Witnesses. The director of defense and Suicide Prevention office for the office of forest resiliency in the department of defense, the acting director of Suicide Prevention program at the department of Veterans Affairs, the Suicide Prevention branch chief at the center for Mental Health services and Substance Abuse at the department of and a and Human Services family professor of Health Care Policy, department of Health Care Policy at the harvard medical school. Thank you all for being here and we are sorry that we are a bit late. Our topic today is a heavy one. Its one that is difficult to discuss. We must address it to ensure the readiness and wellbeing of our troops, their families and veterans. Suicide is a homefront threat to Service Members and veterans. Tragically, rates of suicide for active duty Service Members and veteran populations have increased in the latest reports, particularly affecting young men under 30 who make up nearly half the military. Veteran suicide is a national epidemic. As a member of the Veterans Affairs committee, working to reduce the number of veterans who die by suicide, its one of my top are your teas. Defense and Veterans Affairs have improved capacity and access to Mental Health and other services yet the rates of suicide have not decreased. I see today is an opportunity to understand what more we can do as a subcommittee to make a positive impact in this area. Military families are also affected by suicide. For the first time, the department of defense released data on suicides by spouses. I hope to hear more about how the dod will track and support spouses and independence affected by suicide in the future. While suicide represent a growing Public Health challenge in the civilian world, the unique composition of our military makes this challenge one of particular importance that we must address. Ensuring adequate care and support for Service Members, families, and veterans facing stress of deployment, transitions, Financial Difficulties and access to health care, it must be a top priority. I look forward to hearing from the dod and v. A. Witnesses and how they are developing evidencebased Suicide Prevention methods to combat the rise in suicides among Service Members, veterans and their families and also from dr. Mcke on and dr. Kessler about research and methods and strategies that can help combat suicide in the military. I want to thank all of the witnesses for being here today. I look forward to your testimony and i now turn to Ranking Member jill a brand opening statement. Thank you for holding this important hearing. Suicide in the military is a serious and growing problem. Not enough is being done to address the factors that contribute to this tragedy. To all of our witnesses, welcome and thank you for sharing your expertise about today with us today. Your insight and contriving factors of the suicides is crucial to helping our Committee Support our Service Members. I appreciate mr. Chairman, you inviting an expert from the Veterans Administration as its critical for us to understand the connections and distinctions between military and veteran suicides to address both. According to the 2019 department of defense annual suicide rate, the rate of suicide experience by Service Members has steadily increased over the last six years, spiking in 2018 by over 6 from 2013. There has been a narrative for a long time that military suicide is due primarily to ptsd and combat missions. Of combatke the toll on military members seriously. But the report clearly demonstrates that combat missions are not directly correlate of to the Service Members die by suicide. Suicide is complex and individual. There are a multitude of factors that lead to Mental Health challenges and can, in turn, lead to the devastation of suicide. Military service is very difficult. Makeervice members sacrifices that are hard for some of us to even fathom. When americans enter into military service, they lose control of where and how often they must relocate, the kind of housing they will live in, which schools their children will attend. Its often impossible to maintain a healthy worklife balance and frequently, our Service Members are expected to sacrifice the needs of their families to accomplish a mission. Our gratitude for their sacrifices is not enough. We must also recognize the unique burdens they face and that those burdens can lead to persistent Mental Health challenges like chronic anxiety and depression. Too often, the Mental Health challenges can contribute to suicidal ideations. Some of the burdens are integral to the way of the military to the way military functions and to ensuring that our Service Members learn Critical Skills and are prepared to serve in a war zone. But its incumbent upon the leaders in this committee to determine when such factors are problematic enough that a greater system of comport must be provided. Military and civilian leaders must determine when factors are most disruptive than necessary to accomplish the mission so that they can develop more appropriate strategies for todays military. The military and the department of defense spend more and more each year on Suicide Prevention but the results are not nearly good enough. I would like to challenge our civilian and military leaders to think about military suicide in a more holistic way, understanding the factors that contribute to Mental Health challenges and to suicide. If the military is able to understand how the day to day stressors of serving can impact Service Members, they can work to minimize those stress soars taste on Mission Requirements and create a system of support Service Members need to be successful. This also means taking a real look at the existing systems of support. Currently, the department of defense has a policy that requires Mental Health professionals to report many cases of Mental Health concerns in Service Members to a commander. This policy leads to mistrust and acts as a barrier to treatment because Service Members fear the repercussions to their career if they come forward with their Mental Health challenges. Of course, dod must have policies to keep their Service Members and colleagues safe but their standards for reporting Mental Health challenges are vague and go much further than the standards for civilian Mental Health professionals or even military chaplains. This policy is more likely to force Service Members to suffer in silence and is nothing to help commanders maintain good order and discipline. I urge the department of defense to review the reporting rules for Mental Health professionals to ensure that they are allowing for maximum confidentiality for our Service Members well also protecting them from those around them. If we cannot limit the barriers that stand between our Service Members and access Mental Health care, i believe we can begin to make progress towards addressing our suicide rate. Mr. Chairman, i look forward to hearing from our witnesses and i am committing to working with