EXAMINING THE PROGRESS OF SUICIDE PREVENTION OUTREACH EFFORTS AT THE U.S DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF JACOB B. GADD, DEPUTY DIRECTORVETERANS AFFAIRS AND REHABILITATION COMMISSIONTHE AMERICAN LEGIONBEFORE THESUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONSCOMMITTEE ON VETERANS' AFFAIRSUNITED STATES HOUSE OF REPRESENTATIVESON"EXAMINING THE PROGRESS OF SUICIDE PREVENTION OUTREACH EFFORTS AT THE U.S DEPARTMENT OF VETERANS AFFAIRS"

JULY 14, 2010

Mr. Chairman and Members of the Subcommittee: Thank you for this opportunity to submit The American Legion's views on progress of the Suicide Prevention efforts at the Department of Veterans Affairs (VA) to the Subcommittee today. The American Legion commends the Subcommittee for holding a hearing today to discuss this timely and important issue.

Suicide among service members and veterans has always been a concern; it is the position of The American Legion that one suicide is one too many. However, since the war in Iraq and Afghanistan began, the numbers of service members and veterans who have committed suicide have steadily increased. As our service members are deployed across the world to protect and defend our freedoms, we as a nation cannot allow them to not receive the care and treatment they need when they return home. The tragic and ultimate result of failing to take care of our nation's heroes' mental health illnesses is suicide.

Turning first to VA's efforts in recent years with Mental Health Care, The American Legion has consistently lobbied for budgetary increases and program improvements to VA's Mental Health Programs. Despite recent unprecedented increases in the VA budget, demand for VA Mental Health services is still outpacing the resources and staff available as the number of service members and veterans afflicted with Post Traumatic Stress (PTS) and Traumatic Brain Injury (TBI) continues to grow. This naturally leads to VA's increase in mental health patients.

In 2008, RAND's Center for Military Health Policy Research, an independent, nonprofit group, released a report on the psychological and cognitive needs of all servicemembers deployed in the past six years, titled, "Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery," which estimated that more than 300,000 (20 percent of the 1.6 million) Iraq and Afghanistan veterans are suffering from PTS or major depression and about 320,000 may have experienced TBI during deployment.

The Centers for Disease Control and Prevention estimates 30,000-32,000 US deaths from suicide per year among the population. VA's Office of Patient Care and Mental Health Services reported in April 2010 that approximately 20 percent of national suicides are veterans. The National Violent Death Reporting System reports 18 deaths per day by veterans and VA's Serious Mental Illness Treatment, Research and Evaluation Center reported about five deaths occur each day among VA patients. In a recent AP article, it was cited that there have been more suicides than service members killed in Afghanistan.

The Veterans Health Administration (VHA) has made improvements in recent years for Mental Health and transition between DoD and VA such as the Federal Recovery Coordinators, Polytrauma Rehabilitation System of Care, Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) case management teams, integrating mental health care providers into primary care within VA Medical Center Facilities and Community Based Outpatient Clinics (CBOCs), VA Readjustment (Vet) Centers hiring of Global War on Terrorism (GWOT) Counselors, establishing directives for TBI screening, clinical reminders and a new symptom and diagnostic code for TBI.

Regarding suicide prevention outreach efforts, VA founded the National Suicide Prevention Hotline, 1-800-273-TALK (8255) by collaborating with the National Suicide Prevention Lifeline where veterans are assisted by a dedicated call center at Canandaigua VA Medical Center in New York. The call center is staffed with trained VA crisis health care professionals to respond to calls on a 24/7 basis and facilitate appropriate treatment. VA reported in 2010 a total of 245,665 calls, 128,302 of which were identified as veterans. Of these veterans, 7,720 were rescues.

VA hired Local Suicide Prevention Coordinators at all of the 153 VA Medical Centers nationwide in an effort to provide local and immediate assistance during a crisis, compile local data for the national database and train hospital and local community on how to provide assistance. One of primary responsibilities of the Local Suicide Prevention Coordinators is to track and monitor veterans who are placed on high risk of suicide (HRS). A safety plan for that individual veteran is created to ensure they are not allowed to fall through the cracks.

In 2009, VA instituted an online chat center for veterans to further reach those veterans who utilize online communications. The total number of VeteransChat contacts reported since September 2009 was 3,859 with 1471 mentioning suicide. VA has also had targeted outreach campaigns which included billboards, signage on buses and PSA's with actor Gary Sinise to encourage veterans to contact VA for assistance.

The American Legion Suicide Prevention and Referral Programs

The American Legion has been at the forefront of helping to prevent military and veteran suicides in the community. The American Legion approved Resolution 51, The American Legion Develop a Suicide Prevention and Outreach Referral Program, at the 2009 National Convention. In addition, VA's National Suicide Prevention Coordinator Dr. Janet Kemp facilitated an Operation S.A.V.E. Training for our Veterans Affairs and Rehabilitation Commission members. VA&R Commission members and volunteers subsequently developed American Legion state, district and post training programs to provide referrals for veterans in distress with VA's National Suicide Prevention Hotline. The American Legion currently has over 60 posts with active Suicide Prevention and Referral Programs.

In December 2009, The American Legion took the lead in creating a Suicide Prevention Assistant Volunteer Coordinator position, under the auspices of VA's Voluntary Service Office. Each local suicide prevention office is encouraged to work with veteran service organizations and community organizations to connect veterans with VA's programs in their time of transition and need. The Suicide Prevention offices can increase their training of volunteers to distribute literature and facilitate training in order to further reach veterans in the community.

