Veteran Suicide Prevention: Maximizing Effectiveness and Increasing Awareness

Chairman Roe, Ranking Member Walz and distinguished members of the committee, on behalf of National Commander Brett Reistad and our nearly 2 million members, we thank you for the opportunity to share the views of The American Legion regarding Veteran Suicide Prevention.

Introduction

Suicide prevention is a top priority of The American Legion.

Deeply concerned about the number of military veterans who take their own lives at rates higher than that of the general population, the nation’s largest organization of wartime veterans established a Suicide Prevention Program under the supervision of its TBI/PTSD standing committee, which reports to the national Veterans Affairs & Rehabilitation Commission.

The TBI/PTSD Committee reviews methods, programs and strategies that can be used to treat traumatic brain injuries (TBI) and post-traumatic stress disor­der (PTSD). In order to reduce veteran suicide, this committee seeks to influence legislation and operational policies that can improve treatment and reduce suicide among veterans, regardless of their service eras.

This white paper report examines recent trends in veteran suicide and their poten­tial causes and recommends steps to address this public health crisis.

Summary

“I hate war as only a soldier who has lived it can, only as one who has seen its brutality, its futility, its stupidity.”

- Dwight D. Eisenhower

Since 2001, the U.S. military has been actively engaged in combat operations on multiple continents in the Global War on Terror. More than 3 million Americans have served in Iraq or Afghanistan through the first 17 years of the war. Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) have become known as the “signature wounds” of the war, and in recent years, countless studies, articles and reports have documented an inordi­nately high suicide rate among those who have come home from the war, those of previous war eras and among active-duty personnel.

The American Legion is deeply concerned by the high suicide rate among service­members and veterans, which has increased substantially since 2001.1 The suicide rate among 18-24-year-old male Iraq and Afghanistan veterans is particularly troubling, having risen nearly fivefold to an all-time high of 124 per 100,000, 10 times the national average. A spike has also occurred in the suicide rate of 18-29-year-old female veterans, doubling from 5.7 per 100,000 to 11 per 100,000.2 These increases are startling when compared to rates of other demographics of veterans, whose suicide rates have stayed constant during the same time period.

In order to combat this crisis, The American Legion believes it is imperative to determine the causes of the increase in the suicide rate among these youngest of veterans.

With no current end date to the Global War on Terror in sight, the Post-9/11 cohort will continue to grow, as will the number of veterans who require psy­chological care. The Department of Veterans Affairs projects a Post-9/11 veteran population of just under 3.7 million by 2020.3 As our nation deals with the effects of nearly two decades of conflict, the need for mental health services to care for U.S. military veterans is certain to increase in the years to come.4

It is difficult to determine if the suicide rate among veterans is higher now than it was after previous wars, mainly due to the quality of data previously collected. In the past, bias and stigma against mental injury prevented accurate data collection, research and treatment. After World War II, those suffering from PTSD symptoms were often labeled as malingerers, neurotics, having moral turpitude, or as latent homosexuals.5 Accurate numbers may also have been hard to determine after previous wars due to classifications of suicide as deaths by motor vehicle accident, poisoning, drowning or as other accidents.

High suicide rates among veterans are not a recent phenomenon. In 1922, The American Legion declared the “worst casualties of World War are just appearing” as high rates of veteran suicide were gaining national notice four years after the armistice that ended World War I.6 In 1921, The Washington Herald reported that the state of New York lost more than 400 Great War veterans to suicide in that year alone.7 Similarly high rates of suicide emerged after the Second World War, the Korean War and the Vietnam War.8

Historically, the peacetime suicide rate among American military personnel has been much lower than the civilian rate. Experts have explained this phenomenon by invoking the “healthy soldier effect” which suggests that sound emotional, psychological and physical fitness are necessary for an individual to serve in the military. This healthy baseline is then complemented by the sociocultural protective factors of gainful employment, stable hous­ing, additional education and good leadership.9 Supporting this premise is the fact that the suicide rate in the U.S. Army remained stable from 1977 to 2003 before jumping 80 percent in 2004. In 2008, the suicide rate among active duty military personnel exceeded that of the civilian population for the first time in history.10 This sharp increase corresponded with the beginning of the Global War on Terror, the longest war in American history.

Suicidal behavior is complex. There is no single cause. Multiple factors instead feed into four primary causes discussed in this report:

·                     Post-traumatic stress disorder

·                     Traumatic brain injury

·                     Loss of a sense of purpose

·                     Loss of a sense of belonging

This report concludes with steps The American Legion recommends to help prevent veteran suicide and reduce a rate of self-inflicted death that in recent years has risen to a crisis level.

Causes

Post-traumatic Stress Disorder

PTSD, which was first accepted as a recognized diagnosis by the American Psychiatric As­sociation in 1980, has become a household term since the terrorist attacks of Sept. 11, 2001. The condition, however, is as old as warfare itself.