our colleagues on the committee to further support our Service Members and their wellbeing. Thank you, senator gillibrand. W will start from left to right. Opportunity for the to appear before you with her colleagues. With our colleagues. With me today is mike kelly, cap the director of the Mental Health with me today as my colleague, the director of the Mental Health program. We are disheartened that the rates of suicide in our military are not going in the desired direction. Loss of every life is heartbreaking and each one has a deeply personal story. With each death, we know there are families and often children with shattered lives. The dod has the responsibility of supporting and protecting those who defend our country. Its imperative we do Everything Possible to prevent suicide now military community. Because data informs our ability to take meaningful steps and fulfill our commitment to transparency, the department has expanded our recording of suicide related data. This past september, we published our first annual suicide report. To supplement our longstanding yeareport, the calendar 2018 suicide rates are consistent with the prior two years across all components. When compared to the past five years, the rates have been steady for the reserve and the National Guard. We have seen a statistically significant increase for the active component. Acceptable, military suicide rates are comparable to the u. S. Population rate after accounting for age and sex differences with the exception of the National Guard. We continue to observe heightened risks for our youngest Service Members and Air National Guard members. Asr, thef the Department Published data for military members for the first time. Suicide rates for our military spouses and dependents in calendar year 2017 were comparable to or lower than the u. S. Population rates after accounting for age and sex. Findings, thesr Department Must and will do more to target our air of greatest concern, our young and enlisted members and their National Guard members as well as continue to support our families. We know suicide is a complex interaction of many factors we know suicide is a complex interaction of many factors. Of life that impacts suicide. We are committed to addressing suicide comprehensively through Public Health. Guided by the Defense Strategy for Suicide Prevention, the dod has many ongoing and future efforts underway. These efforts support seven key evidence informed strategies which include identifying and supporting people at risk, strengthening access and delivery of suicide care, teaching coping and problem solving skills, creating protective environments, strengthening economic support, and lessening harm and preventing future risk. Examples, a few identify and supporting people at risk we will teach young Service Members how to recognize and respond to suicide red flags on social media to help others who might be showing warning signs. With respect to strengthening access and delivery to suicide care, we are partnering with the v. A. To increase National Guard members accessibility to Mental Health care via mobile that centers. That centers. With problemsolving skills, we are piloting an Interactive Education Program to teach foundational skills early in a members career to help with everyday life stressors. Respectal example, with to crating protective environments, we are developing a comedic case and campaign to promote social norms for firearms and medication to ensure family safety. In a written testimony, we provide additional current efforts as well as new promising practices we are piloting and evaluating that line to the seven strategies. I am happy to go through these in more detail. We have also developed an enterprisewide Program Evaluation framework to better measure effectiveness of our efforts. Partnerships are integral to reaching our goals. We work closely with the federal, state, local and other nongovernmental stakeholders to continue to enhance our toolkit and ensure availability of Suicide Prevention resources for Service Members and their families. In closing, i thank you for your unwavering dedication to the support of our men, women, and families who defend our great nation. I welcome your insight, your input, and your partnership. I fully recognize we have more to do and i take this charge incredibly seriously. I look forward to your questions. Chairman tillis, Ranking Member jill a brand, members of the subcommittee, thank you for the opportunity to discuss the dod Public Health challenge, suicide. I wanted to be here with their Suicide Prevention directors. Every life lost is a tragedy. As a physician and former line officer, i have been shaken by suicides. Let me discuss what ive seen. Our military suicide rate was once low. When i was a resident at walter reed in 2001, or active duty suicide rate was half the rate of a similar population. Like the rest of america, dod has seen suicides increase. Even as we created a centralized Suicide Prevention infrastructure and in Large Committee care, her activeduty suicide rate now approaches 25 per 100,000. The National Guard rate is higher. What are we doing . First, we are being transparent. We have been working over the past 10 years to increase the suicide to decrease the suicide rate and more needs to be done. Goal byeach our ensuring all evidencebased intervention for suicide are used and evaluated in regard to suicide outcomes. V. A. dod practical guidelines for suicide risk colleagues me and my was recently rep. Reed , published and some up sized the annals of journal medicine. It evidence for cognitive behavior, Crisis Response planning and lethal means restrictions as. Base remains thin. On the other hand, are evidence based remains thin. This means we need to treat a number of people with a treatment thats been proven to work to achieve a single changed outcome. We need to translate Public Health successes from other domains into the management of suicide. Crisis ond an opioid evidencebased practice, achieving a death rate from intentional and accidental publices 1 to 4 of the rate. Our Public Health effort include heart assessments of policies, pain protocols, screening, pharmacy controls and training efficacy. Implement a policy stemmed from outcomes. Our efforts saved lives. Work onto continue suicidal behavior. I found and list these like other Young Americans were easily separated from their money, placing them in financial peril. There are more ways for Service Members to find trouble today. Abuse, our games on drug the force still uses too much alcohol. I never anticipated that mentoring sailors unsafe relationships would be a leadership skill. It remains so. We must rid our nation of sexual trauma, child abuse. Our partners and kids are a source of strength and our children sustain military culture. Interventions we leverage now are critical. Veterans who get health care at the v. A. Diet less by suicide so transition into v. A. Care is crucial. When i served at the