asian/Pacific Islander 0 0.0 4 0.2 2 0.1 3 0.2 16 0.9
----------------------------------------------------------------------------------------------------------------
Caucasian 895 63.9 1078 62.2 894 55.9 814 47.9 1142 64.1
----------------------------------------------------------------------------------------------------------------
Unknown 417 29.8 540 31.1 619 38.7 794 46.7 507 28.5
----------------------------------------------------------------------------------------------------------------
*Includes age <20 years old
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005
-----------------------------------------------------------------------------------------------------------------
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
Characteristic --------------------------------------------------------------------------
N % N % N % N % N %
----------------------------------------------------------------------------------------------------------------
Total* 1403 100.0 1737 100.0 1600 100.0 1702 100.0 1784 100.0
----------------------------------------------------------------------------------------------------------------
Total, age 20 and over 1401 100.0 1734 100.0 1598 100.0 1701 100.0 1781 100.0
----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Mechanism of Suicide
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X60 Intentional self-poisoning (suicide) by and 5 0.4 4 0.2 8 0.5 5 0.3 12 0.7
exposure to non-opioid analgesics, anti-
pyretics, and anti-rheumatics
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X61 Intentional self-poisoning (suicide) by and 39 2.8 49 2.8 38 2.4 43 2.5 53 3.0
exposure to antiepileptic, sedative-hypnotic
anti-parkinsonism, and psychotropic drugs, not
elsewhere classified
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X62 Intentional self-poisoning (suicide) by and 26 1.9 42 2.4 30 1.9 27 1.6 48 2.7
exposure to narcotics and psychodysleptics
(hallucinogens), not elsewhere classified
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X63 Intentional self-poisoning (suicide) by and 1 0.1 3 0.2 1 0.1 0 0.0 2 0.1
exposure to other drugs acting on the autonomic
nervous system
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X64 Intentional self-poisoning (suicide) by and 100 7.1 97 5.6 103 6.4 112 6.6 102 5.7
exposure to other and unspecified drugs,
medicaments, and biological substances
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X65 Intentional self-poisoning (suicide) by and 2 0.1 2 0.1 5 0.3 0 0.0 1 0.1
exposure to alcohol
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X66 Intentional self-poisoning (suicide) by and 2 0.1 3 0.2 1 0.1 6 0.4 3 0.2
exposure to organic solvents and halogenated
hydrocarbons and their vapors
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X67 Intentional self-poisoning (suicide) by and 34 2.4 62 3.6 35 2.2 59 3.5 50 2.8
exposure to other gases and vapors
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005--Continued
-----------------------------------------------------------------------------------------------------------------
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
Characteristic --------------------------------------------------------------------------
N % N % N % N % N %
----------------------------------------------------------------------------------------------------------------
DDDDD
DDDDD
e12,L
4,b2,
tp0,p
1,6/
7,f6,
g1,t1
,4,xl
s65,4
,5,4,
5,4,5
,4,5,
4,5
X68 Inten 1 0.1 1 0.1 1 0.1 0 0.0 0
tiona
l
self-
poiso
ning
(suic
ide)
by
and
expos
ure
to
pesti
cides
----------------------------------------------------------------------------------------------------------------
X69 Inten 3 0.2 6 0.3 4 0.3 3 0.2 4
tiona
l
self-
poiso
ning
(suic
ide)
by
and
expos
ure
to
other
and
unspe
cifie
d
chemi
cals
and
noxio
us
subst
ances
----------------------------------------------------------------------------------------------------------------
X70 Inten 163 11.6 214 12.3 189 11.8 207 12.2 189
tiona
l
self
harm
(suic
ide)
by
hangi
ng,
stran
gulat
ion,
and
suffo
catio
n
----------------------------------------------------------------------------------------------------------------
X71 Inten 17 1.2 19 1.1 12 0.8 10 0.6 15
tiona
l
self
harm
(suic
ide)
by
drown
ing
and
subme
rsion
----------------------------------------------------------------------------------------------------------------
X72 Inten 192 13.7 248 14.3 255 16.0 227 13.3 277
tiona
l
self
harm
(suic
ide)
by
handg
un
disch
arge
----------------------------------------------------------------------------------------------------------------
X73 Inten 145 10.3 174 10.0 150 9.4 171 10.1 170
tiona
l
self
harm
(suic
ide)
by
rifle
,
shotg
un,
and
large
r
firea
rm
disch
arge
----------------------------------------------------------------------------------------------------------------
X74 Inten 566 40.4 726 41.9 675 42.2 728 42.8 758
tiona
l
self
harm
(suic
ide)
by
other
and
unspe
cifie
d
firea
rm
disch
arge
----------------------------------------------------------------------------------------------------------------
X75 Inten 0 0.0 0 0.0 0 0.0 0 0.0 2
tiona
l
self
harm
(suic
ide)
by
explo
sive
mater
ial
----------------------------------------------------------------------------------------------------------------
X76 Inten 6 0.4 4 0.2 6 0.4 14 0.8 12
tiona
l
self
harm
(suic
ide)
by
smoke
,
fire,
and
flame
s
----------------------------------------------------------------------------------------------------------------
X77 Inten 0 0.0 0 0.0 0 0.0 0 0.0 0
tiona
l
self
harm
(suic
ide)
by
steam
, hot
vapor
s,
and
hot
objec
ts
----------------------------------------------------------------------------------------------------------------
X78 Inten 34 2.4 33 1.9 33 2.1 35 2.1 28
tiona
l
self
harm
(suic
ide)
by
sharp
objec
t
----------------------------------------------------------------------------------------------------------------
X79 Inten 0 0.0 0 0.0 0 0.0 0 0.0 0
tiona
l
self
harm
(suic
ide)
by
blunt
objec
t
----------------------------------------------------------------------------------------------------------------
X80 Inten 31 2.2 18 1.0 30 1.9 27 1.6 22
tiona
l
self
harm
(suic
ide)
by
jumpi
ng
from
a
high
place
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005--Continued
-----------------------------------------------------------------------------------------------------------------
FY 2001 FY 2002 FY 2003 FY 2004 FY 2005
Characteristic --------------------------------------------------------------------------
N % N % N % N % N %
----------------------------------------------------------------------------------------------------------------
DDDDD
DDDDD
e12,L
4,b2,
tp0,p
1,6/
7,f6,
g1,t1
,4,xl
s65,4
,5,4,
5,4,5
,4,5,
4,5
X81 Inten 14 1.0 10 0.6 7 0.4 12 0.7 8
tiona
l
self
harm
(suic
ide)
by
jumpi
ng or
lying
befor
e
movin
g
objec
t
----------------------------------------------------------------------------------------------------------------
X82 Inten 1 0.1 4 0.2 5 0.3 4 0.2 7
tiona
l
self
harm
(suic
ide)
by
crash
ing
of
motor
vehic
le
----------------------------------------------------------------------------------------------------------------
X83 Inten 7 0.5 6 0.3 3 0.2 4 0.2 2
tiona
l
self
harm
(suic
ide)
by
other
speci
fied
means
----------------------------------------------------------------------------------------------------------------
X84 Inten 5 0.4 6 0.3 4 0.3 4 0.2 11
tiona
l
self
harm
(suic
ide)
by
unspe
cifie
d
means
----------------------------------------------------------------------------------------------------------------
V87 Seque 7 0.5 3 0.2 3 0.2 3 0.2 5
lae
of
inten
tiona
l
self
harm
----------------------------------------------------------------------------------------------------------------
*Includes age <20 years old
----------------------------------------------------------------------------------------------------------------
Committee on Veterans' Affairs
Washington, DC.
December 21, 2007
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301
Dear Secretary Gates:
On December 12, 2007, the House Committee on Veterans' Affairs held
a hearing to assess the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide. This
hearing raised concerns regarding the discrepancy between the numbers
of veteran suicides reported by VA as compared to those reported by CBS
News on November 13, 2007.
Accurate data is crucial in identifying risk factors and providing
better treatment and suicide prevention programs. For this reason, we
respectfully request that the Department of Defense share their data on
suicide among the active military population with the Committee.
Specifically, we request the number of active duty suicides for
each year from 1995 through 2006. We ask that this information be
listed by military branch, year of death, age, race, gender and manner
of suicide. Additionally, we ask for the methodology the Department
uses to collect data on active duty suicides.
Undoubtedly, you share our desire to ensure that every measure is
taken to prevent those in the military from committing suicide. We
would greatly appreciate your willingness to share any information you
may have regarding this issue with the Committee.
Thank you for your prompt consideration and attention to this
request. Should you have any questions, please feel free to contact
either Committee Staff Director, Malcom Shorter, at 202-225-9756 or
Republican Staff Director, Jim Lariviere, at 202-225-3527.
Sincerely,
Bob Filner
Chairman
Steve Buyer
Ranking Member
CW/mh
*****
The Secretary of Defense
Washington, DC
January 17, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
Thank you for the letter you signed with Representative Buyer
requesting data on the number of active duty suicides from 1995 through
2006. I have asked Dr. David Chu, Under Secretary of Defense for
Personnel and Readiness, to address this matter. We will get back to
you as soon as possible.
With best wishes,
Sincerely,
Robert M. Gates
----------
Committee on Veterans' Affairs
Washington, DC.
May 6, 2008
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301-1000
Dear Secretary Gates:
I would appreciate it if you could respond to the enclosed request
regarding assessing the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide.
Previous letters were sent to you on December 21, 2007, and the
Committee received notices on January 17, 2008, indicating that your
office was looking into the matter.
Because your response will be entered into the record for today's
Full Committee hearing on ``The Truth About Veterans' Suicides,'' the
Committee would appreciate a reply back from your office by no later
than May 20, 2008. If you have any questions in this regard, please
contact Mark Heyman, Professional Staff Member, at (202) 225-9756.
Sincerely,
Bob Filner
Chairman
Enclosure
MS/jz
----------
Committee on Veterans' Affairs
Washington, DC.
May 21, 2008
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301-1000
Dear Secretary Gates:
I would appreciate it if you could respond to the enclosed request
regarding assessing the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide.
Previous letters were sent to you on December 21, 2007, and May 6,
2008, and the Committee received notices on January 17, 2008,
indicating that your office was looking into the matter.
Because your response will be entered into the record for today's
Full Committee hearing on ``The Truth About Veterans' Suicides,'' the
Committee would appreciate a reply back from your office by no later
than June 4, 2008.
If you have any questions in this regard, please contact Mark Heyman,
Professional Staff Member, at (202) 225-9756.
Sincerely,
Bob Filner
Chairman
Enclosure
MS/jz
----------
The Secretary of Defense
Washington, DC
June 3, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
Thank you for your letter regarding a Department of Defense
assessment of the Department of Veterans Affairs' programs for veterans
at risk for suicide. I have asked Dr. David Chu, Under Secretary of
Defense for Personnel and Readiness, to address the matter. He will get
back to you as soon as possible.
With best wishes,
Sincerely,
Robert M. Gates
----------
Committee on Veterans' Affairs
Washington, DC.
June 5, 2008
Honorable Robert M. Gates
Secretary
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301-1000
Dear Secretary Gates:
I would appreciate it if you could respond to the enclosed request
regarding assessing the programs that the Department of Veterans
Affairs (VA) provides for veterans who are at risk for suicide.
Previous letters were sent to you on December 21, 2007; May 6, 2008;
and May 21, 2008, and the Committee received notices on January 17,
2008, and June 4, 2008, indicating that your office was looking into
the matter.
Because your response will be entered into the record for today's
Full Committee hearing on ``The Truth About Veterans' Suicides,'' the
Committee would appreciate a completed response to the enclosed request
by no later than June 19, 2008. If you have any questions in this
regard, please contact Mark Heyman, Professional Staff Member, at (202)
225-9756.
Sincerely,
Bob Filner
Chairman
Enclosure
MS/jz
Department of Veterans Affairs
MEMORANDUM
Date: May 5, 2008
From: Under Secretary for Health (10)
Subj: Blue Ribbon Work Group on Suicide Prevention in the Veteran
Population
To: Secretary (00)
1. At your request, VHA has developed a draft charter and draft
membership list for your consideration for the Blue Ribbon Work Group
on Suicide Prevention in the Veteran Population (see attachments). We
have also contacted prospective members to determine their willingness
to do so and to do so without compensation.
2. With your approval, we will proceed with formally contacting
the members that you have approved and setting up the one-time meeting.
Michael J. Kussman, MD, MS, MACP
APPROVE/DISAPPROVE Date 5/5/08
James B. Peake, M.D.
Attachments:
Draft Charter
Draft Membership and Staff Support List (with approval/
disapproval lines for each)
CVs for Potential Members of The Work Group
CVs for Potential Member of The Expert Panel
----------
DEPARTMENT OF VETERANS AFFAIRS
CHARTER OF THE
BLUE RIBBON WORK GROUP ON SUICIDE PREVENTION IN THE
VETERAN POPULATION
A. OFFICIAL DESIGNATION: Blue Ribbon Work Group on Suicide
Prevention in the Veteran Population (``Work Group'').
B. OBJECTIVES AND SCOPE OF ACTIVITY: The Blue Ribbon Work Group on
Suicide Prevention in the Veteran Population advises the Secretary on
research and programs relevant to the prevention of suicide in the
veteran population.
C. PERIOD OF TIME NECESSARY FOR THE COMMITTEE TO CARRY OUT ITS
PURPOSES: Established as an Executive Branch Task Force that will meet
one time for approximately 3 days with a final report to the Secretary
within 15 days.
D. OFFICIAL TO WHOM THE COMMITTEE REPORTS: The Blue Ribbon Work
Group on Suicide Prevention in the Veteran Population reports to the
Secretary of Veterans Affairs.
E. OFFICE RESPONSIBLE FOR PROVIDING THE NECESSARY SUPPORT FOR THE
COMMITTEE: The Veterans Health Administration, Department of Veterans
Affairs, is responsible for providing administrative and logistical
support to the Blue Ribbon Work Group on Suicide Prevention in the
Veteran Population.
F. DUTIES OF THE COMMITTEE: The Blue Ribbon Work Group on Suicide
Prevention in the Veteran Population provides advice and consultation
to the Secretary on various matters relating to research, education and
program improvements relevant to the prevention of suicide in the
veteran population. The Blue Ribbon Work Group on Suicide Prevention in
the Veteran Population will create a report within 15 days of the
completion of its meeting with recommendations for improvements in VA's
programs related to suicide prevention, research, and education.
Recommendations will be directly related to the primary objective of
reducing risk of suicide in the veteran population.
G. MEMBERSHIP: Blue Ribbon Work Group on Suicide Prevention in the
Veteran Population membership shall include only Executive Branch
employees who are experts in public health suicide programs (including
suicide prevention and education programs), suicide research
(especially epidemiology and suicidiology), and clinical treatment
programs for patients at risk for suicide. The Work Group will be
comprised of five (5) members. The Work Group process will be informed
by the testimony and counsel of a panel (The Expert Panel) with
nationally recognized expertise in public health suicide programs,
suicide research, and clinical treatment programs for patients, and
other relevant areas. Members of The Expert Panel will have no
significant direct relationship with the Department of Veterans
Affairs. The role of each member of the panel is to individually
provide: expert opinion, interpretation, and conclusions on information
and data presented to the Work Group; expert information and data from
other (non-VA) sources; and recommendations to the Work Group on
opportunities for improvement in VA's programs. The Expert Panel will
be comprised of nine (9) members. Employees of the Department of
Veterans Affairs and other Federal Government employees may be called
upon the Work Group to provide background briefings on any relevant
information to better inform the Work Group decision process and The
Expert Panel.
H. EXPENSES: All Work Group and Expert Panel members will receive
travel expenses and a per diem allowance in accordance with the Federal
Travel Regulations for any travel made in connection with their duties
as members of the Work Group or Expert Panel. No member of the Work
Group or the Expert Panel will receive honorarium.
I. ESTIMATED NUMBER AND FREQUENCY OF MEETING: The Group is expected
to meet once for approximately three (3) days. Administrative support
to the Work Group will be provided by the Veterans Health
Administration. The Veterans Health Administration, Office of Mental
Health Services, will support the Chair in the development of the
schedule, operation of the meeting, general logistical requirements,
and production of the final report. A representative of the Secretary
will be present at the meeting, and the meeting will be conducted in
accordance with an agenda provided by the Secretary.
J. COMMITTEE TERMINATION DATE: The Work Group and The Expert Panel
will be terminated upon completion and transmittal of the final report
to the Secretary.
K. DATE CHARTER IS FILES:
Approved: James B. Peake, M.D.
Secretary of Veterans Affairs
Date 5/5/08
----------
Membership
Work Group
CDR (USPHS) Alex E. Crosby, MD, MPH, Medical
Epidemiologists, Surveillance Team/ESB/DVP/NCIPC Centers for Disease
Control and Prevent (CDC), Atlanta, GA
APPROVE/DISAPPROVE Date 5/5/08
COL (USA) Charles W. Hoge, MD, Director, Division of
Psychiatry And Behavior Services, Walter Reed Army Institute Of
Research, Silver Spring, MD
APPROVE/DISAPPROVE Date 5/5/08
COL (USAF) Robert Roy Ireland, MC, Chairman, Program
Director for Mental Health Policy, Clinical and Program Policy, Office
of the Assistant Secretary of Defense (Health Affairs, Falls Church, VA
APPROVE/DISAPPROVE Date 5/5/08
Richard McKeon, PhD, MPH, Special Advisory Suicide
Prevention, CMHS, Substance Abuse and Mental Health Services
Administration (SAMHSA)
APPROVE/DISAPPROVE Date 5/5/08
Jane Pearson, MA, PhD, Associate Director for Preventive
Interventions, Division of Services and Intervention Research, National
Institute of Mental Health
APPROVE/DISAPPROVE Date 5/5/08
Expert Panel:
Dan Blazer II, MD, MPH, PhD, Professor of Psychology, Co-
Director of Clinical Training, Catholic University of America
APPROVE/DISAPPROVE Date 5/5/08
Greg Brown, PhD, University of Pennsylvania
APPROVE/DISAPPROVE Date 5/5/08
Martha Livingston Bruce, PhD, MPH, Professor, Program in
Clinical Epidemiology and Health Services Research, Graduate School of
Medical Sciences, and Associate Vice-Chair for Research, Weill Medical
College of Cornell University
APPROVE/DISAPPROVE Date 5/5/08
Eric D. Caine, MD, Chair of Psychiatry, John Romano
Professor Psychiatry and Chair, Department of Psychiatry, University of
Rochester
APPROVE/DISAPPROVE Date 5/5/08
Jan Fawcett, MD Professor of Psychiatry, School of
Medicine, Department of Psychiatry, University of New Mexico
APPROVE/DISAPPROVE Date 5/5/08
Robert D. Gibbons, Director, Center for Health
Statistics, University of Illinois at Chicago
APPROVE/DISAPPROVE Date 5/5/08
David Alan Jobes, PhD, ABBPP, Professor of Psychology,
Department of Psychology, The Catholic University of America
APPROVE/DISAPPROVE Date 5/5/08
Mark S. Kaplan, PhD, Portland State University, Member,
Suicide Prevention Action Network-USA National Scientific Advisory
Council
APPROVE/DISAPPROVE Date 5/5/08
Thomas R. Ten Have, Director of the Biostatistics
Analysis Center of the Center for Clinical Epidemiology and
Biostatistics and Senior Scholar, Center for Clinical Epidemiology and
Biostatistics, University of Pennsylvania School of Medicine; Member,
Biomedical Graduate Studies, University of Pennsylvania School of
Medicine
APPROVE/DISAPPROVE Date 5/5/08
Administrative Support/Planning:
Secretary's Representative Jaewon Ryupao, JD (Secretary
to specify)
Seth Eisen, MD, Director, Health Services Research and
Development (12)
Ira Katz, MD, Deputy Chief Patient Care Services Officer
for Mental Health (116)
Antoinette Zeiss, Ph.D., Deputy Chief Mental Health
Services (116)
John O'Hara, Executive Assistant, Office of Policy and
Planning (008)
Technical Writer TBD
Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans
----------------------------------------------------------------------------------------------------------------
Population-based Studies of Vietnam-era Veterans
-----------------------------------------------------------------------------------------------------------------
Author Publication Study and Comparison Limitations and
Year Institution, Sponsor Groups Key Findings Concerns
----------------------------------------------------------------------------------------------------------------
Cypel, 2008 WRIISC, EES, VHA Women veterans who Women Vietnam era Only 12 suicide
served in Vietnam veterans had lower deaths reported in
(n=4586) or all-cause mortality women Vietnam
elsewhere during the (SMR=0.87). SMR for veterans
Vietnam era suicide was 1.22 for
(n=5325), compared women veterans who
with the U.S. served in Vietnam,
population. but this was not
Mortality followed statistically
through 2004 using significant
BIRLS and SSA death
files
----------------------------------------------------------------------------------------------------------------
Herrell, 1999 VET registry, HSR&D, 103 male twin pairs Homosexual Analysis of
VHA were identified in orientation was discordant twin
which one member of significantly pairs is a strong
the pair reported associated with scientific design
male sexual partners suicidal ideation because it adjusts
but the other did and suicide attempts for confounding
not. Suicidal (approximately 2.5- based on genetic
ideation and suicide fold increased risk predisposition.
attempts were after adjusting for Data were gathered
assessed by a substance abuse and via interview at a
structured depression single point in
psychiatric time and do not
interview. address risk for
suicide.
----------------------------------------------------------------------------------------------------------------
Bullman,1996 EES, VHA Vietnam veterans In comparison with Death certificate
with nonlethal the U.S. male data might be
wounds (n=34,534) population, veterans inaccurate; no data
were assessed for hospitalized because on psychological
risk of suicide of a combat wound or and behavioral
through 1991 wounded more than characteristics
once had increased that might have
suicide risk predisposed
(SMR=1.22 for individuals to both
hospitalized injury as well as
veterans; SMR=1.58 suicide.
for multiple wounded
veterans)
----------------------------------------------------------------------------------------------------------------
Rates and Risks of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
Population-based Studies of Post-Vietnam Veterans
-----------------------------------------------------------------------------------------------------------------
Author Publication Study and Comparison Limitations and
Year Institution, Sponsor Groups Key Findings Concerns
----------------------------------------------------------------------------------------------------------------
Bullman, 2005 EES, VHA Gulf War Veterans Relative risk for Death certificates
potentially exposed suicide not might not be
to chemical warfare increased (RR=1.05) accurate; exposure
agents (n=100,487) data might not be
with those not accurate
likely to have been
exposed (n=224,980).
----------------------------------------------------------------------------------------------------------------
Kang, 2001 EES, VHA Gulf War Veterans Relative risk for Death certificates
(n=695,516) compared suicide not might not be
with other military increased (RR=0.92 accurate; ``health
on active duty from for males) soldier effect''
8/90 thru 4/91
(n=746,291). Deaths
through 1997
obtained from BIRLS
and SSA.
----------------------------------------------------------------------------------------------------------------
Kang, 1996 EES, VHA Gulf War Veterans Small increase in Death certificates
(n=695,516) compared death rate from might not be
with other military accidents (SMR=1.25) accurate; ``health
on active duty (n= but no increase in soldier effect''
746,291). Deaths suicide rates. There
through 9/93 were 261 suicides
obtained from BIRLS among the Gulf War
and SSA veterans
----------------------------------------------------------------------------------------------------------------
Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
Clinical Cohort Studies
-----------------------------------------------------------------------------------------------------------------
Author Publication Study and Comparison Limitations and
Year Institution, Sponsor Groups Key Findings Concerns
----------------------------------------------------------------------------------------------------------------
Zivin, 2007 SMITREC, VHA Veterans receiving Among depressed Lower rate of
treatment in VA for veterans, 1683 suicide among
depression between (0.21%) committed veterans with PTSD
1999 and 2004 suicide during and depression is
(n=807,694). Cause followup. Rate of surprising and
of death determined suicide was 90/ counter-intuitive,
from state death 100,000/yr among though it may be
certificates males, 29/100,000/yr explained by the
obtained from NDI among females. Risk more intensive
was higher among treatment received
whites, younger by such veterans.
veterans, those Important
without service- contributors to
connected suicide risk, such
disabilities, those as family
with prior inpatient structure, stress,
hospitalizations, and prior suicide
veterans with attempts, were not
comorbid substance assessed
abuse, and those
living in the
southern or western
United States. PTSD
with comorbid
depression was
associated with a
lower suicide rate.
----------------------------------------------------------------------------------------------------------------
Desai, 2007 NEPEC, VHA VA mental health Overall, a decreasing Short follow-up
outpatient users in trend in suicide period (1 year).
three cohorts: 1995 rates over time Did not control for
(76,105), 1997 among outpatient potential
(81,512) and 2001 users (13.2/10,000/ confounders such as
(102,184) followed yr in 1995 versus prior suicide
for trends in 10.3/10,000/yr in attempts or
suicide rates during 2001) which was not suicidal ideation.
the year after their statistically Sicker patients may
mental health visit. significant. Greater attend larger
Study occurred per capita mental programs,
during a period of health expenditure accounting for some
system-wide was associated with of the results.
reorganization lower suicide risk. Sample likely under-
including bed Outpatients at represented the
closures larger programs were more chronically
at greater suicide ill patients.
risk.
----------------------------------------------------------------------------------------------------------------
Gibbons, 2007 VA CSP, NIMH All veterans newly Overall rate of Data apply only to
diagnosed with suicide attempts was suicide attempts--
depression in 2003 364/100,000 among suicides would not
or 2004 (n=226,866), those receiving necessarily show up
followed up for at treatment with an in VA medical
least 6 months in SSRI, versus 1057/ records.
VA. Inpatient and 100,000 among the Administrative
outpatient records untreated. Risk of codes may not
assessed for suicide was higher accurately reflect
administrative codes during the period clinical status of
indicating suicide prior to initiating veteran.
attempt. an SSRI
----------------------------------------------------------------------------------------------------------------
Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
Clinical Cohort Studies_Continued
-----------------------------------------------------------------------------------------------------------------
Author Publication Study and Comparison Limitations and
Year Institution, Sponsor Groups Key Findings Concerns
----------------------------------------------------------------------------------------------------------------
Tiet, 2006 HSR&D, VHA Veterans aged 19 and Veterans who had Study examined
older seeking recently experienced veterans only at
treatment for physical or sexual one point in time,
substance use abuse had a 3- to 5- so author's belief
disorder or other fold increased risk that abuse events
psychiatric of a suicide precipitate suicide
disorders between attempt. attempts is still
July and September, speculative.
1997 (n=34,245).
----------------------------------------------------------------------------------------------------------------
Desai, 2005 NEPEC, VHA All VA mental health Suicide was higher Facilities could not
inpatients among whites, older be accurately
discharged between veterans, and those ranked for quality
1994 and 1998 with depression, as based on suicide
(n=121,933). Death well as veterans rates due to the
within one year of with lengths of instability of
discharge was inpatient stay under suicide estimates
ascertained through 14 days and those once adjusted for
VA records and the with higher risk for case mix.
National Death suicide. Readmission
Index. 481 suicides with 6 months was
were identified in associated with
the study sample decreased suicide
risk. No facility-
level
characteristics were
associated with
suicide risk.
----------------------------------------------------------------------------------------------------------------
Kausch, 2003 VHA Reviewed charts of 40% of patients Retrospective chart
consecutive reported a prior review; no
admissions (n=114) suicide attempt. 59% denominator to
to a Gambling of those with allow calculation
Treatment Program at history of drug of rates; did not
the St. Louis VA. dependence had a study completed
history of suicide suicides
attempts
----------------------------------------------------------------------------------------------------------------
Desai, 2003 NEPEC, VHA Homeless veterans Two-thirds of This sample was self-
(n=7224) participants selected based on
participating in a reported suicidal willingness to
national ideation sometime in enter into
demonstration their life, and over intensive case
project of intensive half had attempted management. Whether
case management. suicide. Younger homelessness causes
age, substance suicidal ideation
abuse, and or suicidal
psychiatric symptoms ideation causes
were associated with homelessness cannot
risk for suicide be determined since
attempts. the study examined
veterans at only
one point in time
----------------------------------------------------------------------------------------------------------------
Rates and Risk of Suicide and other Suicidal Behaviors among U.S. Veterans--Continued
----------------------------------------------------------------------------------------------------------------
Clinical Cohort Studies_Continued
-----------------------------------------------------------------------------------------------------------------
Author Publication Study and Comparison Limitations and
Year Institution, Sponsor Groups Key Findings Concerns
----------------------------------------------------------------------------------------------------------------
Thompson, 2002 Philadelphia MIRECC, Compared cause of Confirmed and Total number of
VHA death among veterans suspected suicide suicides as small
receiving medical accounted for 1.1% (36). Lack of
and mental of deaths. Suicide denominator (``at
healthcare at the was much higher risk'' group) makes
Philadelphia VA among mental health calculation and
(4123 deaths). than general medical comparison of rates
patients. impossible.
----------------------------------------------------------------------------------------------------------------
Kausch, 2001 Case Western, VHA Survey of all VA Of 248 completed Retrospective study
medical centers in suicides, most (63%) with no control
1992 identifying were committed by group.
suicide attempts and males with alcohol
suicides in fiscal addiction; 38% had a
year 1991. mood disorder, and
38% a personality
disorder. There were
7 suicide attempts
on inpatient units
and 37 suicide
attempts in
outpatient substance
use disorder
treatment.
----------------------------------------------------------------------------------------------------------------
Sernyak, 2001 NEPEC, VHA All veterans who had Veterans receiving Only 10 deaths due
clozapine initiated clozapine had lower to suicide among
during a VA hospital overall death rates, clozapine-treated
stay between 1992 primarily due to veterans makes
and 1995 (n=1415) reduced risk of statistical
were compared with a death from comparisons
match group of respiratory disease. difficult.
veterans with Suicides and Clozapine users are
schizophrenia not accidental deaths not likely to be
receiving clozapine. did not differ representative of
VA databases and the between the groups. all veterans with
National Death Index Suicide rate among serious mental
were used to clozapine users was illness.
identify all deaths 150/100,000/yr
over a 3 year follow-
up time.
----------------------------------------------------------------------------------------------------------------
Definitions:
Suicidal ideation: Thoughts of harming or killing oneself. The
severity of suicidal ideation can be determined by assessing the
frequency, intensity, and duration of these thoughts.
Suicide attempt: A non-fatal, self-inflicted destructive act with
explicit or inferred intent to die.
Suicide: Fatal self-inflicted destructive act with explicit or
inferred intent to die.
Self-inflicted injuries: Refers to suicidal and non-suicidal
behaviors such as self-mutilation.
Abbreviations:
BIRLS: Beneficiary Identification and Records Locator Subsystem,
maintained by VBA
CDC: Center for Disease Control and Prevention
DoD: Department of Defense
EES: VA Environmental Epidemiology Service
HSR&D: VA Health Services Research and Development Service
MIRECC: Mental Illness Research, Education, and Clinical Center
NEPEC: Department of Veterans Affairs Northeast Program Evaluation
Center located in West Haven, CT
NDI: National Death Index, maintained by the National Center for Health
Statistics
NIMH: National Institute of Mental Health
RR: Relative risk
SSA: Social Security Administration
SMITREC: Serious Mental Illness Treatment Research and Evaluation
Center located in Ann Arbor, MI
SMR: Standardized Mortality Ratio
SSRI: Selective serotonin reuptake inhibitor (e.g. Prozac, Zoloft,
Paxel)
VA CSP: VA Cooperative Studies Program
VET Registry: Vietnam Era Twin Registry, a population-based database of
male-male twin pairs housed at Hines, IL
WRAMC: Walter Reed Army Medical Center
WRIISC: War-Related Illness and Injury Study Center located in
Washington, DC
Summary prepared by:
Joseph Francis, MD, MPH
Acting Deputy Chief Quality and Performance Officer
Office of Quality and Performance (10Q)
202-266-4513
[email protected]
Updated April 30, 2008
The Comprehensive VHA Mental Health Strategic Plan
Aligned with the Recommendations of the Action Agenda (AA)
Key
1. Completed or incorporated into ongoing operations.
2. Goal achieved by alternate mechanisms.
3. In planning.
4. Requires reevaluation or further guidance.
President's New Freedom Commission Goal 1. Americans understand that
mental health is essential to overall health.
Commission Recommendation 1.1. Advance and implement a national
campaign to reduce the stigma of seeking care and a national strategy
for suicide prevention.
Create a VA National Mental Health Campaign to increase awareness
in veteran community that mental health is essential to overall health
and that very effective modern treatments can promote recovery in
mental illness. Request that Secretary Principi serve as the champion
for this campaign and declare 2004 Veterans Mental Health Year. A.
Initiate a campaign targeted at Iraqi Freedom and Enduring Freedom
veterans and their families. B. Develop monthly messages on VA's
Intranet home page focused on the theme that mental health is essential
to overall health. The message would change monthly. C. Develop
destigmatizing messages on VA's Internet home page for veterans, their
families and the general public focused on the themes that mental
health is essential to overall health and on the availability of
effective new treatments. The monthly message would be developed with
the help of VA Mental Health Consumer/Advocate Councils to be
culturally competent and acceptable to veterans and their families D.
Secretary Principi and other senior officials would include this theme
in public addresses, speeches, and VSO convention addresses.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.1 A, B, C, D Promote mental health Identify a spokesperson Ongoing 1
Initiatives 1-4...... awareness in to represent VA in this
collaboration with VA effort. This will be a
Office of cross-cutting campaign
Communications, EES, with emphasis on
NAMI, SMI Committee special groups, e.g.,
Consumer Liaison PTSD, women, older
Council, etc. groups, returning
service personnel. This
will be accomplished by
outreach to veterans &
families; use of public
service announcements,
train VA staff in these
approaches to new vets/
families. Mental Health
Strategic Healthcare
Group (MHSHG) will
coordinate Mental
Health Awareness Day,
with educational
activities mandated at
each VAMC and kickoff
of Veterans Mental
Health Year in 2005.
----------------------------------------------------------------
MHSHG will create a An enhanced 3
Mental Health Workgroup communication plan is
to identify existing under development
resources and develop a
communications plan,
based on the Action
Agenda recommendation
1.1.1 A, B, C, D, to
inform the veteran
community, including
families, Veterans
Support Organizations,
VHA staff, Veterans
Benefits Administration
staff, and veterans
themselves as well as
the public of the
importance of mental
health care.
------------------------------------------------------------------------------------------
Promote effective 1. Provide ``State of Ongoing 1
outreach and the Art'' outreach,
reintegration of soon screening and referral
to be or recently to military personnel
deactivated military transitioning from
personnel. active or reserve
status to civilian
status. 2. Readjustment
Counseling Service
(RCS)/MHSHG to extend
seamless care model to
mental health service
for combat veterans. 3.
RCS/MHSHG to develop
and coordinate VHA
outreach to National
Guard, Reserve, and
soon to be or recently
discharged military
personnel and to the
families of these
groups. 4. RCS/MHSHG to
develop models of care
to address mental
health needs of
recently discharged
combat veterans.
------------------------------------------------------------------------------------------
Promote destigmatization Design and establish To be reevaluated 4
through partnering with Career Development
VBA, Department of Centers in VHA Medical
Labor, state and local Centers and Community-
programs to provide based Outpatient
career development Clinics (CBOCs), for
services. recently deactivated
military personnel
based on partnerships
between Psychology
Services in Mental
Health, VBA, and DoL.
----------------------------------------------------------------------------------------------------------------
Promote a Mental Health Awareness Day, for instance in May, which
is Mental Health Month.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.2 Institute an annual Mental Health Awareness Ongoing 1
Mental Health Awareness Day annually and
Day. partner with other
national organizations
to reach broader
audience.