PTSD symptoms among those who have conducted or witnessed the trauma of battle are addressed in some of the earliest literature. Reactions to trauma, for example, are described in The Epic of Gilgamesh, The Odyssey, The Old Testament and Shakespeare’s Henry IV. Among the symptoms recorded in these earliest accounts are reoccurring nightmares, anxi­ety, loss of interest and feeling of hopelessness in reaction to traumatic events.11

Suicidal behavior is multi-factorial, and the exact cause of the high veteran suicide rate remains a matter of considerable debate. However, what cannot be disputed is the truth that combat is an extremely stressful and traumatic experience. Exposure to combat can result in significant psychological injury, which when left untreated can have a long-term effect on a veteran’s health, well-being, family and society.

Since the Vietnam War, clinicians have noted that suicidal behavior is a frequent manifes­tation of PTSD. Multiple studies have clearly established that combat veterans have higher rates of PTSD when compared to veterans who have not seen combat.12 The greater the exposure to combat the more likely the veteran’s mental health will be negatively affected.13 In addition, veterans who have sustained Military Sexual Trauma (MST) are at a higher risk for developing PTSD; studies have documented that sexual trauma is a risk factor for suicide.14

In 2008, the RAND Corp. reported that at least 20 percent of Iraq and Afghanistan veterans have PTSD and/or depression.15 The current rate of PTSD is consistent with that of veterans from the Vietnam War and previous conflicts.16

The increased rate of veteran suicide since 2001 is often associated with an increase in PTSD due to combat exposure. A 2017 study of U.S. Army Infantry units, Special Forces person­nel and combat medics revealed that suicide risk varies by military occupation specialty and combat experience. Troops in combat arms occupations had significantly higher rates of PTSD and higher rates of suicide.17 The connection between PTSD and suicide may be explained by the symptoms of PTSD experienced. PTSD is correlated to mood alterations including anxiety, depression, irritability, insomnia and survivor’s guilt. These symptoms and changes in mood have all been shown to be considerably related to suicide attempts.18

In addition to the symptoms, PTSD is also often accompanied by secondary effects, such as strained intimate relationships after deployment.19 Research on combat veterans and their families has shown that veterans with PTSD are more likely to have severe relationship problems and higher divorce rates when compared to their peers without PTSD.

An anonymous and confidential study in 2009 showed that a relationship exists between PTSD in combat veterans and higher rates of substance abuse.20 Substance abuse and rela­tionship problems can subsequently lead to legal and financial problems, all of which can place a veteran at risk for suicidal ideation and behavior.

In order to better understand how PTSD is connected to suicidality, it is important to first understand the effects of PTSD on the human brain. PTSD should not be considered a mental illness but rather a psychological injury that alters the way an individual’s brain functions. Traumatic and extremely stressful events are often associated with drastic chang­es in the human brain.

Research has shown that individuals with PTSD experience a hyperactive amygdala as well as volume reduction and decreased functioning in the hippocampus and prefrontal cortex. This is a troublesome combination because the amygdala produces conditioned fear and stress responses to stimuli. The prefrontal cortex keeps the amygdala’s responses in check. A failure of the prefrontal cortex to control the amygdala would cause a reduction in an indi­vidual’s ability to self-regulate responses to mental and emotional stimuli.21 The inability of the brain to function normally in its critical roles may place a veteran with PTSD at higher risk of suicide.

Traumatic Brain Injury

TBI is the most common injury suffered by servicemembers in the current conflicts in Iraq, Afghanistan and across the globe. According to DoD, at least 370,688 service members were medically diagnosed with TBI between 2000 and 2017.22

The detonation of improvised explosive devices and indirect fire account for over 60 percent of U.S. battle casualties.23 Shock waves from blasts can cause severe injury to the human brain. Due to modern armored vehicles, protective body armor and improvements in battlefield care, servicemembers are surviving attacks that in previous conflicts would have proven fatal. The ratio of being wounded to killed in the war in Afghanistan is 7.4 in to 1, compared to 1.7 to 1 during the Second World War and 2.6 to 1 during the Vietnam War.24 Saved lives of military personnel often means more return home with brain injuries.

In a 2008 study, military personnel with TBI were significantly more likely to report phys­ical and mental health problems than those with other injuries.25 This is because chronic neurodegeneration is often the consequence of traumatic brain injury. Symptoms of TBI may include memory and concentration issues, irritability and depression. Many also expe­rience apathy, anger, disinhibition and a lower tolerance for frustration.

In 2009, a study of active-duty soldiers concluded that TBI contributes to an increased risk for suicide.26 Distressingly, each additional TBI increases the risk. In 2011, research showed that among Veterans Health Administration users, veterans with TBI were nearly twice as likely to die from suicide as veterans without a TBI diagnosis.27 Veterans with TBI are more likely to suffer from concentration issues and depression which place them at risk for suicide.