Health Care Center in chicago, shared clinical spaces worked. Finally, we will stay focused on the people in front of us. The hopelessness of suicide can stem from a loss of belonging. All of us and our families can bring many to one another as we protect freedom worldwide. Thank you, i look forward to answering your questions. Thank you, dr. Miller. [no audio] [inaudible] without objection. Opportunityate the you have created [inaudible] i am honored to be in attendance today among this distinguished panel is part of our collaborative efforts addressing veterans suicide. Within my position, im often asked why. In the context of suicide. I have asked this question myself for several years after losing my friend and my colleague, a marine cobra driver f oif. Cide during oe when i ask what i may have missed, it has become clear to me that suicide is a complex issue with no single cause. Beyond it being a National Issue that affects people from all walks of life, not just veterans and Service Members. Suicide is often the result of a complicated combination of risk and protective factors at the personal, communal and societal levels. Thus, i wholeheartedly signed on to fully commit heart and mind to the secretaries, to the executive in charge, and to the priority, clinical Suicide Prevention. Isdaily action, the v. A. Implementing a comprehensive Public Health approach to reach all veterans including those who. O not receive v. A. Health services in this context, we look to the 2019 National Veterans suicide annual report to inform our current situational awareness. One of the key ways in which this years report is different from those in prior years is that it places veterans suicide in the broader context of suicide deaths in america. Thatthe report, we know the suicide rate is alarmingly rising in and across our nation. The average number of adult suicides per day rose from 86 in 2005 to 124 in 2017. These numbers included 15. 9 veteran suicides per day in 2005 and 16. 8 per day in 2017. We know suicide is one of the leading causes of death in the United States. As the father of four young daughters, the fact that suicide has become the second leading cause of death within their current age demographic, its difficult for me to comprehend. The haunting questions and the daunting data, there is hope. Although the rates of suicide are increasing across the nation, we know that the rate of suicide is rising more slowly for veterans engaged in v. A. Ha compared to those not engaged in care. We know that depression and suicide all too often share a tragic relationship but suicide rates have meaningfully decreased among veterans with a diagnosis of depression and who vha thisged in recent translates to 87 veteran lives saved in 2017 compared to 2016. Although female veterans are at higher risk for suicide than their nonveteran peers, there was not an increase in suicide among female veterans with recent vha care compared to the rising rate of suicides in female veterans not recently using vha services. We know evidencebased treatment can effectively address suicide. Leader. Is the national in advancing best practice and universal screening for suicide as well as sameday access in Mental Health and primary care services. Over 4 million veterans have been screened for suicide within the last year alone. Over one million sameday access Mental Health appointments have been fulfilled in 2018. That providing aroundtheclock, unfailing access to suicide Crisis Prevention Services is meaningful. Often, the time between the decision to enact suicide and Suicide Attempt or death can be as brief as 50 or 60 minutes. The v. A. Has become the worldwide leader in the provision of Crisis Services through the veterans and military crisis line. 1800 calls per day, answered within an astounding average of eight seconds. Anchors of hope and progressive actions, we fully acknowledge and commit to the fact that more must be done in the name of Suicide Prevention. The mission is obviously and painfully far from complete. One life lost to suicide is one too many. We therefore appreciate this committees partnership with the v. A. , dod and beyond to facilitate crosscutting and silo breaking, evidencebased clinical and community Suicide Prevention strategies. This concludes my testimony and i am prepared to answer any questions. Thank you, dr. Mckeon. Thank you for inviting us to participate in this important hearing on Suicide Prevention. In american dies by suicide every 11 minutes. Suicide as a temp leading cause of death in the United States and the second leading cause of death between ages 1034. We lost over 47,000 americans to suicide in 2017, almost the same number we lost to opioid overdoses. For each of these tragic deaths, there are grief stricken families and friends impacted workplaces and schools, and a diminishment of our committees. The National Survey on drug use and health is also shown that approximately 1. 4 million American Adults reported attempting suicide each year and over 10 million adults report seriously considering suicide. Our concern is intensified by the cdc report that suicide has been increasing in 49 of the 50 states with 25 of the states experiencing increases of more than 30 . These increases have been taking place among both men and women and across the lifespan. Federal efforts to prevent suicide have been steadily increasing over time, thus far, they have been insufficient to hold this tragic rise. We know where efforts must engage multiple sectors including health care, schools, workplaces, faith communities, and many others. The coordinated efforts can save lives. Suicide prevention grants has shown that counties with grant supported youth Suicide Prevention activities had fewer Youth Suicides that matched counties that were not. The greatest impact wasnt penties that had the longest r of sustained funding foriod. Prevention inde the infrastructure of states, local government, and tribal communities. In the White Mountain apache tribe in arizona, Youth Suicide was reduced by almost 40 . In that community, youth are experiencing suicidal thoughts wherever they may be on the reservation. They are being seen by a trained worker. Samhsa also proves boats also promotes zero suicide. We use the latest evidencebased data on suicide, care protocols, planning, treatment and care transition. Its inspired by the success of the Henry Ford Health care system in reducing suicide by more than 60 . Center stone in tennessee has shown similar results. The state of missouri achieved a 32 decrease in suicide deaths among clients served in committed to Behavioral Health centers. Sam psy has been working to include followup after discharge from psychiatric. In a study of youth on medicaid and 33 states who had been admitted to a psychiatric hospital, the odds of death by suicide were 76 lower for youth who had a Mental Health visit within 30 days of discharge. Mh study demonstrated that rapid telephonic followup after Emergency Department