----------------------------------------------------------------------------------------------------------------
Identify Mental Health an Employee Education Services (EES) focus
area in 2005. All health care workers should understand that mental
health is essential to overall health; reduce stigma by their
interactions with veterans and their families; and understand the major
suicide risk factors and the principles of suicide prevention. A. Use
the Mental Illness Research, Educational and Clinical Centers (MIRECC)
and National Center for PTSD (NCPTSD) Education Groups for VA staff
education for Best Practices. B. A satellite broadcast program similar
to the ``Face Behind the File'' series can be launched in which
veterans; perhaps some with national stature address their mental
health and physical problems and their interconnection. The profiles
will illustrate veterans overcoming disability and demonstrating
recovery and individual success. C. Develop a Mental Health Speakers
Bureau for Continuing Medical Education (CME) credits and patient
education.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.3 A, B, C Educate all VHA health MHSHG will assign a Ongoing 1
Initiatives 1-2 care providers that staff person to work
mental health is with EES in the
essential to overall development of
health and that education programs
integrating mental which will include
health care with issues related to all
medical health care special emphasis
promotes recovery in groups, i.e., PTSD,
both aspects of health. women veterans, older
adults, etc. These
programs will emphasize
the interrelationships
between mental health
and physical health and
the recovery model of
care.
----------------------------------------------------------------
Task MIRECCs and NCPTSD Ongoing. Reassigned to 2
with development of a OMHS PSR section
joint education plan by
12/31/2005. This plan
will include the three
tenets of recovery;
consumer self
determination,
empowering
relationships and
veteran consumer
participation in the
development and
delivery of mental
health care services.
----------------------------------------------------------------------------------------------------------------
Endorse the National Strategy for Suicide Prevention (2001) and the
Institute of Medicine's report, ``Reducing Suicide: A National
Imperative'' (2003). Implement their recommendations. A. Develop a
Suicide Prevention Program for VA patients, families, staff and the
community. B. Develop electronic suicide prevention database using
institutional surveillance mechanisms that support population-based
screening.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.4 A, B Reduce suicide among Promote evidence based Ongoing 1
veterans. strategies for suicide
assessment and
prevention, including
emphasis on special
emphasis groups. MHSHG
will work with HSR&D,
NEPEC, and SMITREC to
develop and test an
electronic suicide
prevention database.
Develop a national
systematic program for
suicide prevention.
MHSHG develops a plan
to educate all staff
that interact with
veterans, including
clerks and telephone
operators, about
responding to crisis
situations involving at-
risk veterans. This
would include suicide
protocols for intake,
telephone operators,
and other first contact
personnel.
----------------------------------------------------------------------------------------------------------------
Develop and promote support programs that: A. reinforce help
seeking from marital and family counselors, etc B. establish crisis-
support, and C. support programs for development of more adaptive
coping skills and resilience.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.1.5 A, B, C Promote coping skills, 1. Educate and train DoD Ongoing through 2
Initiatives 1-11..... resiliency and mental health care activities of multiple
community support. providers about VHA and office
VBA programs and
eligibility
requirements equivalent
to a TAP for staff; 2.
Develop and disseminate
educational material on
VHA and VBA programs
and eligibility
requirements for mental
health patients and
families; 3. Outreach
to active duty,
especially those with
life altering injuries,
and recently
deactivated military
personnel and their
families to make them
aware of VHA and VBA
programs and
eligibility
requirements for
persons with mental
health problems.
----------------------------------------------------------------
In its National Mental To be reevaluated 4
Health Campaign, MHSHG
will promote veterans'
seeking help from
multiple sources and
points of entry (e.g.,
marital and family
counselors, legal
counselors, financial
counselors, mental
health specialists,
clergy and other
appropriate community
leaders), and promote
to all VHA and VBA
staff a biopsychosocial/
spiritual orientation
to health care that
includes cultural
competency with
relation to unique
veterans, racial,
ethnic, sexual
orientation, and gender
sensitivities.
----------------------------------------------------------------
Medical Centers Requires additional 4
establish contacts guidance
through the Chaplain
Service with faith-
based organizations and
community resources to
assist with culturally
competent suicide
prevention and other
mental health issues at
local and national
levels.
----------------------------------------------------------------
MHSHG develops a plan In planning and 3
for 24 hour mental concurrence
health care
availability throughout
VHA.
----------------------------------------------------------------
MHSHG directs the VISNs Ongoing 1
to develop plans,
including peer support
programs, to assist
veterans in coping with
common problems.
----------------------------------------------------------------
Peer Support: FY-05: A strategy for broad 3
Issue national implementation of peer
Information Letter to support is included in
promote paid Peer-led the Uniform MH Services
services programming, package
(directly or through
contract with community
providers) as an
adjunct to traditional
mental health services
at all facilities
serving veterans with
serious mental illness.
FY-06: Issue national
directive with detailed
procedural guidance.
Peer Support: FY-06:
Explore expansion of
Vet Centers to include
veterans with SMI.
------------------------------------------------------------------------------------------
Ease Transition of Initiate universal MST Universal MST screening 2
victims of Military screening at MTFs and is ongoing at all VA
Sexual Trauma (MST) all components of facilities.
from active duty into national guard and
the VA health care reserves for separating
system. servicemembers (self-
administered with
counselors available).
----------------------------------------------------------------
TAP literature will OMHS has established a 2
include material on resource center for
MST. training and for
monitoring MST programs
----------------------------------------------------------------
Establish EPRP MST Required MST screening 1
screening supporting is in place
indicator: 90% of all
veterans will be
screened for MST; 80%
of all veterans
screening positive will
be referred for
counseling within 30
days of screening.
----------------------------------------------------------------
VISN 4/5 MIRECC to Ongoing, Reassigned to 2
expand work to focus on MST Resource Center
female veteran
transition issues
including MST.
------------------------------------------------------------------------------------------
Provide seamless The outpatient and Strategies for ensuring 3
transition of women Inpatient Mental health transitional care are
veterans from providers will serve as included in the Uniform
outpatient care to more team members for both MH Services Package
acute levels of mental treatment modalities
health care and vice for female veterans.
versa.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 1.2. Address mental health with the same
urgency as physical health
Develop a modular VA-adapted mental health collaborative care model
dissemination package as the basis for national rollout, in
collaboration with the mental health Quality Enhancement Research
Initiative (QUERI) Mental Health, VA Central Office and Veterans
Integrated Service Networks (VISN) leaders.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.2.6 Initiatives 1-5 Develop a collaborative MHSHG will collaborate Ongoing. Implementation 2
care model for mental with Mental Health has been based on TIDES
health disorders that QUERI to develop and other models
elevates mental health infrastructure needed
care to the same level for national rollout,
of urgency/intervention including an
as medical health care. organizational
structure in which the
Mental Health QUERI
Depression Working
group connects to
MHSHG, Primary and
Ambulatory Care SHG,
OQP, National Clinical
Practice Guidelines
Council and the
Performance Measures
Workgroup, as well as
to the TIDES Leadership
Group. The development
will include a VA
integrated care model.
----------------------------------------------------------------
Align performance Ongoing 1
measures to promote
evidence-based
collaborative care for
depression.
----------------------------------------------------------------
Work with OQP to rapidly Ongoing 1
update depression
guidelines to include
evidence-based
collaborative care for
depression.
----------------------------------------------------------------
Develop a VA integrated Completed 1
care model similar to
the Four Quadrant
Clinical Integration
Model for dissemination
to VA medical centers.
This will be done in
collaboration with the
Quality Enhancement
Research Initiative
(QUERI) program and
VISN leadership.
------------------------------------------------------------------------------------------
Assure that medical co- Develop a tool and Ongoing 1
morbidities are process for assessing
identified and physical co-morbidities
addressed in the mental in mental health
health care population patients. Collect and
at the same rate as monitor data at a
medical issues in the national level on
primary care medical co-morbidities
population. in the mental health
population using
existing electronic
databases; Promote and
support epidemiological
research in the area of
medical co-morbidities
in the mental health
population; Collect and
monitor data at a
national level
regarding access to
medical care for the
mental health
population using
existing electronic
databases.
----------------------------------------------------------------------------------------------------------------
Identify good working models of Mental Health/ Primary Care/
Geriatric integration (including a module on differentiating normal and
abnormal aspects of aging) in terms of service delivery and workload/
supervision arrangements. Promote research activities on mental health/
primary care integration best practices.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.2.7 Initiatives 1- Develop an accurate Continue the MH CARES DOMs have been 2
13 mental health Advisory Work Group to transitioned to OMHS.
projection model for further develop the Projection models are
the full continuum of projection model with run by OPP
mental health care. special emphasis on
domiciliaries and
geropsychiatry.
------------------------------------------------------------------------------------------
A projection model has Responsibility 2
been developed by a transferred to OMHS,
combined subgroup (SMI who work with OPP on
Committee and GEC). this projection model
Validation of this
model as an accurate
projection tool will
occur from now through
the end of FY07. This
will be monitored by
the continuing subgroup
which will become a
subgroup of the AASC.
This projection model
will be further
evaluated in relation
to its utility in
conjunction with the
algorithm to guide
clinical decisions for
long term psychiatric
and nursing home care
described in 1.2.8.
Expand to cover all MH.
------------------------------------------------------------------------------------------
Develop innovative The MHSHG will continue Ongoing 2
programs of integrated to work closely with
care involving some geriatrics and primary
combination of primary care to develop
care, geriatrics, and clinical models of care
mental health. and guidelines that
better integrate mental
and physical health.
------------------------------------------------------------------------------------------
Educate VHA providers on Develop a module on Training for some target 3
the normal and abnormal differentiating normal groups completed.
aspects of aging. and abnormal aspects of Further training is
aging. Address being planning; was
principles of deferred to focus on
information processing returning veterans
and memory processes
for older adults, based
on normal age-related
changes. Provide
information on sensory
needs (e.g., use of
large font).
Differentiate normal
cognitive changes with
aging from changes
indicating dementia or
other cognitive
functional problems.
Cover evidence on
demographics of aging
and mental health,
challenging common
distortions (e.g., that
depression is normative
for older adults).
Discuss evidence that
older adults benefit at
least as much from
psychotherapy and
psychotropic medication
as do younger adults.
Discuss adaptations of
psychotherapy that
enhance its
effectiveness with
older adults. In accord
with recovery
principles, articulate
respect for the older
veteran's choices for
mental health
resources.
------------------------------------------------------------------------------------------
Integrate primary Expand two existing In planning and 3
medical care with pilots (VA Conn HCS & development
homeless services. West LA) to other
facilities. Incorporate
primary care into the
women's homeless
demonstration program.
------------------------------------------------------------------------------------------
Identify outreach to Add an indicator to the Ongoing. Indicator 1
homeless recently intake form to assess completed and continues
discharged military outreach. A draft to be utilized.
servicepersons. document has already
been sent to the field
for evaluation of
feasibility and other
comments.
------------------------------------------------------------------------------------------
Ensure that mental Every returning service Ongoing--PDHRA process 2
health examinations are man/woman will meet
a part of all physical with a mental health
examinations in VHA. professional as part of
the post-deployment and
separation medical
examinations and be
provided with a brief
pamphlet that reviews
the information
provided during the
session. He/she will be
encouraged to share
this pamphlet with his/
her family. Those found
to have significant
readjustment problems
in the course of the
examination would be
triaged to care as
appropriate. Those who
decline intervention at
time of screening, or
who are not presently
symptomatic, but deemed
at risk for future
readjustment problems
based on the exam, will
have their medical
record flagged for
repeat screening at
future medical
appointments.
------------------------------------------------------------------------------------------
Eliminate gender Charge a women's mental Ongoing 1
disparities and provide health committee to
accessible mental identify and design
health services to evidence based optimal
women veterans. women's mental health
practice models.
----------------------------------------------------------------
Expand women's HSR&D Assigned to Women's 2
research agenda to Mental Health Committee
evaluate women's mental
health programs
effectiveness and
patient outcomes.
----------------------------------------------------------------
Appoint a women's health Completed. 1
representative to the
SMI Committee.
------------------------------------------------------------------------------------------
Women veterans will have Women Veterans Program Participation in 2
access to mental health Manager will planning is part of the
services in a milieu participate in the MH WVPM duties and
that promotes comfort EOC planning process responsibilities as
and security. for both inpatient and identified in the VHA
residential programs. Handbook.
------------------------------------------------------------------------------------------
Expand dental services NEPEC and Dental Service Mental Health 2
for homeless veterans. will jointly develop a Enhancement funding has
means of monitoring been used to expand
services delivered. dental services for SMI
and homeless veterans
------------------------------------------------------------------------------------------
Realign Domiciliary The domiciliary programs Completed. 1
Program. that primarily treat
substance abuse and
PTSD patients should be
placed under MH in VACO
and the field. A
subgroup of the AASC
will be formed to
explore details of how
this can be
accomplished while
maintaining domiciliary-
type services for frail
elderly veterans and
for enhancing services
for special populations
such as women veterans.
Subgroup to include
representatives of MH,
GEC and the Women's
Strategic Planning Task
Force, as well as
others selected by the
Exec Comm of the AASC.
Subgroup to be formed
and begin to explore
implementation plans by
10/1/04.
----------------------------------------------------------------------------------------------------------------
Eliminate variability in access to mental health, substance abuse,
long term psychiatric care and homeless services by 2008. A. Complete
expansion of specialty mental health services in all Community Based
Outpatient Clinics (CBOCs). B. Use tele-mental health approaches for
smaller sites including access to specialized services such as PTSD and
substance abuse counseling. C. Implement the Veterans' Millennium
Health Care Act requirements for long-term psychiatric care. D. Produce
VHA mental health strategic plan and VISN-level tactical plans to
ensure uniform implementation.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
1.2.8 A, B, C, D Provide a full continuum Implement Performance MH in CBOCs have been 3
Initiatives 1-40 of compassionate care Measure for FY05: 85% expanded, and initial
to veterans with mental of CBOCs serving more performance measures
illness. than 1,500 veterans have been met. Further
will provide on-site, enhancement will occur
contract, or tele- through Uniform MH
mental health services Services package
at or above 10% of all
clinic visits by FY05.
Increase to 15% of all
clinic visits by FY07.
----------------------------------------------------------------
All Networks that are Ongoing 1
below the 85% standard
at COB 3rd Qtr FY04
must submit an Action
Plan to the Action
Agenda Steering
Committee Task Force
for review and
recommended approval,
and the Task Force will
monitor progress.
Appendix B of the
Secretary's Mental
Health Task Force
contains a list of over
200 CBOCs that are
below the standards as
of 6/30/04.
----------------------------------------------------------------
Establish a Point of Directors of MH in 2
Contact for Mental parent VAMCs have
Health in CBOCs and responsibility for MH
notify VACO MHSHG who in CBOCs
that individual is.
----------------------------------------------------------------
All CBOCs should provide Ongoing 1
access to mental health
services, either on
site or by contract
with offsite being the
option of last resort.
In remote locations
telemental health may
be used. The level care
of care and the
competencies of the
staff available at the
CBOCs must be
equivalent to the care
at the parent medical
center and not at the
expense of the parent
facility (VHA Directive
2001-060). This
workgroup recommends an
integrated model of 1.0
FTE behavioral health
clinician per 1,500
primary care patients.
Clinicians who operate
at a distance from
VAMCs in CBOCs manage a
broader and more
complex range of mental
health disorders and
require an adjusted
case load size. Develop
a national performance
measure that addresses
the mental health staff/
patient ratios in
CBOCs. All VISNs should
develop a plan of how
to deliver mental
health services in
CBOCs to patients with
primary substance use
disorder diagnoses.
----------------------------------------------------------------
Develop national Requires additional 4
performance measure guidance; decisions
that addresses MH staff/ will be related to
patient ratios in mental health
CBOCs. productivity work group
recommendations.
----------------------------------------------------------------
Update CBOC application Ongoing 1
directive and form to
include requirement to
specifically detail MH
services and staffing
to be provided at all
new CBOCs. Ask for a
focused evaluation from
the Mental Health
representative on each
CBOC application
currently under review
and secure additional
information as needed.
----------------------------------------------------------------
All medical centers and Included in Uniform MH 3
CBOCs will develop Services Package
service agreements
between primary care
and mental health on
bipolar disorder,
schizophrenia, PTSD, SA
defining treatment and
referral guidelines.
------------------------------------------------------------------------------------------
Reduce geographic Expand homeless programs Ongoing 1
variation and include to bring all VISNs up
access to specialized to the current national
MH and SA service average for provision
delivery to homeless of mental health
veterans. services to homeless
veterans.
----------------------------------------------------------------------------------------------------------------
Consistent with the Projecting need is the 2
recommendation that responsibility of OPP.
variation in service Services have been
availability will be enhanced in recent
reduced, the years.
homelessness subgroup
of MHSPWG developed a
model for meeting the
needs of homeless vets
which suggests that
$11.6 M of new annual
funding over the next 5
years will bring all
VISNs up to the current
national average of
38.4 veterans served by
homeless staff in
homeless programs per
1000 veterans at risk
for homelessness. $33 M
could bring all VISNs
up to the current 85th
percentile or 49.7 for
1000 at risk. It could
cost $86 M to bring all
VISNs up to the level
of the top VISNs (73.4/
1000) in FY03. NEPEC,
in collaboration with
Performance Measures
Work Group, will
develop a performance
measure.
------------------------------------------------------------------------------------------
Provide a full continuum Implement Performance Ongoing 1
of care to homeless Measure for FY05: 75%
veterans with mental of homeless veterans
illness. will receive at least
one mental health or
substance abuse visit
and one primary care
visit within six months
of initial outreach
(The denominator
against which the 75%
measure is calculated
will be all veterans
for whom a Form X is
completed).
----------------------------------------------------------------
75% of veterans with SMI MHICM programs have been 2
who meet clinical expanded. In general,
criteria for MHICM these programs do not
program will be target homeless
enrolled and provided veterans
services. The
denominator for this
measurement is the
population based need
estimate developed by
the SMI Subcommittee of
the MHSPWG. All VISNs
will submit a plan (by
9/30/04) for providing
care to meet this
measure.
----------------------------------------------------------------
VHA Directive 2000-034 Ongoing 1
specifies the evidence
based operational
performance criteria
for MHICM in VHA and
defines the target
population. This
directive to be renewed
and facilities held
accountable for
adhering to all
performance criteria.
----------------------------------------------------------------
Require that all Homeless veterans may be 2
homeless veterans who entered into MHICM
meet clinical programs when they
eligibility criteria complete transitional
for MHICM programs be housing programs
offered assignment to a
MHICM team and
enrollment in the MHICM
program. All MHICM
teams will adhere to
established clinical
standards and
caseloads.
----------------------------------------------------------------------------------------------------------------
Restore VHA's ability Mandate that VAMCs Ongoing planning. There 3
to consistently deliver restore specialized SA is a need to restore
state of the art care treatment programs. All specialized SA
for veterans with SA networks will be ranked treatment, AND to
disorders. on their percentage of account for SA
substance abuse treatment in general MH
treatment capacity, care settings and
which is defined as primary care
follows: The numerator
is the number of
substance abuse
patients treated in
FY03 as defined in the
capacity report, and
the denominator is the
number of enrolled
veterans in the
network. The lowest
quartile of networks
(i.e., the bottom 5) on
this measure will be
required to bring their
networks up to the
national average on
this measure on the
rapid schedule laid out
by the Secretary.
----------------------------------------------------------------
Develop a National Plan SA capacity is being 1
to meet SA capacity expanded through the
requirements. Capacity Mental Health
distributed by VISNs to Enhancement Initiative
meet all dimensions of
access: geographic
distribution,
affordability,
availability,
acceptability, and
accommodation. The plan
uses VHA's clinical
practice guidelines for
substance abuse
treatment as primary
guide in reestablishing
services and show how
VISNs resources will be
reallocated to
accomplish the plan
objectives.
----------------------------------------------------------------
Ensure that primary care Further planning is 3
at all VA facilities needed. Many sites
has physicians trained, remain without OAT in
accredited and spite of ongoing
privileged in primary support for
care provision of buprenorphine staffing
buprenorphine and and training.
Naltrexone or
technology to connect
to services at a larger
medical center.
Recommend that Pharmacy
and Therapeutics
Committees approve
these agents for the
facility's formulary.
Ensure that all VA
facilities have the
resources to provide 5
days of inpatient/
residential
detoxification services
either on-site, at a
nearby VA facility, or
at a contracted
facility. All
facilities will have a
specialized substance
abuse provider to
ensure linkage between
the inpatient and
outpatient follow-up
treatment programs.
----------------------------------------------------------------
Implement HEDIS for Ongoing 1
benchmarked performance
measures for substance
abuse in FY06.
------------------------------------------------------------------------------------------
Establish case Implement a special Ongoing 1
management programs for needs grant program for
homeless veterans with homeless chronically
mental illness and/or ill veterans coupled
substance abuse. with Critical Time
Intervention (CTI)
services at partnering
VAMCs. Current
available funding in
the Homeless Provider
Grant and Per Diem
Program can support
five collaborative
projects. Based on the
outcome of the pilots,
a plan for national
implementation will be
developed. Homeless
veterans with complex
medical problems,
serious mental
illnesses and/or
substance use disorders
will be assigned to a
targeted case
management program.
----------------------------------------------------------------
Eligible veterans who Ongoing 1
receive services in
grant and per diem
programs will have the
number of visits (529
stop codes) consistent
with their need, but no
less than one HCHV
visit per month, to
assure facilitated
access to VA mental
health and medical
services. Telemental
health can be used to
provide these services
in remote locations.
NEPEC to track data and
report to MHSHG.
----------------------------------------------------------------
Establish a performance Ongoing--Four 2
measure requiring that performance measures
homeless veterans have been implemented
suffering from SMI and/ focusing on timely
or SA who receive access for homeless
residential services veterans to VA MH/SUD
receive at least one MH and Primary Care
or SA treatment visit Services.
during residential care
and one follow-up visit
during discharge from
residential care.
------------------------------------------------------------------------------------------
Develop a full range of Provide incentives to Ongoing. 1
supportive services for improve homeless
veterans in veterans access to VA
collaboration with treatment services and
community partners. enhance collaboration
between VA medical
centers and Grant and
Per Diem funded
transitional housing
programs.
----------------------------------------------------------------
Establish financial Ongoing. 1
incentives for
providing necessary VHA
mental health services
to homeless veteran in
Grant and Per Diem
programs. A report of
options will be sent to
the Secretary from the
VHA National Leadership
Board Finance
Committee.
----------------------------------------------------------------
Enhance supported CWT CWT programs have been 2
and employment expanded through the
activities within VA Mental Health
by: 1. Establish a Enhancement Initiative
performance measure/
monitor for assessment
of occupational
dysfunction, and
referral to
transitional and
supported employment
models authorized by 38
USC 1718. Such a
measure/monitor will
establish reasonable
expectations for access
to transitional and
supported employment
separately for veterans
with homelessness and
for those with
psychosis. 2. Provide
approx $6,000,000 in
FY'04 for staffing
resources to implement
supported employments
at 107 existing
vocational programs
authorized by 38 USC
1718. Provide approx
$4,000,000 in FY'05 for
staffing resources to
operate and sustain
work restoration
services authorized
under 38 USC 1718 for
the provision of both
transitional and
supported employment
models at facilities
without existing CWT
programs. These
resources should be
provided through
recurring Specific
Purpose funding with
new permanent positions
established.
----------------------------------------------------------------
Finalize a policy To be reevaluated 4
directive that places a
priority on making
underutilized space on
VAMC campuses available
to nonprofit community-
based organizations
that wish to develop
residential programs
for homeless veterans.
Enhance partnerships
with community partners
to provide transitional
housing.
----------------------------------------------------------------
Mandate that all VISNs Ongoing for veterans 1
address the transition being discharged from
needs of incarcerated state and Federal
veterans and develop a prisons
plan that will be
implemented in FY 2005.
----------------------------------------------------------------
Each VISN will submit a Ongoing 1
specific plan for pre-
release assessments of
veterans in Federal and
state correctional
facilities to determine
degree and type of need
and methods of
providing services. The
assessments to include
mental health, medical
and social service
needs.
------------------------------------------------------------------------------------------
Meet the needs of SMI 1. Meet levels as Requires guidance on 4
veterans for Community projected by the MHSPWG organization of CRC
Residential Care. for FY07. Market level program
plans developed for any
market with a gap that
exceeds 1,000 CRC stops
in FY07. For meeting
these gaps, a plan must
be submitted by 10/1/04
to the AASC. 2.
Increase staffing to
meet the required
minimum one case
management visit per
month. 3. Emphasize
individualized,
recovery-oriented
placements versus
placements that have an
institutionalized
atmosphere and very
little rehabilitation
services.
------------------------------------------------------------------------------------------
Each Medical Center will Each VISN will develop a Ongoing, with all VAMCs 2
have a Mental Health planning initiative to have PTSD clinical
Clinic with adequate address service gaps in teams or specialists.
staffing to meet the outpatient mental Adequacy of staffing is
mental health needs of health care identified assessed through
veterans. by the MHSP model. measures of access,
Analysis and Network intensity, and quality
plan to address issues of care
(with at least a 30%
gap closure by COB
FY07) must be submitted
to MHSHG and AASC by 10/
04. Markets with
positive gaps over
16,000 (actual CARES)
stops in FY07 MHSP
model need to be
addressed. This is the
same market level gap
used in the original
CARES model. Each VA
facility that currently
does not have one will
have a PTSD clinical
team or PTSD
specialists or a plan
to secure these
services. The role of
these clinicians is to
serve the facility MHC
and CBOC based OPC
services and also to
provide consultative or
clinical support to
acute inpatient units
for patients with PTSD.
----------------------------------------------------------------------------------------------------------------
Expand PTSD outpatient Each VAMC has a PTSD 1
services in VISNs with clinical team or
gaps as identified in specialist
the PTSD subgroup
report. Twelve VISNs,
3, 4, 5, 8, 9, 10, 11,
12, 15, 19, 22 and 23
are identified as
having PTSD care gaps
in the P.L. 108-170
solicitation and will
be considered the first
priority for new PCT
development. In
addition, other VISNs
especially those with
significant Global War
on Terrorism troop
returnees (2, 6, 16, 17
and 21) will also
receive priority in
expanding new PCTs.
------------------------------------------------------------------------------------------
Medical Centers will Each VISN which has a Planning is in progress 3
have adequate beds and market(s) with a MHSP
staffing to meet the projected service gap
needs of the local in inpatient mental
veteran populations for health both for FY'02
acute inpatient and for FY'07 that
psychiatric services. exceeds 7,300 bed days
of care at the market
level must submit a
plan to close that gap
by FY'07 with phased in
increments of a minimum
of 10% per year. Those
markets that exceed a
7,300 BDOC gap either
for FY'02 or for FY'07
will assess and report
if a plan is needed.
Reports should be
submitted to the AASC
no later than 10/1/04.
------------------------------------------------------------------------------------------
Expand clinical Explore development of a The Uniform MH Services 3
monitoring systems to Work Restoration Package includes a
include Work Information Management strategy for broader
Restoration services. System (WRIMS) for use implementation of CWT
in each VAMC and CBOC and SE
(using the CMIS of
VISNs 1 as a model), to
ensure that each
veteran is offered the
choice in participating
in work restoration
services; Increase Work
Restoration services
until all veterans in
VAMCs and CBOCs have
equal access to work
skills training and
development; Implement
the Evidence-Based
practice of Supported
Employment into all
Work Restoration
programs; Add work
restoration to Illness
Mgt Training of
unemployed patients who
are participating in
programs transferring
from LT custodial care
to rehabilitation in
the community; Add work
restoration training to
MHICMs and other
community support
teams.
------------------------------------------------------------------------------------------
Meet the needs of SMI General psychiatry PRRTP The Uniform MH Services 3
veterans for (residential care) Package includes a
residential services increase at strategy for making
rehabilitation the VISN level by FY'07 residential care
services. based on the MHSP Model services available to
projection. VISNs that those who need them
have a gap of 15 or
more PRRTP beds should
develop a plan to
reduce the gap by at
least 30% by FY07,
phased in annually with
a minimum of 10%
improvement each year.
The plan to be
developed by 10/1/04
and reviewed by the
Action Agenda Steering
Committee.
------------------------------------------------------------------------------------------
Meet the needs of SARRTP (residential The Uniform MH Services 3
veterans with substance care) services increase Package includes a
abuse for residential at the market level by strategy for making
rehabilitation FY'07 based on the MHSP residential care
services. Model projection. services available to
Market areas that have those who need them
a gap of 15 or more
SARRTP beds, after
taking into account bed
section 86, DOM/SA,
develop a plan to
reduce the gap by at
least 30% by FY07. The
plan to be developed by
10/1/04 and reviewed by
the Action Agenda
Steering Committee.
------------------------------------------------------------------------------------------
Meet the needs of 1. PRRP (residential The Uniform MH Services 3
veterans with PTSD for care) services to be Package includes a
residential increased at the VISN strategy for making
rehabilitation level by FY07 based on residential care
services. the MHSP Model services available to
projection. VISN areas those who need them
that have a gap of
5,475 or more PRRP beds
(taking into account
Dom PTSD program beds
as equivalents) will
develop a plan to
correct the gap. The
plan to be developed by
10/1/04 and reviewed by
the Action Agenda
Steering Committee.
Preliminary analyses
indicates that VISNs 4,
6, 9, 16 and 22 would
develop plans.
------------------------------------------------------------------------------------------
Allocate additional Proposed that VHA adopt Ongoing. Standards 1
resources for enhanced the standards outlined adopted in SA operating
outpatient treatment of in the integrated plan, FY 2005.
all Mental Illness treatment of patients Resources allocated in
Chemical Abuse (MICA) contained in the MICA FY 2005/06/07
patients. These Task Force report
treatments must consist (January 2004) at each
of appropriate facility with a
integration of substantial population
substance abuse and of individuals who meet
mental health treatment the definitions for
services. MICA.
------------------------------------------------------------------------------------------
Expand Opiate Agonist Open OAT clinics at The Uniform MH Services 3
Treatment (OAT) in Phoenix, AZ; Denver, Package includes a
urban centers with high CO; Tampa, FL; Orlando, strategy for making
prevalence of heroin FL; Salt Lake City, UT. buprenorphine
use and large CARES- prescribing available
projected gaps in VA at all VAMCs
methadone treatment.
------------------------------------------------------------------------------------------
Ensure effective 1. Authorize a joint In planning. Programs 3
utilization of the review and refinement are being at NHCUs in
continuum of long term by Mental Health, each VISN to place
inpatient mental health Geriatrics and Extended mental health staff who
care. Care, and the SMI can ensure that
Committee, of the 1996 recommendaton #3 is
VHA Program Guide accomplished: educating
1103.22 ``Integrated staff in competent care
Psychogeriatric Patient for patients with both
Care''; by 2/2005. 2. functional and
Promulgate throughout behavioral health
VA the algorithm for problems
functional decisions on
level of nursing and
mental health care for
older veterans needed
(presented in full
report of the Older
Adult subgroup) over
the next year (and then
ongoing), as a
recommendation by the
Secretary for
decisionmaking in each
VISN. This will be done
in conjunction with
ongoing efforts in
Geriatrics and Extended
Care to develop a broad
new, compassionate
model of nursing home
care for Veterans. 3.
All nursing home care
facilities will have
staff educated in and
competent to care for
patients with both
functional and
behavioral health
problems. In some
circumstances,
specialized units such
as dementia units, or
psychogeriatric units
may be necessary to
meet local needs.
------------------------------------------------------------------------------------------
Ensure adequate day VISNs without Day The Uniform MH Services 3
treatment facilities Treatment (or Package includes a
for SMI veterans. equivalent) capacity strategy for making
should add it at the psychosocial
most appropriate rehabilitation
facility, based on size available at all VAMCs.
and access Day treatment with a
considerations. PSR orientation already
implemented in most
VISNs
----------------------------------------------------------------
Facilities serving over Included in the Uniform 3
1,000 veterans in the MH Services Package
psychosis registry
without a Day Treatment
(or equivalent)
facility should add one
with appropriate
staffing and education.
Peer Specialists should
be used whenever
feasible.
----------------------------------------------------------------
Existing Day Treatment Enhancements in day 3
programs with waiting treatment are included
lists will provide in the Uniform MH
resources to eliminate Services Package
them.
----------------------------------------------------------------------------------------------------------------
President's New Freedom Commission Goal 2. Mental health care is
consumer and family driven.
Commission Recommendation 2.1. Develop an individualized plan of
care for every adult with a serious mental illness and child with a
serious emotional disturbance.
Develop a performance measure based on percentage of Seriously
Mentally Ill (SMI) patients whose family members have been contacted to
participate in developing an individualized plan of care. A. Create
data capture mechanism for family contacts that include implementation
of a clinic stop code for family work and a family education/counseling
field on encounter forms.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.1.9 A Initiatives 1- Ensure that every mental Operationalize Family Planning is underway to 3
5 health patient has an Education clinic stop evaluate how to capture
individualized code and encounter form family involvement in
treatment plan that procedure code in FY- care
includes family 05; Implement (VISN 10
involvement in pilot) Family
treatment plan and Involvement Performance
process. Measure nationwide in
FY-05.
----------------------------------------------------------------
The FPE/FE Task Force of In planning 3
MH QUERI outlined the
following in FY-05:
Develop policy
directive on Family
Involvement/Education
to include issues of
confidentiality and
expectation that the
care plan for all
patients with
schizophrenia establish
at least one family
contact or document the
reason for its absence.
------------------------------------------------------------------------------------------
Expand seamless 1. Assign Transition Care management programs 2
transition efforts to case managers to focus focus on seriously
fully cover veterans on mental health injured
with mental health programs, based on
diagnoses. caseload to WRAMC,
Brooke etc. where the
bulk of the mental
health MEBs and PEBs
are conducted; 2.
Develop case management
program for all DoD
``complex care''
patients coming into
VHA health care system;
3. Include VHA social
worker/case manager and
patient family in
transition planning for
DoD personnel with
mental health problems
who will be
transitioning to VHA
health care system,
with a special focus on
pain management; 4.
Improve transition
planning, referral/
placement and
information exchange
for patients with
mental illness coming
into VHA health care
system; 5. Improve
outcomes for patients
eligible for VA
services and/or
benefits thru use of
recovery approach to
provision of services.
----------------------------------------------------------------
1. Assign Transition Care management programs 2
Social Workers to focus focus on seriously
on mental health injured
including: 2. Survey
all MTFs to determine
the need for social
workers focused on
mental health programs;
3. Ensure that Points
of Contact at VISN and
local treatment systems
have appropriate
knowledge about mental
health programs and
capabilities; 4. Have
transition social
workers followup on
referrals at three and
six months to ensure
effective program
placement; Identify
VACO point(s) of
contact for problem
resolution.
------------------------------------------------------------------------------------------
Mental health 1. Every military man Ongoing. VA has worked 2
assessments are an and woman meet with DoD to support
integral part of all individually with a PDHRAs
exams of separating mental health
military service professional as part of
personnel. the post-deployment and
separation exams. 2. An
MOU needs to be
developed with DoD to
spell out authority,
responsibility,
accountability, and
funding for the
necessary clinical
capacity to be assured.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 2.2. Involve consumers and families
fully in orienting the mental health system toward recovery.
Involve veteran consumers and families in educating staff/veterans/
family members on recovery.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.2.10 Initiatives 1- Seek stakeholder input For VHA staff Ongoing 1
2 into mental health educational efforts,
programming related to MHSHG will ensure that
recovery. stakeholders are
included in planning
educational programs
related to recovery.
----------------------------------------------------------------
Assess barriers and Need further guidance on 4
explore implementation collaborations between
of Vocational Rehab and VBA and MH
education for DoD
patients with mental
health problems while
they await their MEBs
or PEBs.