Sense of Belonging

In the late 19th century, Emile Durkheim, often referred to as a founder of the field of so­ciology, wrote one of the first analyses on suicide. Durkheim believed that one of the main causes was lost sense of belonging to society. Durkheim also noted that the transition to modern urban industrialized society had negatively impacted how individuals connected to their communities. Durkheim concluded that high levels of isolation and decreased social integration can lead to suicidal behavior.28

During the First World War, psychiatrists noted that “shell-shocked” soldiers treated near the frontlines with the support of their comrades had a high likelihood of recovery and mental health improvements. Soldiers who were evacuated away from their units and placed in hospitals often developed chronic symptoms and were eventually discharged from the military.29 This indicates that a sense of belonging to a group or society contributes to a higher level of psychological well-being.

Today’s veterans rejoin a civilian society which is largely disconnected from the current Global War on Terror and military service in general. Fewer Americans than in the past have direct family or social ties to the Armed Forces. War bond drives and the need for American workers to rush into factories to create munitions, planes, ships or tanks for the war effort are a thing of the past, which had previously connected U.S. society with the war effort. A smaller percentage of Americans serve in the military today than at any other time since the period between World Wars I and II.30

In a 2011 Pew Research Center study, 84 percent of Post-9/11 veterans said that the public does not understand the problems faced by those in the military or their families. 31

Average Americans may view veterans as “damaged heroes” often portrayed in media as objects in need of charity and pity rather than as potential leaders, co-workers, peers and friends.32 Research has shown that the current average American’s perception of veterans is largely formed by how veterans, servicemembers and the military are portrayed in the media. Veterans are often portrayed as troubled individuals who struggle to readjust to civilian life due to mental health and substance abuse issues.

In a recent online survey, participants were asked to describe the way Post- 9/11 veterans are most often depicted in the media. Among the top responses were: PTSD, homeless, troubled, unemployed, injured, suffering, victims, and unstable. Forty-one percent of those surveyed stated that the way veterans are portrayed in the media is generally accurate.33

Stereotypes can affect how a veteran re-integrates into society. Research has shown that negative perceptions cause adverse outcomes in an individual’s performance, motivation and self-esteem.34 Public perceptions of veterans in need of charity and pity do not pro­mote recovery from a psychological injury like PTSD but may actually act as a self-fulfilling prophecy. In order to facilitate recovery, individuals need social support and understanding. The kind of society that veterans return to can influence how quickly they recover from psy­chological injuries. The key piece is intimate connections and meaningful trusting relation­ships with others in society.

Israel has extremely low PTSD rates among its veteran population. A 2016 study in Israel surveyed veterans of combat operations in major wars from 1948 until 1982. The surveys showed that the probability of PTSD among those who had combat experience was less than 1 percent.35 The low PTSD rates might be attributed to Israel’s cohesive society, in which everyone shares a commonality of service and military experience. When Israeli vet­erans return home, they receive social support from family and loved ones who have served and understand the difficulties of transition, which may be a contributing factor to the low rates of PTSD.

Many veterans also face alienation when they enter academia. In a 2011 study conducted by the University of Nevada Reno, over half of student veterans stated that they do not fit in on campus, and almost one-third said they feel unfairly judged by their peers.36

When service members transition from the military into civilian life, they undergo multiple personality and social identity changes. Losing camaraderie and belongingness to a unit can strip individuals of their social support; many veterans refer to their former military units as family. The loss of trusting relationships and a social support system can reduce the way a veteran manages intimate relationship stressors, financial instability and may lead to substance abuse or legal issues.

The severity of PTSD cannot be explained by merely looking at the source or causal event alone.37 How PTSD manifests itself in an individual is also impacted by social support sys­tems in place that a veteran can depend on. Veterans can be affected differently by similar traumatic experiences. The conditions may vary depending on their level of social support and solidarity in the society they return to. A close cohesive and understanding society enhances recovery and can help to reduce the symptoms of PTSD and help prevent suicide. Israel has extremely low PTSD rates among its veteran population. A 2016 study in Israel surveyed veterans of combat operations in major wars from 1948 until 1982. The surveys showed that the probability of PTSD among those who had combat experience was less than 1 percent.35 The low PTSD rates might be attributed to Israel’s cohesive society, in which everyone shares a commonality of service and military experience. When Israeli vet­erans return home, they receive social support from family and loved ones who have served and understand the difficulties of transition, which may be a contributing factor to the low rates of PTSD.

Many veterans also face alienation when they enter academia. In a 2011 study conducted by the University of Nevada Reno, over half of student veterans stated that they do not fit in on campus, and almost one-third said they feel unfairly judged by their peers.36

When service members transition from the military into civilian life, they undergo multiple personality and social identity changes. Losing camaraderie and belongingness to a unit can strip individuals of their social support; many veterans refer to their former military units as family. The loss of trusting relationships and a social support system can reduce the way a veteran manages intimate relationship stressors, financial instability and may lead to substance abuse or legal issues.