discharge reduced the number of Suicide Attempts. Similarly, the v. A. Safe that study showed a combination of Collaborative Safety planning in the Emergency Department and rapid telephonic followup reduced Suicide Attempts and increased linkage to v. A. Care. Safe study showed the screening in Emergency Rooms led to a doubling of the identification of people experience and suicidal thoughts. In those that were identified, they were at equivalent rest to being seen in the emergency room because of known suicide risk. Suicide rate is the National Suicide lifeline. It answers calls to the to which thenumber med to which the military lifeline can be accessed by pressing 1. Evaluation studies have showed that calls the lifeline lifelineecreased incidences decreased. The fcc has recommended the as a new8 be assigned national Suicide Prevention hotline number. We have worked together to fund a series of mayors and governors challenges to prevent suicide among all veterans, Service Members and their families. We have convened cities and states for policy academies to promote comprehensive Suicide Prevention. We believe that this type of strong interdepartmental effort that incorporates states and committees as partners is necessary to reduce veterans suicide. We have worked together through the federal working group on Suicide Prevention as well as the National Action alliance on Suicide Prevention. Smsa and the entire federal government is involved in an unprecedented number of Suicide Prevention activities but we all know we need to do more. We need to implement take comprehensive public approach that incorporates everything we now know about preventing suicide. We must constantly be looking to improve our efforts and learn from both our successes. We owe it to those who serve this mention all those we have lost to suicide as well as those who love them to strive to improve until suicide among veterans, Service Members and all americans is dramatically reduced. Thank you in this concludes my testimony and i would be happy to answer any questions. Dr. Kessler. Thank you for the opportunity to talk to you today. Suicide is a national problem, not a military or v. A. Problem. The suicide rate in the United States has gone up for the last 15 years, its one of the few countries in the world thats the case. In most countries its flat or going down. Suicide is also fundamentally Mental Health problem. The vast majority of people who die by suicide, psychological autopsies, had Mental Health problems. Most people with a Mental Health problem have an onset in childhood or adolescence. In the United States, the best estimates suggest the median age , 50 of people who will have a Mental Health disorder, it starts at the age of 13. The military is no exception. Which imtar study involved in with the uniformed represent of sample of people in the army, a vast majority of the people had a Mental Health problem, they told us it started when they were a kid. Those early problems are typically relatively mild. They are not the kind of things that would get someone excluded from being in service. They are also not the kind of things that people get treated for. It is only later where the problem gets more concert concurrent. It is tougher to treat it at that point. If it were nipped in the bud, it would be an easier thing to do. What we need to do, one thing of enormous value would be to develop more focus at the early end of the spectrum, rather than late in the spectrum. Lets not wait until they are jumping off the bridge and tried to grab their back. If we can find people with relatively mild problems and get them into treatment early enough, that could be in normas. Enormous. Allenge it is a challenge because there is a reluctance to report these things. How to get people to admit mild problems is tough. Everyone wants to stop smoking after cancer, not before they get cancer. If we work on that problem, we get under norma payoff. The treatment of mild mental disorders compare favorably to cancer. It is tough when they get to the point of suicide. Relatively mild things, costeffectively, they can be treated. The big difference is that when we have physical disorders, there is usually only a small number of things that happen. Towe break our arm, you get the emergency room. Which of these things the National Senate for ptsd, is the leading Research Center in the world. They list 10 different kinds of psychotherapy for ptsd. Seven different kinds of pills. Each one of them works with 30 or 40 of people. There is nothing that works for everybody. There is no one that is best. As a result, most treatment for middle disorders is trial and error. You get the first treatment, which the doctor you see is the one who has the most experience, whether that is the best one for you. Trial and error is the way these things go. Because people who are depressed are depressed, they give up early. They do not stick through the trial and error process. Often they quit with tragic consequences. There are ways of doing a better job than trial and error. It is called purses and medicine. We could do a heck of a lot better than what we are doing right now in the Mental Health domain. V. A. And dod are beginning efforts in that. We need to do more to get the right treatment to the right people, right away. Other things we can do more concretely. I will mention them. I have them in my testimony. There has been an idea to do an inception survey. People who joined the dod do a survey about their history of Mental Health disorders or problems so that we can nip them in the bud. That is something we should explore in a serious way. There are challenges in admitting things but it can be doable. To figurelso be great out a principal way of evaluating when we do those early interventions, how do we know which one works . We need a commitment to a strong evaluation process where you decide whether it works or not. The people who develop it do not do the evaluations. Stick with the good things and cut with your losses cut your losses on the bad things. I am running out of time. I will stop. There are several things along those lines that we can do that are concrete and doable. V. A. And dod are extraordina ry organizations because they are the biggest integrated Health Care Systems in the country. They have highlevel expertise and can do this in a way that other places in the country cannot. I would urge you to help them do that. Mr. Chairman, thank you for the opportunity to share these thoughts with you and your subcommittee. I look forward to answering questions. Thank you for your opening statement. I have decided i will miss the next boat because i dont want to miss the testimony. Them. Ff has instructed senator solomon is not on this committee but he is very much incerned with the trend alaska. I have offered to have senator solomon speak in my turn. I will speak after the other members. Thank you. I appreciate you. Let me ask a couple of basic questions and i will get to