----------------------------------------------------------------------------------------------------------------
Implement administrative incentives that facilitate work with
veteran's families.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.2.11 / 2.2.12 Reduce barriers to Implement (VISN 10 In planning 3
Initiatives 1-3 working with families. pilot) Family
Involvement Performance
Measure, including
developing stop codes
and other incentives
for tracking workload.
MHSHG and Mental Health
QUERI will review
results of VISN 10
performance measure
pilot prior to
advocating for national
performance measure.
----------------------------------------------------------------
Implement Family MOU is in concurrence 3
Education in every
Network through
partnership with NAMI
(Family to Family
Program).
----------------------------------------------------------------
Offer Family-to-Family In planning 3
Education in
partnership with NAMI
in every Network.
Partner every facility,
outpatient clinic and
CBOC with corresponding
county NAMI Affiliate,
or other comparable
Family Education
program where FFEP is
not offered and/or
there is an already
existing Family
Education program; FY-
06: Implement FPE in
pilot Networks;
Implement FPE/FE
utilizing technology in
pilot Networks; Work:
Insure Family Education
addresses issues
regarding Work
Restoration.
----------------------------------------------------------------------------------------------------------------
Educate staff. A. Begin process of educating staff with a satellite
broadcast introducing the current evidence base for the recovery based
model of treatment. B. Develop programs for staff use on family psycho-
education. C. Educate staff on clinical benefits and effective
approaches to working with families, including issues of older couples
and intergenerational families.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.2.13 A, B, C Educate staff on the MHSHG will work with EES Ongoing 1
Initiatives 1-3 evidence based recovery to develop an
model of treatment. educational program,
including a satellite
broadcast, for staff
regarding the recovery
model of treatment
including issues of
older veterans, female
veterans and other
special emphasis
groups.
----------------------------------------------------------------
Train staff on QUERI FPE FPE is being 2
via EES Broadcast and disseminated through
develop FPE Tool Kit; with multiple supports
Disseminate FPE Task
Force Tool Kit
(planned) which will
include working with
diverse families to
include older couples
and intergenerational
families.
----------------------------------------------------------------
Develop programs for A number of centers are 2
staff use on family involved in training
psycho-education at the
VA Palo Alto MIRECC and
NCPTSD (VAPAHCS is the
educational site for
the National Centers
for PTSD).
----------------------------------------------------------------------------------------------------------------
Include veteran consumers and family members in facility mental
health councils.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.2.14 Initiatives 1- Establish facility All facility Mental Additional guidance is 4
3 mental health council Health Services will required
that include consumer report to MHSHG about
membership. membership composition
of the facility mental
health council.
----------------------------------------------------------------
All facility mental Additional guidance is 4
health councils will required
have at least one
veteran consumer and
one family member as
standing members of the
facility mental health
council.
----------------------------------------------------------------
To provide guidance to Additional guidance is 4
the field, VACO to required
develop and issue a
Directive promoting the
establishment of
consumer/advocate
liaison councils at
both VISN and facility
levels by 2nd Qtr
FY'05. Such a Directive
to include language
about the communication
chain to maximize the
effectiveness of the
council.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 2.3. Align relevant Federal programs to
improve access and accountability for mental health services.
Develop Peer Support Program as an adjunct to mental health
services. A. Explore models of peer support certification (e.g. those
developed by Georgia). B. Determine whether a directive on Peer Support
is advisable.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.15 A, B Partner with other Pilot State Peer A strategy for 3
Initiatives 1-5 Federal agencies to Specialist developing peer support
develop peer support Certification projects is included within the
programs. (such as Georgia/South Uniform MH Services
Carolina, Hawaii, etc); Package
Peer Support: FY-05:
Issue national
Information Letter to
promote paid Peer-led
services programming,
(directly or through
contract with community
providers) as an
adjunct to traditional
mental health services
at all facilities
serving veterans with
serious mental illness.
FY-06: Issue national
directive with detailed
procedural guidance.
----------------------------------------------------------------
Establish partnership Requires additional 4
with SAMHSA and guidance
continue participation
in Federal partners
workgroup at VACO
level. Establish
nationwide method for
reimbursing peer
support. Add Work
Restoration to Peer
Counseling and Vets
Helping Vets programs.
Oversight of this
effort to be conducted
by the AASC.
----------------------------------------------------------------
Develop a partnership Requires additional 4
between the MHSHG and guidance
RCS to develop model
systems for consumer
and family driven
services with VHA and
to create a national
Program of Excellence
in Peer Counseling
Services within VHA.
----------------------------------------------------------------
VISN 1 MIRECC will Manuals for psychosocial 3
develop a ``How To'' rehabilitation,
manual on developing a including peer support,
Peer Support program. are under development
----------------------------------------------------------------
Transition planning and Explore early transfer Plans for DoD VA 3
referral/placement for of patients with mental partnerships are being
OEF and OIF returnees health problems to the developed
VA treatment system and
the use of VA health
care providers to
conduct MEBs and PEBs.
----------------------------------------------------------------------------------------------------------------
Initiate a national Recovery and Rehabilitation Task Force to
develop a ``How To'' manual on developing a Peer Support Program.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.16 Provide support for the VISN 1 MIRECC will In planning, with 3
development of a Peer facilitate the reassignment to OMHS
Support Program. following efforts: 1.
Family Support/
education--Implement
family education
program in each VISN;
educate staff; appoint
family POC within each
facility. 2. Veteran
Advisory Councils/peer
support. 3. Change VHA
culture to recovery
oriented service
delivery. Reference AA
Recommendation 5.3.61.
----------------------------------------------------------------------------------------------------------------
Develop task oriented veteran-consumer councils in each facility.
A. Insure consumer council has communication mechanism to facility
leadership.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.17 A combined with 2.3.14
----------------------------------------------------------------------------------------------------------------
Develop paid positions for veterans) within the facility/network to
work with Mental Health leadership in developing Peer to Peer Programs.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.18 Initiatives 1- Utilize veterans in the Hire or identify In planning 3
3 provision of mental existing staff as a
health care. Reference permanent veteran
AA Recommendation mental health consumer
5.3.61. in the MHSHG and in
each Network to work
with Mental Health
leadership in
developing Peer
Programming and to
represent the consumer
perspective in other
mental health planning/
management initiatives
and to serve as peer/MH
para professional.
----------------------------------------------------------------
Pilot Certified Peer A strategy for broad 3
Specialists in selected implementation of peer
VISNs (suggest VISNs 7 support services is
and 20) Pilot Peer included in the Uniform
Bridgers in selected MH Services Package
VISNs (suggest VISNs 2
and 3); Modify current
State Certified Peer
Specialists training to
tailor for VHA
implementation
nationwide.
----------------------------------------------------------------
Issue national directive A strategy for broad 3
on Peer programs; implementation of peer
Establish Network support services is
performance monitor to included in the Uniform
require a formal Peer MH Services Package
Support Program at each
facility serving
greater than 2,500
veterans with SMI; FY-
06: Establish a clinic
stop code for Peer-Led
Groups, and a Peer
Provider category on
encounter forms.
----------------------------------------------------------------------------------------------------------------
Hire veterans as Peer / Mental Health Para Professionals.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.19 See 2.3.18 and 5.3.61. FY 06. Establish network A strategy for broad 3
performance monitor to implementation of peer
require a formal paid support services is
peer support program at included in the Uniform
each facility serving MH Services Package
greater than 2,500
veterans with SMI. FY
07. Expand that monitor
to include facilities
with more than 1,200
veterans with SMI.
----------------------------------------------------------------------------------------------------------------
Issue a national directive to facility leadership on the creation
of local Peer Support programs. A. Identify a facility coordinator for
the development of peer programs. B. Develop a progressive performance
measure that addresses incremental steps to the implementation of a
facility Peer Support program. C. Create data capture mechanisms for
peer support and peer training that include implementation of clinic
stop codes and modification of encounter forms to include fields for
peer support as well as peer training.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.20 A, B, C See 2.3.18 and 5.3.61
----------------------------------------------------------------------------------------------------------------
Make housing with support more available for those veterans who are
homeless or at risk for homelessness, particularly older veterans and
those veterans who are new to the system.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.21 Initiatives 1- Provide additional Task HSR&D with creating DOMS have been moved 2
6 homeless housing. a Management within OMHS. Projecting
Consultation Project to need is the
develop a demand model responsibility of OPP
for residential
services at all
facilities. The needs
of older veterans and
veterans new to the
system will addressed
in this model.
----------------------------------------------------------------
Work with HUD to Ongoing 1
maintain current
capacity and create new
capacity in the HUD/
VASH.
----------------------------------------------------------------
Continue support of Ongoing 1
joint VA/HUD/HHS
collaborative
initiative in chronic
homelessness.
----------------------------------------------------------------
Expand grant and per Ongoing 1
diem and domiciliary
care programs.
----------------------------------------------------------------
Develop programs focused For planning with DoD 3
on prevention of COE
homelessness and
unemployment for DoD
patients with mental
health problems
(Legislative authority
may be required).
----------------------------------------------------------------
Make underutilized space For program by program 3
at VA facilities evaluation
available for community
organizations to
provide programs.
----------------------------------------------------------------------------------------------------------------
Work with state, local and community partners to increase
opportunities for veterans to participate in supported employment
programs. Support legislation to increase VA's authority to form
partnerships to provide supported employment opportunities for
veterans.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.3.22 Initiatives 1- Increase opportunities Partner with Department Specific elements 4
3 for veterans to of Labor (DOL) to require reevaluation
participate in develop Work
supportive employment. Restoration services
that promote
entrepreneurship and
private enterprise;
Develop contract with
Department of Defense
(DoD) to expand the CWT
Veterans Construction
Team (VCT) to assist
veterans in restoring
lost construction
skills; Develop policy
and procedures for
utilization of non-
appropriated CWT
Special Therapeutics
Rehabilitation
Activities Fund (STRAF)
to contract with state,
local and community
partners to provide job
development and coaches
for Supported
Employment services;
Increase outreach by
providing CWT, IT, CWT/
TR programs in shelters
for homeless veterans.
----------------------------------------------------------------
Improve outcomes for Additional guidance is 4
patients eligible for required about
VA services and/or recommendation related
benefits thru use of to benefits
recovery approach to
provision of services.
----------------------------------------------------------------
MHSHG to create a RFP Evaluations of CWT 3
for the development of funding are in
new or expanded CWT/TR progress.
programs and that they
be provided with
$500,000 annually to
support these programs.
This alternative
centralized funding
mechanism would be
established and
supported to sustain
the provision of
residential
rehabilitation in the
CWT/TR program for SMI
veterans until
authority is restored
for use of non-
appropriated dollars.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 2.4. Create a comprehensive State Mental
Health Plan
Ensure that VISNs participate in State Mental Health Plan
development.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.4.23 Initiatives 1- All VISNs will actively Participate in Ongoing 1
3 participate in the President's 10 Year
development of their Plan to End Chronic
State mental health Homelessness.
plans.
----------------------------------------------------------------
FY-05/06: Partner with The state service 3
state-funded Consumer- liaison program needs
run services to provide updating.
supports for housing,
employment and other
community services to
veterans.
----------------------------------------------------------------
VISNs will work with The state service 3
their state(s) and The liaison program needs
National Association of updating.
State Mental Health
Program Directors to
develop strategic plans
and processes for
collaboration of the
delivery of mental
health service. The
VISNs submit their
proposals to 10N and
the MHSHG for
consideration.
----------------------------------------------------------------------------------------------------------------
Encourage development of state plans that provide supported
housing, employment and other community services to veterans.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.24 collapsed with 2.2.23
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 2.5. Protect and enhance the rights of
people with mental illnesses.
Identify a family point of contact within each facility to
coordinate services, education and liaison with National Alliance for
the Mentally Ill.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.25 Ensure facility MHSHG will initiate a AN MOU with NAMI is in 2
coordination with NAMI. Task Force including concurrence
representatives from
the Mental Health QUERI
FPE/FE Task Force, and
charge it with
developing a process
for implementing FE.
----------------------------------------------------------------------------------------------------------------
Assist with development of an Advanced Directive for every veteran
with serious mental illness who desires one. Advanced Directives can
designate power of attorney at times the veteran is deemed not
competent to make decisions for him/herself.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.26 Across the age span, Develop and disseminate OMHS is collaborating 3
there will be no to the VISNs a mental with Ethics on MH
disparity between health advanced advance directives
mental health and directive policy. This
medical health of policy will address the
veterans in completing following issues:
a mental health and a Across the age span,
medical advanced there will be no
directive. disparity between
mental health and
physical health in
completing a medical
advance directive. When
data on advanced
directive compliance
are reviewed by
facility, rates of
completion for veterans
with and without SMI
will be compared. If
rates are not
equivalent, training
for staff described
under Goal 1 (re.
destigmatization)
should be repeated for
relevant staff, with an
emphasis on the rights
and abilities of
veterans with SMI and
veterans of all ages to
state their advanced
directive wishes.
----------------------------------------------------------------------------------------------------------------
Partner with academic institutions that have a commitment to the
understanding and development of psychosocial rehabilitation (e.g.
Robert Wood Johnson Foundation).
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.27 Initiatives 1- Provide psychosocial Create working group to Ongoing 1
3 rehabilitation expand partnerships by
expertise to VHA staff. participating in
research and training
activities.
----------------------------------------------------------------
Identify current Ongoing 1
partnerships through a
survey of MIRECCs, PSR
fellowship programs,
Mental Health QUERI,
and field clinicians
and researchers.
----------------------------------------------------------------
Partner with OAA to OAA has established 7 2
develop VHA psychosocial
psychosocial rehabilitation
internships in fellowship programs
association with
universities and
foundations. Increase
linkages in Supported
Education with state
and regional colleges
and training schools.
Supported education
must increase
marketability in an
ever-changing job
market in which all
employees rapidly
become obsolete as
technology continually
transforms.
----------------------------------------------------------------------------------------------------------------
Explore grants awarded to not for profit groups targeted at Peer
Development and Education.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.28 Initiatives 1- Refer to 2.3.18 Peer: FY-05: Explore Ongoing. Technical 2
2 development of a VA Assistance for peer
Technical Assistance support is available
Center for Peer Support from a number of
Services and/or develop centers
grant/contractual
arrangement with
established technical
assistance
organizations.
----------------------------------------------------------------
Part of the Special OMHS is developing a 2
Needs Grant for peer support program
Homeless Chronically for homeless veterans
Mentally Ill Veterans
MHSHG is requiring non-
profit organizations
that receive funding to
develop ``Vet-to-Vet''
peer counseling model.
Ten such programs are
planned for funding.
----------------------------------------------------------------------------------------------------------------
Charge Veterans Benefits Administration (VBA)'s Vocational
Rehabilitation Service with identifying and developing opportunities
for training veteran/consumers as mental health service providers.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.29 Align VBA work Expand the partnership Recommendations for 4
restoration efforts with VHA/CWT Program to partnership with VBA
with VHA work improve access and should be clarified
restoration efforts. services to VR&E
programs for veterans
with mental illness by
development of
supported employment
models that include
veteran/consumers as
employment specialists,
job coaches, and other
support roles. MHSHG
will prepare memo to
USB from USH with this
proposal.
----------------------------------------------------------------------------------------------------------------
Strengthen and expand local partnerships with NAMI and with
National Mental Health Association (NMHA) for consultation on the
development of peer facilitated programs.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
2.5.30 Refer to 2.5.25
----------------------------------------------------------------------------------------------------------------
President's New Freedom Commission Goal 3. Disparities in mental
health services are eliminated.
Commission Recommendation 3.1. Improve access to quality care that
is culturally competent.
Develop a culturally competent health care workforce A. Intensify
efforts to improve the cultural diversity of health care staff and seek
to recruit professional staff that better reflect the veteran enrollee
population. B. Institute health professional scholarship programs
targeted to attract minority candidates. C. Provide incentives for
university affiliates to send undergraduate and graduate health care
professional trainees to VA health care sites with large minority
populations.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.31 A, B, C Ensure that VHA The Office of Academic To be reevaluated. OAA 4
Initiatives 1-2 workforce is culturally Affiliations to develop has been developing
diverse in ethnicity, and fund health other training
gender, and age. professional initiatives.
scholarship programs
targeted to attract
minority candidates.
----------------------------------------------------------------
The Office of Academic Requires additional 4
Affiliations to develop guidance
incentives for
university affiliates
to send undergraduate
and graduate health
care professional
trainees to VA health
care sites with large
minority populations.
----------------------------------------------------------------------------------------------------------------
Request that the Office of Research and Development (ORD) support
research on minority mental health treatment. A. Identify areas of
research specifically needed to close the gap in providing mental
health care for minority veterans.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.32A Conduct research to SOTA conference with VISN 4 HSR&D COE focuses 2
assess and remedy HSR&D and HSR&D COE on on health disparities
potential disparities minorities will review including MH
in treatment for existing portfolio and disparities
minorities, including develop solicitations
ethnicity, gender, age. as appropriate for
research on minority
mental health
treatment. The research
will cover
psychobiology of
ethnicity, service/
treatment disparities,
and health related
characteristics of
other special emphasis
groups.
----------------------------------------------------------------------------------------------------------------
28Collaborate in national interagency efforts to address minority
issues, staff training needs, and assessment instruments, etc
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.33 Initiatives 1- Ensure that there are MHSHG will designate a Ongoing. Federal 1
3 effective interagency liaison to other Partners on MH focuses
relationships to Federal agencies to on a broad array of
address minority collaborate with their issues
issues, staff training efforts in this area.
needs, and assessment
instruments, etc.
----------------------------------------------------------------
MHSHG will explore Ongoing. Topic covered 2
options to collaborate as part of Federal
with HHS minority Partners work group
offices in this area.
----------------------------------------------------------------
VA will initiate Ongoing. Topic covered 1
collaboration with as part of Federal
National Federal Partners work group
Partners' work group in
this area.
----------------------------------------------------------------------------------------------------------------
Incorporate a cultural competence strategy in the VHA Strategic
Plan.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.34 Initiatives 1- Ensure that all VHA By January of 2005, the Task Force developed and 3
2 staff are culturally MHSHG to establish a has produced an
competent Cultural Competency implementation plan
Task Force to focus on that has been approved
clinician education and in PCS. It will be
health care services. implemented as part of
Representation to be the Universal MH
from VACO and the field Services
as well as MIRECCs,
QUERI and EES. This
Task Force to provide
an action plan to be
implemented by end of
FY2006 and to include
an evaluation component
to assess effectiveness
of the implementation
in improving cultural
competency. Refer to
3.1.31 and 3.1.37.
----------------------------------------------------------------
Convene a work group to To be evaluated as part 3
review literature and of the implementation
track the of the Uniform MH
implementation of the Services Package
recommendations of the
Commission's Cultural
Competence
Subcommittee, the
Surgeon General's
Report on Mental
Health, Minority
Supplement, and
evaluate the
effectiveness of VA's
cultural competence
training program.
----------------------------------------------------------------------------------------------------------------
Fund EES to develop and implement comprehensive, cultural
competence training, including a module on aging, for all VA employees.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.35 Refer to 1.2.7
----------------------------------------------------------------------------------------------------------------
Develop a knowledge management system to disseminate timely,
program specific education that will keep staff continuously apprised
of new information on best practices and research related to racial and
ethnic differences in care needs and interventions.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.36 Initiatives 1- Enhance the current MHSHG to urge VHA to Planning and preparation 3
3 information develop information
dissemination system to systems such as data
speed the dissemination warehouses and
of information on associated tools that
research findings and allow real-time access
best clinical and to clinical data, and
management practices to encourage training
throughout the VHA of managers and
mental health providers in use of
community. these tools as well as
sharing of best
practices.
----------------------------------------------------------------
Develop web-based ORD is developing a 2
educational programs on major program on
best practices and personalized medicine
research related to
racial and ethnic
differences in care
needs and
interventions.
----------------------------------------------------------------
Develop a registry of Ongoing MH enhancements 2
best practices similar and the evolving
to SAMHSA's National Uniform MH Services
Registry of Effective Package disseminate
Programs. evidence-based
practices
----------------------------------------------------------------------------------------------------------------
Partner with Indian Health Service (IHS) to improve access to
culturally competent mental health and substance abuse care for
American Indian and Native Alaskan veterans.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.1.37 Initiatives 1- Partner with IHS to VHA will designate a VA Ongoing operations 1
2 improve access to the liaison to work with
full continuum of MH IHS to promote this
care for Native collaboration;
Americans and Alaskan specialty groups will
Indians. be included in the
planning.
----------------------------------------------------------------
OAA will review and Requires reevaluation 4
disseminate the
cultural competence
education pilot in VISN
1 MIRECC. Refer to
3.1.31 and 3.1.34.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 3.2. Improve access to quality care in
rural and geographically remote areas.
Identify national, state and local partners who are focused on
improving health care in rural America. VHA is a stakeholder in any
process involving rural health care and should request to participate
in national initiatives and activities. This should include any actions
taken on the part of the Department of Health and Human Services (HHS)
to establish a State rural health initiative, especially those
involving National Institute of Mental Health (NIMH), Health Resources
and Services Administration (HRSA), IHS or the Substance Abuse and
Mental Health Services Administration (SAMHSA).
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.2.38 Initiatives 1- Collaborate with other VHA to have a designated Rural issues are being 3
2 agencies in delivering liaison from the MHSHG addressed through
quality health care to to focus on rural multiple mechanisms
veterans in rural mental health care within VHA
areas. issues and participate
in the activities of
HHS, NIMH, IHS, HRSA,
SAMHSA.
----------------------------------------------------------------
VA liaisons will Liaison between VA and 3
advocate inclusion of state MH systems is
veterans located in being strengthened
rural areas in all
state MH plans.
----------------------------------------------------------------------------------------------------------------
VHA should pursue a wide range of options for providing rural
mental health care; particular attention should be paid to the needs of
older veterans living in rural areas. VHA should examine existing and
planned community access sites to ensure that they have mental health
access that meet veteran's needs. Options for providing mental health
services include but are not limited to on site staffing, tele-mental
health, use of mid level providers, partnerships with State agencies,
and fee for services with local private providers.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.2.39 Initiatives 1- Ensure that veterans in Develop internet-based Requires reevaluation 4
5 rural areas have access services to facilitate
to quality mental Peer Support services
health care. for veterans.
----------------------------------------------------------------
Case management models Ongoing operations 1
in rural areas where
MHICM is not feasible/
practical will be
developed by NEPEC.
----------------------------------------------------------------
Design and launch a Telemental health is 3
major demonstration being expanded and
project on telehealth enhanced
addiction and mental
health services for
veterans, including
recently separated
military personnel,
living in remote and
rural areas.
----------------------------------------------------------------
VHA to examine existing A strategy for 3
and planned community delivering MH in rural
access sites to ensure areas is included in
that they have mental the Uniform MH Services
health access that Package
meets the veteran needs
in those areas. Mental
health providers to be
available in all CBOCs,
and they will provide
training using the
psychoeducational
modules described in
the various
recommendations above.
Tele-mental health
options, as described
in later
recommendations, will
be widely available for
use of older adults,
PTSD, women, SA, etc.
----------------------------------------------------------------
MHSHG will collaborate VA is in ongoing 2
with SAMHSA's Registry dialogue with SAMHSA
of Effective Programs about providing MH
to establish a parallel services in rural areas
mechanism to have a VHA
registry of best
practices/demonstration
programs including, for
example, telemedicine
programs and practices
in remote areas and
best practices for
rural communities.
----------------------------------------------------------------------------------------------------------------
VHA should request participation in SAMHSA efforts to identify and
disseminate best practices to the rural community.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
3.2.40 collapsed 3.2.39
----------------------------------------------------------------------------------------------------------------
There are no items for Commission recommendations 4.1 and 4.2, as
these deal with children & schools.
President's New Freedom Commission Goal 4. Early mental health
screening, assessment, and referral to services are common practice.
Commission Recommendation 4.3. Screen for co-occurring mental and
substance use disorders and link with integrated treatment strategies.
Ensure that every clinician knows that mental health and substance
use disorders can and do co-occur with other disorders that they assess
and treat.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.41 Initiatives 1- Implement a broad range, HSR&D will evaluate Processes for screening, 2
3 self-administered current instruments and followup, and
screening for mental pilot a proposed mental monitoring of outcomes
health disorders. The health screening for MH conditions are
screening will be instrument. being developed
conducted annually
throughout the
veteran's lifespan by
the veteran's primary
care team or identified
care manager.
------------------------------------------------------------------------------------------
Provide education to Require 8 hours annually MH training for primary 2
primary care providers of CMEs on mental care providers is being
regarding mental health health for primary care provided through the
disease management and providers and on Integrated Care
to mental health medical health for programs
providers regarding mental health
common medical providers. Recommend
conditions found in increasing medicine
psychiatric patients. residency training
program requirements
for mental health
electives and/or
training.
------------------------------------------------------------------------------------------
Improve diagnosis and Provide outreach to Programs for seamless 1
treatment of mental active duty, especially transition and outreach
health disorders among those with life are operational
returning service altering injuries, and
personnel with serious recently deactivated
physical injuries. military personnel and
their families to make
them aware of VHA and
VBA programs and
eligibility
requirements for
persons with mental
health problems.
Develop partnership
between the MHSHG and
RCS to lead VHA
outreach to special
populations; 1. Partner
with DoD MTFs to screen
all patients for mental
health and substance
abuse problems; 2.
Expand use of clinical
reminder currently used
to screen for mental
health and substance
abuse in OIF and OEF
veterans to all new
patients coming into
the VA health care
system.
----------------------------------------------------------------------------------------------------------------
Ensure that screening and evaluation for these disorders are part
of accepted clinical practice for every health care provider.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.42 collapsed with 4.3.41
----------------------------------------------------------------------------------------------------------------
Ensure that diagnosis of a mental health or substance abuse
disorder results in an automatic screen for the other disorder as a
routine clinical practice.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.43 See above 4.3.41
----------------------------------------------------------------------------------------------------------------
Require cross training in the two areas including the acquisition
of a minimum number of CME/CEU credits in the assessment and treatment
of the two disorders for mental health and substance abuse service
providers and non-specialists in these areas.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.3.44 Initiatives 1- Mental health and MICA Task Force is Plans for meeting the 2
2 substance abuse working on specific needs of patients with
providers will be recommendations on Dual Diagnoses are
competent in assessment mandatory CMEs. included in the Uniform
and treatment for both MH Services Package
mental health and
substance abuse
disorders and these
competencies will be
documented.
----------------------------------------------------------------
Link with SAMHSA Co- Resource enhancements, 2
occurring Disorders education, and
Project to develop strategic planning are
educational program. in progress. VA is in
dialogue with SAMHSA
over many issues
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 4.4. Screen for mental disorders in
primary health care, across the lifespan, and connect to treatment and
supports.
Require annual screening for mental health and substance abuse
disorders across the life span by the veteran's primary care team or
other providers responsible for the veteran's VA health care. A. Pilot
test the clinical reminder developed for veterans from Operation Iraqi
Freedom for use as a screen in primary care and specialty care clinics
for all recently deployed individuals. B. Evaluate whether early
screening and treatment can prevent chronic mental and multi-system
illnesses.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.45 A, B Require annual screening Work with MHSHG and Annual screening for MH 1
for Mental Health and MIRECCs to develop and conditions is in place
Substance Abuse test a comprehensive
Disorders across the tool for annual
lifespan by the screening.
veterans' primary care
provider.
----------------------------------------------------------------------------------------------------------------
Evaluate the dual diagnosis/co-occurring VA programs to identify
best practices and to determine which programs were most effective.
Fund research to develop a valid screen for suicide risk and
prevention.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.46 Initiatives 1- Suicide prevention. Endorsement and Ongoing 1
4 implementation of the
National Strategy for
Suicide Prevention
(2001) and the
Institute of Medicine's
report, Reducing
Suicide: A National
Imperative (2002).
----------------------------------------------------------------
Develop methods for Ongoing 1
tracking veterans with
risk factors for
suicide and systems for
appropriate referral of
such patients to
specialty mental health
care.
----------------------------------------------------------------
EES in conjunction with Mechanisms to document 3
MHSHG develop mandatory mandatory training are
education programs for being developed
VA health care
providers about suicide
risks and ways to
address these risks.
Incorporate best
practices for suicide
prevention.
----------------------------------------------------------------
Recommend support for VISN 19 MIRECC and 1
new MIRECC with focus Canandaigua COE are
on suicide prevention, operational
in collaboration in
other MIRECCs working
in this area.
----------------------------------------------------------------------------------------------------------------
Increase collaboration with VBA to provide the full range of
supports and services that are needed by patients with mental health,
substance abuse and co-occurring disorders.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.47 Initiatives 1- Eliminate the MHSHG will evaluate and There have been a legal 1
2 disincentives in the address these opinion that comp and
work restoration disincentives. Link VA pension are fully
program for veterans. work restoration protected while
program to Supported veterans participate in
Employment in the CWT for voc rehab.
Veterans Benefits
Administration (VBA)
that focuses on
competitive work, rapid
job search, coupled
with job coaching, and
training veteran/
consumers as mental
health service
providers. MHSHG will
prepare memo to USB
from USH with this
proposal.
------------------------------------------------------------------------------------------
Increase collaboration Recommend that VARO G&PD liaisons evaluate 2
with VBA. Benefits Counselors veterans clinically to
annually assess all identify those who may
veterans in the G&PD be eligible for
programs to determine additional benefits.
eligibility for
benefits. MHSHG will
prepare memo to USB
from USH with this
proposal.
----------------------------------------------------------------------------------------------------------------
Work with Residency Review Committees to encourage incorporation of
mental health modules into all residency programs.
----------------------------------------------------------------------------------------------------------------
Mental Health Strategies
AA Rec.# Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.48 Incorporate mental The Coordination Council Integration of MH and 3
health education and for education program, Primary Care, and
training into residency ``Mental Health for introduction of MH into
programs. Primary Care other medical care
Providers,'' described settings lay the
in Action Agenda groundwork for
recommendation 5.3.65, residency training.
will work through VHA
clinical services & OAA
to promote inclusion of
a mental health module
in all residency
training programs. The
Council will also work
with professional
organizations to
include such a module
as a requirement by
Residency Review
Committees.
----------------------------------------------------------------------------------------------------------------
Contract with the Institute of Medicine for a literature review to
determine effective prevention strategies for mental illness in combat
veterans, with and without physical injury. Recommendations should also
include an agenda for needed research.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
4.4.49 Determine effective VHA will contract with Research on early 3
prevention strategies IOM, and other intervention or
for mental illness in pertinent agencies, for prevention of PTSD is
combat veterans with/ literature review after included within the
without physical consultation with activities of NCPTSD,
injuries. specialty groups. MIRECC, other VA COEs
and the DoD COE.
Contracting with IOM
may not be necessary
----------------------------------------------------------------------------------------------------------------
President's New Freedom Commission Goal 5. Excellent mental health
care is delivered and research is accelerated.
Commission Recommendation 5.1. Accelerate research to promote
recovery and resilience, and ultimately to cure and prevent mental
illnesses.
Convene an Evidence Based Practices (EBP) Steering Committee to
focus on recovery and rehabilitation. Representatives from NIMH and
SAMHSA should be invited to participate as committee members. The
Mental Health Strategic Health Care Group (MHSHG) should be staffed to
coordinate and manage this activity. This steering Committee
continuously review advances published in the scientific literature and
A. Identify new research that is needed; B. Identify research results
that are ready for demonstration projects or pilot testing, and C.
Identify models that can be disseminated as EBP or best practices.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.1.50 A, B, C Emphasize recovery and MHSHG will propose a Ongoing. Recovery 2
Initiatives 1-5...... rehabilitation in structure and resources coordinators have been
mental health care. to facilitate recovery, appointed in each VAMHC
including supporting
the work of the EBP
Steering Committee.
----------------------------------------------------------------
1. Establish a joint DoD/ Ongoing 1
VA ``Center of
Excellence'' focused on
traumatic brain injury
and other life altering
injuries; 2. Develop
longitudinal tracking
system for veterans
from OIF and OEF; 3.
Evaluate the
effectiveness of the
mental health
transition program.
----------------------------------------------------------------
Pilot and research State Peer support programs 2
Peer Specialist are in place and will
certification programs; be supported through
Pilot partnership with the Uniform MH Services
NY Assoc of Psych Rehab Package
Services to develop
Peer Bridgers in VISNs
2 and/or 3.
----------------------------------------------------------------
Task the MIRECCs to Psychosocial 2
review the role and Rehabilitation Centers
function of Day have been developed,
Hospitals and Day and will be
Treatment Center to disseminated throughout
ensure adequate VAMCs
dissemination of
recovery based care in
the centers.
----------------------------------------------------------------
Identify recovery- Ongoing. All RFPs have 1
oriented research emphasized use of PSR
across the age span evidence-base as source
that is ready to be of program proposals
tested for
generalizability or
developed into best
practice models;
Develop demonstration
pilots to test
implementation
strategies prior to
national program
dissemination.
----------------------------------------------------------------------------------------------------------------
Facilitate the work of the Steering Committee by tasking the
MIRECCs to: A. Identify recovery-oriented research across the age span
that is ready to be tested for generalizability or developed into best
practice models. B. Develop demonstration pilots to test implementation
strategies prior to national program dissemination.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.1.51 A, B Refer to 5.1.50
----------------------------------------------------------------------------------------------------------------
Task the National Center for PTSD to develop a research agenda to
close the gap in developing prevention and evidence based early
interventions for acutely traumatized veterans. Research should have
sufficient analytic power to identify racial and ethnic differences in
response.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.1.52 Develop a research Present suggestions to Ongoing activities of 1
agenda to close the gap NCPTSD Scientific NCPTSD, MIRECC, other
in developing Advisory Board & ORD VA COEs and DoD COE
prevention and evidence and jointly develop a
based early plan to conduct
interventions for targeted research.
acutely traumatized
veterans.
----------------------------------------------------------------------------------------------------------------
Emphasize and strengthen the VA mental health research portfolio
focused on rehabilitation/recovery; A. Establish a Cooperative Study
Program Center of Excellence in Mental Health. The Center(s) will issue
Request for Proposals to conduct clinical trials and large-scale
demonstration programs. B. Initiate an educational study to evaluate
the impact of the Office of Academic Affiliations (OAA)
Interdisciplinary Fellowship Program in Psychosocial Rehabilitation
training program on shifting the emphasis of care from a traditional
medical model to a recovery oriented model. C. Create a Mental Health
Liaison position in ORD to develop the behavioral health research
agenda and to assist with implementation.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.1.53 A, B, C Promote research related Convene a MHSHG/ORD ORD successfully manages 2
Initiatives 1-6...... to rehabilitation and workgroup to analyze mental health--and
recovery. the ORD mental health substance abuse--
research portfolio and related projects within
develop solicitations its current structures
for clinical trials and
large-scale
demonstration projects
in the area of
rehabilitation and
recovery.
----------------------------------------------------------------
Establish a Cooperative To be reevaluated 4
Study Program Center of
Excellence in Mental
Health.
----------------------------------------------------------------
Create a Mental Health Ongoing 1
Liaison position in ORD
to monitor the mental
health portfolio across
research services, to
coordinate development
of solicitations for
new research, and to
coordinate mental
health research
initiatives across
services.
----------------------------------------------------------------
Develop position To be reevaluated 4
description and hire a
high-level scientific
program manager to
facilitate strategic
planning for ORD mental
health research, to
monitor mental health
portfolios in
consultation with
research leadership and
investigators in the
field, and to serve as
a liaison to mental
health leadership and
the mental health
community.
----------------------------------------------------------------
Establish a steering To be reevaluated 4
Committee of
researchers and chief
officers to advise on
research efforts in
this area.