The severity of PTSD cannot be explained by merely looking at the source or causal event alone.37 How PTSD manifests itself in an individual is also impacted by social support sys­tems in place that a veteran can depend on. Veterans can be affected differently by similar traumatic experiences. The conditions may vary depending on their level of social support and solidarity in the society they return to. A close cohesive and understanding society enhances recovery and can help to reduce the symptoms of PTSD and help prevent suicide.

Sense of Purpose

Many service members find purpose and meaning during their time in the military. Serving our nation in uniform, whether here at home or in combat operations overseas, can be per­sonally rewarding in numerous ways. Servicemembers often report that having a mission, working as a team, and completing daily tasks to be fulfilling. The military provides individ­uals the opportunity to contribute to something larger than themselves, to learn new skills and to grow.

The loss of the psychological benefits from their military obligations can lead some veter­ans to struggle with despair as they transition into civilian life. For many veterans, service is core to their identity and the way they define purpose in their lives. In a 2009 study, 92 percent of veterans surveyed stated that serving their community was important to them.38 Data from the same survey shows that volunteering in communities can help veterans tran­sition smoothly into civilian life. Fifty-five percent of veterans who volunteer regularly said their transition was going well, compared to 46 percent of non-volunteering veterans.

A significant relationship exists between an individual’s sense of purpose in life and his or her psychological well-being and levels of self-efficacy. The ability to maintain an un­derstanding of one’s purpose for existence has shown to be an important factor to protect individuals from suicidal ideation. Having a sense of purpose increases feelings of being able to deal with difficult life events, helps fight symptoms of depression, and contributes significantly to lower suicidal behavior and thoughts.39 A renewed sense of purpose can also help mediate the effects of moral injury, guilt and cognitive dissonance felt after losing faith in what some Post-9/11 veterans have deemed to be a futile war.40

Post-9/11 veterans have stood out in the veteran community for their desire to continue to serve and give back, not only to local communities but across the globe. Veterans of Iraq and Afghanistan are finding ways to apply the skills they learned in the military in giving back to their communities in ways not seen before. Team Rubicon and The Mission Con­tinues, non-profit organizations founded by Post-9/11 veterans, are challenging veterans to volunteer in disaster response, social services or youth programs. Research on The Mission Continues participants has shown dramatic increases in self-worth, strengthened relation­ships and enriched family life.41

In addition to volunteering on civic projects, Post-9/11 veterans are running for public office in record numbers. Until 2011, the number of veterans in Congress decreased every year since the end of the Vietnam War. The number of veterans running for public office significantly increased in 2016, and more veterans of the current wars entered races for public office in 2018. Veterans show through many avenues that they are a population that desires to continue to provide meaningful service to our nation.

In February 2015, the Joint Chiefs of Staff wrote a letter addressed to all of those who have served in the military since Sept. 11, 2001. In their letter, the Joint Chiefs challenged vet­erans to begin serving in their communities as soon as they take their uniforms off.42 The Joint Chiefs astutely recognized that veterans need a sense of purpose to live fulfilling lives.

The American public should follow the Joint Chiefs guidance and encourage veterans to regain their lost sense of purpose through public service, volunteering, rewarding careers, learning new skills or crafts, or advocating for issues important to them, just to name a few options.

Risk factors for veteran suicide

Primary risks factors for suicide	Secondary risk factors for suicide
·         PTSD & depression from o   Combat o   Deployment o   MST ·         Traumatic brain injury ·         Loss of sense of purpose ·         Loss of sense of belonging	·         Substance abuse ·         Financial distress ·         Intimate relationship problems ·         Legal issues

Conclusion

Progress by the Department of Veteran Affairs

The Department of Veterans Affairs (VA) has taken great strides to reduce veteran suicide. Of particular note, VA has expanded the Veterans Crisis Line (VCL), which responds to 500,000 phone calls every year as well as thousands of electronic chats and text messages. Since its launch in 2007, through September 2016, VCL staff dispatched emergency services to callers in crisis over 66,000 times.43

VA has hired hundreds of Suicide Prevention Coordinators (SPCs), mental health profes­sionals that specialize in suicide prevention. SPCs are based in VA medical centers and local community-based outpatient clinics all over the country. Over 80 percent of the SPCs are conducting five outreach activities per month for at-risk veterans.44 These events provide opportunities for VA to connect to veterans who may have fallen through the cracks and are not currently seeking VA health care.

In 2017, VA implemented REACH VET, a predictive analytics mechanism that utilizes existing data from VHA records to identify veterans who may be at risk for suicide. REACH VET measures variables such as age, gender, prescription medications, missed appoint­ments, emergency room visits, and other variables to determine risk and notify primary care providers. By utilizing data and predictive analytics, VA is reaching more veterans who may have slipped through the system.