the question that is going on in my state. Dr. Kessler, what do you think is driving the increased rates in america . It is very troubling. Does anyone know . I wish i knew. Common mental disorders, anxiety and depression disorders seem to be illnesses of affluence. People in developing countries that are worried about starving to death dont get depressed. They are happy to be alive. That going on. F why it is, there is all kinds of things that you can say. It is social media, we just dont know. There are biological factors that are involved. Stress is involved. There is a combination between individual vulnerability and things that happen in the environment. If there is one magic bullet, we would not be in the pickle we are in today. Thank you. The chairman reference, i was up there last weekend. Alaska, it ist in an army base. It is not a huge army base. It is a first stryker brigade. Months, they have had 10 suicides and one attempted suicide. That is an astounding number for a unit that is not that big. I understand you were informed army the epic oon the conducted this summer. Things thaty you would like to highlight, positive born give or negative. It is a remote base with cold winters. But, may be more broadly, for the military . Thank you you for the question. What is happening in Fort Wainwright is concerning. Of what the army undertook to understand why there is such a high concentration within such a small period of time. I would say in terms of services and whether it is the army or Fort Wainwright in particular, places have things to look at are there higher concentrations and what might be occurring. We have a body for Suicide Prevention, that is interprize wide. We discussed these issues. The army shares Lessons Learned. We can promulgate those Lessons Learned more thoroughly than wainwright itself. In terms of specific lessons, some of the takeaways, common challenges that we see as risk factors for suicide were present at that installation. Relationship issues, financial issues. There were unique factors. Morerctic conditions, isolated and remote areas. An understanding ways that the army could implement specific policies to get after some of those specific challenges are underway. Thank you. I had a couple of things. I have been up there on deployment. It is really dark in the winter. That is associated with mood disorders. Mood disorders are common. Science is not there. Suicides are antis atrophic. If the suicide rate is one and 4000 and you have 4000 people, you might get three or four suicides. But 10 . That is a huge number. That is one where i think we need to run through the bios and social stressors. Back andy hard to look say what exactly it was. That is one of the frustrating things about suicide. We are not taking perspective measures in regard to the treatment of disorders and Anxiety Disorders and Substance Abuse disorders. Another thing, culturally, that i have known and going to college in upstate new york, there is a lot more drinking in the winter than there was in the summer. That is a concern with young folks because of the impulsivity and propensity to be impulsive and the effect on mood and the thatt on sleep and a alcohol has. Thank you mr. Chairman. I want to share a story of someone whose parents shared their story with me. One thing that stands out is the acknowledgment that suicide is not caused by a single condition but that it is linked to a number of can tripping factors. I believe we need to do more to listen to our Service Members when it comes to the stress factors. I want to share their story. Brandon joined the navy but broke a leg during the qualification course. According to his family and other members of the unit, in the midst of these setbacks, brandons supervisor verbally abused, degraded and demeaned him and others on a daily basis. Even though his immediate supervisor had abusive the hatred towards his subordinates and had been relieved for his behavior, brandons command did nothing to protect him. Broken collarbone meant he would be forced to remain in this environment for another year. On june 25, 2018, brandon was so unhappy and felt so hopeless that he walked out of the flightline and approached a helicopter, apologized for what endeds about to see and his life by jumping into the tail rotor. What would be the effect on brandons mental state, given these circumstances and what risk factors would he be experiencing . The mental state of hopelessness is in fact a mental state. Why it is that some people become hopeless in the face of adversity and others not is a tricky thing. Stress is in peoples lives. Not just the stresses that are manageable but things that get you in a box, there is no way out. A lot of people who commit suicide, if they end up not dying by mistake, they say what did you do, why did you do it . They say there is not anything else i could do. It was the last resort. Of things where you get into life situations where there is no way out and this sense of hopelessness, in excess of biggiesness, the two are financial problems and your love life. Having bad leaders is not a good thing. Not one of the top three or four or five. Trick in a lot of therapy, with people who are suicidal is to say it is not the only way out. I can tell you some other ways. You want to prove to her that you loved her so you kill yourself . How about you prove to her that you left her by having a nice life. You show them that there are other ways out, it seems that is what we have to do. Would you agree that leaders ignoring a toxic environment would dissuade people like brandon from seeking Mental Health treatment . And that the possibility of a Mental Health provider contacting his command may have dissuaded brandon from seeking health . Pointhink that is a great. When i came here in 2011, my office promulgated this. It is a hard question. One that we do not always have answers. We have a zerotolerance policy visavis bullying. These are things that are culturally are not things that are culturally acceptable or ok. Happen,xtent that they they are leadership failures. When we get into the investigation phase, that is what we see. I wanted to take one point off of ron. I remember in an earlier stars sergeantseople with that are a little older or thane, they do better hardcharging, young sergeants who are less socially astute. In the military, the best way to is gently and to catch them being good. I think this is one of the barriers to Mental Health treatment, the dods rules for Mental Health providers identified nine conditions under which treatment must be reported to a chain of command. One of the requirements for reporting is in the case of harm to mission. Our Mental Health providers are Mental Health providers brief . Ed . We have a split Judiciary Role as psychiatrists. In that role, i dont but telling a commander that someone was not fit for duty, visavis the mission. We have changed our culture. I have mentioned that in this room before. A lot of times, folks