------------------------------------------------------------------------------------------
Evaluate the Commission an evaluation The PSR program has 3
interdisciplinary of PSR fellowship recently been expanded
fellowship program in programs to determine to 7 sites and a Hub
PSR to determine its program impact on site has been created
impact in disseminating career trajectory, job to ensure national
the rehabilitation/ duties (extent to which training consistency
recovery model. current position and evaluation.
involves PSR), Evaluation of its
attitudes toward PSR impact is being planned
and recovery,
dissemination of PSR
and recovery principles
to other staff, and
perceived barriers and
facilitators to
implementing PSR and
recovery-oriented
programs.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 5.2. Advance evidence-based practices
using dissemination and demonstration projects and create a public-
private partnership to guide their implementation.
Develop a knowledge management system to disseminate almost real-
time, program specific education that will keep staff continuously
apprised of new information on best practices and research.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.54 Develop a knowledge See also 3.1.36 Prioritization from 4
management system to senior leadership will
link research, be needed to prioritize
guideline development development of a MH
and implementation, real-time data analysis
clinical tools, sharing capability
of best practices, and
real-time data analysis
related to racial and
ethnic differences in
care needs and
interventions in order
to create continuous
expansion of the
evidence base and
increased knowledge
generated by a spirit
of inquiry.
----------------------------------------------------------------------------------------------------------------
Implement an improved Clinical Practice Guideline (CPG) process to
reduce the time between initiation of development and release of a CPG
and ensure timely, periodic updates. Invite additional Federal partners
to join the CPG effort.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.55 Initiatives 1- Ensure regular and Establish a working Ongoing 1
4 timely updates of group to monitor the
mental health CPGs. literature and provide
focused additions and
revisions for expedited
approval. Renew CPGs
every 3 years or sooner
as indicated by the
development of new
treatment
methodologies.
----------------------------------------------------------------
The National Clinical Ongoing 1
Practice Guidelines
Council will have a
member with expertise
in evidence-based
mental health care.
------------------------------------------------------------------------------------------
Expedite the approval of Once approved by MHSHG First CPG in MH since 3
mental health CPGs, and the National approval of the MHSP,
including updates. Clinical Practice on Major Depressive
Guidelines Council, Disorder, is being
final approvals must be developed. This item
completed within 60 should be addressed
days. upon approval of this
CPG when completed.
----------------------------------------------------------------
Ensure that draft Ongoing 1
recommendations from
the Medication Advisory
Panel (MAP) are
approved by the
National Clinical
Practice Guidelines
Council to be
consistent with CPGs.
----------------------------------------------------------------------------------------------------------------
Implement QUERI-MH current priorities & major projects including:
A. Measure care gaps in depression & schizophrenia B. Develop
Nat.Clin.Reminders key care processes for depression, schizophrenia,
SA, & co-occurring disorders. C. Develop/implement evidence-based
guidelines & perf measures across age span. D. Implement evidence-based
antipsychotic practices in schizophrenia, promoting use of appropriate
antipsychotic doses & newer atypical antipsychotics, and monitor
important side effects. E. Implement evidence-based depression
collaborative care model in primary care with particular attention to
elderly; evaluate impact on quality/outcomes/cost effectiveness. F.
Convene group to review literature/track implementation of
recommendations (Commission's Cultural Competence Sub., Surgeon
General's Report on MH-Minority Supplement, & evaluate effectiveness of
VA's cultural competence trng. program. G. Prioritize interventions
that assess applicability of existing family psychoeducation models to
vets/families, & studies of interventions including advance directives,
behavioral family management, intensive case management or assertive
community treatment, and work restoration programs.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.56 A--G Promote implementation Put treatment Ongoing 1
Initiatives 1-11 of research on evidence initiation, engagement
based practices. and continuation
measures in official VA
performance system.
Implement benchmarked
performance measures.
----------------------------------------------------------------
Appoint a representative Ongoing 1
from the MHSHG to the
national CPG work
group.
----------------------------------------------------------------
Collaborate with Mental Multiple centers are 2
Health QUERI to contributing to the
continue development of development of clinical
clinical tools and tools
implementation
strategies to improve
medication management
for schizophrenia and
to implement a
collaborative care
approach.
----------------------------------------------------------------
Support Mental Health Multiple centers are 2
QUERI, Substance Use contributing to the
Disorders QUERI, and development of clinical
MHSHG Informatics tools
Section to develop and
implement clinical
practice tools.
----------------------------------------------------------------
Support Mental Health Ongoing 1
QUERI initiatives to
measure gaps in
depression and
schizophrenia care.
----------------------------------------------------------------
Support Mental Health Ongoing 1
QUERI and SMITREC in
creating and analyzing
national registries for
psychosis and
schizophrenia.
Collaborate with Mental
Health QUERI on
development, testing,
and implementation of
outcomes monitoring.
----------------------------------------------------------------
Solicit new research and Ongoing 1
promote Mental Health
QUERI implementation
research efforts in
management of
individuals with
depression or
schizophrenia who have
comorbid substance use
disorders or medical
disorders.
----------------------------------------------------------------
Prioritize the study and Ongoing 1
implementation of
psychosocial and
recovery-oriented
interventions,
including family
psychoeducation,
behavioral family
management, intensive
case management or
assertive community
treatment, work
restoration programs,
and peer support.
----------------------------------------------------------------
Collaborate with the Ongoing. Integrated care 2
Office of Quality and programs have been
Performance in implemented in more
developing and than 100 facilities
implementing evidence-
based guidelines and
performance measures
across the adult age
span; Implement an
evidence-based
collaborative care
model for depression in
primary care settings
with particular
attention to the
elderly, evaluating its
impacts on quality and
outcomes and measuring
its cost effectiveness.
----------------------------------------------------------------
Solicit new research and Ongoing. 1
promote Mental Health
QUERI implementation
research efforts in
psychosocial
rehabilitation and
recovery.
----------------------------------------------------------------
Implement the QUERI- Evidence based practices 2
Mental Health current from multiple sources
priorities and major have been incorporated
projects in EBPs. in MH enhancements
----------------------------------------------------------------------------------------------------------------
Investigate strategies for sustaining treatment adherence and
retention for individuals with major depressive disorder and
schizophrenia; and strategies for increasing treatment engagement for
patients who are not currently in treatment.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.2.57 Promote treatment Continue to solicit new Ongoing. Involving 2
adherence and retention research in this area MIRECCs and other
for veterans with Major through Mental Health centers as well as
Depression and QUERI solicitation. QUERI
Schizophrenia.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 5.3. Improve and expand the workforce
providing evidence-based mental health services and supports.
Work with the Senate and House Veterans Affairs Committees to enact
the physician salary reform legislation to maintain our ability to
recruit and retain a high quality psychiatrist workforce.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.58 VHA must have competent A market survey of MD MD pay has been 1
MDs, who are adequately salaries to be increased
reimbursed. performed in all
markets, and the
physician pay bill
amended to reflect the
results of the survey.
----------------------------------------------------------------------------------------------------------------
Implement legislation designating psychologists and social workers
as Title 38 hybrid employees.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.59 Done
----------------------------------------------------------------------------------------------------------------
Collaborate and affiliate with Historically Black Colleges and
Universities (HBCUs) and Hispanic Association of Colleges and
Universities (HACUs) to help us in developing diversity in our
workforce and cultural competence among the providers.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.60 Expand diversity in the Collaborate and There are multiple 2
VHA workforce. affiliate with ongoing initiatives to
Historically Black increase diversity in
Colleges and the MH workforce
Universities (HBCUs)
and Hispanic
Association of Colleges
and Universities
(HACUs) to help us in
developing diversity in
our workforce and
cultural competence
among the providers.
The previously (3.1.34)
recommended Cultural
Competency Task Force
will be responsible for
accomplishing this
collaboration.
----------------------------------------------------------------------------------------------------------------
Train veterans who have recovered from mental illness in peer
support, to develop a cadre of peer counselors.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.61 Initiatives 1- VHA will have veterans 1. MH QUERI to develop Peer support programs 2
5 trained and competent an RFP in 2005 for the have been expanded.
as peer counselors. assessment of the Evaluations are being
Reference AA effectiveness of peer planned
Recommendations 2.3.16, support. 2. MHSHG
2.3.18, 2.3.19 and recommends the
2.3.20. development of peer
support programs
consistent with the
recovery model and
would become Centers of
Excellence to
disseminate best
practices.
----------------------------------------------------------------
Pilot Peer Specialists Peer support programs 2
and Peer Bridgers have been expanded. A
models in selected strategy for further
VISNs; FY-07: Develop expansion is included
VHA Peer Certification in the Uniform MH
process and implement Services Package
nationwide.
----------------------------------------------------------------
Identify additional The need for additional 3
formal Peer-Specialist resources to support
training programs recruitment of
(colleges, foundations, certified peer
etc.) for targeted specialists will be
recruitment into paid evaluated during the
Peer-Provider/ implementation of the
Specialist positions Uniform MH Services
and for additional peer Package
specialist training
venues FY 07.
----------------------------------------------------------------
Work with SAMHSA's To be reevaluated 4
Center for Mental
Health Services and
National Association of
State Mental Health
Directors to develop
strategy for
collaborative
initiatives to improve
veteran access to
premier community-
based, consumer-run
services.
----------------------------------------------------------------
Issue national Included in the Uniform 2
Information Letter MH Services Package
promoting and providing
broad guidance on the
recruitment of peer
professionals/para-
professionals, and the
development of paid
Peer-led support
services (directly or
through contract with
community providers) as
an adjunct to
traditional mental
health services at all
facilities serving
veterans with serious
mental illness.
----------------------------------------------------------------------------------------------------------------
Enhance clinical pastoral programs to connect to faith-based
initiatives, and to add a spiritual dimension to the biopsychosocial
framework, and thus reach the majority of veterans who are religiously
committed.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.62 Initiatives 1- Spiritual assessment Establish MHSHG liaison Requires additional 4
2 will be a routine part to the National guidance
of mental health Chaplain Center to
evaluation, and provide input into the
treatment provided Clinical Pastoral
according to the Education Program and
veteran's preference. other training
programs. Include
education about initial
presentation and
referral to enhance
mental health outreach
to veterans. MHSHG
Liaison will also
participate in
activities of the
National Chaplain
Center Faith Based
Initiative.
----------------------------------------------------------------
Link the registry of Requires additional 4
mental health best guidance
practices to the Best
Practices in Chaplaincy
program.
----------------------------------------------------------------------------------------------------------------
Extend Mental Health Liaison/Consultation to primary and specialty
care to support and educate that workforce.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.63 Initiatives 1- Implement collaborative Implement collaborative Ongoing 1
2 care models for MH care models for
care. depression care, etc.
to promote the mental
health liaison role and
provide multi-modal
education on mental
health for non-mental
health clinicians and
staff.
----------------------------------------------------------------
Develop a mechanism to Productivity workgroup 3
account for liaison and has been empanelled
teaching time of mental
health providers.
----------------------------------------------------------------------------------------------------------------
The MHSHG should enhance the Mental Health Leaders' training and
support the annual meetings of the VISN Mental Health Liaisons.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.64 Initiatives 1- Ensure highly competent Reestablish and enhance Ongoing 1
8 Mental Health the Behavioral Health
Leadership. Leadership Training
program.
------------------------------------------------------------------------------------------
Ensure effective Develop options for Requires additional 4
organizational effective mental health guidance
leadership in leadership that will
addressing the further the goals of
treatment of mental the PNFC on mental
disorders. health incorporate this
process into the
ongoing patient care
services review and add
a mental health task
force member to that
committee for
continuity. The Mental
Health Chief Consultant
will become a member of
the NLB and Executive
Committee by July/
August 2004.
----------------------------------------------------------------
Require that a mental Ongoing 1
health leader,
representing care of
veterans with mental
disorders, be a member
of the highest level
decisionmaking body in
every VISN.
----------------------------------------------------------------
Extend the mission of Completed. 1
the Secretary's Task
Force for three years;
request this task force
submit a progress
report to the Secretary
by 9/30/04.
----------------------------------------------------------------
The PCS will provide Completed. Such reports 1
quarterly reports to were sent during the
the task force on time the Task Force was
implementation of the meeting.
recommendations.
Resource needs and
budget implications
will be addressed in
these reports. This
information will be
utilized in the
preparation of the ELDA
and FY 2006 budget.
------------------------------------------------------------------------------------------
Promote, expand, and Expand the size of the Meeting structure was 2
support the annual meeting to allow revised to be more
``Best Practices in attendance of all VISN inclusive
Network Mental mental health leaders
Healthcare Systems'' and at least one
conference. representative from
each facility.
----------------------------------------------------------------
Each VISN must support Meeting structure was 2
the annual attendance revised to be more
of at least one VISN inclusive
mental health leader or
representative. VISN
Directors, CMOs and
QMOs will be invited.
----------------------------------------------------------------
Link ECF program and Ongoing 1
HPDM for preparation of
future MH leaders.
----------------------------------------------------------------------------------------------------------------
EES should develop a CME/CEU training program: ``Mental Health for
Primary Care Providers;'' in coordination with the Mental Health,
Geriatrics and Extended Care, and Acute Care Strategic Health Care
Groups. These groups could be convened as Coordination Council to
oversee development in this area.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.65 Initiatives 1- Develop CME/CEU training Form a Coordination The Integrated Care 2
2 program on mental Council involving EES, program is ongoing
health care in the MHSHG, Acute Care SHG,
primary care setting. Geriatrics and Extended
Care SHG, and Mental
Health QUERI to oversee
education program and
plan implementation of
collaborative care for
depression.
----------------------------------------------------------------
MHSHG and EES will The Integrated Care 1
develop training program is ongoing
programs for mental
health managers,
providers, and staff.
Programs will emphasize
evidence base for
collaborative care and
recovery programs.
----------------------------------------------------------------------------------------------------------------
Expand Office of Academic Affairs and the Mental Health Strategic
Healthcare Group's programs for training of interdisciplinary teams and
collaborative care. The recovery orientation in these programs should
be enhanced and expanded.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.3.66 Build on the model Work with OAA to expand PSR fellowship has been 1
Psychosocial the PSR Fellowship expanded to 7 sites.
Rehabilitation Special Program to provide Other forms of training
(PSR) Fellowship training in life span and career development
program, expanding it issues in recovery. The are being evaluated
to training at more program will fund
than the fellowship stipends for a wide
level. variety of mental and
physical health
disciplines, provide
training in sites with
interprofessional
recovery-oriented care,
and include a didactic
component on the
recovery model and
interprofessional
collaboration in
implementing the model.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 5.4. Develop the knowledge base in four
understudied areas: mental health disparities, long-term effects of
medications, trauma and acute care.
Enhance research programs and EBP related to treatment of minority
veteran populations and cultural competence.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.67 Increase research that Solicit research on ORD is implementing a 3
expands the evidence variation in treatment major program in
base related to ethnic response among ethnic personalized medicine
variability in disease groups to inform
manifestations and evidence-based
treatment response; to guidelines; solicit
inequities in access; research on disparities
and to disparities in in access and
evaluation and availability of
treatment. Conduct services, treatment
research on gaps in practices, and
cultural competency and outcomes. Solicit
strategies to close research on cultural
gaps. competency, including
descriptive studies and
intervention research.
----------------------------------------------------------------------------------------------------------------
Enhance trauma research related to combat trauma, terrorism, and
prevention of chronic PTSD after exposure to traumatic events.
Screening, prevention, neurobiology, treatment and recovery should be
priorities.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.68 Initiatives 1- Enhance trauma research. Engage NCPTSD, MIRECCs, Ongoing 1
2 ORD, DoD/ USUHS in
these projects. Include
minority &
collaborative care
issues.
----------------------------------------------------------------
Establish a joint DoD/VA Ongoing 1
``Center of
Excellence'' focused on
traumatic brain injury
and other life altering
injuries; Develop
longitudinal tracking
system for veterans
from OIF and OEF.
Trauma research agenda
to also include trauma
related to MST.
----------------------------------------------------------------------------------------------------------------
Assess the effects of long-term medications: A. Task a Work Group
consisting of the Pharmacy Benefits Management (PBM), Mental Health
QUERI, Clozapine Center, and Serious Mental Illness Treatment Research
and Evaluation Center (SMITREC) to perform a literature review, analyze
the Clozapine and Psychosis Registries, and report their findings and
recommended actions to the Office of Patient Care Services.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.69 Develop algorithm for MHSHG will take A work group has 3
use of atypical responsibility for recently been formed
antipsychotics. organizing a work group
that will utilize the
National Consensus
Guidelines to develop
an algorithm for: use
of atypical
antipsychotics with
consideration of
medical complications
and cost, including
recommendations for
changing therapy when
medical complications
develop; develop
monitors for medical
complications related
to the use of the
atypical
antipsychotics; and
education of primary
care and mental health
providers on the
complications of
atypical
antipsychotics.
----------------------------------------------------------------------------------------------------------------
Assess the VHA's provision of Acute Mental Health Care: A. Develop
and test a valid VA demand model for acute inpatient and outpatient
mental health care. B. Develop a national electronic database to track
veterans who request admission or transfer to a VA acute inpatient
mental health facility but are denied admission because of
unavailability of a hospital bed or inadequate staffing.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
5.4.70 A, B See recommendation 1.2.8
----------------------------------------------------------------------------------------------------------------
President's New Freedom Commission Goal 6. Technology is used to
access mental health care and information.
Commission Recommendation 6.1. Use health technology and
telehealth to improve access and coordination of mental health care,
especially for Americans in remote areas or in underserved populations.
Expand the charge to the VHA Telemental Health Field Work Group to
coordinate the implementation of the 6.1 action agenda items, in
conjunction with VISN leadership, VISN mental health clinicians, and
VISN telemental health coordinators.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.71 Initiatives 1- Expand the charge to the The Telemental Health Ongoing. 1
2 VHA Telemental Health Field Work Group to
Field Work Group. continue to meet
virtually or in person
to coordinate the
implementation of 6.1
action agenda items, in
conjunction with VISN
leadership, VISN mental
health clinicians, and
VISN telemental health
coordinators.
----------------------------------------------------------------
Expand telemental health Homeless programs 2
to target homeless continue to be expanded
veterans. through other
mechanisms
----------------------------------------------------------------------------------------------------------------
Commission the VHA Telemental Health Work Group to perform a needs
assessment for telemental health services. The needs assessment should
focus on identification of underserved veteran populations, access to
mental health services in CBOCs and Vet Centers, and provision of
specialty mental health and substance abuse consultations in rural and
remote areas.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.72 Initiatives 1- Improve access through Together, the Office of Ongoing 1
5 use of technology. Care Coordination, the
Mental Health Strategic
Healthcare Group, VISN
Leadership, and each
VHA Telemental Health
Field Work Group VISN
representative will
assure that the need
for telemental health
services are clearly
determined, in
conjunction with other
mental health needs
assessments already
being undertaken by
VISN mental health
clinicians, VISN CBOC
administrators, and
VISN telemedicine
coordinators.
----------------------------------------------------------------
Improve transition Ongoing 1
planning, referral/
placement and
information exchange
for patients with
mental illness coming
into VHA health care
system.
----------------------------------------------------------------
1. Ensure that all Ongoing 1
mental health programs
within VHA, including
RCS, have standardized
systems of electronic
technology to access
information while
maintaining
confidentiality and
informed consent; 2.
Explore ``at home''
mental health care
coordination for
recently discharged
veterans, especially
those in rural areas or
in areas where
specialty care is
limited.
----------------------------------------------------------------
Improve the electronic Ongoing 1
exchange of information
from DoD to VA on
patients awaiting MEBs
and PEBs.
----------------------------------------------------------------
Include questions on Current planning 3
screening tools for
older veterans to
determine difficulties
with transportation or
other resources that
restrict ability to
attend outpatient
appointments; and to
identify needs of
caregivers for older
veterans who are home
bound due to medical
problems and/or who
have a dementing
illness.
----------------------------------------------------------------------------------------------------------------
Based on the results of the needs assessment, each VISN should be
tasked with the development of a telemental health implementation plan
designed to improve access to mental health care within the VISN. A.
Each VISN Telemental Health Plan should identify adequate equipment and
staffing resources to assure that it can be successfully implemented.
B. Implementation of VISN Telemental Health Plans should be assessed
through such strategies as VHA performance measures/monitors and
official reports to VACO leadership on a regular basis. C. Formalize
the registration of telemental health programs throughout VHA.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.73 A, B, C Expand mental health Each VISN will: submit a Ongoing 1
Initiatives 1-5...... telehealth care to all Telemental Health plan
facilities, CBOCs, and to Office of Care
Vet Centers. Coordination (OCC) by 6/
30/05; Outcomes
approved on National
Performance Measures
will be developed to
assure implementation
is successful; All
Telemental Programs
will be approved by
OCC.
----------------------------------------------------------------
Action Agenda Steering Completed 1
Committee to appoint a
group to review the
data on pilot
telemental health use
and make
recommendations on an
outcomes monitoring
system and feedback
mechanism.
----------------------------------------------------------------
Together with the Office Ongoing 1
of Care Coordination,
the Mental Health
Strategic Healthcare
Group and VISN
Leadership, each VHA
Telemental Health Field
Work Group VISN
representative will
assure that their VISN
Telemental Health Plans
are viable, and that
they identify adequate
equipment and staffing
resources to assure
that it can be
successfully
implemented.
----------------------------------------------------------------
Together with the Office Mechanisms for 3
of Care Coordination, accountability are
the Mental Health being developed
Strategic Healthcare
Group and VISN
Leadership the VHA
Telemental Health Field
Work Group will work to
assure that
implementation of the
VISN Telemental Health
Plans be assessed
through accountability
strategies such as
official reports to
VACO on a regular
basis, and the
establishment of
applicable VHA
performance measures/
monitors.
----------------------------------------------------------------
Together with the Office Ongoing 1
of Care Coordination,
the Mental Health
Strategic health care
Group and VISN
Leadership, the VHA
Telemental Health Field
Work Group will extend
its annual telemental
health service
inventory by
formalizing the
registration of
telemental health
programs throughout
VHA.
----------------------------------------------------------------------------------------------------------------
Expand use of existing telemental health and telehome care
technologies as well as develop new technologies, including : A.
Identify mental health care coordination opportunities using in-home
messaging devices, etc. B. Expand on the existing telemental health
collaborations with VHA and the Readjustment Counseling Services. C.
Identify existing sharing programs and evaluate telemental health
opportunities with the DHHS, IHS, DoD. D. Develop and implement family
psychoeducational video programs and telehome care family therapy
programs. E. Increase telemental health consultation between mental
health specialists at the medical centers and CBOC staff. F. Utilize
telemental health technologies that make telemental health and telehome
care accessible to the visually and hearing impaired.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.74 A-F Combine with 6.1.73 A. Together with the Home telemental health 1
Initiatives 1-6 Office of Care is currently being
Coordination (OCC), the developed
Mental Health Strategic
Healthcare Group
(MHSHG) and VISN
Leadership, the VHA
Telemental Health Field
Work Group will
identify mental health
care coordination
opportunities using in-
home messaging devices,
mental illness
management dialogues,
interactive voice
response programs, and
other new technologies
to bring mental health
services to the
patients' homes, to
half-way houses, to
homeless shelters, and
the state veterans
homes.
----------------------------------------------------------------
Together with the Office To be reevaluated 4
of CC, the MHSHG and
VISN Leadership, the
VHA Telemental Health
Field Work Group will
expand on the existing
telemental health
collaborations with VHA
and the Readjustment
Counseling Services.
----------------------------------------------------------------
Together with the Office Included in the 3
of CC, the MHSHG and activities of DoD COE
VISN Leadership, the
VHA Telemental Health
Field Work Group will
identify existing
sharing programs and
evaluate telemental
health opportunities
with the DHHS, IHS,
DoD.
----------------------------------------------------------------
Together with the Office Requires additional 4
of CC, the MHSHG and guidance
VISN Leadership, the
VHA Telemental Health
Field Work Group will
develop and implement
family
psychoeducational video
programs and telehome
care family therapy
programs.
----------------------------------------------------------------
Together with the Office Ongoing. 1
of CC, the MHSHG and
VISN Leadership, the
VHA Telemental Health
Field Work Group will
increase telemental
health consultation
between mental health
specialists at the
medical centers and
CBOC staff.
----------------------------------------------------------------
Together with the Office Ongoing. Attention 1
of CC, the MHSHG and continuously paid to
VISN Leadership and ADA requirements.
Office of Geriatrics
and Extended Care, the
VHA Telemental Health
Field Work Group will
utilize telemental
health technologies
that make telemental
health and telehome
care compliant with
ADA.
----------------------------------------------------------------------------------------------------------------
Charge Northeast Program Evaluation Center (NEPEC), the MIRECCs,
SMITREC and Health Services Research and Development (HSR&D) with
providing outcomes monitoring and feedback regarding national, VISN,
and individual facility telemental health and care coordination
programs.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.75 Initiatives 1- Develop outcomes Together, the Office of In planning 3
2 monitoring and feedback CC, the MHSHG and VISN
system. Leadership and the VHA
Telemental Health Field
Work Group to establish
a plan to monitor
outcomes of telemental
health activities,
utilizing existing
mental health and VHA
venues.
----------------------------------------------------------------
Charge workgroup with In planning 3
exploring outcome
measures specifically
related to older
adults' access and
utilization.
----------------------------------------------------------------------------------------------------------------
Establish a full-time position for a VHA Telemental Health
Coordinator. Provide adequate administrative staff and resources for
necessary meetings and collaborations.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.76 Provide full time The Office of CC and Ongoing 1
coordination of the MHSHG to facilitate
telemental health care. adequate leadership and
administrative staff
resources necessary to
successfully implement
these action items.
----------------------------------------------------------------------------------------------------------------
Work with the HHS in the review recommended by the Commission of
how best to deliver and finance telehealth services.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.77 Initiatives 1- Optimize telehealth Work with HHS in the Requires additional 4
2 mental health delivery review recommended by guidance
both in VA and the the Commission of how
private sector. best to deliver and
finance telehealth
services.
----------------------------------------------------------------
Explore financial and Ongoing. 1
other incentives to
increase the use of
telemental health.
----------------------------------------------------------------------------------------------------------------
Develop and implement adequate means to accurately capture and
reflect workload generated by telemental health and telehome care (stop
codes, encounter forms, etc.).
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.1.78 Capture workload Develop and implement Ongoing 1
generated by telemental adequate means to
health services. accurately capture and
reflect workload
generated by telemental
health providers.
Charge Office of Care
Coordination with
developing a system of
secondary stop codes
and guidelines for
using correctly to
capture data
accurately. Ensure
mental health review of
plans to finalize and
implement telemental
health stop codes.
----------------------------------------------------------------------------------------------------------------
Commission Recommendation 6.2. Develop and implement integrated
electronic health record and personal health information systems.
Establish a Mental Health IT Work Group to enhance VHA's electronic
health record (VistA/CPRS and MHP/MHA) and personal health information
systems (MyHealtheVet). This group should be charged with the
responsibility of developing in more detail the other recommendations
included under Action Agenda items 6.2.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.79 Initiatives 1- Establish a MH IT Work Charge this group with Requires additional 4
2 Group to work with IDMC developing in more guidance
and MHSHG. detail the other
recommendations
included under Action
Agenda items 6.2.
----------------------------------------------------------------
Develop electronic Ongoing 1
method to monitor
community employment in
the CWT supported
employment program.
Include NEPEC
monitoring of Supported
Employment.
----------------------------------------------------------------------------------------------------------------
VISTA/CPRS should be modified to provide optimal functionality for
the care of veterans with serious mental illness.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.80 Initiatives 1- Ensure that all mental Improve Transition Ongoing 1
2 health programs within planning, referral/
VHA, including RCS, placement and
have standardized information exchange
systems of electronic for patients with
technology to access mental illness coming
information while into VHA health care
maintaining system.
confidentiality and
informed consent.
----------------------------------------------------------------
Modify CPRS to include Requires additional 4
the identification of a guidance
Primary Mental Health
Provider as well as
Primary Care Provider.
----------------------------------------------------------------------------------------------------------------
Develop a mental health treatment planning tool. VHA should
consider build/buy options including the Commercial Off the Shelf
(COTS) product currently being used at several facilities. The
treatment planner should facilitate the participation of the patient
and his/her family in the treatment planning process. The Mental Health
IT Work Group should submit a formal request to the Informatics & Data
Management Committee (IDMC) for the development of a treatment planner.
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.81 Develop a MH treatment Mental Health IT Work To be reevaluated 4
planning tool. Group will review
treatment planner
options including
review of the planner
developed in VISN 3.
The treatment planner
will facilitate the
participation of the
patient and his/her
family in the treatment
planning process. The
Mental Health IT Work
Group to submit a
formal request to the
Informatics & Data
Management Committee
(IDMC) for the
development of a
treatment planner.
----------------------------------------------------------------------------------------------------------------
Develop MyHealtheVet to better serve the needs of veterans with
mental illnesses. A. Provide adequate resources to the Office of
Information to ensure continuity and availability of the MyHealtheVet
platform. B. Conduct a pilot test or a functional test of the use of
mental health patient's use of to assess possible implementation issues
unique to this patient population. C. Fund development of a mental
health portal as an addition to MyHealtheVet to better serve the needs
of veterans with mental illness and their families. D. Develop criteria
that veterans and their families could use to evaluate non-VHA mental
health information sites (see http://helping.apa.org/dotcomsense/ for
an example developed by the American Psychological Association).
----------------------------------------------------------------------------------------------------------------
Mental Health
AA Rec.# Strategies Initiatives
----------------------------------------------------------------------------------------------------------------
6.2.82 A, B, C, D Develop a MH component The MH IT Work Group Some initial MH 3
within MyHealtheVet. will implement this components for
Action Agenda MyHealtheVet have been
recommendation. developed and are
online. Additional MH
components for
MyHealtheVet are under
development
----------------------------------------------------------------------------------------------------------------
A Comprehensive VHA Strategic Plan of Mental Health Services July
2004
Crosswalking between the U.S. National Strategy for Suicide Prevention,
the VHA Comprehensive Mental Health Strategic Plan, and VHA's Suicide
Prevention Actions
------------------------------------------------------------------------
VHA Suicide
U.S. National Strategy for VHA Comprehensive MH Prevention Actions
Suicide Prevention Strategic Plan and Plans
------------------------------------------------------------------------
Endorse the National
Strategy for
Suicide Prevention
(2001) and the
Institute of
Medicine's report,
``Reducing Suicide:
A National
Imperative''
(2003). Implement
their
recommendations..
------------------------------------------------------------------------
Promote awareness that
suicide is a public health
problem that is preventable
------------------------------
Develop broad-based support
for suicide prevention
------------------------------
Develop and implement
strategies to reduce the
stigma associated with being
a consumer of mental health,
substance abuse and suicide
prevention services
Identify Mental
Health an Employee
Education Services
(EES) focus area in
2005. All health
care workers should
understand that
mental health is
essential to
overall health;
reduce stigma by
their interactions
with veterans and
their families; and
understand the
major suicide risk
factors and the
principles of
suicide prevention
Education and
------------------------------------------------------------------------
Develop and implement suicide
prevention programs
------------------------------
Increase access to and
community linkages with
mental health and substance
abuse services
----------------------------------------------------
Develop and promote effective
clinical and professional
practices
Develop a Suicide VHA has created a
Prevention Program national system
for VA patients, that includes: 1)
families, staff and Overall
the community. enhancement of
mental health
services; a)
Enhanced access to
care; b)
Integration of
mental health and
primary care; c)
transformation of
the specialty
mental health care
system to focus on
rehabilitation and
recovery; d) Broad-
based training in
evidence-based
Psychotherapy and
pharmacotherapy;
e) Outreach and
clinical programs
to support the
engagement of OEF/
OIF veterans; 2)
Programs
specifically
addressing suicide
prevention; a)
Suicide Prevention
Hotline; b)
Suicide Prevention
Coordinators in
each Medical
Center; c)
Programs to
identify high-risk
patients and
enhance their
care; d) Training
for all staff; e)
Community
outreach; and 3)
Inclusion of
suicide prevention
activities in the
uniform mental
health services
package that is
under development;
------------------------------------------------------------------------
Promote evidence
based strategies
for suicide
assessment and
prevention,
including emphasis
on special emphasis
groups. MHSHG will
work with HSR&D,
NEPEC, and SMITREC
to develop and test
an electronic
suicide prevention
database. Develop a
national systematic
program for suicide
prevention. MHSHG
develops a plan to
educate all staff
that interact with
veterans, including
clerks and
telephone
operators, about
responding to
crisis situations
involving at-risk
veterans. This
would include
suicide protocols
for intake,
telephone
operators, and
other first contact
personnel
Improve and expand Develop electronic SMITREC initiative
surveillance systems suicide prevention based on
database using information from
institutional the National Death
surveillance Index; Evolving
mechanisms that interactions with
support population- the CDC's National
based screening. Violent Death
Reporting System;
Validation and
utilization of
attempt reporting
by the Suicide
Prevention
Coordinators;
Exploration of
interactions with
state or county
medical examiners
------------------------------------------------------------------------
Develop methods for A Category 2 flag,
tracking veterans to be managed by
with risk factors the Suicide
for suicide and Prevention
systems for Coordinators is
appropriate under development.
referral of such It would serve to
patients to facilitate
specialty mental tracking and
health care. follow-up.
------------------------------------------------------------------------
Medical Centers Deferred by VHA
establish contacts senior leadership
through the
Chaplain Service
with faith-based
organizations and
community resources
to assist with
culturally
competent suicide
prevention and
other mental health
issues at local and
national levels.
------------------------------------------------------------------------
Promote and support research Fund research to ORD has been
on suicide and suicide develop a valid meeting with
prevention screen for suicide Federal partners
risk and to develop a
prevention. research agenda;
research at the
VISN 19 MIRECC and
the Canandaigua
COE is
accelerating;
nevertheless,
developing a valid
screen for suicide
risk and
prevention may
prove elusive-
instead, VA is
pursuing a two
stage process,
screening for MH
conditions and
providing clinical
evaluations for
those identified
as having these
conditions.
------------------------------------------------------------------------
Implement training for EES in conjunction Ongoing training
recognition of at-risk with MHSHG develop including Suicide
behavior and delivery of mandatory education Prevention
effective treatment programs for V A Awareness Day,
health care Operation Save,
providers about Facility-based
suicide risks and activities
ways to address organized by the
these risks. suicide prevention
Incorporate best coordinators; and
practices for other EES
suicide prevention. activities
------------------------------------------------------------------------
Recommend support Implementation of
for new MIRECC with the VISN 19 MIRECC
focus on suicide and Canandaigua
prevention, in Center of
collaboration in Excellence as
other MIRECCs centers for
working in this research,
area. demonstrations,
training, and
technical,
assistance for the
system as a whole
------------------------------------------------------------------------
Promote efforts to reduce Individualized
access to lethal means and interventions
methods of self-harm between providers
and/or suicide
prevention
coordinators with
high-risk patients
and/or their
families; VA
policy for gun
safety programs is
under
consideration
------------------------------------------------------------------------
Improve reporting and Addressed through
portrayals of suicidal ongoing
behavior, mental illness, collaborations in
and substance abuse in the the Federal
entertainment and news media. partnership on
suicide
preventions
------------------------------------------------------------------------
Information Provided by VA From Discussion with Secretary Peake during
Post-Hearing Meeting
In response to Dr. Rudd testimony of increased risk of suicide for
wounded warriors.
Discharge Plan, both mental health and wounded warriors (increased risk
of suicide) need one. What do we do to ensure followup after
discharge of both mental health patients as well as wounded
warriors?
Response: The Federal Recovery Coordinators (FRC) actively started
working with discharge for patients January 28, 2008. FRCs develop
Federal Individualized Recovery Plans (FIRPs) for servicemembers or
veterans who have catastrophic wounds, illness and injuries, including
mental health issues, which will require longitudinal care,
coordination and oversight. Using the Federal Individual Recovery Plan,
based on the input of clinical and non-clinical case managers as well
as the patient and the family, the Federal Recovery Coordinator (FRC)
will ensure that the servicemember, veteran and family have access to
and delivery of support programs and resources for family members and
caregivers.