VA has made concerted efforts to destigmatize mental illness through its “Be There” cam­paign. This initiative seeks to teach community leaders, colleagues, friends and family members of veterans how they can make differences in a veteran’s life. The campaign seeks to increase social cohesion by educating the American public.

In 2017, VHA had more than 1,100 veterans working as peer specialists, veterans with formal training who lead support groups, conduct outreach, case manage and help other veterans navigate the services available to them. A 2017 study showed that veterans who worked alongside peer specialists benefited and had increased levels of “patient activation” or buy-in. Veterans also showed increased levels of knowledge, self-efficacy and beliefs in managing their personal health.45

VA has implemented numerous successful initiatives and programs. However, as an average of 20 veterans a day continue to take their own lives, according to the June 2018 analysis, much more must be done, and VA must continue to strive to provide patient-centered care and improve the patient experience through adequately staffed and properly funded pro­grams and services.

 

A June 2018 analysis by VA showed that veteran suicide has increased at a faster rate for those who have not recently used VA care and services available to them than for those who have used those services.

The American Legion’s Concerns

Hiring Process

Despite VA’s most recent hiring initiative, many hospitals and clinics are struggling with se­vere staffing shortages which can be attributed to the tedious hiring process, a high employ­ee turnover rate and a significantly reduced recruitment, retention and relocation budget. The shortage of employees can lead to overworked staff, poor patient experiences and lower quality of care. Exemplary patient experience is vital to keeping veterans in the VA care network, which studies have shown significantly decreases risk of suicide.

According to a 2018 evaluation by the National Academies of Science, Engineering and Medicine, the Department of Veteran Affairs has “difficulty recruiting, problems with re­tention, and lengthy hiring procedures that contribute to high vacancy rates throughout the system, and these vacancy rates can be a barrier to service.”46

This is further supported by reports of veteran experience at VA. When veterans were sur­veyed, 54 percent stated that the process of getting mental health care was burdensome, and 49 percent stated that it was not easy to schedule an appointment. Seventy-seven percent of veterans said that improving customer service was an important change needed at VA.47

After applying for employment at VA through USAJOBS.gov, qualified medical profession­als can wait multiple months to begin work or even receive notice. Many applicants report a tedious, confusing and bureaucratic application process. While waiting to hear back from VA, many potential candidates seek employment elsewhere.

VA also struggles with a high employee turnover rate. In 2016, GAO found that Veterans Health Administration personnel losses in key clinical occupations increased to 7,700 an­nually. These positions include physicians, registered nurses and psychologists. Dissatisfac­tion with certain aspects of work, dissatisfaction with senior management, burnout and lack of benefits were reported as top reasons for resigning. In addition, 50 percent of employees reported that one or more benefits, such as tuition reimbursement, would have encouraged them to stay with VHA.48

In order to discover and resolve the root cause of the current resignation rates, The Amer­ican Legion recommends that Congress fund a nationwide VA climate survey of men­tal health professionals. The American Legion also urges Congress to pass legislation to improve VA’s tedious hiring process and increase VA’s recruitment, retention and relocation budget. These measures will allow VA to retain quality mental health providers, incentivize exemplary performance, and increase employee morale.

Dangerous Drugs

Starting in the late 1970s, benzodiazepines, commonly known as “benzos” became one of the most prescribed psychotropic drugs in the United States. Benzodiazepines are a class of psycho-active drugs that were initially well-favored due to their immediate effect on anxiety, insomnia and agitation. Xanax, Valium and Klonopin are a few well-known benzo­diazepines. Beginning in the late 1980s, multiple studies revealed that benzodiazepines had severe negative side-effects, and high potential for abuse and dependency. VA researchers published reports that cited studies highlighting the risks of benzodiazepines well before the Global War on Terror began in 2001.49 However, despite knowledge regarding these dangers, VA medical providers have continued to prescribe benzodiazepines to veterans.

In 2010, VA Clinical Practice Guidelines for the Treatment of PTSD cautioned providers against the use of benzodiazepines, citing growing evidence of negative side effects, includ­ing an increase of PTSD symptoms, risk of suicidal thoughts and of accidental overdose. Despite the severe risks, over 25 percent of veterans newly diagnosed with PTSD are still being prescribed harmful and potentially deadly amounts of medications.50 According to a 2013 study, 43 percent of servicemembers who attempted suicide between 2008 and 2010 had taken psychotropic medications.51 The link between certain dangerous prescription medications and veteran suicide should be recognized, and steps should be taken to reduce unnecessary prescriptions.