would struggle, especially early in this century, and we would separate them. That had a Chilling Effect on access and care. We do not do that anymore. We obviously have some Mission Imperatives around insider threat. Case,k that the kelly some of those concerns were heralded. That balance usually goes to the patient. I think that we get it. That is the way we train our residents right now. Not surprised to hear that we have fallen short of the market times. I am sorry about that. Thank you. Csally. Mic all i want to thank everybody for their testimony. I served 26 years in uniform. This touched me personally when a cadet in my air force academy took his own life. As we see the trends going on in our society, all of us know someone or love someone who has been in a Mental Health crisis and at suicide risk or has taken their own lives. Someone close to me said, after having gone through this, suicide does not transfer the pain end the pain youre feeling, it just transfers it to those who survive. They are deep wounds for children and other loved ones when somebody feels like they have no other hope. 20 veterans, everyday, are taking their own lives. 20. They deploy, they survive combat and come back and come to this place where the enemy has not taken them so they have taken their own lives. It is so important that we take all of the efforts that are happening across the federal government and throughout society and at the state and local level, our best efforts to try to address this issue. We are seeing trends going up. We are a part of what is going on in our society as well. It is not all combat related. There are other factors that are happening. A couple of examples in arizona, which asu has done a study. Veterans are two times more likely overall to commit suicide than the regular population. For female veterans, it is three times more likely in arizona. These rates are too high and unacceptable. With a sense of urgency, i think we need to not throw our money at the issue but think outside the box. What is not working, what is working, what else can we do . A couple of examples in arizona, in 2015, a 53yearold army veteran, thomas murphy, drove and shot himself. Describede, he physical pain and difficulty he was having eating treatment that he thought he needed from the da. The vast majority of veterans are not in the da system. I want to highlight a good news example in arizona. 2017, it started. It is working to connect veterans and Service Members and earlier to whatever on in the chain of events that theen, there is one example o question was could somebody help clean up after his pets. Once a volunteer showed up, the pet and caring for the pat was a barrier for him to get treatment for Substance Abuse. They were able to meet him where he was and ensure someone would take care of his dog while he went in and got the treatment he needed. This is a great example. I dont want to spend all of the time of where, at the local level, with local volunteers and support, we could be empowering local communities in order to be the neighbor, be the friend and remove the neighbors and get people what they need. What else can we do to incentivize them . Especially for the vast majority veterans who have taken their own lives that are not in the system . I was in arizona two weeks with one was working of the individuals and i was very impressed by what is occurring there. I was trying to count how may times you said local and federal and the importance of the relationship between them. That is what i think that we can work on, together. Combining the power and the resources at the federal level with the local level. Realizing that at the federal level, we can do it cannot do it on our own. There is local specific data and covereds that cant be by us. They can be covered in other ways and partnered by ways we can do and do so well. That is where taking a look at Suicide Prevention, not just from a clinicallybased perspective but from a Community Based perspective is so important. Your example is a great one. There is another example, the veteran treatment courts introduced last week would expand these. Instead of veterans spiraling down or taking their own lives, they are given a chance to spiral up with accountability, treatment and support. We need these types of programs in every community, fit for that community. The other concern i have is if somebody is in crisis and they are in suicide risk, i have seen this firsthand, there are not a lot of choices. They go to the emergency room and get locked down because they are a risk or get put into a Mental Health ward where they are high functioning but they need some help and they dont fit in with the other population. It can put them into a worse crisis. There is not a lot of options for someone who is high functioning but need hurts. Needs help. Any other comments on that . There is a gap for people who are crying out for help but our high functioning and need a path forward. One option that does not require taking someone to the emergency room but that will be done only if nudity needed is contacting the national Suicide Prevention hotline. Assessed and a determination made about what kind of help is needed without going to the emergency room. There are other forms of Crisis Services. Rather than somebody being transported to an emergency room , to receive an evaluation, that same evaluation can be done with a person. There are crisis stabilization and in phoenixa and tucson that provide 72 hours of crisis stabilization. Police officers can drop somebody off a police need to be involved. Improving Crisis Services is an important component. Not all of the components but one very important component. I am way over my time but, thank you so much. Thank you. Matt mentioned the coordination between local and national. Here is a great example where that is the case concerning an enormous number of programs that are local and nobody else knows they exist. To mix and match the right things is one thing. The other challenge is getting the right treatment to the right person. The states with the highest proportions of veterans are kentucky, West Virginia and tennessee. They came from there and joined the military and move back. It is hard to get specialized. If you live in los angeles, they have ultra specialized things. The kind of thing that richard is saying, get things that you can have that can be remote things. The right thing to the right person. Coordinationt of in figuring out how to get assistant to work. A system to work. Mdcsally. Ou, senator i want to go back in terms of levels set on data. Sex, it isr age and roughly to civilian society. But for the national onal guard. Is that right . Yes. It is higher. Guess the question, the first question that i have, you talked about programs. We have heard state, local, federal, nonprofit. We have heard community. Been as at has there National Effort to try to identify best practices and programs with demonstrable efficacy, in a way to