Phase One of the FRC Program, scheduled to be completed in May
2008, targeted those catastrophically wounded, ill or injured arriving
from theatre to the military treatment facility (MTF). Phase Two, which
will begin immediately after Phase One, is complete, will expand the
program's scope to include those servicemembers and veterans who were
discharged from an MTF prior to January 2008.
At this time, FRCs are accepting servicemembers/veterans injured
prior to January 2008 into the FRCP on a referral basis. As mentioned
above, Phase Two will start in June 2008, and will expand the program's
scope to include those servicemembers and veterans who were discharged
from an MTF prior to January 2008. Identification of this population
will be conducted through a review of VA rehabilitation databases, to
include spinal cord and blind rehabilitation, along with the polytrauma
centers. In tandem, DoD will work through TRICARE in an effort to
identify the same population for potential inclusion into the FRCP.
Staffing support has been initiated to support this expansion effort.
An additional registered nurse is being actively recruited to champion
this effort along with additional FRCs whose geographic placement will
be based on identified patient needs.
Federal Recovery Coordinators are nurses and masters prepared
social workers with experience in Mental Health issues and receive
ongoing training which improves their ability to both identify and
prioritize those servicemembers and veterans in need of mental health
services and programs. Thus they will ensure that the clinical case
manager addressed any mental health issues that the patient or family
may have.
As of May 13, the Combat Veteran Call Center has made 8,598 calls
and has spoken to 2,953 veterans. The percentage of unique veterans
spoken with on this initiative is 34.3%.
----------
Information Provided by VA From Discussion with Secretary Peake during
Post-Hearing Meeting
In response to Maris testimony.
Reanalysis of data; pulling out base population, including veterans.
Response: The National Violent Death Reporting System (NVDRS)
database is owned by CDC. VA uses the information, however, we feel
outreach efforts to make its use more prevalent should be initiated by
CDC.
To compare information of veterans using VHA health care services
with all veterans and all Americans, VA uses information on all
veterans' suicides from the NVDRS. The NVDRS has been tracking suicides
among veterans and others in an increasing number of States since 2003,
in six States since 2003, in 13 since 2004, and in 16 since 2005. Only
preliminary information is available for 2006. It is likely that the
counts and rates presented for this year will increase as additional
case reports are received.
To give a view of suicide rates over time, the NVDRS document
attached dated 5-15-08 looks at NVDRS data for all veterans and
compares it to information on VMA health care users and all Americans
in separate tables for each grouping of NVDRS States.
Calculations for VHA patients were based on causes of death from
the National Death Index for veterans from the relevant States
identified from clinical and administrative records. Figures for the
general populations were derived from the CDC's Web-based Injury
Statistics Query and Reporting System (WISQARS) site, again, for the
relevant States.
The National Violent Death Reporting System (NVDRS) Update, 5-15-08 11am
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For VHA Patients in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
FY03 FY04 FY05
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Suicide Suicides / Suicide Suicides / Suicide Suicides /
Pop. Deaths 100,000 Pop. Deaths 100,000 Pop. Deaths 100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 10,342 5 48.3 11,453 6 52.4 12,847 7 54.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 232,427 88 37.9 236,043 89 37.7 240,439 83 34.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 255,853 76 29.7 239,609 75 31.3 235,410 66 28.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 498,622 169 33.9 487,105 170 34.9 488,696 156 31.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 4,818 1 20.8 5,431 1 18.4 5,945 2 33.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 33,030 8 24.2 34,404 6 17.4 35,641 6 16.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 6,985 0 0.0 6,471 0 0.0 6,388 0 0.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 44,834 9 20.1 46,306 7 15.1 47,974 8 16.7
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For General U.S. Population in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)--Continued
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CY03 CY04 CY05
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Suicide Suicides / Suicide Suicides / Suicide Suicides /
Pop. Deaths 100,000 Pop. Deaths 100,000 Pop. Deaths 100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 2,882,507 520 18.0 2,940,762 498 16.9 2,979,291 524 17.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 8,478,693 1,676 19.8 8,554,240 1,730 20.2 8,626,030 1,697 19.7
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 1,829,120 512 28.0 1,853,752 491 26.5 1,885,066 489 25.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 13,190,320 2,708 20.5 13,348,754 2,719 20.4 13,490,387 2,710 20.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 2,811,814 91 3.2 2,846,934 109 3.8 2,878,825 98 3.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 8,868,182 515 5.8 8,937,771 510 5.7 9,008,792 544 6.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 2,617,145 111 4.2 2,632,363 87 3.3 2,657,046 95 3.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 14,297,141 717 5.0 14,417,068 706 4.9 14,544,663 737 5.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For All Veterans in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CY03 CY04 CY05 CY06 Partial
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Suicide Suicides / Suicide Suicides / Suicide Suicides / Suicide Suicides /
Pop. Deaths 100,000 Pop. Deaths 100,000 Pop. Deaths 100,000 Pop. Deaths 100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 97,430 51 52.3 97,761 48 49.1 101,622 40 39.4 105,108 40 38.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 1,728,183 423 24.5 1,695,677 412 24.3 1,664,851 374 22.5 1,631,152 306 18.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 1,171,401 326 27.8 1,157,448 314 27.1 1,139,862 319 28.0 1,125,567 251 22.3
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 2,997,014 800 26.7 2,950,886 774 26.2 2,906,335 733 25.2 2,861,826 597 20.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 26,503 3 11.3 26,891 4 14.9 27,728 3 10.8 28,104 7 24.9
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 167,872 11 6.6 173,324 18 10.4 177,874 18 10.1 182,547 13 7.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 44,773 1 2.2 43,732 2 4.6 42,828 2 4.7 41,667 3 7.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 239,147 15 6.3 243,947 24 9.8 248,430 23 9.3 252,318 23 9.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
For VHA Patients in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland,
Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
FY04 FY05
----------------------------------------------------------------------------------------------------------------
Suicide Suicides / Suicide Suicides /
Pop. Deaths 100,000 Pop. Deaths 100,000
----------------------------------------------------------------------------------------------------------------
Males, 18-29 22,130 8 36.2 25,353 15 59.2
----------------------------------------------------------------------------------------------------------------
Males, 30-64 494,213 202 40.9 510,042 180 35.3
----------------------------------------------------------------------------------------------------------------
Males, 65+ 460,764 156 33.9 454,915 159 35.0
----------------------------------------------------------------------------------------------------------------
All Males 977,106 366 37.5 990,311 354 35.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 11,189 1 8.9 12,381 3 24.2
----------------------------------------------------------------------------------------------------------------
Females, 30-64 70,609 9 12.7 73,261 12 16.4
----------------------------------------------------------------------------------------------------------------
Females, 65+ 13,615 0 0.0 12,350 0 0.0
----------------------------------------------------------------------------------------------------------------
All Females 95,414 10 10.5 97,991 15 15.3
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
For the General U.S. Population in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia,
Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia,
Wisconsin)
-----------------------------------------------------------------------------------------------------------------
CY04 CY05
----------------------------------------------------------------------------------------------------------------
Suicide Suicides / Suicide Suicides /
Pop. Deaths 100,000 Pop. Deaths 100,000
----------------------------------------------------------------------------------------------------------------
Males, 18-29 5,759,748 1154 20.0 5,825,312 1117 19.2
----------------------------------------------------------------------------------------------------------------
Males, 30-64 15,981,610 3647 22.8 16,172,388 3593 22.2
----------------------------------------------------------------------------------------------------------------
Males, 65+ 3,371,832 971 28.8 3,439,314 1029 29.9
----------------------------------------------------------------------------------------------------------------
All Males 25,113,190 5,772 23.0 25,437,014 5,739 22.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 5,487,877 235 4.3 5,549,163 236 4.3
----------------------------------------------------------------------------------------------------------------
Females, 30-64 16,507,912 1160 7.0 16,702,515 1133 6.8
----------------------------------------------------------------------------------------------------------------
Females, 65+ 4,783,669 181 3.8 4,843,413 180 3.7
----------------------------------------------------------------------------------------------------------------
All Females 26,779,458 1,576 5.9 27,095,091 1,549 5.7
----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For All Veterans in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
Virginia, Wisconsin)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CY04 CY05 CY06 Partial
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Suicide Suicides / Suicide Suicides / Suicide Suicides /
Pop. Deaths 100,000 Pop. Deaths 100,000 Pop. Deaths 100,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 190,949 100 52.4 198,183 88 44.4 204,917 89 43.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 3,311,746 889 26.8 3,261,900 833 25.5 3,206,111 750 23.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 2,111,452 592 28.0 2,086,273 674 32.3 2,066,921 491 23.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 5,614,146 1,581 28.2 5,546,357 1,595 28.8 5,477,950 1,330 24.3
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 51,664 9 17.4 53,454 9 16.8 54,207 9 16.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 333,660 39 11.7 342,846 37 10.8 352,071 30 8.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 75,115 2 2.7 73,945 3 4.1 72,625 4 5.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 460,438 50 10.9 470,245 49 10.4 478,902 43 9.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------
For VHA Patients in the 16 States with NVDRS data for CY2005 (Alaska,
Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New
Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
FY05
------------------------------------------------------------------------
Suicide Suicides /
Pop. Deaths 100,000
------------------------------------------------------------------------
Males, 18-29 31,966 17 53.2
------------------------------------------------------------------------
Males, 30-64 594,346 217 36.5
------------------------------------------------------------------------
Males, 65+ 524,948 189 36.0
------------------------------------------------------------------------
All Males 1,151,261 423 36.7
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 15,988 4 25.0
------------------------------------------------------------------------
Females, 30-64 88,531 14 15.8
------------------------------------------------------------------------
Females, 65+ 14,293 0 0.0
------------------------------------------------------------------------
All Females 118,811 18 15.2
------------------------------------------------------------------------
------------------------------------------------------------------------
For the General U.S. Population in the 16 States with NVDRS data for
CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts,
New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island,
South Carolina, Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
CY05
------------------------------------------------------------------------
Suicide Suicides /
Pop. Deaths 100,000
------------------------------------------------------------------------
Males, 18-29 6,630,344 1,350 20.4
------------------------------------------------------------------------
Males, 30-64 18,026,867 4,196 23.3
------------------------------------------------------------------------
Males, 65+ 3,858,225 1,177 30.5
------------------------------------------------------------------------
All Males 28,515,436 6,723 23.6
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 6,318,615 275 4.4
------------------------------------------------------------------------
Females, 30-64 18,602,682 1,309 7.0
------------------------------------------------------------------------
Females, 65+ 5,406,681 196 3.6
------------------------------------------------------------------------
All Females 30,327,978 1,780 5.9
------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
For All Veterans in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland,
Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah,
Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
CY05 CY06 Partial
----------------------------------------------------------------------------------------------------------------
Suicide Suicides / Suicide Suicides /
Pop. Deaths 100,000 Pop. Deaths 100,000
----------------------------------------------------------------------------------------------------------------
Males, 18-29 222,255 100 45.0 229,855 98 42.6
----------------------------------------------------------------------------------------------------------------
Males, 30-64 3,636,370 931 25.6 3,575,055 842 23.6
----------------------------------------------------------------------------------------------------------------
Males, 65+ 2,334,819 736 31.5 2,313,321 558 24.1
----------------------------------------------------------------------------------------------------------------
All Males 6,193,443 1,767 28.5 6,118,231 1,498 24.5
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 58,614 9 15.4 59,514 10 16.8
----------------------------------------------------------------------------------------------------------------
Females, 30-64 376,875 43 11.4 387,015 34 8.8
----------------------------------------------------------------------------------------------------------------
Females, 65+ 82,077 3 3.7 80,703 4 5.0
----------------------------------------------------------------------------------------------------------------
All Females 517,566 55 10.6 527,232 48 9.1
----------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
For VHA Patients in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
---------------------------------------------------------------------------------------------------------------------------------------------------------
FY03 FY04 FY05
--------------------------------------------------------------------------------------------------------------------------------------------------------
95% CI 95% CI 95% CI
Suicides / ------------------------ Suicides / ------------------------ Suicides / -----------------------
100,000 Lower Upper 100,000 Lower Upper 100,000 Lower Upper
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 48.3 15.7 112.8 52.4 19.2 114.0 54.5 21.9 112.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 37.9 30.4 46.6 37.7 30.3 46.4 34.5 27.5 42.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 29.7 23.4 37.2 31.3 24.6 39.2 28.0 21.7 35.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 33.9 29.0 39.4 34.9 29.9 40.6 31.9 27.1 37.3
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 20.8 0.5 115.6 18.4 0.5 102.6 33.6 4.1 121.5
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 24.2 10.5 47.7 17.4 6.4 38.0 16.8 6.2 36.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 0.0 0.0 52.8 0.0 0.0 57.0 0.0 0.0 57.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 20.1 9.2 38.1 15.1 6.1 31.1 16.7 7.2 32.9
--------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
For General U.S. Population in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
---------------------------------------------------------------------------------------------------------------------------------------------------------
CY03 CY04 CY05
--------------------------------------------------------------------------------------------------------------------------------------------------------
95% CI 95% CI 95% CI
Suicides / ------------------------ Suicides / ------------------------ Suicides / -----------------------
100,000 Lower Upper 100,000 Lower Upper 100,000 Lower Upper
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 18.0 16.5 20.3 16.9 15.5 18.5 17.6 15.9 19.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 19.8 18.8 20.7 20.2 19.3 21.2 19.7 18.7 20.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 28.0 25.6 30.5 26.5 24.2 28.9 25.9 23.7 28.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 20.5 19.8 21.3 20.4 19.6 21.1 20.1 19.3 20.8
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 3.2 2.6 4.0 3.8 3.1 4.6 3.4 2.8 4.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 5.8 5.3 6.3 5.7 5.2 6.2 6.0 5.5 6.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 4.2 3.5 5.1 3.3 2.6 4.1 3.6 2.9 4.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 5.0 4.6 5.4 4.9 4.5 5.3 5.1 4.7 5.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For All Veterans in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CY03 CY04 CY05 CY06
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
95% CI 95% CI 95% CI 95% CI
Suicides / -------------------- Suicides / -------------------- Suicides / -------------------- Suicides / -------------------
100,000 Lower Upper 100,000 Lower Upper 100,000 Lower Upper 100,000 Lower Upper
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 52.3 39.0 68.8 49.1 36.2 65.1 39.4 28.1 53.6 38.1 27.2 51.8
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 24.5 22.2 26.9 24.3 22.0 26.8 22.5 20.2 24.9 18.8 16.7 21.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 27.8 24.9 31.0 27.1 24.2 30.3 28.0 25.0 31.2 22.3 19.6 25.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 26.7 24.8 28.5 26.2 24.4 28.1 25.2 23.4 27.0 20.9 19.2 24.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 11.3 2.3 33.1 14.9 4.1 38.1 10.8 2.2 31.6 24.9 10.0 51.3
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 6.6 3.3 11.7 10.4 6.2 16.4 10.1 6.0 16.0 7.1 3.8 12.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 2.2 0.1 12.4 4.6 0.6 16.5 4.7 0.6 16.9 7.2 1.5 21.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 6.3 3.5 10.3 9.8 6.3 14.6 9.3 5.9 13.9 9.1 5.8 13.7
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
For VHA Patients in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland,
Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
FY04 FY05
----------------------------------------------------------------------------------------------------------------
95% CI 95% CI
Suicides / ------------------------ Suicides / -----------------------
100,000 Lower Upper 100,000 Lower Upper
----------------------------------------------------------------------------------------------------------------
Males, 18-29 36.2 15.6 71.2 59.2 33.1 97.6
----------------------------------------------------------------------------------------------------------------
Males, 30-64 40.9 35.4 46.9 35.3 30.3 40.8
----------------------------------------------------------------------------------------------------------------
Males, 65+ 33.9 28.8 39.6 35.0 29.7 40.8
----------------------------------------------------------------------------------------------------------------
All Males 37.5 33.7 41.5 35.7 32.1 39.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 8.9 0.2 49.8 24.2 5.0 70.8
----------------------------------------------------------------------------------------------------------------
Females, 30-64 12.7 5.8 24.2 16.4 8.5 28.6
----------------------------------------------------------------------------------------------------------------
Females, 65+ 0.0 0.0 27.1 0.0 0.0 29.9
----------------------------------------------------------------------------------------------------------------
All Females 10.5 5.0 19.3 15.3 8.6 25.2
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
For the General U.S. Population in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia,
Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia,
Wisconsin)
-----------------------------------------------------------------------------------------------------------------
CY04 CY05
----------------------------------------------------------------------------------------------------------------
95% CI 95% CI
Suicides / ------------------------ Suicides / -----------------------
100,000 Lower Upper 100,000 Lower Upper
----------------------------------------------------------------------------------------------------------------
Males, 18-29 20.0 18.9 21.2 19.2 18.1 20.3
----------------------------------------------------------------------------------------------------------------
Males, 30-64 22.8 22.1 23.6 22.2 21.5 22.9
----------------------------------------------------------------------------------------------------------------
Males, 65+ 28.8 27.0 30.6 29.9 28.1 31.7
----------------------------------------------------------------------------------------------------------------
All Males 23.0 22.4 23.6 22.6 22.0 23.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 4.3 3.8 4.9 4.3 3.7 4.8
----------------------------------------------------------------------------------------------------------------
Females, 30-64 7.0 6.6 7.4 6.8 6.4 7.2
----------------------------------------------------------------------------------------------------------------
Females, 65+ 3.8 3.3 4.4 3.7 3.2 4.3
----------------------------------------------------------------------------------------------------------------
All Females 5.9 5.6 6.2 5.7 5.4 6.0
----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For All Veterans in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
Virginia, Wisconsin)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CY04 CY05 CY06 (Partial)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
95% CI 95% CI 95% CI
Suicides /100,000 ------------------------ Suicides /100,000 ------------------------ Suicides /100,000 -----------------------
Lower Upper Lower Upper Lower Upper
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 18-29 52.4 42.6 63.7 44.4 35.6 54.7 43.4 34.9 53.4
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 30-64 26.8 25.1 28.6 25.5 23.8 27.3 23.4 21.7 25.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Males, 65+ 28.0 25.8 32.5 32.3 29.9 34.7 23.8 21.7 26.0
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Males 28.2 26.8 29.5 28.8 27.3 30.2 24.3 23.0 25.6
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 17.4 8.0 33.1 16.8 7.7 32.0 16.6 7.6 31.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 30-64 11.7 8.3 16.0 10.8 7.6 14.9 8.5 5.7 12.2
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 65+ 2.7 0.3 9.6 4.1 0.8 11.9 5.5 1.5 14.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All Females 10.9 8.1 14.3 10.4 7.7 13.8 9.0 6.5 12.1
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------
For VHA Patients in the 16 States with NVDRS data for CY2005 (Alaska,
Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New
Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina,
Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
FY05
------------------------------------------------------------------------
95% CI
Suicides -----------------------
/100,000 Lower Upper
------------------------------------------------------------------------
Males, 18-29 53.2 31.0 85.1
------------------------------------------------------------------------
Males, 30-64 36.5 31.8 41.7
------------------------------------------------------------------------
Males, 65+ 36.0 31.1 41.5
------------------------------------------------------------------------
All Males 36.7 33.3 40.4
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 25.0 6.8 64.1
------------------------------------------------------------------------
Females, 30-64 15.8 8.6 26.5
------------------------------------------------------------------------
Females, 65+ 0.0 0.0 25.8
------------------------------------------------------------------------
All Females 15.2 9.0 23.9
------------------------------------------------------------------------
------------------------------------------------------------------------
For the General U.S. Population in the 16 States with NVDRS data for
CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts,
New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island,
South Carolina, Utah, Virginia, Wisconsin)
-------------------------------------------------------------------------
CY05
------------------------------------------------------------------------
95% CI
Suicides -----------------------
/100,000 Lower Upper
------------------------------------------------------------------------
Males, 18-29 20.4 19.3 21.4
------------------------------------------------------------------------
Males, 30-64 23.3 22.6 24.0
------------------------------------------------------------------------
Males, 65+ 30.5 28.8 32.2
------------------------------------------------------------------------
All Males 23.6 23.0 24.1
------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 4.4 3.9 4.9
------------------------------------------------------------------------
Females, 30-64 7.0 6.7 7.4
------------------------------------------------------------------------
Females, 65+ 3.6 3.1 4.2
------------------------------------------------------------------------
All Females 5.9 5.6 6.1
------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
For All Veterans in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland,
Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah,
Virginia, Wisconsin)
-----------------------------------------------------------------------------------------------------------------
CY05 CY06 (Partial)
----------------------------------------------------------------------------------------------------------------
95% CI 95% CI
Suicides / -------------------- Suicides / -------------------
100,000 Lower Upper 100,000 Lower Upper
----------------------------------------------------------------------------------------------------------------
Males, 18-29 45.0 36.6 54.7 42.6 34.6 52.0
----------------------------------------------------------------------------------------------------------------
Males, 30-64 25.6 24.0 27.2 23.6 22.0 25.1
----------------------------------------------------------------------------------------------------------------
Males, 65+ 31.5 29.2 33.8 24.1 22.2 26.2
----------------------------------------------------------------------------------------------------------------
All Males 28.5 27.2 29.9 24.5 23.2 25.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Females, 18-29 15.4 7.0 29.1 16.8 8.1 30.9
----------------------------------------------------------------------------------------------------------------
Females, 30-64 11.4 8.3 15.4 8.8 6.1 12.3
----------------------------------------------------------------------------------------------------------------
Females, 65+ 3.7 0.8 10.7 5.0 1.4 12.7
----------------------------------------------------------------------------------------------------------------
10All Females 10.6 8.0 13.8 9.1 6.7 12.1
----------------------------------------------------------------------------------------------------------------
Information Provided by VA From Discussion with Secretary Peake during
Post-Hearing Meeting
Cost of Call Center
Response: Currently, the cost for the suicide hotline in FY 2008 is
projected to be $2.6 million. However, the funding will increase if and
when the calls require additional lines.
Detail of Program Expenses
Specific Purpose Program: Suicide Hotline
----------------------------------------------------------------------------------------------------------------
Estimated Expenses: FTEE Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Comments
----------------------------------------------------------------------------------------------------------------
VA Personnel 37.50 $517,805 $647,760 $642,521 $652,384 $2,460,469
----------------------------------------------------------------------------------------------------------------
Contract Personnel (IPA, etc.)
----------------------------------------------------------------------------------------------------------------
Contract Services & Misc.
------------------------------------------$118,456--------------------------------------$118,456----------------
----------------------------------------------------------------------------------------------------------------
Supplies $1,050 $1,050 $1,050 $1,050 $4,200
----------------------------------------------------------------------------------------------------------------
Other $4,688 $4,688 $4,688 $4,688 $18,752
----------------------------------------------------------------------------------------------------------------
Travel $9,375 $9,375 $9,375 $9,375 $37,500
----------------------------------------------------------------------------------------------------------------
Equipment $5,463 $5,463
----------------------------------------------------------------------------------------------------------------
Total Expenditures: 37.50 $656,837 $662,873 $657,634 $667,497 $2,644,840
----------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Function Station To
VA Personnel (Name) Grade / Position (Title) FTEE Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total (Job Receive Station
Step Duties) Funding Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $16,833 $16,889 $16,909 $17,170 $67,801 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
09 Other Therapists 1.00 $19,403 $19,468 $19,492 $19,792 $78,155 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
06 Other Health Aides 1.00 $12,443 $12,484 $12,499 $12,692 $50,118 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
01 RN 1.00 $21,528 $21,600 $21,626 $21,959 $86,713 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
05 Other Health Aides 1.00 $7,803 $7,829 $7,838 $7,959 $31,429 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $18,696 $18,759 $18,781 $19,070 $75,306 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
06 Other Health Aides 1.00 $12,918 $12,961 $12,977 $13,177 $52,033 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
09 Other Therapists 1.00 $14,954 $15,004 $15,022 $15,253 $60,233 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $16,635 $16,690 $16,710 $16,967 $67,002 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $15,935 $15,988 $16,008 $16,254 $64,185 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $17,917 $17,977 $17,999 $18,276 $72,169 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
02 RN 1.00 $7,386 $7,411 $7,420 $7,534 $29,751 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
06 Other Health Aides 1.00 $10,468 $10,503 $10,516 $10,678 $42,165 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $19,156 $19,234 $19,243 $19,539 $77,172 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
01 RN 1.00 $19,749 $19,815 $19,839 $20,144 $79,547 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $18,594 $18,656 $18,679 $18,966 $74,895 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
05 Nursing Aides 1.00 $9,376 $9,407 $9,419 $9,564 $37,766 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $17,109 $17,166 $17,186 $17,451 $68,912 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Social Worker 1.00 $17,268 $17,325 $17,346 $17,613 $69,552 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
09 Other Therapists 1.00 $15,826 $15,878 $15,898 $16,142 $63,744 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
3 RN 1.00 $23,026 $23,103 $23,131 $23,486 $92,746 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
3 RN 1.00 $20,593 $20,662 $20,687 $21,005 $82,947 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2 RN 1.00 $21,038 $21,108 $21,134 $21,459 $84,739 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
2 RN 1.00 $20,867 $20,936 $20,962 $21,284 $84,049 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Other Therapists 1.00 $15,510 $15,562 $15,581 $15,820 $62,473 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11 Other Therapists 1.00 $15,164 $15,215 $15,233 $15,467 $61,079 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 02/11 RN or SW 0.50 $9,529 $9,541 $9,688 $28,757 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 11 Program Analyst 1.00 $10,591 $19,482 $19,505 $19,806 $69,384 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
RECRUITMENT 6 Program Support 1.00 $6,440 $11,847 $11,861 $12,044 $42,192 528 528
Asst.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
OT $23,135 $1,750 $1,750 $1,750 $28,385 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Awards $10,000 $6,000 $16,000 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sub Total: 37.50 $517,805 $647,760 $642,521 $652,384 $2,460,469
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Contract Personnel (IPA, etc.)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Station To
Personnel Position FTEE Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Function Receive Station
Funding Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sub Total:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Detail of Program Expenses
Specific Purpose Program: Suicide Hotline--Continued
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Contract Services & Misc.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Reason for Station To
Contract (Service provided) Contractor Needed Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Service Receive Station
(Contract) Funding Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Accreditation $5,000 $5,000 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Lifeline $111,456 $111,456 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Advertising $2,000 $2,000 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sub Total: $118,456 $118,456
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Actual Services which are under a contract (copier maintenance, phone service, etc.). Any service provided by the local facility and charged to the program are listed under Supplies or
Other. Also List in order of priority to your program.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Station To
Supplies Purpose Needed Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Comments Receive Station
Funding Number
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Office supplies $1,050 $1,050 $1,050 $1,050 $4,200 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sub Total: $1,050 $1,050 $1,050 $1,050 $4,200
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Includes paper, pens, toner, etc. along with any additional supplies which are consumable and need to be replaced. Also List supplies in order of priority to your program.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Station To
Other Purpose Needed Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Reason for Receive Station
expense Funding Number
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------
Education/tuition/registration $4,688 $4,688 $4,688 $4,688 $18,752 528 528
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Sub Total: $4,688 $4,688 $4,688 $4,688 $18,752
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Any item not covered under contracts or supplies (not to include equipment which is covered below). Also List in order of priority to your program.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Detail of Program Expenses
Specific Purpose Program: Suicide Hot Line--Continued
--------------------------------------------------------------------------------------------------------------------------------------------------------
Travel
---------------------------------------------------------------------------------------------------------------------------------------------------------
Reason Station To Station
Personnel (Name) Traveling to Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total for Trip Receive Funding Number
--------------------------------------------------------------------------------------------------------------------------------------------------------
Employee travel $9,375 $9,375 $9,375 $9,375 $37,500 528 528
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sub Total: $9,375 $9,375 $9,375 $9,375 $37,500
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Please include as much detail on each separate trip and the personnel taking the trips as possible. Also List Travel in order of priority to your
program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
Reason
Equipment Purpose Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Equipment Station To Station
is needed Receive Funding Number
--------------------------------------------------------------------------------------------------------------------------------------------------------
Filing cabinet $1,100 $1,100 528 528
--------------------------------------------------------------------------------------------------------------------------------------------------------
Security System $4,363 $4,363 528 528
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sub Total: $5,463 $5,463
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Equipment consist of items which bear an actual VA property tag all other items go under ``Supplies'' or ``Other''. Also List Equipment in order
of priority to your program.
--------------------------------------------------------------------------------------------------------------------------------------------------------
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Washington, DC.
May 21, 2008
The Honorable James B. Peake, M.D.
The Secretary Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
In reference to our Full Committee hearing on ``The Truth About
Veterans' Suicides'' on May 6, 2008, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on July
7, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Debbie Smith by fax your responses at 202-225-2034. If you have any
questions, please call 202-225-9756.
Sincerely,
BOB FILNER
Chairman
CW:ds
__________
Questions for the Record
The Honorable Bob Filner, Chairman
House Committee on Veterans' Affairs
May 6, 2008
The Truth about Veteran Suicides
Question 1(a): In testimony before the Committee, the VA presented
data regarding suicide rates for the general population and veteran
users grouped into three cohorts: 18-29; 30-64; and, 65+. Please
provide a detailed explanation to the Committee to explain why these
particular age cohorts were chosen.
Response: To ensure consistency with other Veterans Health
Administration (VHA) data on suicides, age groups selected by the
National Serious Mental Illness Treatment Research and Evaluation
Center (SMITREC) were used.
Question 1(b): Please provide the Committee with the data presented
at the May 6, 2008 hearing grouped by the following age cohorts: 20-24;
25-29; 30-34; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 65-69; 70-74;
and, 75+.
Response: The table below provides: Number of Suicides by Age Group
Among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
Veterans Compared to U.S. General Population \1\
---------------------------------------------------------------------------
\1\ Age based on age in 2005. Suicides, n=144, were identified
among a cohort of 490,346 OEF/OIF selected for mortality follow-up
through 2005.
----------------------------------------------------------------------------------------------------------------
Standardized
Age Groups Observed # Expected # Of Mortality Rate 95% confidence
Suicides Suicides \2\ \3\ interval \4\
----------------------------------------------------------------------------------------------------------------
20-24 38 23.6 1.61 1.14-2.21
----------------------------------------------------------------------------------------------------------------
25-29 37 32.7 1.13 0.80-1.56
----------------------------------------------------------------------------------------------------------------
30-34 19 15.1 1.26 0.76-1.97
----------------------------------------------------------------------------------------------------------------
35-39 18 14.8 1.21 0.72-1.92
----------------------------------------------------------------------------------------------------------------
40-44 14 18.7 0.75 0.41-1.26
----------------------------------------------------------------------------------------------------------------
45-49 5 10.6 0.47 0.15-1.10
----------------------------------------------------------------------------------------------------------------
50-54 7 5.2 1.34 0.54-2.75
----------------------------------------------------------------------------------------------------------------
55-59 6 3.5 1.72 0.63-3.74
----------------------------------------------------------------------------------------------------------------
60-64 0 -- -- --
----------------------------------------------------------------------------------------------------------------
65-69 0 -- -- --
----------------------------------------------------------------------------------------------------------------
70-74 0 -- -- --
----------------------------------------------------------------------------------------------------------------
75-+ 0 -- -- --
----------------------------------------------------------------------------------------------------------------
A2 Expected based on U.S. general population.
A3 Standardized Mortality Ratio (SMR) is the ratio of observed to expected with adjustment for race, sex, age,
and calendar year period.
A4 95 percent confidence interval (C.I.).
There were no OEF/OIF veteran suicides in the age groups older than 55-59, therefore expected numbers and SMRs
were not presented.
Question 2: On December 12, 2007, the Committee held a hearing
entitled ``Stopping Suicides: Mental Health Challenges within the U.S.
Department of Veterans Affairs.'' Please provide to the Committee a
detailed explanation of the specific steps and actions undertaken by
the VA to improve mental health care and services since December 13,
2007. Please exclude any steps and actions that the VA had planned to
undertake prior to December 12, 2007.
Response: Since December 13, 2007, the following actions were
initiated to improve mental health care:
Expansion of the suicide prevention coordinator staffing
into teams is underway, with increased access in community based
outpatient clinics (CBOC)
Expansion of mental health staff
Expansion of sites of care--CBOCs
Expansion of veteran centers
Collaborating with the Defense Center of Excellence
(DCoE) on mental health and traumatic brain injury (TBI) by providing a
Deputy Center Director and a mental health subject matter expert
Funding to expand VA's substance use disorder outpatient
intensive care programs by adding 28 new sites and a substance use
disorder care specialist to every post traumatic stress disorder (PTSD)
team or specialty program if one doesn't already exist
Question 3(a): An Associated Press article dated April 15, 2008,
entitled ``Dallas Veterans' Hospital Shutters Psych Ward after Fourth
Patient Suicide of Year'' states that ``[t]he fourth suicide this year
among mentally ill patients treated at the Dallas VA Medical Center has
led the hospital to close its psychiatric ward to new patients, and
investigators from the national Veterans Affairs office are expected to
arrive next week to assess safety.'' Please provide the Committee with
the results of this investigation to date. If the results of this
investigation have not been finalized, please provide the preliminary
findings and recommendations of these investigators.
Response: The Medical Inspector Final Report #2008-D-654 dated May
20, 2008 (Quality of Care Review, Veterans Affairs Medical Center
(VAMC) Dallas, Texas, Veterans Integrated Service Network 17) is
attached.
[The Medical Inspector Final Report #2008-D-654 dated May 20, 2008,
entitled ``Quality of Care Review, Veterans Affairs Medical Center
(VAMC) Dallas, Texas, Veterans Integrated Service Network 17,'' will be
retained in the Committee files.]
Question 3(b): Please provide the Committee with a detailed
explanation regarding the VA's plans to address this situation.
Response: On April 5, 2008, the Dallas VAMC, formally known as the
Department of Veterans Affairs (VA) North Texas Health Care System
(VANTHCS), temporarily stopped admitting new patients to the two
inpatient psychiatry units (a 22-bed unit located on 3 South and a 29-
bed unit located on 3 North) following two previous inpatient suicides
on February 5, 2008 and April 4, 2008. Patients remained on the units
until completion of their course of treatment to ensure continuity of
care. The temporary stand down was put in place to allow adequate time
for a thorough review of mental health staffing and environment of care
issues.
On April 16-17, and April 22-23, 2008, the Office of Medical
Inspector (OMI) and the Office of Mental Health, respectively, visited
the Dallas VAMC to evaluate the mental health program. The OMI and
Office of Mental Health teams made several recommendations for safety
improvements, including environment of care enhancements, staffing/
program enhancements, and organizational/cultural changes needed to
enhance patient safety. The Dallas VAMC leadership embraced these
recommendations and has implemented an action plan successfully
correcting all deficiencies.
On May 8, 2008, Veterans Integrated Service Network (VISN) 17
responded to Office of Mental Health's recommendations with a detailed
action plan. All items on the list were either completed or closed out
in compliance and confirmed with the Deputy Chief of Mental Health
prior to re-opening the inpatient units. VISN 17 also consulted with
the National Center for Patient Safety (NCPS). NCPS determined that the
Dallas VAMC's plan for enhanced safety checks and increased staffing on
the units should mitigate the risk of suicide.
On May 19, 2008, following renovations, the 3 South inpatient unit
was re-opened. New admissions were capped to two per day, with
exceptions for patients hospitalized under the order of protected
custody. While the unit was closed to new admission, patients were
assessed in the emergency department and outpatient clinics and
transferred for inpatient hospitalization as needed to the Waco VAMC
and local psychiatric hospitals. A social worker coordinated admissions
and discharges to ensure continuity of care. Mental health staff was
proactive in providing information to the receiving facilities and
remained in communication with the facilities throughout the
hospitalization.