Additionally, benzodiazepines can be extremely harmful to veterans who are already prescribed opiates for pain therapy. Sixteen percent of veterans with PTSD are prescribed a morphine-equivalent dose of opioids concurrently with a benzodiazepine.52 The concur­rent use of these two medications is extremely dangerous and puts individuals at increased risk for overdose. Combining these medications can lead to depressed breathing, affect heart rhythm, increase sedation and lead to accidental death. Despite this known risk, VA dispenses benzodiazepines and opiates concurrently to thousands of veterans every year. Multiple studies have shown that benzodiazepines have no health benefit in treating PTSD and that there is extreme concern for overdose among veterans who misuse alcohol while on them. This is especially worrisome, considering that nearly 50 percent of veterans with PTSD also struggle with comorbid substance abuse.53

Once initiated, it can be very difficult for veterans to stop or taper off from benzodiazepines. In many cases, providers prescribe medications they know are likely harmful to a veteran who is unwitting to the potential negative side effects. The American Legion recommends that written, informed consent becomes a requirement before a veteran is prescribed benzo­diazepines.54 In addition, providers should clearly document their clinical rationale on why they believe the potential benefits outweigh the severe known risks and have supervisors agree and sign off on the decision.

To minimize the dangers of benzodiazepine misuse, The American Legion recommends that mechanisms be put in place to track and monitor possible toxic prescription combi­nations that veterans receive.55 An automatic flagging system would alert providers, their supervisors, and pharmacists of potential fatal prescription drug combinations. It is also important for state-level prescription drug monitoring program databases to share data. This can help cut down on doctor shopping and the unknowing prescription of dangerous drug combinations. This is especially important considering the potential impacts for many veterans seeking treatment through the Veterans Choice and Community Care programs.

Services to Veterans with Other Than Honorable Discharges

Despite reforms intended to halt administrative separations of veterans suffering from service-related conditions, over 62 percent of servicemembers separated for misconduct between 2011 and 2015 had also been diagnosed with PTSD or TBI.56 Depending on the circumstances, veterans with “bad paper” discharges may not be eligible for a broad array of VA health care and benefits, including mental health services that may be critical for veterans with PTSD or suicidal behavior. This is troublesome because evidence collected by VA continues to indicate that there are decreased rates of suicide among veterans receiving VA health care, as opposed to veterans who do not.

The American Legion strongly urges VA to provide mental health care to any veteran who was deployed in a theater of combat operations or an area at a time during which hostili­ties occurred, or any veteran who participated in or experienced such combat operations or hostilities, including controlling an unmanned aerial vehicle from a location other than such theater or area.57

Gatekeeper Training

In response to the high suicide rate, it is now time to ensure that the necessary stakeholders are given training so they may use their knowledge and skills to identify and refer veterans with suicidal ideation to care. It is imperative that suicide prevention training is provided to community leaders, military officers, NCOs, combat medics, chaplains, human resources staff and office managers. VA and DoD suicide-prevention training programs such as SAVE or ASIST can provide those who may be able to intervene the tools they need to save lives.

Complementary and Alternative Therapy

Lack of access to alternative treatments may cause an increase in patient care program dropouts and a rise in prescription drug use. The American Legion commends VA for establishing its integrative health and wellness pilot program. Many veterans have reported great success with veteran-centric treatments such as acupuncture, yoga, meditation, mar­tial arts and other forms of complementary and alternative therapies. It is our responsibility to our nation’s veterans to expand this successful program and ensure all those in need have access.

The American Legion believes all health-care possibilities should be explored and consid­ered, based on individual veteran needs, to find the appropriate treatments, therapies and cures for veterans suffering from TBI and PTSD. These treatments should be accessible to all veterans; if alternative treatments and therapies are deemed to be effective they need to be made available and integrated into veterans’ current models of care. The American Legion requests that Congress provide VA the necessary funding to make complementary and alternative therapies part of its health-care treatment plan for veterans suffering from injuries such as TBI, PTSD and other mental health conditions.58

Volunteerism

Many veterans return home and miss the sense of purpose and belonging that they felt from military service. The American Legion is among the nation’s leaders in providing volunteer service and believes that the nation depends on veterans to continue to engage in their civic duty. The American Legion recommends and supports any government efforts to create incentives to encourage volunteerism.59

The American Legion’s Commitment

Chairman Roe, Ranking Member Walz, and distinguished members of this committee, The American Legion thanks this committee for holding this important hearing and for the opportunity to explain the views of the nearly 2 million members of this organization. The American Legion remains deeply concerned by the high suicide rate among service­members and veterans and is committed to finding a way to help end this crisis. To ensure that all veterans are being properly cared for at Departments of Defense and Veterans Af­fairs medical facilities, The American Legion has established a Suicide Prevention Program and aligned it under the TBI/PTSD Committee. This committee is currently reviewing methods, programs and strategies that can be used to reduce veteran suicide. That work will help guide American Legion policy and recommendations.

For additional information regarding this testimony, please contact Larry Lohmann Esq., Senior Legislative Associate of The American Legion’s Legislative Division at (202) 861-2700 or llohmann@legion.org

Supporting American Legion Resolutions

No. 19: Homeland Security and the Opioid Epidemic. Aug. 22- 24, 2017, National Con­vention, calling for increased federal surveillance and targeted local law-enforce­ment and public health intervention to curb opioid abuse.