start weeding these wellintentioned efforts that may not be achieving the same level of efficacy into programs. You do not want to completely stifle innovation. The next best idea may come out. National effort, dr. Mckeon, in your department, i know we are looking at departments in the dod to determine where we should invest our resources. At a national level, what concerted effort, if any exists aday to try and identify persistent approach to what are the causes of suicide . I would remit i would mention a couple of things. Using is you approaches that can be used in Health Care Systems. That is only one piece. Between 25 and 30 of people who died by suicide have received current or recent Mental Health treatment. We need Broader Community efforts. Not nearly as much evidence around Community Evidence and what is effective. That is an important area. It is incorporated in the National Strategy for Suicide Prevention. A priority to strengthen Community Efforts and look at what may be effective to assist communities in reducing suicide, other than ones that take place within the Health Care Systems. Forart of a recent meeting Mental Health leadership, we met with Mental Health leaders from nine Different Countries to look at what we were doing in our different nations to prevent suicide. And, how we can approach it come principally. What with the different. Omponents comprehensively what were different components so that we can learn from each other . We need more information about what can be most effective to help in the community. Tried to use both strengthening health care or youth Suicide Prevention and strengthening work in the communities. We have some evidence of success for that. There is more work to be done. Dr. Miller, captain colston, i am not an expert in this field. So that we to learn can be instructed with Public Policy choices. One thing that strikes me is that we have a disproportionately high number of men and women in the National Guard. They have a unique circumstance with things being what it is. I dont know how many of them are in deployments or away from home and coming back away from the structure of the military. The layperson could draw the conclusion that that seems to be a disproportionately high number of suicides. Suicides among veterans is much higher among those who have no connection to the ba or bha. You mentioned oftentimes, suicide happens when they are not on the plan and. Ont initiatives are going that can give us some historically, i believe we have been speaking from a perspective of accountability. We have been overreliance on a clinical perspective in addressing the situation within the walls, metaphorically, and literally, of a Medical Center sort of setting. Ishink what we need to do continue to find ways to engage, as ron has said, the right care at the right time, from the right person, from a clinical perspective. In addition, as richard has said, heavily engaging and measuring the communitybased interventions that address broader issues that we know are related to suicide and Suicide Prevention. I will add, as well, the National Guard has unique challenges in locality and and where they are more geographically dispersed as a key factor. In addition to the mobile vet centers, which i think is an exciting incentive, and also on drill weekends, which is an opportunity for regular care, we have partnered closely with the National Guard euro with the approach of providing as many avenues as we can with the approach of providing as many avenues as we can. Are having financial challenges, relationship issues, parenting challenges, the whole challenges, services are available to all families and people in the military. We have it specific for our youth and more broadly for our military Community Family and they are embedded within communities and can be called upon for search opportunities if there is a need to have additional support. I will pass this to my colleague in a moment, but we have a number of avenues in terms of Mental Care Health access within the dod or local organizations with free Mental Health care available for military members, including the National Guard and the family. Add, sir,just Financial Security and Health Care Security rb issues. I have seen patients from the National Guard who were on medicaid before, patients who did not have access to health care recently. When i was deployed, i once saw a young man who had an opioid addiction and was on morphine, which is what he needed to be on, but not in the desert on that therapy. We need to standardize and optimize care for our garden cohorts just like activeduty forces. Thank you. Transitioning are or experiencing a move seem particularly vulnerable. I understand that 37. 8 of Service Members who died by suicide had either exited service or had a geographical move in the last 90 days or would be in the coming 90 days. Service members deal with stressful factors, as well as Culture Shock of civilian life. Suicide rates among veterans must be directly impacted by the lack of adequate coordination to the dod nda as Head Military members exit service. In a recent survey, 65 of members knew a fellow veteran who attempted suicide and 69 new one who succeeded. How can we better serve younger veterans . Correct that the time of transition is representing a higher risk andod for individuals Service Members with regard to suicide and that time of transition can be embodied by exactly what you are talking about, which occurs from servicemember to veteran. Regarding that which we have spent the last year working carefully on with regard to wraparound services, 360 days before separation, the 360 days post. Im optimistic about what week,d on monday of this which was initiation of executive order 13 820 two, step 1. 1, which was the v. A. Callbacks within the first month contactingon, we are every veteran that we receive on the list of those separating. We are introducing them to the v. A. ,to services with the and we are offering them connection and resources within that conversation. We offer them a followup letter to reiterate the sources, and we offer them Mental Health service connections. That began on monday and we will monitor the progress of that within our agency, broad goals, and i look forward to positive results, maam. Have you also looked into this issue, we passed legislation in early 2019 over medication of veterans that sometimes veterans are given four or five medications, and there is some correlation between increase in suicide, susceptibility because of over medication. Have you begin to look at that and have you had findings up until now . Yes, maam. I feel like we have looked at this for a few years, particularly with opioids and opioid combinations with benzodiazepine. We have monitored it carefully as a whole system with opioid prescribing rates, opioid and benzodiazepine combinations, and we have worked on addressing and tracking down that. And, within that, mike knows this better than the rest of us