Over the past 6 months, Dallas VAMC has invested $250,000 in the
inpatient units to provide upgrades to the environment of care to
decrease suicide risks. An additional $250,000 has been spent on
furniture to also reduce suicide risk. These improvements included the
following: replacing windows and door hardware, clipping ceiling tiles
in bedrooms, installing camera systems in hallway, changing bathrooms
fixtures, enclosing plumbing and electrical wiring, and removing tall
furniture and nightstands. Continuous improvements and modifications
are being made to the environment of care.
The Dallas VAMC is actively recruiting permanent additional staff
and reorganizing the Mental Health Department. Education for all
existing and new staff hired on integrating principles of psychosocial
recovery and suicide prevention is being conducted and will continue.
The Dallas VAMC regularly consults the Office of Mental Health in
preparation for the reopening of 3 North. The tentative opening date
for 3 North is fiscal year (FY) 2009. Outsourcing of services will
discontinue once the unit is re-opened and fully staffed.
Question 3(c): Please provide the current level of mental health
care services at the Dallas facility
Response: The chart below provides the current level of mental
health services at the Dallas facility.
Question 3(d): What is the expected level of services at the Dallas
facility in one year?
------------------------------------------------------------------------------------------------------------------------------------------------
VA North Texas Health Care System (Dallas) Mental Health Services
------------------------------------------------------------------------
Inpatient acute care Health care for homeless
Intensive outpatient veterans
group therapies. Outreach for homeless
Alcohol/drug recovery veterans
counseling. Special programs for women
Anger management......... veterans suffering from trauma
Evaluation and treatment Support groups for wives of
of PTSD. veterans with PTSD
Geriatric psychiatry..... Day treatment
Memory problems.......... Suicide prevention
Homeless domiciliary..... coordinators (Dallas/Bonham/Fort
Compensated work therapy Worth)
(CWT). Recovery services that help
Community residential promote veteran empowerment,
care program (CRCP). development of life and work
Programs to help ex- skills, supportive family and
offenders reintegrate back into social networks and improved
society. problem solving
Assisted housing veterans Trauma team (military
sexual trauma, PTSD)
------------------------------------------------------------------------
Response: In FY 2009, the Dallas VAMC will provide the full
spectrum of mental health services as indicated in the chart above
including the reopening of 3 North.
Question 3(e): What is the length of time the VA plans to outsource
these services to other VA facilities in North Texas, Waco, and Temple?
Response: The inpatient mental health services will continue to be
outsourced in FY 2009 until the renovations of the 29-bed unit is on 3
North and the 22-bed unit on 3 South are complete and the facilities
are in full compliance with national patient safety measures.
Question 4(a): A Dallas Morning News article dated January 18,
2005, entitled ``Dallas VA Hospital is Nation's Worst'' states that the
``Dallas veterans hospital is so dirty, dangerous, and poorly managed,
Federal investigators have found that it ranks as the worst such
medical center in the country.'' Please provide the Committee with
information regarding the current ranking of the Dallas facility.
Response: In May 2008, VA Office of Quality and Performance issued
a second quarter FY 2008 Facility Aggregated Report ranking Dallas 123
out of 139.
Question 4(b): Please provide the Committee with a detailed
explanation of the specific steps undertaken by the VA since 2005 to
improve the Dallas VA Medical Center.
Response: Since 2005, the Dallas VAMC has taken steps to improve
the organization. The graph below shows the total budget, staffing and
equipment purchases from 2005 through 2008. Since 2005, the total
budget increased by 21 percent, staffing increased by 10 percent and
equipment purchase expenditures were 145 percent.
----------------------------------------------------------------------------------------------------------------
VANTHCS Operational Budget** FY 2005 FY 2006 FY 2007 FY 2008 Projected
------------------------------------------------------------------------------------------------------- -----------
Medical $408,470,538.30 $461,669,051.57 $484,666,641.06 $530,439,213.09
----------------------------------------------------------------------------------------------------------------
Administration $ 54,860,479.67 $ 50,051,586.51 $ 57,226,061.12 $ 42,143,425.62
----------------------------------------------------------------------------------------------------------------
Facility $ 50,477,600.71 $ 56,877,468.86 $ 64,230,384.76 $ 49,410,582.70
----------------------------------------------------------------------------------------------------------------
Total $513,808,618.68 $568,598,106.94 $606,123,086.94 $621,993,221.41
----------------------------------------------------------------------------------------------------------------
**Includes general purpose/specific purpose/Consolidated Mail Out Pharmacy
----------------------------------------------------------------------------------------------------------------
[GRAPHIC] [TIFF OMITTED] 43052A.013
[GRAPHIC] [TIFF OMITTED] 43052A.014
Since 2005, the Dallas VAMC has improved its infrastructure and its
ability to provide high quality of care. Its capital budget has
increased by 30 percent since 2005. Below is a detailed list of its
minor and non-recurring Maintenance (NRM) projects and capital funding
for VA North Texas Health Care System.
FY 2005--FY 2008 Minor Projects:
----------------------------------------------------------------------------------------------------------------
Total Project
FY Approved Facility Project Title Cost
----------------------------------------------------------------------------------------------------------------
2005 Dallas Patient Privacy/UFAS $2,200,000
Deficiencies, Ph 8
----------------------------------------------------------------------------------------------------------------
2005 Dallas Relocate Geropsychiatry $6,050,000
----------------------------------------------------------------------------------------------------------------
2006 Dallas Transitional Care Unit $3,630,000
----------------------------------------------------------------------------------------------------------------
2007 Dallas MRI Addition for Research $6,299,000
----------------------------------------------------------------------------------------------------------------
2008 Dallas Upgrade Mental Health Ph 2 $6,984,475
----------------------------------------------------------------------------------------------------------------
FY 2005--FY 2008 Non-Recurring Maintenance (NRM) Projects:
FY 2005
------------------------------------------------------------------------
Total $
Facility Project Title Obligated
------------------------------------------------------------------------
Dallas Cor$ 219,565.00l Panel Deficiencies
------------------------------------------------------------------------
Dallas SCI $ 69,000.00ab
------------------------------------------------------------------------
Dallas Dallas Pharmacy Cle$ 33,000.00tion
------------------------------------------------------------------------
Dallas Bldg. #1 & #2 Con$ 60,000.00or
Renovation
------------------------------------------------------------------------
Dallas Cli$ 44,610.00n Renovation
------------------------------------------------------------------------
Dallas Mental Health Offices $ 35,000.00
------------------------------------------------------------------------
Dallas Modular Bldgs. 5/6 Installation $ 325,000.00
------------------------------------------------------------------------
Dallas Increase Provider/Patient Car$ 125,000.00
------------------------------------------------------------------------
Dallas GU Renovation $ 65,000.00
------------------------------------------------------------------------
Dallas CWT$ 187,603.00
------------------------------------------------------------------------
Dallas Replace PRV Stations $ 261,784.00
------------------------------------------------------------------------
Dallas Sump Pump Replacement $ 170,000.00
------------------------------------------------------------------------
Dallas Install Elevator Monitoring System $ 168,083.00
------------------------------------------------------------------------
Dallas EP/Cat$ 150,000.00
------------------------------------------------------------------------
Dallas Dallas Roof Repairs $ 164,850.00
------------------------------------------------------------------------
Dallas HVAC C$ 81,180.00
------------------------------------------------------------------------
Dallas Asbestos Abatement $ 174,938.00
------------------------------------------------------------------------
Dallas Renovate Can$ 50,000.00
------------------------------------------------------------------------
Dallas Plan For Improvement (PFI) $ 168,196.00
------------------------------------------------------------------------
Dallas Cor$ 571,113.00m/Sprinkler Def.
------------------------------------------------------------------------
Dallas ER Nursing Triage $ 15,000.00
------------------------------------------------------------------------
Dallas Duct Cle$ 423,300.00
------------------------------------------------------------------------
Dallas HVAC C$ 81,180.00
------------------------------------------------------------------------
Dallas FY05 Facility Lump Sum $ 293,364.00
------------------------------------------------------------------------
Total $ 3,936,766.00
------------------------------------------------------------------------
FY 2006
------------------------------------------------------------------------
Total $
Facility Project Title Obligated
------------------------------------------------------------------------
Dallas HVAC C$ 2,037,620.00
------------------------------------------------------------------------
Dallas Pneumatic Tube Installation $ 74,149.00
------------------------------------------------------------------------
Dallas B-1/B-12 Electrical Deficiencies $ 242,062.00
------------------------------------------------------------------------
Dallas Mental Cli$ 439,400.00
------------------------------------------------------------------------
Dallas Diabetes/Women's Cli$ 236,330.00
------------------------------------------------------------------------
Dallas 5A Telemetry $ 65,049.00
------------------------------------------------------------------------
Dallas Bldg. 2, Cha$ 86,652.00
------------------------------------------------------------------------
Dallas Dental Renovation $ 61,199.00
------------------------------------------------------------------------
Dallas QM Renovation $ 70,866.00
------------------------------------------------------------------------
Dallas Cor$ 82,873.00densate
------------------------------------------------------------------------
Dallas Dallas Roof Repairs $ 29,506.00
------------------------------------------------------------------------
Dallas HVAC C$ 2,057,620.00
------------------------------------------------------------------------
Dallas Replace Dallas UGST $ 146,000.00
------------------------------------------------------------------------
Dallas Cor$ 172,043.00
------------------------------------------------------------------------
Dallas Asbestos Abatement $ 140,221.00
------------------------------------------------------------------------
Dallas Renovate Can$ 85,769.00
------------------------------------------------------------------------
Dallas USP 797 Dallas Pharmacy Cle$ 29,207.00
------------------------------------------------------------------------
Dallas Plan For Improvement (PFI) $ 79,000.00
------------------------------------------------------------------------
Dallas Cor$ 47,609.00m/Sprinkler Def.
------------------------------------------------------------------------
Dallas ER Nursing Triage $ 54,247.00
------------------------------------------------------------------------
Dallas Replace CPV$ 49,623.00
------------------------------------------------------------------------
Dallas Cor$ 64,059.00densate
------------------------------------------------------------------------
Dallas Replace CPV$ 29,000.00
------------------------------------------------------------------------
Dallas FY06 Facility Lump Sum $ 335,273.00
------------------------------------------------------------------------
Total $ 6,715,377.00
------------------------------------------------------------------------
FY 2007
------------------------------------------------------------------------
Total $
Facility Project Title Obligated
------------------------------------------------------------------------
Dallas Bonham Electrical Deficiency Cor$ 43,475.00
------------------------------------------------------------------------
Dallas Bonham Fire Sprinkler $ 235,332.00
------------------------------------------------------------------------
Dallas Replace/Repair Ductwork Insulation $ 99,897.00
------------------------------------------------------------------------
Dallas Bonham Roof/Repair Replacements $ 219,979.00
------------------------------------------------------------------------
Dallas Repair Cam$ 161,339.00dway and
Sidewalks
------------------------------------------------------------------------
Dallas Cor$ 68,932.00wer Deficiencies
------------------------------------------------------------------------
Dallas USP 797 Dallas Pharmacy Cle$ 218,000.00
------------------------------------------------------------------------
Dallas Polytrauma Program Renovation $ 218,824.00
------------------------------------------------------------------------
Dallas Brachytherapy $ 30,148.00
------------------------------------------------------------------------
Dallas 9th Floor Building #2 Cal$ 83,504.00
------------------------------------------------------------------------
Dallas QM/PP #8 Domino Moves $ 124,070.00
------------------------------------------------------------------------
Dallas Remove Lithotripter Equipment $ 50,066.00
------------------------------------------------------------------------
Dallas Cor$ 495,533.00ensate
------------------------------------------------------------------------
Dallas Dallas Roof Repairs $ 229,462.00
------------------------------------------------------------------------
Dallas Cor$ 68,578.00iencies, Bldg 2
------------------------------------------------------------------------
Dallas Asbestos Abatement $ 85,513.00
------------------------------------------------------------------------
Dallas Plan For Improvement $ 200,894.00
------------------------------------------------------------------------
Dallas TCU $ 1,638,711.00structure
------------------------------------------------------------------------
Dallas Relocate Pharmacy Cac$ 30,500.00
------------------------------------------------------------------------
Dallas B.2 Steam and Con$ 335,092.00Upgrade
------------------------------------------------------------------------
Dallas Fuel Oil Tank Replacement Dallas/Bonham $ 114,848.00
------------------------------------------------------------------------
Dallas B.2 IT Upgrade $ 335,093.00
------------------------------------------------------------------------
Dallas B.2 Chi$ 346,598.00e
------------------------------------------------------------------------
Dallas 1.5T MRI SITE PREP $ 253,486.00
------------------------------------------------------------------------
Dallas Repair/Replace Cam$ 343,104.00
------------------------------------------------------------------------
Dallas Fisher House Site Preparation $ 397,407.00
------------------------------------------------------------------------
Dallas GI Recovery Expansion $ 143,303.00
------------------------------------------------------------------------
Dallas Radiology Renovation Phase I $ 3,000.00
------------------------------------------------------------------------
Dallas Human Resources (HR) Modular $ 471,651.00
------------------------------------------------------------------------
Dallas MAS Modular Building $ 471,651.00
------------------------------------------------------------------------
Dallas Mental Health Modular $ 383,124.00
------------------------------------------------------------------------
Dallas ASCO $ 272,181.00
------------------------------------------------------------------------
Dallas Additional NRM Mental Health Modular Bldg $ 448,608.00
------------------------------------------------------------------------
Dallas Cor$ 70,513.00C Deficiencies Phase 1
------------------------------------------------------------------------
Dallas Cor$ 47,131.00ctrical Deficiencies
------------------------------------------------------------------------
Dallas OR Vascular Equipment Site Prep. $ 49,790.00
------------------------------------------------------------------------
Dallas Dallas Roof Repairs, Bldg 2 $ 229,462.00
------------------------------------------------------------------------
Dallas Replace Chi$ 1,710,823.00
------------------------------------------------------------------------
Dallas Install Steam trap Monitoring System $ 46,418.00
------------------------------------------------------------------------
Dallas Power Factor Cor$ 16,300.00
------------------------------------------------------------------------
Dallas Building 1 Exterior Renovation Phase 1 $ 20,381.00
------------------------------------------------------------------------
Dallas Building 2 Exterior Renovation Phase 2 $ 67,734.00
------------------------------------------------------------------------
Dallas FY07 Facility Lump Sum $ 2,834,226.00
------------------------------------------------------------------------
Total $ 13,714,681.00
------------------------------------------------------------------------
FY 2008
----------------------------------------------------------------------------------------------------------------
Planned
Facility Project Title Planned Construction
Design Cost Cost
----------------------------------------------------------------------------------------------------------------
Dallas Install steam trap monitoring system $ 50,000 $ 200,000
----------------------------------------------------------------------------------------------------------------
Dallas East Site Utilities $ 400,000
----------------------------------------------------------------------------------------------------------------
Dallas Building 2 Exterior Renovation Ph.1 $ 45,000 $ 250,000
----------------------------------------------------------------------------------------------------------------
Dallas Lot 27 Site Utilities $ 400,000
----------------------------------------------------------------------------------------------------------------
Dallas Corre$ 0Con$ 500,0002
----------------------------------------------------------------------------------------------------------------
Dallas Replace deteriorated Bldg. 2 $ 60,000 $ 706,000
----------------------------------------------------------------------------------------------------------------
Dallas SCI Pool Lift Upgr$ 356,000
----------------------------------------------------------------------------------------------------------------
Dallas Replace CPVC $ 100,000al $ 800,000
----------------------------------------------------------------------------------------------------------------
Dallas Polytrauma Renovation $ 150,000 $ 1,350,000
----------------------------------------------------------------------------------------------------------------
Dallas Window Repair/Replacement $ 70,000 $ 753,000
----------------------------------------------------------------------------------------------------------------
Dallas Corre$ 65,000efi$ 536,201ldg 2
----------------------------------------------------------------------------------------------------------------
Dallas Corre$ 50,0001 H$ 450,000ncies Ph1
----------------------------------------------------------------------------------------------------------------
Dallas Corre$ 50,0001 E$ 412,500eficiencies
----------------------------------------------------------------------------------------------------------------
Dallas Replace Elevators Bldg. 1 $ 90,000 $ 900,000
----------------------------------------------------------------------------------------------------------------
Dallas Chi$ 60,000placement Upgrade*
----------------------------------------------------------------------------------------------------------------
Dallas Bldg 43 Sprinkler Pipe Installation* $ 40,000
----------------------------------------------------------------------------------------------------------------
Dallas Pharmacy Prescription Disp Area* $ 20,000
----------------------------------------------------------------------------------------------------------------
Dallas Upgrade Dallas Cam$ 90,000rk Phl*
----------------------------------------------------------------------------------------------------------------
Dallas Replace Cam$ 100,000arm System*
----------------------------------------------------------------------------------------------------------------
Dallas Bldg 1 Replace FCU $ 42,000s Ph.1 *
----------------------------------------------------------------------------------------------------------------
Dallas Boiler Plant Repl* $ 200,000
----------------------------------------------------------------------------------------------------------------
10Total $1,282,000 $ 8,013,701
----------------------------------------------------------------------------------------------------------------
* Only planned designed costs for FY 2008
----------------------------------------------------------------------------------------------------------------
FY 2007 and FY 2008 Emergency Supplemental:
------------------------------------------------------------------------
FY 2007 and FY 2008 Emergency Supplemental NRM
-------------------------------------------------------------------------
Station Project Title/Description Total Cost
------------------------------------------------------------------------
Dallas Dallas Roof Repairs $ 816,000.00
------------------------------------------------------------------------
Dallas Cor$ 604,780.00Def
------------------------------------------------------------------------
Dallas Repair/Replace Cam$ 400,000.00
------------------------------------------------------------------------
Dallas Cor$ 520,514.00Def (Ph1)
------------------------------------------------------------------------
Dallas Cor$ 462,500.00rical Deficiencies
------------------------------------------------------------------------
Dallas Replace Chi$ 1,800,000.00
------------------------------------------------------------------------
Dallas Window Repair/Replace $ 753,000.00
------------------------------------------------------------------------
Dallas B.1 Exterior Renovation Ph.2 $ 450,000.00
------------------------------------------------------------------------
Dallas Replace Elevators B.1 $ 900,000.00
------------------------------------------------------------------------
Dallas Polytrauma Renovation $ 1,500,000.00
------------------------------------------------------------------------
Total $ 8,206,794.00
------------------------------------------------------------------------
VA North Texas Capital Budget for FY 2005-2008:
------------------------------------------------------------------------------------------------------------------------------------------------
VA North Texas Capital Budget
------------------------------------------------------------------------
FY 2005 Dallas VERA NRM Allocation $ 5,945,530.00
------------------------------------------------------------------------
FY 2005 Dallas Supplemental Appropriation for NRM $ 2,200,000.00
------------------------------------------------------------------------
Total $ 8,145,530.00
------------------------------------------------------------------------------------------------------------------------------------------------
FY 2006 Dallas VERA NRM Allocation $ 6,450,000.00
------------------------------------------------------------------------------------------------------------------------------------------------
FY 2007 Dallas VERA NRM Allocation $ 5,663,301.00
------------------------------------------------------------------------
FY 2007 Dallas Emergency Supplemental Allocation $ 2,581,985.71
------------------------------------------------------------------------
FY 2007 Dallas Energy Funds $ 700,000.00
------------------------------------------------------------------------
FY 2007 Dallas Mental Health (Modular Building) $ 831,732.00
------------------------------------------------------------------------
Total $ 9,777,018.71
------------------------------------------------------------------------------------------------------------------------------------------------
FY 2008 Dallas VERA NRM Allocation $ 3,137,240.00
------------------------------------------------------------------------
FY 2008 Dallas Supplemental Add-on Allocation $ 2,400,000.00
------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------
VA North Texas Capital Budget--Continued
------------------------------------------------------------------------
FY 2008 Dallas Mental Health Allocation $ 10,000.00
------------------------------------------------------------------------
FY 2007/2008 Dallas Emergency Supplemental $ 5,001,701.00
Allocation
------------------------------------------------------------------------
Total $ 10,548,941.00
------------------------------------------------------------------------
Total Capital Funding $ 34,921,489.71
------------------------------------------------------------------------
The Dallas VAMC is a complexity Level I facility, providing
tertiary care services to over 102,000 unique patients, which makes it
VA's 3rd largest health care system in terms of number of unique
patients treated. The Dallas VAMC is a teaching hospital, providing a
full range of patient care services with state-of-the-art technology as
well as advanced education and research. Through its strategic
partnership with University of Texas Southwestern Medical Center and
Baylor College of Dentistry, Dallas VAMC helped train more than 740
medical residents and eight dental residents in FY 2007. The Dallas
VAMC has affiliation agreements with over 100 agencies and
institutions, providing training to approximately 2,000 students.
Question 4(c): Please provide the Committee with a list including
the names of the director and the senior leadership of the Dallas VA
Medical Center during 2004 and 2005, and if still employed by the VA,
their current titles and responsibilities.
Response: In 2004, Dallas VAMC leadership consisted of the
following:
Medical Center Director: Alan G. Harper, retired March 2005.
Associate Director: William E. Cox, transferred to Clarksburg VAMC
as Director, January 2005. He currently has full delegated line
authority and responsibility for executive level management of the
Clarksburg VAMC and its community outpatient clinics.
Assistant Director: Daniel K. Heers, retired April 2005.
Chief of Staff: Robert Cronin, reassigned to staff physician,
Medical Services in March 2005. He currently treats patients in the
Nephrology Clinic and on the inpatient wards for kidney diseases.
Chief Nurse: Burlean Huff was the Acting Executive Nurse for Dallas
from January 2005 to September 2005 until recruitment of Associate
Director of Nursing. He retired December 2007. This position converted
into the Associate Director of Nursing.
In 2005, Dallas VAMC leadership consisted of the following:
Medical Center Director: Betty Bolin Brown transferred to Employee
Education System in Shreveport, LA on April 2007. She is the Executive
Scholar for the Employee Education System.
Current Medical Center Director: Joseph M. Dalpiaz, effective May
2007 has full delegated line authority and responsibility for executive
level management of the VA North Texas Health Care System (VANTHCS).
Associate Director: Jeff Milligan, Associate Director, effective
September 2005, has the responsibility for the direction, evaluation
and control of all administrative activities in the medical center.
Assistant Director: Daniel K. Heers, retired April 2005. Eric D.
Jacobsen, Assistant Director effective December 2005 his
responsibilities include direction of human resources and information
resources management, logistics, facilities and health care environment
management and health services administration.
Chief of Staff: Robert Cronin, Chief of Staff since January 2005,
and reassigned in March 2005 to Staff Physician, Medical Service where
he is responsible for treating patients in the Nephrology Clinic and on
the inpatient wards for kidney diseases. John Sum-Ping, MD, Acting
Chief of Staff effective 2005 through November 2006. Dr. Sum-Ping is
currently Chief, Anesthesiology and Pain Management Service at VANTHCS
and manages all of the anesthesiology and pain management operations at
VANTHCS. Clark R. Gregg effective November 2006 is the current Chief of
Staff responsible for managing clinical operations.
Associate Director of Patient Care Services: Sandra Y. Griffin,
effective September 2005 is the current Associate Director for Nursing
Service having oversight for the daily clinical and administrative
operations of the Nursing Service.
Question 5: The email sent on March 20, 2008, by a VA employee at
the Temple Texas VAMC, suggested that diagnoses of ``adjustment
disorder'' be given instead of diagnoses of PTSD. Please provide the
Committee with the number of adjustment disorder diagnoses and PTSD
diagnoses by facility since 2001.
Response: The attached spread sheet provides data related to
adjustment disorder diagnoses and PTSD diagnosis by facility,
separately for each year from 2001 through 2008.
Question 6(a): Recently, CBS News reported that a VA team leader in
Texas suggested mental health professionals should diagnose patients
with ``adjustment disorder'' rather than post-traumatic stress disorder
in order to save time and money treating veterans. Secretary Peake has
characterized this email as ``inappropriate.'' An email by Dr. Katz
dated February 13, 2008, entitled ``Not for the CBS News Interview
Request'' has also been characterized as inappropriate. Please provide
to the Committee the training materials provided to VA employees
regarding proper electronic mail behavior.
Response: Email training is provided annually to VA employees and
contractors through the VA cyber security awareness training program.
VA annual cyber security awareness training is mandatory for all VA
employees, contractors, students, and volunteers. This requirement is
specified in law through the Federal Information Security Management
Act (FISMA) of 2002 and the Office of Management and Budget (OMB)
Circular A-130, Appendix III. VA-wide compliance statistics are
reported each year in accordance FISMA and to OMB. VA employees can
access the Cyber Security Awareness Course on the VA Intranet. Attached
is the course script for the VA National Rules of Behavior.
[The Course Script entitled, ``VA National Rules of Behavior,''
Developed by the U.S. Department of Veterans Affairs, Office of
Information and Technology, Cyber Security Service, and the
Presentation entitled, ``VHA Privacy Policy Training, FY 2008,'' will
be retained in the Committee files.]
Question 6(b): Please provide the Committee with the training
materials provided to VA employees regarding what constitutes
appropriate behavior and accountability or individual actions,
especially with regards to electronic mail.
Response: The VA Rules of Behavior document that each VA employee
is required to sign prior to gaining access to VA IT systems outlines
the proper use of VA email. Attached is a copy of the Rules of Behavior
document.
Question 6(c): Please provide the Committee with the number of
disciplinary actions, including the reason for the disciplinary action,
undertaken by the VA since 2002 involving electronic mail or in
response to individual actions that the VA has determined to be
inappropriate.
Response: The Department does not track reasons for disciplinary
actions.
Question 7(a): It has been clearly demonstrated that the Department
of Defense and VA must work together to address issues that face
departments, such as suicide, mental health and substance abuse
treatment. Given such demonstrated need: Please provide the Committee
with a detailed list of specific programs being developed by both
departments to jointly address these issues.
Response: VA and the Department of Defense (DoD) have
collaborations on the following:
VA and DoD produced joint Clinical Practice Guidelines
(CPG) on major depressive disorder (MDD), PTSD, and substance use
disorders since the first MDD CPG in 1996.
VA and DoD collaborated on the creation of the mental
health questions in the post deployment health re-assessment (PDHRA).
The questions on PTSD, for example, are identical to those used as the
standard PTSD screen administered to all veterans and are part of VA's
OEF/OIF automated screening tool.
DoD participated with VA and other entities in developing
a plan for improving PTSD clinical research methodology subsequent to
the recent Institute of Medicine (IOM) report on PTSD treatments.
VA and DoD are collaborating on the activities of the
Defense Center of Excellence (DCoE) for psychological health and TBI. A
VA clinician is the new Deputy Director of the DCoE. VA will
collaborate on future DCoE research.
Question 7(b): Please provide the Committee with a detailed
explanation of the individual or joint efforts by both departments to
collect data on suicides or to do a comprehensive study on suicides. If
there have not been any efforts, please explain the lack of such
efforts.
Response: There is an effort underway across Federal agencies,
including VA, DoD, Substance Abuse and Mental Health Services
Administration, Center for Disease Control, and the National Institutes
of Health to examine suicide prevention efforts across systems. A panel
of experts has been assembled to advise a Blue Ribbon Work Group on
Suicide Prevention in the Veteran Population (Work Group) who will
examine current knowledge as well as gaps in knowledge regarding
suicide prevention. The Work Group is meeting in mid-June with a final
report due 15 days following the meeting. New joint efforts to collect
data on suicides based on the recommendations of the Work Group will be
developed from these deliberations.
Another joint effort between VA and DoD is collaboration on the
development of a joint Web site for suicide prevention. The goal of
building such a site is to provide linkage with multiple resources
appropriate for servicemembers, veterans, and their families.
In addition, the Center of Excellence at Canandaigua and the
Serious Mental Illness Treatment Research and Evaluation Center
(SMITREC) at Ann Arbor are planning a study to use population based
data on suicide and suicide attempts to develop real time tracking
systems of suicidal behavior for veterans in VA.
The Center of Excellence at Canandaigua is planning a study of the
reliability of the suicide behavior template data, which includes data
on suicide attempts and completions reported by the suicide prevention
coordinators. Reliability will be established through the use of
vignettes that present a series of diverse scenarios of veterans in
psychological or emotional distress. A rating scale based on consensus
from a consortium of Center of Excellence experts will be developed in
order to define an appropriate assessment of the veteran depicted in
each scenario. These vignettes will be rated by the suicide prevention
coordinators. This will allow us to examine both the inter-rater
reliability and reliability with the expert consensus response.
The Center of Excellence at Canandaigua, in collaboration with
SMITREC at Ann Arbor, will also conduct a study to establish concurrent
validity of the Suicide Behavior Template using administrative and
clinical data. This collaborative study will include establishing the
predictive validity of the reported measures of suicidal behavior using
repeat attempts or death from suicide.
The Center of Excellence at Canandaigua and the SMITREC at Ann
Arbor, Michigan are planning a study of the data from VA's 24-hour
suicide crisis line to determine if there are new, emergent veteran
populations at risk for suicidal behaviors. Both younger veterans and
veterans in rural or underserved areas will be evaluated as part of
this study as to mental health care needs of both groups that VA should
address.
Question 8(a): VHA testified before the Subcommittee on Health on
January 17, 2008, regarding Mr. Boswell's bill H.R. 4204, the
``Veterans Suicide Study Act.'' The testimony given was very critical
of the bill as far as what the bill would accomplish as written.
Specifically, VHA stated that ``[w]e do not believe the study required
by this bill would generate information that would further our
understanding of how to effectively screen and treat veterans who may
be at risk of suicide. It would merely provide us with the rates for
this cohort of veterans. VA has studied suicide rates for multiple
cohorts of veterans and, through such efforts, has already identified
the major clinical risk factors for suicide''. VHA also stated that
this bill, as drafted, would not afford VA the flexibility needed to
develop a thorough and useful study. Is this still the position of the
VA?
Response: We do not believe the study required by this bill would
generate information that would further our understanding of how to
effectively screen and treat veterans who may be at risk of suicide. It
would merely provide us with the rates for this cohort of veterans. VA
has studied suicide rates for multiple cohorts of veterans and has
already identified the major clinical risk factors for suicide. In
fact, we recently completed such a study for OEF/OIF veterans. Using
the data generated from those studies, we have developed protocols and
processes to mitigate those risk-factors. For these reasons, we do not
support section 103.
Further, certain requirements mandated by the bill make its
implementation not feasible. As now drafted, it would not afford VA the
flexibility needed to develop a thorough and useful study. To design
and carry out a study that is best designed to provide usable
information to address the issue of veteran suicide rates, we believe
the Secretary should determine the organization(s) with which the
Department should coordinate the study. For instance, the Center for
Disease Control (CDC) studies suicide rates among the general
population, while VA's role has been to validate the information
compiled by CDC.
Additionally the 180-day timeframe is not realistic, as there is
currently a 2-year time lag in the information released by CDC on
suicide rates. We estimate the cost of this bill to be $1,580,006 in FY
2008 and $2,078,667 over a 10-year period.
Question 8(b): Is VA developing a large scale study on the OEF/OIF
veteran population to track suicides?
Response: VHA's Environmental Epidemiology Service is conducting a
large scale study of suicides among OEF/OIF veterans. Study results are
expected within the next 6 months.
Question 8(c): Does VA believe this needs to be done? If not, why
not?
Response: VA believes this study should be conducted.
Question 9(a): In a July 2005 briefing by the Veterans Health
Administration on ``Modeling and Strategic Planning for Mental Health
and Substance Abuse Services'' slide 14, entitled ``Negative Gaps,''
states that: VISNs will not address gaps where the FY 2013 or 2013
forecast demand is less than the FY 2003 actual demand with one
exception
--In those markets in which enrollment is projected to decline
for the FY 2003 actual demand by more than 10% in FY 2013 and/or by
more than 20% in FY 2023, the VISN should develop plans to reduce
services in line with the projected declines in demand.
Does this accurately reflect the current policy of the VHA? If not,
when was this policy changed and for what reasons?
Response: Since the 2005 presentation, our planning process for
mental health and substance abuse services has significantly evolved
with the creation of the VHA Comprehensive Mental Health Strategic Plan
(MHSP), which was signed as policy by the Secretary in November 2005.
The plan calls for expansion and enhancement of mental health services
to fill gaps in mental health care, and to use the best practices in
care that will offer the greatest likelihood of decreasing mental
health symptoms and improving overall functioning and well-being of
veterans with mental health problems. There is no current policy that
would fit the information as described in this query.
Question 9(b): What is the current strategic plan of the VHA
regarding mental health and substance abuse, especially with regards to
planning for future infrastructure and employment needs? Has this
planning changed since 2005?
Response: The MHSP of 2005 is the current strategic plan of VA
regarding mental health and substance abuse services. It provides
guidance for infrastructure and employment needs, along with many other
elements of enhanced mental health care. The MHSP continues to be
implemented aggressively, with collaboration across many offices in VHA
to guide that process, including the Office of Mental Health Services,
working within Patient Care Services (PCS) and involving many other
offices within PCS; the Office of the Assistant Deputy Under Secretary
for Health for Policy and Planning; and the Office of the Deputy Under
Secretary for Health for Operations and Management.
Additional guidance for implementation of the MHSP is under
development. A VA handbook on Uniform Mental Health Services outlines
services available to all veterans seeking or identified as needing
mental health care. This handbook is an outgrowth of our extensive
experience in implementing enhanced mental health services and reflects
the MHSP. The handbook delineates the essential components of the
mental health program that are to be implemented nationally, to ensure
that all enrolled veterans, wherever they obtain care, have access to
needed mental health services. It also specifies those services that
must be accessible through each VAMC and each CBOC, and delineates that
services must be made available through collaborative fee basis and
contract relationships for veterans who are not close enough to receive
care directly from VA facilities. By establishing the requirements of
what services must be available to each veteran, no matter where in VHA
they receive care VHA is ensuring a patient-centric uniform mental
health services package to meet the care needs for each veteran.
Question 10(a): The recent RAND report, ``Invisible Wounds of
War,'' defined ``minimally adequate exposure to psychotherapy'' (as
part of the definition for minimally adequate care) in the following
manner:
Minimally adequate exposure to psychotherapy. was defined as
having had at least 8 visits with a ``mental health professional such
as a psychiatrist, psychologist or counselor'' in the past 12 months,
with visits averaging at least 30 minutes. Criteria for minimally
adequate courses of treatment were adapted from the National
Comorbidity Study Replication (Wang et al., 2005). Does the VA agree
with this definition? Why or why not?
Response: This definition is not a sufficient representation of
adequate treatment and is limited in a number of significant respects,
as follows:
This definition is very broad and could include a wide
variety of psychotherapies that have not been empirically established
or shown to be effective, such as supportive counseling or other talk
therapies that do not focus on promoting changes in thinking, behavior,
or emotional functioning in a sustained way, as other psychotherapies
have been demonstrated to do. Significantly, the above definition was
initially developed by Wang et al. (2005) for measuring patterns of
services, not for evaluating or establishing standards of care.
Moreover, the references cited for the authors' definition were to
practice guidelines that specifically recommend established evidence-
based psychotherapies, such as cognitive-behavioral therapy (CBT).
In addition to including psychotherapeutic interventions
that have not been scientifically established, the definition could
also include case management, counseling, and other similar
interventions that are not standard treatments for the core symptoms of
PTSD, depression, and other mental health conditions.
The definition of what may be considered adequate
psychotherapeutic treatment is inconsistent with widely accepted
practice guidelines for psychotherapy. This includes guidelines
established by the American Psychiatric Association and the Agency for
Health Care Policy and Research, as well as the VA/ DoD Clinical
Practice Guidelines for PTSD and depression. These guidelines recommend
the delivery of evidence-based psychotherapies, such as CBT for
depressive and anxiety disorders, and cognitive processing therapy
(CPT) and prolonged exposure (PE) therapy for PTSD. Both CPT and PE are
highly recommended in the VA/DoD Clinical Practice Guidelines,
indicating that the intervention is always indicated and acceptable.