This year, The American Legion entered into a partnership with the Defense Centers of Excellence's Real Warrior Campaign to educate and encourage our members to help transitioning service members and veterans receive the mental health treatment they need. Additionally, during our 2010 National Convention we will have a panel to discuss prevention, screening, diagnosis and treatment of TBI with representatives from DoD, VA and the private sector.

Challenges

Despite recent suicide prevention efforts, yet more needs to be done as the number of suicides continues to grow. The American Legion's System Worth Saving (SWS) program, which conducts site visits to VA Medical Center facilities annually, has found several challenges with the delivery of mental health care. VA has the goal to recruit psychologists from their current nationwide level of 3,000 to 10,000 to meet the demand for mental health services. However, VA Medical Center Facilities have expressed concerns with hiring and retaining quality mental health specialists and have had to rely on fee basis programs to manage their workload.

The American Legion applauds last year's action by Congress in passing Advance Appropriations for mandatory spending. However, problems exist in VA itself in allocating the funds from VA Central Office to the Veteran Integrated Service Networks (VISNs) and to the local facilities. This delay in funding creates challenges for the VA Medical Center Facility in receiving its budget to increase patient care services, hiring or to begin facility construction projects to expand mental health services. VA's 2011 budget provides approximately $5.2 billion for mental health programs which is an 8.5 percent, or $410 million, increase over FY 2010 budget authorization. The American Legion continues to be concerned about mental health funds being specifically used for their intent and that Congress continue to provide the additional funding needed to meet the growing demand for treatment.

Challenges in preventing suicide include maintaining confidentiality and overcoming the stigma attached to a service member or veteran receiving care. Additionally, the issue of a lack of interoperable medical records between DoD and VA, while being addressed by Virtual Lifetime Electronic Records (VLER), still exists. The American Legion has supported the VLER initiative and the timely and unfettered exchange of health records between DoD and VA. Unfortunately, DoD and VA still have not finalized both agencies ALTA and VISTA architecture systems since the project began in 2007, which limits DoD and VA's ability to track and monitor high risk suicide patients during their transition from military to civilian life. The American Legion recommends VA take the lead in developing a joint database with the DoD, the National Center for Health Statistics and the Centers for Disease Control and Prevention to track suicide national trends and statistics of military and veteran suicides.

The American Legion continues to be concerned about the delivery of health care to rural veterans. As mentioned, a nationwide shortage of behavioral health specialists, especially in remote areas where veterans have settled, reduces the effectiveness of VA's outreach. No matter where a veteran chooses to live, VA must continue to expand and bring needed medical services to the highly rural veteran population through telehealth and Virtual Reality Exposure Therapy (VRET). DoD and VA have piloted VRET at bases at Camp Pendleton, Camp Lejuene and the Iowa City VA Medical Center. VRET is an emerging treatment that exposes a patient to different computer simulations to help them overcome their phobias or stress. The younger generation of veterans identifies with computer technology and may be more apt to self-identify online rather than at a VA Medical Center or CBOC.

Both DoD and VA have acknowledged the lack of research on brain injuries and the difficulties diagnosing PTS and TBI because of the comorbidity of symptoms between the two. The Defense and Veterans Brain Injury Center (DVBIC) developed and continues to use a 4-question screening test for TBI today. At the same time, Mount Sinai School of Medicine in New York developed the Brain Injury Screening Questionnaire (BISQ), the only validated instrument by the Centers for Disease Control to assess the history of TBI, which has over 100 questions with 25 strong indicators for detecting TBI. Mount Sinai has published data that suggest some of the symptoms, particularly those categorized as "cognitive," when found in large numbers (i.e. 9 or greater), indicate the person is experiencing complaints similar to those of individuals with brain injuries. The American Legion wants to ensure that DoD and VA are working with the private sector to share best practices and improve on evidence-based research, screening, diagnosis and treatment protocols of the "signature wounds" of Iraq and Afghanistan.

Recommendations

The American Legion has seven recommendations to improve Mental Health and Suicide Prevention efforts for VA and DoD:

1. Congress should exercise oversight on VA and DoD programs to insure maximum efficiency and compliance with Congressional concerns for this important issue.
2. Congress should appropriate additional funding for mental health research and to standardize DoD and VA screening, diagnosis and treatment programs.
3. DoD and VA should expedite development of a Virtual Lifetime Medical Record for a single interoperable medical record to better track and flag veterans with mental health illnesses.
4. Congress should allocate separate Mental Health funding for VA's Recruitment and Retention incentives for behavioral health specialists.
5. Establish a Suicide Prevention Coordinator at each military installation and encourage DoD and VA to share best practices in research, screening and treatment protocols between agencies.
6. Congress should provide additional funding for telehealth and virtual behavior health programs and providers and ensure access to these services are available on VA's web pages for MyHealthyVet, Mental Health and Suicide Prevention as well as new technologies such as Skype, Apple i-Phone Applications, Facebook and Twitter.
7. DoD and VA should develop joint online suicide prevention service member and veteran training courses/modules on family, budget, pre, during and post deployment, financial, TBI, PTSD, Depression information.

In conclusion, Mr. Chairman, although VA has increased its efforts and support for suicide prevention programs, it must continue to reach into the community by working with Veteran Service Organizations such as The American Legion to improve outreach and increase awareness of these suicide prevention programs and services for our nation's veterans. The American Legion is committed to working with DoD and VA in providing assistance to those struggling with the wounds of war so that no more veterans need lose the fight and succumb to so tragic a self-inflicted end.

Mr. Chairman and Members of the Subcommittee, this concludes my testimony.