No. 23: Department of Veterans Affairs Provide Mental Health Services for Veterans with Other than Honorable and General Discharges. May 10-11, 2017, Nation­al Executive Committee, calling for access to VA mental health care for qualified veterans who receive Other Than Honorable or General discharges and for quali­fied veterans deployed in combat

No. 2: Suicide Prevention Program. May 9-10, 2018, National Executive Committee, establishing an American Legion Suicide Prevention Program and aligning it with the national TBI/PTSD Committee

No. 28: Volunteerism. Oct. 14-15, 1981, National Executive Committee, encouraging and providing government incentives to increase volunteerism in the United States

No. 160: Complementary and Alternative Medicine. Aug. 30-Sept. 1, 2016, National Convention, calling for legislation to improve VA and DoD pain-management policies and acclerate government research into CAM treatment options for vet­erans

No. 165: Traumatic Brain Injury and Post Traumatic Stress Disorder Programs. Aug. 30-Sept. 1, 2016, National Convention, calling for comprehensive joint DoD-VA TBI-PTSD program in one office that provides oversight and funding for alterna­tive treatment programs. enhanced research into effectiveness treatment programs

 

 

Bibliography

1.      U.S. Department of Veteran Affairs. Suicide Among Veterans and Other Americans 2001- 2014. 2017.

2.      Ibid.

3.      National Center for Veterans Analysis and Statistics. Profile of Post-9/11 Veterans: 2015. 2017.

4.      Bilmes, Linda. “The financial legacy of Af­ghanistan and Iraq: How wartime spending decisions will constrain future U.S. national security budgets.” The Economics of Peace and Security Journal. 9,1. (2014).

5.      Brill and Beebe. A follow Up Study of War Neuroses. VA Medical Monograph. Veterans Administration. 1955.

6.      The New York Times, Veterans’ Suicides Average Two a Day. June 2, 1922.

7.      The Washington Herald. Federal Neglect Caus­es Suicides of 400 War Veterans. July 7, 1921.

8.      Postservice mortality among Vietnam veterans. Journal of the American Medical Association, 257,6. (1987).

9.      Castro and Kintzle. “Suicides in the Mil­itary: The Post-Modern Combat Veteran and the Hemingway Effect.” Military Mental Health. 2014.

10.  Bachynski, Canham-Chervak, Black, et al. “Mental health risk factors for suicides in the US Army, 2007–8.” Injury Prevention. 18:405-412. (2012).

11.  Kucmin, et al. History of trauma and post­traumatic disorders in literature. Medical University of Lublin. 2016.

12.  Castro and Kintzle. “Suicides in the Mil­itary: The Post-Modern Combat Veteran and the Hemingway Effect.” Military Mental Health. 2014.

13.  Castro and McGurk. “The intensity of com­bat and behavioral health status.” Trauma­tology. 13,4. (2017).

14.  Kimerling, et al. “Military Sexual Trauma and Suicide Mortality.” American Journal of Preventive Medicine. 50,6. (2016).

15.  Tanielian, et al. Invisible Wounds: Mental Health and Cognitive Care Needs of Amer­ica's Returning Veterans. RAND Corpora­tion. 2008.

16.  Dohrenwend, et al. “The Psychological Risks of Vietnam for U.S. Veterans: A Revisit with New Data and Methods.” Science. 313, 5789. (2006).

17.  R.J. Ursano et al. Suicide attempts in U.S. Army combat arms, special forces and com­bat medics. BMC Psychiatry. 2017.

18.  Hendin H. and Haas A. “Suicide and Guilt and Manifestations of PTSD in Vietnam Combat Veterans.” American Journal of Psychiatry. 148, 5. (1991).

19.  Monson, Taft, and Fredman. Military Related PTSD and Intimate Relationships: From De­scription to Theory-Driven Research and Inter­vention Development. Clin Psychol Rev. 2009.

20.  Wilk, et al. “Relationship of combat experi­ences to alcohol misuse among U.S. soldiers returning form the Iraq war.” Drug and Alcohol Dependence. 108. (2010).

21.  Bremner J. “Traumatic stress: effects on the brain.” Dialogues in Clinical Neuroscience. 8, 4. (2006).

22.  Defense and Veterans Brain Injury Center (DVBIC). DoD Worldwide Numbers for Traumatic Brain Injury. 2017

23.  Ling, et al. “Explosive Blast Neurotrauma.” Journal of Neurotrauma, 26,6. (2009).

24.  Alyson, et al. By The Numbers: Today’s Military. NPR. 2011.

25.  Hoge, et al. “Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq” The New England Journal of Medicine. 358. (2008).

26.  Bryan and Clemans. Repetitive Traumatic Brain Injury, Psychological Symptoms, and Suicide Risk in a Clinical Sample of Deployed Military Personnel. JAMA Psychiatry. 2013.