This was affirmed by a recent report on evidence-based treatments for
PTSD by the Institute of Medicine. These practice guidelines also
generally recommend 12-16 sessions of 50-90 minutes each, as opposed to
the standard of eight 30-minute sessions included in the definition in
the RAND report.
Psychotherapies identified as ``evidence-based,'' including CBT,
CPT, and PE, are psychotherapies that have been shown in randomized
clinical trials to be more effective than other forms of psychotherapy,
such as supportive counseling. Evidence-based psychotherapies are
structured with established protocols and have manuals to help guide
the treatment process. They also have the benefit of being time-
limited. Moreover, evidence-based psychotherapies typically provide
long-term benefits and have thus been found to be cost-effective.
Data on mental health care delivery in VA indicate that
psychotherapy, particularly individual psychotherapy, is provided at
levels of frequency and intensity well below those recommended in
practice guidelines. Evidence-based psychotherapy appears to be
especially under-used. Unfortunately, psychotherapy codes in medical
records do not indicate the specific type of psychotherapy provided, so
precise data on the delivery of evidence-based psychotherapies in VA is
unknown. However, a recent survey of VA program leaders found that lack
of implementation of evidence-based psychological treatments was due,
in large part, to limited knowledge and skills and lack of
administrative support (Willenbring et al., 2004).
VA has recently developed several national initiatives to train VA
mental health providers in the delivery of a number of evidence-based
psychotherapies for a variety of mental health conditions, including
CPT and PE for PTSD, CBT for depression and anxiety, and social skills
training for serious mental illnesses. CPT was the first funded
initiative, initially funded in early FY 2007. In May 2008, VA began
the training rollout for all mental health professionals.
Question 10(b): On average, over the last 5 years, how many visits
with a psychiatrist, psychologist or counselor could a veteran expect
over the course of one year, and what is the average length of each
visit?
Response: The following table provides summary data of veterans who
received mental health services in an outpatient mental health program
from FY 2003 through FY 2007:
----------------------------------------------------------------------------------------------------------------
Veterans with a MH Dx* seen as an Outpatient by Fiscal Year
-----------------------------------------------------------------------------------------------------------------
Avg Number of
Total Outpatient Outpatient
Veterans with a MH Dx Encounters with MH Encounters with MH
FY Seen by MH Provider Provider for Provider for
Veterans with MH Dx Veterans Seen by
MH Provider
----------------------------------------------------------------------------------------------------------------
FY03 708,882 7,345,328 10.4
----------------------------------------------------------------------------------------------------------------
FY04 771,235 7,514,644 9.7
----------------------------------------------------------------------------------------------------------------
FY05 831,890 7,914,211 9.5
----------------------------------------------------------------------------------------------------------------
FY06 878,246 8,489,263 9.7
----------------------------------------------------------------------------------------------------------------
FY07 944,969 9,387,070 9.9
----------------------------------------------------------------------------------------------------------------
*Outpatient Diagnoses 290.x-319.x excluding Tobacco Use 305.1xData provided by VSSC on June 23, 2008 using VA Outpatient Workload and Enrollment Data. Fee data not included.
Veterans Only.
----------------------------------------------------------------------------------------------------------------
The duration and intensity of treatment varies depending on the
acuity level of the veteran. Typically in the early stages of recovery
veterans are seen more frequently for both medication management and
psychotherapy. As the veteran progresses and becomes more stable, the
frequency and duration of treatment decreases. The duration of
medication management sessions range from 15--60 minutes. Most
psychotherapy sessions are 60 minutes but they also can be 30 minute
brief treatment sessions, or they may be up to 90 minutes for some
sessions of PE therapy for PTSD. Group therapy sessions tend to be 60
minutes.
__________
ATTACHMENT TO QUESTION 5
VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01
(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Uniques with Uniques with PTSD Dx Uniques with PTSD Dx Uniques with Adj Uniques with Adj Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder Disorders Dx Disorders Dx Only (w/o and Adj Disorder Dx
Disorder Dx) ------------------------ PTSD Dx) -----------------------
----------------- N % of Total ------------------------ ------------------------
N % of Total N % of Total N % of Total N % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
VHA 257,332 193,954 75.4% 180,006 70.0% 77,326 30.0% 63,378 24.6% 13,948 5.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (402) Togus, ME 2,494 2,132 85.5% 1,978 79.3% 516 20.7% 362 14.5% 154 6.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (405) White River Junction, VT 1,426 1,114 78.1% 1,055 74.0% 371 26.0% 312 21.9% 59 4.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (518) Bedford, MA 1,155 917 79.4% 829 71.8% 326 28.2% 238 20.6% 88 7.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (523) VA Boston HCS, MA 6,655 4,435 66.6% 3,957 59.5% 2,698 40.5% 2,220 33.4% 478 7.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (608) Manchester, NH 1,206 1,013 84.0% 964 79.9% 242 20.1% 193 16.0% 49 4.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (631) Northampton, MA 1,442 1,236 85.7% 1,183 82.0% 259 18.0% 206 14.3% 53 3.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (650) Providence, RI 1,952 1,729 88.6% 1,687 86.4% 265 13.6% 223 11.4% 42 2.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V01) (689) VA Connecticut HCS, CT 2,444 2,062 84.4% 1,983 81.1% 461 18.9% 382 15.6% 79 3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Albany, NY 2,535 1,951 77.0% 1,730 68.2% 805 31.8% 584 23.0% 221 8.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Bath, NY 852 648 76.1% 595 69.8% 257 30.2% 204 23.9% 53 6.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Buffalo, NY 2,396 1,648 68.8% 1,532 63.9% 864 36.1% 748 31.2% 116 4.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Canandaigua, NY 1,227 995 81.1% 946 77.1% 281 22.9% 232 18.9% 49 4.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V02) (528) Syracuse, NY 1,698 1,209 71.2% 1,112 65.5% 586 34.5% 489 28.8% 97 5.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (526) Bronx, NY 1,090 850 78.0% 812 74.5% 278 25.5% 240 22.0% 38 3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (561) New Jersey HCS, NJ 3,344 2,848 85.2% 2,739 81.9% 605 18.1% 496 14.8% 109 3.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (620) VA Hudson Valley HCS, NY 1,536 1,369 89.1% 1,213 79.0% 323 21.0% 167 10.9% 156 10.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (630) New York Harbor HCS, NY 4,879 3,327 68.2% 2,959 60.6% 1,920 39.4% 1,552 31.8% 368 7.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V03) (632) Northport, NY 1,794 1,375 76.6% 1,281 71.4% 513 28.6% 419 23.4% 94 5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (460) Wilmington, DE 988 717 72.6% 664 67.2% 324 32.8% 271 27.4% 53 5.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (503) Altoona, PA 503 329 65.4% 313 62.2% 190 37.8% 174 34.6% 16 3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (529) Butler, PA 407 249 61.2% 236 58.0% 171 42.0% 158 38.8% 13 3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (540) Clarksburg, WV 1,652 1,452 87.9% 1,342 81.2% 310 18.8% 200 12.1% 110 6.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (542) Coatesville, PA 2,735 1,655 60.5% 1,444 52.8% 1,291 47.2% 1,080 39.5% 211 7.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (562) Erie, PA 513 354 69.0% 324 63.2% 189 36.8% 159 31.0% 30 5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (595) Lebanon, PA 1,540 1,000 64.9% 891 57.9% 649 42.1% 540 35.1% 109 7.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (642) Philadelphia, PA 2,996 2,711 90.5% 2,604 86.9% 392 13.1% 285 9.5% 107 3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (646) Pittsburgh, PA 2,337 1,985 84.9% 1,863 79.7% 474 20.3% 352 15.1% 122 5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V04) (693) Wilkes-Barre, PA 1,628 1,120 68.8% 1,063 65.3% 565 34.7% 508 31.2% 57 3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V05) (512) Baltimore HCS, MD 2,925 1,651 56.4% 1,436 49.1% 1,489 50.9% 1,274 43.6% 215 7.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V05) (613) Martinsburg, WV 1,972 1,476 74.8% 1,320 66.9% 652 33.1% 496 25.2% 156 7.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V05) (688) Washington, DC 2,226 1,905 85.6% 1,765 79.3% 461 20.7% 321 14.4% 140 6.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (517) Beckley, WV 961 765 79.6% 733 76.3% 228 23.7% 196 20.4% 32 3.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (558) Durham, NC 2,411 2,105 87.3% 2,027 84.1% 384 15.9% 306 12.7% 78 3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (565) Fayetteville, NC 1,246 1,041 83.5% 1,011 81.1% 235 18.9% 205 16.5% 30 2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (590) Hampton, VA 1,703 1,500 88.1% 1,441 84.6% 262 15.4% 203 11.9% 59 3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (637) Asheville, NC 1,680 1,482 88.2% 1,397 83.2% 283 16.8% 198 11.8% 85 5.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (652) Richmond, VA 1,321 948 71.8% 890 67.4% 431 32.6% 373 28.2% 58 4.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (658) Salem, VA 1,521 1,282 84.3% 1,210 79.6% 311 20.4% 239 15.7% 72 4.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01--Continued
(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Uniques with Uniques with PTSD Dx Uniques with PTSD Dx Uniques with Adj Uniques with Adj Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder Disorders Dx Disorders Dx Only (w/o and Adj Disorder Dx
Disorder Dx) ------------------------ PTSD Dx) -----------------------
----------------- N % of Total ------------------------ ------------------------
N % of Total N % of Total N % of Total N % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V06) (659) Salisbury, NC 2,696 2,090 77.5% 1,964 72.8% 732 27.2% 606 22.5% 126 4.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (508) Decatur, GA 2,895 2,700 93.3% 2,616 90.4% 279 9.6% 195 6.7% 84 2.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (509) Augusta, GA 1,856 1,606 86.5% 1,562 84.2% 294 15.8% 250 13.5% 44 2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (521) Birmingham, AL 2,310 2,001 86.6% 1,864 80.7% 446 19.3% 309 13.4% 137 5.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (534) Charleston, SC 1,403 1,166 83.1% 1,131 80.6% 272 19.4% 237 16.9% 35 2.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (544) Columbia, SC 3,707 2,611 70.4% 2,302 62.1% 1,405 37.9% 1,096 29.6% 309 8.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (557) Dublin, GA 1,456 1,276 87.6% 1,163 79.9% 293 20.1% 180 12.4% 113 7.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (619) Montgomery-West, AL 2,046 1,773 86.7% 1,695 82.8% 351 17.2% 273 13.3% 78 3.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V07) (679) Tuscaloosa, AL 1,814 1,718 94.7% 1,676 92.4% 138 7.6% 96 5.3% 42 2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (516) Bay Pines, FL 4,285 2,950 68.8% 2,775 64.8% 1,510 35.2% 1,335 31.2% 175 4.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (546) Miami, FL 3,024 2,051 67.8% 1,937 64.1% 1,087 35.9% 973 32.2% 114 3.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (548) West Palm Beach, FL 2,191 1,652 75.4% 1,558 71.1% 633 28.9% 539 24.6% 94 4.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (573) Gainesville, FL 4,897 3,470 70.9% 3,181 65.0% 1,716 35.0% 1,427 29.1% 289 5.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (672) San Juan, PR 1,969 976 49.6% 929 47.2% 1,040 52.8% 993 50.4% 47 2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V08) (673) Tampa, FL 6,006 3,791 63.1% 3,398 56.6% 2,608 43.4% 2,215 36.9% 393 6.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (581) Huntington, WV 1,806 1,623 89.9% 1,594 88.3% 212 11.7% 183 10.1% 29 1.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (596) Lexington, KY 1,788 1,482 82.9% 1,382 77.3% 406 22.7% 306 17.1% 100 5.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (603) Louisville, KY 1,857 1,017 54.8% 866 46.6% 991 53.4% 840 45.2% 151 8.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (614) Memphis, TN 1,588 1,073 67.6% 935 58.9% 653 41.1% 515 32.4% 138 8.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (621) Mountain Home, TN 2,154 1,658 77.0% 1,580 73.4% 574 26.6% 496 23.0% 78 3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V09) (626) Middle Tennessee HCS, TN 3,466 2,656 76.6% 2,502 72.2% 964 27.8% 810 23.4% 154 4.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (538) Chillicothe, OH 1,612 1,173 72.8% 1,031 64.0% 581 36.0% 439 27.2% 142 8.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (539) Cincinnati, OH 2,006 1,586 79.1% 1,422 70.9% 584 29.1% 420 20.9% 164 8.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (541) Cleveland--Wade Park, OH 4,347 2,752 63.3% 2,452 56.4% 1,895 43.6% 1,595 36.7% 300 6.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (552) Dayton, OH 1,776 1,206 67.9% 1,087 61.2% 689 38.8% 570 32.1% 119 6.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V10) (757) Columbus, OH 937 601 64.1% 565 60.3% 372 39.7% 336 35.9% 36 3.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (506) Ann Arbor, MI 885 689 77.9% 659 74.5% 226 25.5% 196 22.1% 30 3.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (515) Battle Creek, MI 1,983 1,506 75.9% 1,371 69.1% 612 30.9% 477 24.1% 135 6.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (550) Danville, IL 2,108 960 45.5% 837 39.7% 1,271 60.3% 1,148 54.5% 123 5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (553) Detroit, MI 1,225 738 60.2% 661 54.0% 564 46.0% 487 39.8% 77 6.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (583) Indianapolis, IN 1,247 751 60.2% 667 53.5% 580 46.5% 496 39.8% 84 6.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (610) Northern Indiana HCS, IN 981 675 68.8% 651 66.4% 330 33.6% 306 31.2% 24 2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V11) (655) Saginaw, MI 723 526 72.8% 491 67.9% 232 32.1% 197 27.2% 35 4.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (537) Jesse Brown VAMC (Chicago), IL 2,938 1,750 59.6% 1,589 54.1% 1,349 45.9% 1,188 40.4% 161 5.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (556) North Chicago, IL 1,300 872 67.1% 759 58.4% 541 41.6% 428 32.9% 113 8.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (578) Hines, IL 1,219 858 70.4% 807 66.2% 412 33.8% 361 29.6% 51 4.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (585) Iron Mountain, MI 388 350 90.2% 344 88.7% 44 11.3% 38 9.8% 6 1.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (607) Madison, VVI 863 702 81.3% 668 77.4% 195 22.6% 161 18.7% 34 3.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (676) Tomah, VVI 917 815 88.9% 786 85.7% 131 14.3% 102 11.1% 29 3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01--Continued
(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Uniques with Uniques with PTSD Dx Uniques with PTSD Dx Uniques with Adj Uniques with Adj Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder Disorders Dx Disorders Dx Only (w/o and Adj Disorder Dx
Disorder Dx) ------------------------ PTSD Dx) -----------------------
----------------- N % of Total ------------------------ ------------------------
N % of Total N % of Total N % of Total N % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V12) (695) Milwaukee, WI 1,756 1,267 72.2% 1,121 63.8% 635 36.2% 489 27.8% 146 8.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Columbia, MO 1,025 805 78.5% 755 73.7% 270 26.3% 220 21.5% 50 4.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Eastern KS HCS, KS 2,510 1,795 71.5% 1,473 58.7% 1,037 41.3% 715 28.5% 322 12.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Kansas City, MO 1,804 1,161 64.4% 1,026 56.9% 778 43.1% 643 35.6% 135 7.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (589) Wichita, KS 880 752 85.5% 730 83.0% 150 17.0% 128 14.5% 22 2.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (657) Marion, IL 1,254 1,075 85.7% 1,047 83.5% 207 16.5% 179 14.3% 28 2.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (657) Poplar Bluff, MO 1,074 858 79.9% 825 76.8% 249 23.2% 216 20.1% 33 3.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V15) (657) SI. Louis, MO 2,074 1,374 66.2% 1,307 63.0% 767 37.0% 700 33.8% 67 3.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (502) Alexandria, LA 775 628 81.0% 592 76.4% 183 23.6% 147 19.0% 36 4.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (520) Biloxi, MS 3,776 2,812 74.5% 2,599 68.8% 1,177 31.2% 964 25.5% 213 5.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (564) Fayetteville, AR 1,693 1,474 87.1% 1,384 81.7% 309 18.3% 219 12.9% 90 5.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (580) Houston, TX 2,524 2,187 86.6% 2,114 83.8% 410 16.2% 337 13.4% 73 2.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (586) Jackson, MS 1,120 810 72.3% 786 70.2% 334 29.8% 310 27.7% 24 2.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (598) Little Rock, AR 3,549 2,279 64.2% 2,032 57.3% 1,517 42.7% 1,270 35.8% 247 7.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (623) Muskogee, OK 1,784 1,547 86.7% 1,515 84.9% 269 15.1% 237 13.3% 32 1.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (629) New Orleans, LA 2,961 2,774 93.7% 2,743 92.6% 218 7.4% 187 6.3% 31 1.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (635) Oklahoma City, OK 2,619 2,055 78.5% 1,904 72.7% 715 27.3% 564 21.5% 151 5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V16) (667) Shreveport, LA 2,205 1,294 58.7% 1,108 50.2% 1,097 49.8% 911 41.3% 186 8.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V17) (549) Dallas, TX 4,653 3,197 68.7% 2,953 63.5% 1,700 36.5% 1,456 31.3% 244 5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V17) (671) San Antonio, TX 4,448 3,612 81.2% 3,383 76.1% 1,065 23.9% 836 18.8% 229 5.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V17) (674) Temple, TX 2,885 2,433 84.3% 2,356 81.7% 529 18.3% 452 15.7% 77 2.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (501) Albuquerque, NM 4,263 3,169 74.3% 2,909 68.2% 1,354 31.8% 1,094 25.7% 260 6.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (504) Amarillo, TX 832 707 85.0% 696 83.7% 136 16.3% 125 15.0% 11 1.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (519) Big Spring, TX 527 486 92.2% 479 90.9% 48 9.1% 41 7.8% 7 1.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (644) Phoenix, AZ 3,789 2,552 67.4% 2,302 60.8% 1,487 39.2% 1,237 32.6% 250 6.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (649) Northern Arizona HCS 1,220 716 58.7% 601 49.3% 619 50.7% 504 41.3% 115 9.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (678) Tucson, AZ 1,825 1,282 70.2% 1,233 67.6% 592 32.4% 543 29.8% 49 2.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V18) (756) EI Paso, TX 1,179 953 80.8% 898 76.2% 281 23.8% 226 19.2% 55 4.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (436) Fort Harrison, MT 1,085 921 84.9% 895 82.5% 190 17.5% 164 15.1% 26 2.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (442) Cheyenne, WY 688 561 81.5% 546 79.4% 142 20.6% 127 18.5% 15 2.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (554) Denver, CO 3,536 3,076 87.0% 2,919 82.6% 617 17.4% 460 13.0% 157 4.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (575) Grand Junction, CO 773 421 54.5% 347 44.9% 426 55.1% 352 45.5% 74 9.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (660) Salt Lake City, UT 1,621 1,424 87.8% 1,365 84.2% 256 15.8% 197 12.2% 59 3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V19) (666) Sheridan, WY 543 447 82.3% 414 76.2% 129 23.8% 96 17.7% 33 6.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (463) Anchorage, AK 684 538 78.7% 522 76.3% 162 23.7% 146 21.3% 16 2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (531) Boise, ID 1,065 1,027 96.4% 1,022 96.0% 43 4.0% 38 3.6% 5 0.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (648) Portland, OR 4,225 3,604 85.3% 3,357 79.5% 868 20.5% 621 14.7% 247 5.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (653) Roseburg, OR 1,851 1,592 86.0% 1,525 82.4% 326 17.6% 259 14.0% 67 3.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (663) VA Puget Sound, WA 6,081 5,465 89.9% 5,221 85.9% 860 14.1% 616 10.1% 244 4.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01--Continued
(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Uniques with Uniques with PTSD Dx Uniques with PTSD Dx Uniques with Adj Uniques with Adj Uniques with PTSD Dx
-------------------------------------------------------- PTSD and/or Adj ------------------------ Only (w/o Adj Disorder Disorders Dx Disorders Dx Only (w/o and Adj Disorder Dx
Disorder Dx) ------------------------ PTSD Dx) -----------------------
----------------- N % of Total ------------------------ ------------------------
N % of Total N % of Total N % of Total N % of Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (668) Spokane, WA 1,281 1,132 88.4% 1,099 85.8% 182 14.2% 149 11.6% 33 2.6%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (687) Walla Walla, WA 903 698 77.3% 631 69.9% 272 30.1% 205 22.7% 67 7.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V20) (692) White City, OR 812 749 92.2% 730 89.9% 82 10.1% 63 7.8% 19 2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (358) Manila, PI 192 189 98.4% 187 97.4% 5 2.6% 3 1.6% 2 1.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (459) Honolulu, HI 1,515 1,331 87.9% 1,221 80.6% 294 19.4% 184 12.1% 110 7.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (570) Fresno, CA 1,366 894 65.4% 812 59.4% 554 40.6% 472 34.6% 82 6.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (612) N. California, CA 4,272 3,706 86.8% 3,481 81.5% 791 18.5% 566 13.2% 225 5.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (640) Palo Alto, CA 3,247 2,580 79.5% 2,319 71.4% 928 28.6% 667 20.5% 261 8.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (654) Reno, NV 1,114 728 65.4% 670 60.1% 444 39.9% 386 34.6% 58 5.2%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V21) (662) San Francisco, CA 2,592 2,014 77.7% 1,874 72.3% 718 27.7% 578 22.3% 140 5.4%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (593) Las Vegas, NV 2,206 1,504 68.2% 1,350 61.2% 856 38.8% 702 31.8% 154 7.0%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (600) Long Beach, CA 1,599 857 53.6% 762 47.7% 837 52.3% 742 46.4% 95 5.9%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (605) Lorna Linda, CA 2,146 1,912 89.1% 1,837 85.6% 309 14.4% 234 10.9% 75 3.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (664) San Diego, CA 2,050 1,846 90.0% 1,815 88.5% 235 11.5% 204 10.0% 31 1.5%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V22) (691) West Los Angeles, CA 5,877 3,940 67.0% 3,407 58.0% 2,470 42.0% 1,937 33.0% 533 9.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (437) Fargo, ND 434 341 78.6% 332 76.5% 102 23.5% 93 21.4% 9 2.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (438) Sioux Falls, SD 632 462 73.1% 445 70.4% 187 29.6% 170 26.9% 17 2.7%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (568) Black Hills HCS, SD 1,007 718 71.3% 650 64.5% 357 35.5% 289 28.7% 68 6.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (618) Minneapolis, MN 2,415 1,806 74.8% 1,727 71.5% 688 28.5% 609 25.2% 79 3.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (636) Central Iowa, IA 1,026 551 53.7% 468 45.6% 558 54.4% 475 46.3% 83 8.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (636) Iowa City, IA 1,057 662 62.6% 629 59.5% 428 40.5% 395 37.4% 33 3.1%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (636) Nebraska-W Iowa, NE 1,322 979 74.1% 949 71.8% 373 28.2% 343 25.9% 30 2.3%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
(V23) (656) St. Cloud, MN 1,616 1,339 82.9% 1,213 75.1% 403 24.9% 277 17.1% 126 7.8%
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------
ATTACHMENT TO QUESTION 6(B)
September 18, 2007
VA Handbook 6500
Appendix G
Department of Veterans Affairs (VA) National Rules of Behavior
1. Background
a.
Section 5723(b)(12) of title 38, United States Code, requires the Assistant
Secretary for Information and Technology to establish ``VA National Rules
of Behavior for appropriate use and protection of the information which is
used to support Department's missions and functions.'' The Office of
Management and Budget (OMB) Circular A-130, Appendix III, paragraph
3(a(2)(a) requires that all Federal agencies promulgate rules of behavior
that ``clearly delineate responsibilities and expected behavior of all
individuals with access'' to the agencies' information and information
systems, as well as state clearly the ``consequences of behavior not
consistent'' with the rules of behavior. The National Rules of Behavior
that begin on page G-3, are required to be used throughout the VA.
b.
Congress and OMB require the promulgation of national rules of behavior for
two reasons. First, Congress and OMB recognize that knowledgeable users are
the foundation of a successful security program. Users must understand that
taking personal responsibility for the security of their computer and the
VA data that it contains or that may be accessed through it, as well as the
security and protection of VA information in any form (e.g. digital,
paper), are essential aspects of their job. Second, individuals must be
held accountable for their use of VA information and information systems.
c.
VA must achieve the Gold Standard in data security which requires that VA
information and information system users protect VA information and
information systems, especially the personal data of veterans, their family
members, and employees. Users must maintain a heightened and constant
awareness of their responsibilities regarding the protection of VA
information. The Golden Rule with respect to this aspect of an employee's
job is to treat the personal information of others the same as they would
their own.
d.
Since written guidance cannot cover every contingency, personnel are asked
to go beyond the stated rules, using ``due diligence'' and highest ethical
standards to guide their actions. Personnel must understand that these
rules are based on Federal laws, regulations, and VA Directives.
2. Coverage
a.
The attached VA National Rules of Behavior must be signed annually by all
VA employees who are provided access to VA information or VA information
systems. The term VA employees includes all individuals who are employees
under title 5 or title 38, United States Code, as well as individuals whom
the Department considers employees such as volunteers, without compensation
employees, and students and other trainees. Directions for signing the
rules of behavior by other individuals who have access to VA information or
information systems, such as contractor employees, will be addressed in
subsequent policy. VA employees must initial and date each page of the copy
of the VA National Rules of Behavior; they must also provide the
information requested on the last page, sign and date it.
b.
The VA National Rules of Behavior address notice and consent issues
identified by the Department of Justice and other sources. It also serves
to clarify the roles of management and system administrators, and serves to
provide notice of what is considered acceptable use of all VA information
and information systems, VA sensitive information, and behavior of VA
users.
c.
The VA National Rules of Behavior use the phrase ``VA sensitive
information''. This phrase is defined in VA Directive 6500, paragraph 5q.
This definition covers all information as defined in 38 USC 5727(19), and
in 38 USC 5727(23). The phrase ``VA sensitive information'' as used in the
attached VA National Rules of Behavior means:
L All Department data, on any storage media or in any form or format,
which requires protection due to the risk of harm that could result from
inadvertent or deliberate disclosure, alteration, or destruction of the
information. The term includes information whose improper use or disclosure
could adversely affect the ability of an agency to accomplish its mission,
proprietary information, records about individuals requiring protection
under various confidentiality provisions such as the Privacy Act and the
HIPAA Privacy Rule, and information that can be withheld under the Freedom
of Information Act. Examples of VA sensitive information include the
following: individually identifiable medical, benefits, and personnel
information, financial, budgetary, research, quality assurance,
confidential commercial, critical infrastructure, investigatory, and law
enforcement information, information that is confidential and privileged in
litigation such as information protected by the deliberative process
privilege, attorney work-product privilege, and the attorney-client
privilege, and other information which, if released, could result in
violation of law or harm or unfairness to any individual or group, or could
adversely affect the national interest or the conduct of Federal programs.
d.
The phrase ``VA sensitive information'' includes information entrusted to
the Department.
3. Rules of Behavior
a.
Immediately following this section is the VA approved National Rules of
Behavior that all employees (as discussed in paragraph 2a of Appendix G)
who are provided access to VA information and VA information systems are
required to sign in order to obtain access to VA information and
information systems.
__________
Department of Veterans Affairs (VA) National Rules of Behavior
I understand, accept, and agree to the following terms and
conditions that apply to my access to, and use of, information,
including VA sensitive information, or information systems of the U.S.
Department of Veterans Affairs.
1. GENERAL RULES OF BEHAVIOR
a.
I understand that when I use any government information system, I have NO
expectation of Privacy in VA records that I create or in my activities
while accessing or using such information system.
b.
I understand that authorized VA personnel may review my conduct or actions
concerning VA information and information systems, and take appropriate
action. Authorized VA personnel include my supervisory chain of command as
well as VA system administrators and Information Security Officers (ISOs).
Appropriate action may include monitoring, recording, copying, inspecting,
restricting access, blocking, tracking, and disclosing information to
authorized Office of Inspector General (OIG), VA, and law enforcement
personnel.
c.
I understand that the following actions are prohibited: unauthorized
access, unauthorized uploading, unauthorized downloading, unauthorized
changing, unauthorized circumventing, or unauthorized deleting information
on VA systems, modifying VA systems, unauthorized denying or granting
access to VA systems, using VA resources for unauthorized use on VA
systems, or otherwise misusing VA systems or resources. I also understand
that attempting to engage in any of these unauthorized actions is also
prohibited.
d.
I understand that such unauthorized attempts or acts may result in
disciplinary or other adverse action, as well as criminal, civil, and/or
administrative penalties. Depending on the severity of the violation,
disciplinary or adverse action consequences may include: suspension of
access privileges, reprimand, suspension from work, demotion, or removal.
Theft, conversion, or unauthorized disposal or destruction of Federal
property or information may also result in criminal sanctions.
e.
I understand that I have a responsibility to report suspected or identified
information security incidents (security and privacy) to my Operating
Unit's Information Security Officer (ISO), Privacy Officer (PO), and my
supervisor as appropriate.
f.
I understand that I have a duty to report information about actual or
possible criminal violations involving VA programs, operations, facilities,
contracts or information systems to my supervisor, any management official
or directly to the OIG, including reporting to the OIG Hotline. I also
understand that I have a duty to immediately report to the OIG any possible
criminal matters involving felonies, including crimes involving information
systems.
g.
I understand that the VA National Rules of Behavior do not and should not
be relied upon to create any other right or benefit, substantive or
procedural, enforceable by law, by a party to litigation with the United
States Government.
h.
I understand that the VA National Rules of Behavior do not supersede any
local policies that provide higher levels of protection to VA's information
or information systems. The VA National Rules of Behavior provide the
minimal rules with which individual users must comply.
i.
I understand that if I refuse to sign this VA National Rules of Behavior as
required by VA policy, I will be denied access to VA information and
information systems. Any refusal to sign the VA National Rules of Behavior
may have an adverse impact on my employment with the Department.
2. SPECIFIC RULES OF BEHAVIOR
a.
I will follow established procedures for requesting access to any VA
computer system and for notification to the VA supervisor and the ISO when
the access is no longer needed.
b.
I will follow established VA information security and privacy policies and
procedures.
c.
I will use only devices, systems, software, and data which I am authorized
to use, including complying with any software licensing or copyright
restrictions. This includes downloads of software offered as free trials,
shareware or public domain.
d.
I will only use my access for authorized and official duties, and to only
access data that is needed in the fulfillment of my duties except as
provided for in VA Directive 6001, Limited Personal Use of Government
Office Equipment Including Information Technology. I also agree that I will
not engage in any activities prohibited as stated in section 2c of VA
Directive 6001.
e.
I will secure VA sensitive information in all areas (at work and remotely)
and in any form (e.g. digital, paper etc.), to include mobile media and
devices that contain sensitive information, and I will follow the mandate
that all VA sensitive information must be in a protected environment at all
times or it must be encrypted (using FIPS 140-2 approved encryption). If
clarification is needed whether or not an environment is adequately
protected, I will follow the guidance of the local Chief Information
Officer (CIO).
f.
I will properly dispose of VA sensitive information, either in hardcopy,
softcopy or electronic format, in accordance with VA policy and procedures.
g.
I will not attempt to override, circumvent or disable operational,
technical, or management security controls unless expressly directed to do
so in writing by authorized VA staff.
h.
I will not attempt to alter the security configuration of government
equipment unless authorized. This includes operational, technical, or
management security controls.
i.
I will protect my verify codes and passwords from unauthorized use and
disclosure and ensure I utilize only passwords that meet the VA minimum
requirements for the systems that I am authorized to use and are contained
in Appendix F of VA Handbook 6500.
j.
I will not store any passwords/verify codes in any type of script file or
cache on VA systems.
k.
I will ensure that I log off or lock any computer or console before walking
away and will not allow another user to access that computer or console
while I am logged on to it.
l.
I will not misrepresent, obscure, suppress, or replace a user's identity on
the Internet or any VA electronic communication system.
m.
I will not auto-forward e-mail messages to addresses outside the VA
network.
n.
I will comply with any directions from my supervisors, VA system
administrators and information security officers concerning my access to,
and use of, VA information and information systems or matters covered by
these Rules.
o.
I will ensure that any devices that I use to transmit, access, and store VA
sensitive information outside of a VA protected environment will use FIPS
140-2 approved encryption (the translation of data into a form that is
unintelligible without a deciphering mechanism). This includes laptops,
thumb drives, and other removable storage devices and storage media (CDs,
DVDs, etc.).
p.
I will obtain the approval of appropriate management officials before
releasing VA information for public dissemination.
q.
I will not host, set up, administer, or operate any type of Internet server
on any VA network or attempt to connect any personal equipment to a VA
network unless explicitly authorized in writing by my local CIO and I will
ensure that all such activity is in compliance with Federal and VA
policies.
r.
I will not attempt to probe computer systems to exploit system controls or
access VA sensitive data for any reason other than in the performance of
official duties. Authorized penetration testing must be approved in writing
by the VA CIO.
s.
I will protect Government property from theft, loss, destruction, or
misuse. I will follow VA policies and procedures for handling Federal
Government IT equipment and will sign for items provided to me for my
exclusive use and return them when no longer required for VA activities.
t.
I will only use virus protection software, anti-spyware, and firewall/
intrusion detection software authorized by the VA on VA equipment or on
computer systems that are connected to any VA network.
u.
If authorized, by waiver, to use my own personal equipment, I must use VA
approved virus protection software, anti-spyware, and firewall/intrusion
detection software and ensure the software is configured to meet VA
configuration requirements. My local CIO will confirm that the system meets
VA configuration requirements prior to connection to VA's network.
v.
I will never swap or surrender VA hard drives or other storage devices to
anyone other than an authorized OI&T employee at the time of system
problems.
w.
I will not disable or degrade software programs used by the VA that install
security software updates to VA computer equipment, to computer equipment
used to connect to VA information systems, or to create, store or use VA
information.
x.
I agree to allow examination by authorized OI&T personnel of any personal
IT device [Other Equipment (OE)] that I have been granted permission to
use, whether remotely or in any setting to access VA information or
information systems or to create, store or use VA information.
y.
I agree to have all equipment scanned by the appropriate facility IT
Operations Service prior to connecting to the VA network if the equipment
has not been connected to the VA network for a period of more than three
weeks.
z.
I will complete mandatory periodic security and privacy awareness training
within designated timeframes, and complete any additional required training
for the particular systems to which I require access.
aa.
I understand that if I must sign a non-VA entity's Rules of Behavior to
obtain access to information or information systems controlled by that non-
VA entity, I still must comply with my responsibilities under the VA
National Rules of Behavior when accessing or using VA information or
information systems. However, those Rules of Behavior apply to my access to
or use of the non-VA entity's information and information systems as a VA
user.
bb.
I understand that remote access is allowed from other Federal government
computers and systems to VA information systems, subject to the terms of VA
and the host Federal agency's policies.
cc.
I agree that I will directly connect to the VA network whenever possible.
If a direct connection to the VA network is not possible, then I will use
VA-approved remote access software and services. I must use VA-provided IT
equipment for remote access when possible. I may be permitted to use non-VA
IT equipment [Other Equipment (OE)] only if a VA-CIO-approved waiver has
been issued and the equipment is configured to follow all VA security
policies and requirements. I agree that VA OI&T officials may examine such
devices, including an OE device operating under an approved waiver, at any
time for proper configuration and unauthorized storage of VA sensitive
information.
dd.
I agree that I will not have both a VA network connection and any kind of
non-VA network connection (including a modem or phone line or wireless
network card, etc.) physically connected to any computer at the same time
unless the dual connection is explicitly authorized in writing by my local
CIO.
ee.
I agree that I will not allow VA sensitive information to reside on non-VA
systems or devices unless specifically designated and approved in advance
by the appropriate VA official (supervisor), and a waiver has been issued
by the VA's CIO. I agree that I will not access, transmit or store remotely
anyP
VA sensitive information that is not encrypted using VA approved
encryption.
ff.
I will obtain my VA supervisor's authorization, in writing, prior to
transporting, transmitting, accessing, and using VA sensitive information
outside of VA's protected environment.
gg.
I will ensure that VA sensitive information, in any format, and devices,
systems and/or software that contain such information or that I use to
access VA sensitive information or information systems are adequately
secured in remote locations, e.g., at home and during travel, and agree to
periodic VA inspections of the devices, systems or software from which I
conduct access from remote locations. I agree that if I work from a remote
location pursuant to an approved telework agreement with VA sensitive
information that authorized OI&T personnel may periodically inspect the
remote location for compliance with required security requirements.
hh.
I will protect sensitive information from unauthorized disclosure, use,
modification, or destruction, including using encryption products approved
and provided by the VA to protect sensitive data.
ii.
I will not store or transport any VA sensitive information on any portable
storage media or device unless it is encrypted using VA approved
encryption.
jj.
I will use VA-provided encryption to encrypt any e-mail, including
attachments to the e-mail, that contains VA sensitive information before
sending the e-mail. I will not send any e-mail that contains VA sensitive
information in an unencrypted form. VA sensitive information includes
personally identifiable information and protected health information.
kk.
I may be required to acknowledge or sign additional specific or unique
rules of behavior in order to access or use specific VA systems. I
understand that those specific rules of behavior may include, but are not
limited to, restrictions or prohibitions on limited personal use, special
requirements for access or use of the data in that system, special
requirements for the devices used to access that specific system, or
special restrictions on interconnections between that system and other IT
resources or systems.
3. Acknowledgement and Acceptance
a.
I acknowledge that I have received a copy of these Rules of Behavior.
b.
I understand, accept and agree to comply with all terms and conditions of
these Rules of Behavior.
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[Print or type your full name]
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Signature
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Date
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Office Phone
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Position Title
----------
Questions for the Record
The Honorable Stephanie Herseth Sandlin
Question 1: What can the VA do to address the health care needs of
Guard and Reserve members, who account for more than half of all
veterans who took their own lives after returning from Iraq or
Afghanistan?
Response: In order to ensure that Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) combat veterans receive high quality
health care and coordinated Department of Veterans Affairs (VA)
services and benefits as they transition from the Department of Defense
(DoD) to VA, VA and the National Guard developed a creative
partnership. Late in 2005, following the signing of a memorandum of un-
derstanding (MOU) between the National Guard and VA, the National Guard
hired 54 (now 60) National Guard transition assistance advisors (TAA)
to serve as VA/National Guard liaisons in the field at the State level,
assisting National Guard service members and their families in
accessing VA benefits and services. In February 2006, the newly hired
National Guard/VA TAAs were trained by VA staff about VA benefits and
services at the Veterans Benefit Administration (VBA) Academy in
Baltimore. The purpose of the training was to enhance the outreach
skills of the TAAs by learning about VA benefits and services and to
connect them with VA resources and staff members in the field at the VA
medical centers (VAMC) and the regional offices (RO). This knowledge
will assist them in helping Guard/Reserve members in obtaining VA
benefits and services and address access issues in the 50 States and 4
territories. Annual refresher training was held in January 2007 and
2008 in conjunction with the National Guard Family Program Conference.
The TAAs have been the critical link in facilitating access to VA by
National Guard/Reserves in each of the 50 States and 4 territories
(Puerto Rico, Virgin Islands, Guam and District of Columbia) and
providing VA with critical information on numbers of returning troops,
location, homecoming and reintegration events. TAAs also facilitate
enrollment of returning troops into the Veterans Health Administration
(VHA).
The National Guard is presently expanding the TAA program with a
goal of two TAAs for States with large number of deployed troops. The
VHA OEF/OIF Outreach Office continues to collaboration with the 60 TAAs
at monthly teleconferences, through quarterly newsletters, and monthly
identification of success stories and best practices in the States.
Outreach staff work with VA experts at annual training events to ensure
they are updated on changes in VA services/benefits. TAAs facilitate
the development and maintenance of State coalitions using the State
Triad Leadership of the Adjutant General, State Director of Veterans
Affairs (DVA) and VA to integrate and coordinate the delivery of VA
services and benefits to Guard and Reservists in each State. Over 47
States have developed State MOUs through the Leadership Triad of the
State Director DVA, Adjutant General and VA. These State partnerships
are the foundation for State coalitions with participation by community
and State organizations to address the coming home needs of the Guard
and the Reserve members.
In addition VA operates a system of over 200 community based
counseling centers, known as Vet Centers, located near where veterans
and their families reside. Vet Centers are staffed by small multi-
disciplinary teams of dedicated providers, many of which are combat
veterans themselves, providing a broad range of counseling, outreach,
and referral services to OEF/OIF veterans in order to help them
readjustment to civilian life. Services include individual counseling,
group counseling, marital and family counseling, bereavement
counseling, medical referrals, assistance in applying for VA benefits,
employment counseling, guidance and referral. alcohol/drug assessments,
information and referral to community resources, military sexual trauma
counseling and referral, outreach and community education.
On May 2, 2008 VA began contacting nearly 570,000 OEF/OIF combat
veterans to ensure they know about VA medical services and other
benefits. The Department will reach out and touch every veteran of the
war to let them know it is here for them. The first of those calls are
going to an estimated 17,000 veterans who were sick or injured while
serving in Iraq or Afghanistan. If any of these 17,000 veterans do not
now have a care manager to work with them to ensure they get
appropriate health care, VA will offer to appoint one for them.
Question 2: What is the VA doing, and what should the VA be doing
to address the unique mental health care needs of younger veterans?
Response: VA has several resources to train staff to better
understand the needs of younger veterans and their families. These
resources include:
My HealtheVet. Younger veterans use the Internet to
obtain information and communicate. We have developed mental health
content for My HealtheVet and continue to expand that content.
VA also has clinical programs geared to returning
veterans, many of whom are younger, such as:
Serving returning veterans mental health needs
teams (SeRV-MH teams) to address issues of younger veterans and
families in clinical care. Monthly conference calls are held
for the SeRV-MH team and include discussion of various issues,
such as non-traditional scheduling to meet the needs of working
or school engaged patients, and care needs of younger families.
Additionally, as many younger veterans are married
and may have young children. The new Housing and Urban
Development/VA supported housing (HUD/VASH) voucher program
offers opportunities for housing of homeless veterans with
families.
The Iraq Clinician War Guide, developed by the National
Center for Post Traumatic Stress Disorder (NCPTSD) in collaboration
with DoD in 2004, is posted on the NCPTSD Web site, as well as being
used in VA training sessions across the country.
A national conference, Evolving Paradigms in Treating
Combat Veterans. Was developed as a joint VA/ DoD training effort in
2007.
Conferences for Veterans Integrated Service Networks
(VISN) 5 and 6 staff were held in 2006/2007 with a focus on Family
Transition Meetings. Training to other VISNs is being planned.
Many younger veterans have families with young children,
and reintegration into the family after deployment to a combat zone can
be stressful for the veteran's family. We have used the Sesame Street
project, ``Talk, Listen, Connect'', to help families of servicemembers
and veterans guide their children's adjustment to a parent who returns
form Iraq or Afghanistan. Copies of the video and accompanying
materials are currently available at all VA facilities and we will be
disseminating additional copies to staff system-wide to train them to
use this valuable tool.
Question 3: What should the VA be doing to address the mental
health care needs of veterans, especially veterans in rural or
underserved areas?
Response: The Center of Excellence at Canandaigua and the Serious
Mental Illness Treatment Research and Evaluation Center (SMITREC) at
Ann Arbor, Michigan are planning a study of the data from VA's 24-hour
Suicide Crisis Line to determine if there are new, emergent veteran
populations at risk for suicidal behaviors. Both younger veterans and
veterans in rural or underserved areas will be evaluated as part of
this study as to mental health care needs of both groups VA should
address.
VA also has increased availability of mental health services in
community based outpatient clinics (CBOC) designed to bring care closer
to the veterans. As of the end of the first quarter of fiscal 2008, 93
percent of CBOCs reported mental health visits. All 21 VISNS have some
form of VA/State-community collaborations including telemental health
or VA staff placements in community health or mental health centers;
Tribal or Indian Health Service clinical sites. VA's Office of Mental
Health Services and Office of Rural Health are collaborating to improve
access to services for veterans in remote areas, including an increased
effort at telemental health capabilities. VA has authorized facilities
to arrange for fee basis and contract services in situations where
timely services cannot be provided by existing VA facilities.
__________
Questions for the Record
The Honorable John J. Hall
Question: When a veteran gets a prescription or has to order a
refill there is no way for a doctor to expedite the delivery of the
medication which can take 10 days. Someone needing an anti-depressant
should be able to get that sent quickly by allowing the doctor to
overnight the delivery. Why can't his be done?
Response: At the request of a Department of Veterans Affairs (VA)
prescriber, VA medical center pharmacy staff will make urgently needed
prescription medications available to patients within 24 hours of
notification, using the most appropriate means available. This
requirement applies to all points of service including community based
outpatient clinics (CBOC).
Current practice within VA system: Newly prescribed medications are
available immediately through VA pharmacies or through non-VA contract
pharmacies serving VA CBOCs. Refills for previously filled
prescriptions are primarily available through VA's consolidated mail
outpatient pharmacies (CMOP), or alternately through VA medical center
pharmacies. Current CMOP prescription refill processing times average 5
days after the refill is requested (1 day to send data to CMOP; 1.5
days to fill the prescription; and 2.5 days to mail/ship the package to
the patient).
Current practice outside the VA system: VA has contracts with
community pharmacies to provide urgently needed outpatient CBOC
prescriptions, or to provide medications when the VA medical center
does not offer 24/7 outpatient pharmacy services. VA's current contract
pharmacy prescription volume is approximately 300,000 per year.
Ongoing Emphasis: A VHA policy Directive intended to reemphasize
VA's practice of providing urgently needed outpatient medications in a
timely manner has been approved. The new Directive was distributed to
the field in May 2008. Enclosed is a copy of Directive 2008-028, Access
to Urgently Needed Outpatient Prescription Medications.
VA/DoD Partnering: VA's requirements have been included in the
Department of Defense's (DoD) TRICARE retail pharmacy network (TRx)
which will allow VA to use DoD's 50,000 retail pharmacies to fill
urgently needed outpatient prescriptions if a VA pharmacy is not
available. It is expected that VA will be able to begin using the TRx
retail contract sometime in late 2009.
Vet centers refer veterans to the local VA medical centers for
medical care and follow up of prescriptions if needed. In the mental
health mental status evaluation, any indicators of need for medical
psychiatric or primary care are automatically referred to the medical
center. If the veteran is on medications and have challenges in getting
prescriptions filled, they are referred to the local VA medical center
or CBOC.
__________
Department of Veterans Affairs
VHA DIRECTIVE 2008-028
Veterans Health Administration
Washington, DC 20420
May 16, 2008
ACCESS TO URGENTLY NEEDED OUTPATIENT PRESCRIPTION MEDICATIONS
1. PURPOSE: This Veterans Health Administration (VHA) Directive
defines expectations for access to urgently needed outpatient
prescription medications.
2. BACKGROUND:
a. Urgently needed outpatient medications are medications that, in
the clinical judgment of the prescriber, if not taken within 24 hours
of determining the need of those medications have the potential to
result in serious patient harm.
b. Local restrictions on the use of overnight mail or package
delivery service to deliver urgently needed outpatient prescription
medications have the potential to cause unnecessary hospital visits,
hospitalizations and patient harm.
3. POLICY: It is VHA policy that at the request of a VA prescriber,
VA medical center pharmacy staff will make urgently needed outpatient
prescription medications available to patients within 24 hours of
notification, using the most appropriate means available. This
requirement applies to all points of service including Community Based
Outpatient Clinics.
4. ACTION:
a. Facility Director. The facility Director, or designee, is
responsible for ensuring written policies are established to address
the timely delivery of urgently needed outpatient prescription
medications.
b. VA Prescriber. The VA prescriber must notify the pharmacy when
a new prescription or refill is urgently needed due to a change in the
patient's clinical condition. NOTE: If the prescriber determines that
medication is needed sooner than 24 hours, the prescriber needs to make
arrangements for the patient to receive urgent medical care or instruct
the patient to contact the local emergency medical care system.
c. Chief of Pharmacy. The Chief of Pharmacy must contact the
patient or the patient's representative to determine the most
appropriate means to make the prescription available and must take all
necessary steps to make the prescription available. This may include:
1. Making the prescription available at a VA pharmacy for
pick up.
2. Providing the prescription through a non-VA pharmacy
under contract to VA.
3. Mailing or shipping the medication overnight via
commercial or government carrier.
THIS VHA DIRECTIVE WILL EXPIRE MAY 31, 2013
5. REFERENCES: None.
6. FOLLOW-UP RESPONSIBILITY: The Pharmacy Benefits Management
Services office (119) is responsible for the content of this Directive.
Questions may be referred to (202) 4617326.
7. RESCISSIONS: None
Michael J. Kussman, MD, MS, MACP
Under Secretary for Health
DISTRIBUTION: CO: E-mailed 5/19/08
FLD: VISN, MA, DO, OC, OCRO, and 200--E-mailed 5/19/08
__________
Questions for the Record
The Honorable Shelley Berkley
Question 1: What are we doing to follow through with a veteran
after it has been identified that they have a mental health issue to
decrease their risk of committing suicide?
Response: For veterans found to be at risk for suicide, the
Veterans Health Administration (VHA) supplements basic mental health
services with increased monitoring and intense treatment directed
toward reducing suicidality, as well as the underlying mental health
problem. For a veteran identified as having a mental health problem,
the most basic approach to decreasing the risk of suicide is to provide
appropriate, evidence-based treatment for the mental health problem. To
ensure veterans' mental health needs are addressed, VHA has been
enhancing the mental health services it provides through substantial
increases in the allocation of funds, and has hired almost 4,000 new
mental health staff members over the past 3 years. Between 2005 and
2007, there was a 10.3-percent increase in uniques, and a 7.6-percent
increase in encounters.
Question 2: How much of the Joshua Omvig Suicide Prevention Act
(aside from the establishment of the suicide hotline) has been
initiated since its enactment in November 2007?
Response: The Comprehensive Program for Suicide Prevention Among
Veterans Report (Public Law 110-110) was submitted to Congress in
February 2008 and is attached for your review. In the report we stated
that we are able to monitor risk and needs and respond to them under
existing legal authority. Since the report was released the Department
of Veterans Affairs (VA) has the following updated information:
Requirement: Designation of Suicide Prevention Counselors--To
support the identification of patients at high risk, the suicide
prevention coordinators have been collecting information from
providers, other staff, and community contacts about veterans who have
survived suicide attempts. In preliminary findings, we have identified
approximately 1,000 attempts per month. To address the increased needs
for these vulnerable veterans, VA has implemented standardized
approaches to enhancing care while, at the same time, encouraging
innovation and creativity.
Further developments in process at this time include tests of the
coordinators inter-rater reliability and its sensitivity in the
identification of suicide attempts. Both will be necessary before the
number of attempts (or reattempts) in a facility can be used as a
measure for epidemiological or quality improvement purposes.
Requirement: Hotline--From the time the veterans' Hotline was
established in July, 2007 until the end of May, 2008, we received
49,544 calls. From the start of 2008 until the end of May we received
40,165 calls, with 16,436 confirmed as coming from veterans and 2,543
from family members or friends. These led to 3,240 referrals to the
suicide prevention coordinators at VA facilities and 909 ``rescues''
requiring emergency services.
Attached: Report to Congress on Comprehensive Program for Suicide
Prevention Among Veterans
----------
REPORT TO CONGRESS
PUBLIC LAW 110-110
COMPREHENSIVE PROGRAM FOR
SUICIDE PREVENTION AMONG VETERANS
Department of Veterans Affairs
February 2008
Report to Congress on VA's Implementation of 38 U.S.C. Sec. 1720F,
``Joshua Omvig Veterans Suicide Prevention Act''
Issue: Implementation of section 3(b)(1) of Public Law 110-110, the
``Joshua Omvig Veterans Suicide Prevention Act,'' requires the
Department of Veterans Affairs (VA) to submit a report to Congress not
later than 90 days after November 5, 2007, on the Department's
implementation of its comprehensive suicide prevention program, as
established by 38 U.S.C. Sec. 1720F.
Information on the status of the implementation of the VA comprehensive
program for suicide prevention
Requirement: Establishment--The Secretary shall develop and carry
out a comprehensive program designed to reduce the incidence of suicide
among veterans incorporating the components described in this section.
VA Response: Recommendations for suicide prevention programs within
VA were included in the 2004 VA Comprehensive Mental Health Strategic
Plan. Implementation began shortly after the plan was approved and
suicide prevention programs in VA medical centers were accelerated in
spring 2006. Ongoing activities have been monitored by Office of
Inspector General as documented in report number 06-03706-126 from May
10, 2007.
Requirement: Staff Education--In carrying out the comprehensive
program under this section, the Secretary shall provide for mandatory
training for appropriate staff and contractors (including all medical
personnel) of the Department who interact with veterans. This training
shall cover information appropriate to the duties being performed by
such staff and contractors. The training shall include information on--
(1) recognizing risk factors for suicide; (2) proper protocols for
responding to crisis situations involving veterans who may be at high
risk for suicide; and (3) best practices for suicide prevention.
VA Response: VA held its first Suicide Prevention Awareness Day for
all VA medical centers in April 2007, which included a program that
focused on recognizing risk factors for suicide, proper protocols for
responding to crisis situations involving veterans who may be at high
risk for suicide, and best practices for suicide prevention. It held
its second Suicide Prevention Awareness Day in September 2007, and
scheduled the event during National Suicide Prevention Week. The
program consisted of required training for all staff on general
principles of suicide prevention, and the use of specific new VA
resources: the national VA Suicide Prevention Hotline and the Suicide
Prevention Coordinators who are located at each VA medical center. VA
Suicide Prevention Awareness Day is now an annual event held during
Suicide Prevention Week each September. VA has also held several
regional conferences on suicide prevention attended by mental health
providers, primary care clinicians, administrators, and a wide range of
other medical center staff members. Additional mandatory training
initiatives are being developed for fiscal year (FY) 2008, including a
Web-based curriculum with associated written materials for all staff
with patient contact.
A major responsibility of Suicide Prevention Coordinators is
coordination of local training in suicide prevention. This includes
providing training for both providers and non-clinical staff with
patient contact. Suicide Prevention Coordinators also provide special
training to staff members who respond to telephone calls. Additional
education and training includes outreach to the community, with a focus
on ``guide'' training, designed for non-clinical staff who interact
with veterans to help them better understand suicide risk and to assist
veterans in accessing needed services.
Requirement: Health Assessments of Veterans--In carrying out the
comprehensive program, the Secretary shall direct that medical staff
offer mental health in their overall health assessment when veterans
seek medical care at a Department medical facility (including a center
established under section 1712A of this title) and make referrals, at
the request of the veteran concerned, to appropriate counseling and
treatment programs for veterans who show signs or symptoms of mental
health problems.
VA Response: VA policy for all new Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) veterans upon their initial visit to
VA medical centers or clinics is to screen them for depression, Post-
Traumatic Stress Disorder (PTSD), and problem drinking. Screening for
depression and problem drinking is required on an annual basis for all
veterans, and screening for PTSD is required annually for the first 5
years after enrollment, and every 5 years afterward. Whenever veterans
screen positive for one of these conditions, they must receive a
followup clinical evaluation that considers both the condition(s)
related to the positive screen, and the risk of suicide. When this
process confirms the presence of a mental disorder or suicide risk,
veterans must be offered mental health treatment. Whenever there is a
referral or request for mental health services, veterans must receive
an initial evaluation within 24 hours. When this evaluation identifies
urgent need, treatment must be provided immediately; otherwise,
veterans must receive a full diagnostic and treatment planning
evaluation and the initiation of care within 2 weeks.
Requirement: Designation of Suicide Prevention Counselors--In
carrying out the comprehensive program, the Secretary shall designate a
suicide prevention counselor at each Department medical facility other
than centers established under section 1712A of this title. Each
counselor shall work with local emergency rooms, police departments,
mental health organizations, and veterans service organizations to
engage in outreach to veterans and improve the coordination of mental
health care to veterans.
VA Response: Each VA medical center is required to appoint a full-
time Suicide Prevention Coordinator. The primary responsibility of the
Suicide Prevention Coordinator is to support the identification of
patients at high risk for suicide, and to ensure that their monitoring
and care are intensified. Other responsibilities include training and
education, both within VA and in the community.
Requirement: Best Practices Research--In carrying out the
comprehensive program, the Secretary shall provide for research on best
practices for suicide prevention among veterans. Research shall be
conducted under this subsection in consultation with the heads of the
following entities: (1) The Department of Health and Human Services.
(2) The National Institute of Mental Health. (3) The Substance Abuse
and Mental Health Services Administration. (4) The Centers for Disease
Control and Prevention.
VA Response: The Mental Illness Research, Education and Clinical
Center (MIRECC) at Denver, Colorado, and the Center of Excellence in
Mental Health and PTSD at Canandaigua, New York, focus specifically on
suicide prevention. Ongoing studies are addressing suicide risk
factors, validation of suicide ideation screening instruments,
structure/quality of mental health care and its relationship to suicide
prevention, and risk factors for suicide as it relates to depression.
Findings from two major studies were presented at the House Veterans'
Affairs Committee (HVAC) hearing on December 12, 2007. One, conducted
by VA's Office of Environmental Epidemiology, investigated the
mortality and causes of death in returning OEF/OIF veterans. Another,
conducted by VA's Serious Mental Illness Research Education and
Clinical Center, studied rates of suicide, risk factors, and their
local variability in all of those receiving health care from VA.
Research under development by the Center of Excellence at Canandaigua,
includes clinical trials on the effectiveness of peer support for
suicide prevention, and psychological autopsy studies involving
linkages of VA medical centers with local coroners or medical
examiners.
VA plans to support several additional research programs and
activities aimed at reducing and preventing suicide, including new
research solicitations and a periodic update of a literature synthesis
of best practices for suicide prevention. In January 2008, a new
research solicitation was initiated seeking studies to validate
screening instruments and to identify successful strategies and
interventions for suicide prevention.
VA has convened a new targeted working group, the Interagency
Working Group to Inform Research on Suicide Prevention, comprised of
experts from the Department of Health and Human Services, National
Institute on Mental Health, Substance Abuse and Mental Health Services
Administration, Centers for Disease Control and Prevention, and the
Department of Defense to assess the current state of knowledge and
their respective relevant portfolios of research in order to provide
recommendations on specific efforts that should be undertaken by VA.
Requirement: Sexual Trauma Research--In carrying out the
comprehensive program, the Secretary shall provide for research on
mental health care for veterans who have experienced sexual trauma
while in military service. The research design shall include
consideration of veterans of a reserve component.
VA Response: Ongoing research supported by the Office of Research
and Development that is specific to sexual trauma includes studies
examining sexual violence and gynecologic health; screening and
treatment responses; risks, outcomes, and services for women; and a
longitudinal study of Military Sexual Trauma; and effects on PTSD and
Health Behavior. These studies include a wide range of subjects,
including National Guard and Reserve component veterans. Male veterans
are also targeted in a study addressing sexual assault prevalence among
Gulf War veterans suffering from PTSD.
Requirement: 24-Hour Mental Health Care--In carrying out the
comprehensive program, the Secretary shall provide for mental health
care availability to veterans on a 24-hour basis.
VA Response: VA policy requires 24/7 mental health coverage in all
VA emergency departments and 24-hour urgent care centers. Twenty-four
hour coverage for veterans who do not have ready access to these
services is facility based and may include access to local or regional
call centers, or to providers covering inpatient units. National
coverage is available for all veterans through the Suicide Prevention
Hotline.
The Veterans Health Administration is developing a uniform policy
that will require each medical center or clinic that does not have an
emergency department or 24/7 urgent care center to designate one or
more nearby VA or community-based facilities to provide 24/7 emergency
mental health coverage. Elements of the policy already approved ensure
that: (1) providers and responders to telephone calls to the facility
make veterans aware of coverage; (2) facilities develop contracts or
memoranda of understanding with the designated emergency departments to
facilitate bidirectional communication; and (3) contracts or memoranda
of understanding to ensure that veterans receiving care in the
designated facilities are transferred back to VA as soon as it is
medically appropriate. Elements still under development include issues
related to payment for emergency services and hospitalizations.
Requirement: Hotline--In carrying out the comprehensive program,
the Secretary may provide for a toll-free hotline for veterans to be
staffed by appropriately trained mental health personnel and available
at all times.
VA Response: VA has partnered with the Substance Abuse and Mental
Health Service Administration to include services for veterans in its
Suicide Prevention Hotline program. When calls are made to the national
toll-free Suicide Prevention Hotline, a message states that if the
caller is a United States military veteran, or if the call pertains to
a veteran, the caller should press ``1.'' With this action, the veteran
or person calling is immediately connected to VA's suicide prevention
call center at Canandaigua, which is staffed by VA mental health
professionals who have real-time access to veterans' electronic medical
records.
Additionally, staff members at the Veterans Benefits Administration
Call Center have received training on managing callers with warning
signs of suicide. They immediately transfer these calls to the hotline
call center.
Requirement: Outreach and Education for Veterans and Families--In
carrying out the comprehensive program, the Secretary shall provide for
outreach to and education for veterans and the families of veterans,
with special emphasis on providing information to veterans of Operation
Iraqi Freedom and Operation Enduring Freedom and the families of such
veterans. Education to promote mental health shall include information
designed to--(1) remove the stigma associated with mental illness; (2)
encourage veterans to seek treatment and assistance for mental illness;
(3) promote skills for coping with mental illness; and (4) help
families of veterans with--(A) understanding issues arising from the
readjustment of veterans to civilian life; (B) identifying signs and
symptoms of mental illness; and (C) encouraging veterans to seek
assistance for mental illness.
VA Response: Through its Readjustment Counseling Service (Vet
Centers), VA has hired 100 OEF/OIF peer specialists to complement its
existing peer outreach program to provide education and outreach to
returning veterans. Staffs from Vet Centers attend each post-deployment
health reassessment to provide information about the availability and
effectiveness of VA services. This allows Vet Centers to facilitate
counseling services. Vet Centers also provide extensive outreach
services to National Guard and Reserve units, and to the community to
provide education about readjustment and related mental health issues,
and the availability of care.
VA has funded over 90 OEF/OIF teams in mental health to provide
further outreach and education in VA facilities, in National Guard and
Reserve units, and in the communities. The messages they deliver are
related to destigmatizing mental illness, increasing knowledge of the
symptoms and warning signs of mental disorders, and ensuring that
veterans and families are aware that effective, high-quality mental
health treatment is readily available in VA facilities.
Other sources of information for veterans and families include the
Internet (e.g., www.ncptsd.va.gov, the National Center for PTSD's Web
site), and numerous media reports.
Requirement: Peer Support Counseling Program--(1) In carrying out
the comprehensive program, the Secretary may establish and carry out a
peer support counseling program, under which veterans shall be
permitted to volunteer as peer counselors--(A) to assist other veterans
with issues related to mental health and readjustment; and (B) to
conduct outreach to veterans and the families of veterans. (2) In
carrying out the peer support counseling program under this subsection,
the Secretary shall provide adequate training for peer counselors.
VA Response: VA provides a number of distinct types of peer
counseling in a number of different contexts.
Vet Centers have recently hired 100 returning veterans as OEF/OIF
peer specialists to provide outreach, education, and counseling to
returning veterans and their families. These OEF/OIF veterans
complement the counseling and outreach services provided by an even
larger number of ex-veterans who serve as staff members in Vet Centers.
The services provided by Vet Centers are based on problem-focused, not
diagnosis-focused, care for readjustment problems. Peer counseling is a
key component of the overall program. Training for the OEF/OIF peers
specialists is provided through the Vet Center program.
VA's homeless program established the Peer Housing Location
Assistance Group (PHLAG) program as a 2-year pilot program started in
late 2006, and is located at six VA medical centers. The program
utilizes formerly homeless veterans trained as peer specialists to
provide assistance to homeless veterans completing residential
treatment programs. They also assist homeless veterans to locate
community housing and make a successful transition to independent
living. Veterans Integrated Service Network 5's (VISN) MIRECC trained
the peer specialists and is evaluating the outcome of the pilot
program.
VA's specialty care programs include peer support services for
patients with serious mental illness. Beginning in FY 2005, 123.5 Full-
time Equivalent (FTE) peer support technicians have been funded from
mental health enhancement funds in 47 mental health programs across 27
states. Peer Support Technicians provide a variety of peer support
services under the supervision of a mental health provider in homeless
programs, therapeutic employment programs, residential programs, and
day programs. Peer Support Technicians assist veterans in identifying
personal recovery goals and in determining necessary steps to achieve
their goals; teach problem solving techniques; assist and support
skills training; and help veterans locate VA and community resources.
Having availed themselves of mental health services, Peer Support
Technicians share their own experiences and the skills, strengths, by
serving as positive role models to other veterans working on their own
recovery from serious mental illness. Several states offer
certification as peer support specialists. VA facilities have developed
training and continuing education for Peer Support Technicians
utilizing both internal VA resources, as well as non-VA training
entities. Peer support technicians and their supervisors obtain
additional information and support from monthly conference calls. Two
national face-to-face training meetings have been conducted on peer
support and a third conference is planned for later in FY 2008.
Requirement: Other Components--In carrying out the comprehensive
program, the Secretary may provide for other actions to reduce the
incidence of suicide among veterans that the Secretary considers
appropriate.
VA Response: VA's comprehensive program for suicide prevention must
be viewed as a dynamic activity that will evolve over time as new
information becomes available on needs, opportunities, and best
practices. The two Centers of Excellence with their capacity for
research and technical assistance (Denver and Canandaigua), the ongoing
studies on rates and risk factors being conducted by the Office of
Environmental Epidemiology and the Serious Mental Illness Research
Education and Clinical Center, the hotline call center, and the Suicide
Prevention Coordinators at each medical center, constitute a core
infrastructure to support the identification of needs, and the
development of opportunities to allow enhancement of the program over
time.
To allow ongoing scanning of the clinical and scientific
literature, as well as activities in the field, both within VA and in
community-based programs, VA has appointed a Suicide Prevention
Steering Committee cochaired by the Deputy Chief Patient Care Services
Officer for Mental Health and the Director of the Center of Excellence
at Canandaigua and with multidisciplinary staffing from relevant VA
program offices. The steering committee has been charged with
identifying opportunities for program development. Additional input
from outside agencies comes from the Interagency Working Group to
Inform Research on Suicide Prevention convened by VA's Office of
Research and Development, and from VA's active participation in the
workgroup on suicide prevention of the Federal Partnership on Mental
Health.
Information on the time line and costs for complete implementation
of the program within 2 years.
VA's comprehensive program on suicide prevention, as specified in
the Joshua Omvig Veterans Suicide Prevention Act has been completely
implemented. It is a dynamic program that will evolve over time in
response to needs and opportunities. The basic structures and processes
required by the Act have already been established and implemented.
Expenditures for the suicide prevention program include $.97
million for the Hotline; $1.97 million for the Center of Excellence in
Canandaigua; $2.20 million for the Mental Illness Research, Education
and Clinical Center in Denver; $90,000 for the Serious Mental Illness
Research, Education and Clinical Center for monitoring of suicide rates
and risk factors; and $14.32 million for Suicide Prevention
Coordinators. The expenditures for suicide prevention for FY 2008 will
be more than $19.55 million.
A plan for additional programs and activities designed to reduce
the occurrence of suicide among veterans.
VA's comprehensive program for suicide prevention must be viewed as
a dynamic activity that will evolve over time as new information
becomes available on needs, opportunities, and best practices. The two
Centers of Excellence with their capacity for research and technical
assistance (Denver and Canandaigua), the ongoing studies on rates and
risk factors being conducted by the Office of Environmental
Epidemiology and the Serious Mental Illness Research Education and
Clinical Center, the hotline call center, and the suicide prevention
coordinators at each medical center, constitute a core infrastructure
to support the identification of needs, and the development of
opportunities to allow enhancement of the program over time.
VA also established a Suicide Prevention Steering Committee,
convened the Interagency Working Group to Inform Research on Suicide
Prevention, and participates in the workgroup on suicide prevention of
the Federal Partnership on Mental Health, all to support the ongoing
enhancement of its comprehensive program for suicide prevention.
Recommendations for further legislation or administrative action
that the Secretary considers appropriate to improve suicide prevention
programs within the Department of Veterans Affairs.
VA is able to monitor risk and needs and respond to them under
existing legal authority. VA does not recommend further legislative
action.
Committee on Veterans' Affairs
Washington, DC,
May 21, 2008
Michael Shepherd, M.D.
Physician, Office of Healthcare Inspections
Office of Inspector General
U.S. Department of Veterans Affairs
Washington, DC 20420
Dear Michael:
In reference to our Full Committee hearing on ``The Truth About
Veterans' Suicides'' on May 6, 2008, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on July
7, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Debbie Smith by fax your responses at 202-225-2034. If you have any
questions, please call 202-225-9756.
Sincerely,
BOB FILNER
Chairman
CW:ds
----------
U.S. Department of Veterans Affairs
Washington, DC
July 2, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
United States House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
This is in response to your May 21, 2008, letter to Dr. Michael
Shepherd, Senior Physician, Office of Healthcare Inspections, Office of
Inspector General, following the May 6, 2008, hearing on ``The Truth
About Veterans' Suicides.'' Enclosed is Dr. Shepherd's answer to the
additional hearing question.
Thank you for your interest in the Department of Veterans Affairs.
Sincerely,
GEORGE J. OPFER
Inspector General
Enclosure
----------
Question from the Honorable Stephanie Herseth Sandlin
For Michael Shepherd, M.D.
Senior Physician, Office of Healthcare Inspections
Office of Inspector General, U.S. Department of Veterans Affairs
Before the Committee on Veterans' Affairs
United States House of Representatives Hearing
``The Truth about Veterans' Suicides''
May 6, 2008
Question: In your written statement, you indicated that there are
ongoing enhancements in the availability of mental health services at
community-based outpatient clinics (CBOCs) that may help mitigate
vocational and logistical challenges facing some veterans residing in
more rural areas. What are the ``ongoing enhancements'' that are taking
place at CBOCs?
Answer: Because mental health conditions may require multiple modes
of therapy and in some cases multiple weekly visits, treatment for
veterans residing in rural areas is especially challenging. Traveling
long distances to appointments can interfere with work and academic
obligations which can diminish the ability and incentive for veterans
to seek or stay involved in treatment programs. VA reports having taken
the following steps to expand access to mental health care, which
includes rural areas:
Increasing CBOC and Outreach Clinic Program sites over
the past few years. Outreach clinics are ``part-time'' VA clinic or
contract sites that do not have enough patient volume to sustain full-
time hours. Mental health services are also available at outreach
sites.
Planning to open 44 new CBOCs and 23 new Vet Centers over
the next 2 years.
Expanding telemental health from use in 259 CBOCs in
fiscal year 2007 to 295 CBOCs in fiscal year 2008.
Changing the mission of the Veterans Integrated Service
Network 16 Mental Illness, Research, Education, and Clinical Center to
focus on improving access to evidenced-based mental health practices in
rural and other underserved populations.
While this indicates some increase in rural VHA mental health
presence, the intent of my statement was to point out the need for
continued progress in this important area.