27.  Brenner, Ignacio, and Blow. “Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services.” J Head Trauma Rehabil. 25, 4. (2011).

28.  Emile Durkheim: Selected Writings. Edited by Anthony Giddens. Cambridge University Press. 1972.

29.     Crocq and Crocq. “From Shell Shock and War Neurosis to Posttraumatic Stress Disor­der: A History of Psychotraumatology.” Dia­logues in Clinical Neuroscience. 2,1. (2000).

 

30.              War and Sacrifice in the Post-9/11 Era. Pew Research Center. 2011.

31.  Ibid.

32.  Strengthening Perceptions of America’s Post-9/11 Veterans Survey Analysis report. Greenberg Quinlan Rosner Research. 2014.

33.  Ibid.

34.  Walton, Murphy, and Ryan. “Stereotype threat in organizations. Implications for equity and performance.” Annual Review of Organizational Psychology and Organiza­tional Behavior. 2. (2015).

35.  Lubin, et al. “Combat Experience and Mental Health in the Israel National Health Survey.” ISR J Psychiatry. 53, 3. (2016).

36.  Elliott, et al. “U.S. military veterans transi­tion to college: Combat, PTSD, and alien­ation on campus.” Journal of Student Affairs Research And Practice. 48,3. (2011).

37.  Pearlin, et al. “The stress process.” Journal of Health and Social Behavior. 22. (1981).

38.  Yonkman and Bridgeland. All Volunteer Force: From military to Civilian Service. Civic Enterprises. 2009.

39.  Wang, et al. “Purpose in life and reasons for living as mediators of the relationship between stress, coping, and suicidal behavior.” The Journal of Positive Psychology. 2,3. (2007).

40.  Kelly, D. Treating Young Veterans: Promot­ing Resilience Through Practice and Advo­cacy. Springer Publishing Company. 2011.

41.  Matthieu, et al. Impacts of The Mission Continues Fellowship Program on Post 9/11 Disabled Military Fellows, Their Families, and Their Communities. Center of Social Development. 2013.

42.  The Joint Chiefs of Staff. A Call to Contin­ued Service. 2015. https://www.benefits. va.gov/GIBILL/docs/letters/Call%20to%20 Continued%20Service%20Letter.pdf.

43.  Department of Veteran Affairs OIG. Health Care Inspection: Evaluation of the VHA Veterans Crisis Line. 2017.

44.  Department of Veteran Affairs OIG. Eval­uation of Suicide Prevention Programs in VHA Facilities. 2017.

45.  Chinman, et al. “Provision of peer specialist services in VA patient aligned care teams: protocol for testing a cluster randomized implementation trial.” Implementation Science. 2017.

46.  National Academies of Sciences, Engineer­ing, and Medicine. Evaluation of the De­partment of Veterans Affairs Mental Health Services. Washington, DC. The National Academies Press. 2018.

47.  Ibid.

48.  Veterans Health Administration: Actions Needed to Better Recruit and Retain Clin­ical and Administrative Staff. United States Government Accountability Office. 2017.

49.  Kosten, et al. “Benzodiazepine use in post­traumatic stress disorder among veterans with substance abuse.” Journal of Nervous and Mental Disease.188, 7. (2000).

50.  Krystal, et al. “It Is Time to Address the Cri­sis in the Pharmacotherapy of Posttraumatic stress Disorder: A Consensus Statement of the PTSD Psychopharmacology Working Group.” Biological Psychiatry. 82. (2017)

51.  Bush, et al. “Suicides and suicide attempts in the U.S. military, 1998-2010.” Suicide and Life-Threatening Behaviour. 43, 3. (2013).

52.  Hawkins, et al. “Prevalence and Trends of Concurrent Opioid Analgesic and Benzo­diazepine Use Among Veterans Affairs Pa­tients with Post-traumatic Stress Disorder, 2003–2011.” Pain Medicine. 16,10. (2015).

53.  Back, Waldrop, and Brady. “Treatment challenges associated with comorbid sub­stance use and posttraumatic stress disorder: Clinicians' perspectives.” American Journal of Addiction. 18. (2009).

54.  Resolution No. 165: Traumatic Brain Injury and Post Traumatic Stress Disorder Pro­grams. The American Legion. 2016.

55.  Ibid.

56.  DOD HEALTH: Actions Needed to Ensure Post Traumatic Stress Disorder and Trau­matic Brain Injury Are Considered in Mis­conduct Separations. United States Govern­ment Accountability Office. 2017.

57.  Resolution No. 23: Department of Veterans Affairs Provide Mental Health Services for Vet­erans with Other than Honorable and General Discharges. The American Legion. 2017.

58.  Resolution No. 160: Complementary and Alter­native Medicine. The American Legion. 2016.

59.  Resolution No. 28: Volunteerism. The American Legion. 1981.