but there are important Clinical Practice Guidelines to attend to. You could exacerbate issues if you taper too quickly or in a way that is not advised, so making sure that we are doing is consistentthat with Clinical Practice Guidelines is also important. Weve had an important emphasis on that within our system. Dr. Kessler, part of your testimony you said you thought it would be interesting to have an inception survey since a lot of the data shows that many Service Members coming with Mental Health challenges. As i said in my opening remarks, a lot of Service Members do not want their commanders to know that they have a history of Mental Illness or there may be an impediment to exemplary service. Do you have any thoughts about if we did create an inception survey, how to allow it to be confidential . And im thinking about the fact that our chaplains are able to provide guided Spiritual Counseling on a confidential basis that never goes to the commander. Is there an argument to be made to allow Mental Health guidance and services to be given in a confidential setting, included and the inception survey, then continue that throughout a servicemembers career, and upon separation . So that you have a continuum care for Mental Health that is outside of the chain of command, so there is no barrier or fear of being degraded or devalued, or being sidelined . You know, in the work that we have done with new soldiers, where we have 50,000 new soldiers, and we survey the rate within 48 hours of the beginning of service, you tell them this is confidential. Some University Guys doing it, their commanders will never know about it. We find 1 of people who told us they tried to kill themselves in the past, if you admit that, then you are not in the army. So all of those people did not say that area that is half of the people who would ever make a Suicide Attempt in the army. They made it before they joined. And on purpose, they did not talk about it. It is clear there are things going on. Most of these problems are relatively mild, but there are some that are pretty severe. What do you do about that . It is a challenge. There are several things we have worked on, like with College Students in the same age group. Saying you want to be all you can be, you want to master the stresses, so we will teach you ways to be more resilient. So you are a winner and not a loser for getting help. There is rebranding that could be done that could do good. It is tough to rebrand that you tried to kill yourself, you know what i mean . So the idea of doing something more confidential that goes beyond military sources, a lot of people know they can go to the chaplains. Chaplains feel beleaguered because they are getting this stuff. As an outsider, it makes sense, but you really have to turn to the folks here at the dod. As an outsider, i certainly feel that has a lot of common sense to it. Maam, i have a 22nd followup. Anyone can speak on the issue. The most trouble i was in in the military when i was a clinical psychologist was when i did not report that the spouse of one f16 driver was experiencing Substance Use disorder issues. When there was an on installation event involving the situation, the commanding for notwas livid at me telling him about this. I said, why would i tell you . He said because i would not have asigned this person to be f16 driver. I said, how fair is that . What was really underline his emotion was the fact that he was afraid that he was going to get in trouble and that fingers were going to get pointed, so at all levels, i think we also need to take a look at the culture in which we blame and point fingers , and we allow people to take a chance in some cases and use clinical discretion and interpersonal discretion instead of blaming when something bad happens as a first resort. Related, so weve been working for a long time on trialing on trying to deal with sexual violence. And more than half of the survivors are men in round numbers, but the number of men willing to report is very low because they do not want to be justued or made fun of, or appear that they are not Strong Enough or tough enough for the job, so they do not report. Then we have seen evidence that ,ntreated sexual trauma particularly among men, is one of the leading reasons for suicide amongst that cohort. One of the reforms you put in place a long time ago is that we let people report if they had been sexually assaulted confidentially to get access to services. Not really working because the men still have low reporting, at least to put that into place. Extentnking that to the any of you have thoughts on this issue, making a recommendation to the committee about how to create a safe space Mental Health reporting, similar to the allowance we make for military sexual trauma reporting, to just get services into these people so they do not lose hope or decide or fall prey to suicide. Rightt, by the way, was when he talked about nondisclosing. Policy wise, he was fine on that nondisclosure. I think something along those lines codified in law might not be a bad idea because right now, it is a training and cultural issue of how we practice as psychologists and psychiatrists. I would be grateful if you each do a recommendation to the committee by letter after youve thought about it because i do believe having a requirement i the chain of command to report any Mental Health issue is a significant barrier to seeking treatment, and weve seen it in the military sexual trauma context. I would love your recommendations about ways you can implement Something Like this that you think would be productive based on years of experience and expertise. I appreciate that. I just wanted to share one new additional thing we are doing. The panel has spoken to the importance that we are trying to change the culture around hope seeking, about how we view Mental Health, how you view suicide, and certainly we need to do that nationally and not only within the military, but one new Pilot Initiative we are working on is a Training Program focused on trying to talk about a lot of those concerns that Service Members may have worked are the perceived barriers . The concerns and impact it may have on security clearance or the confidential laterally concerned, confidential concern, and talking about different resources they can use. They could use chaplains. A variety of different options in addition to Mental Health rationales to seek help, so i think that is an Important Initiative that we are beginning to help break that concern of i cant breathe shout or im not aware of the various portals of where i could reach out resources. Thank you. Dr. , i want to come back to your opening statement. You were talking about identifying atrisk persons, and i think you may have referred to it as a red flag. It brings up Something Else i want to talk about. If the existence for a program , thenhat is known couldnt have the unintended consequence of having other people try to do everything they can not to be flagged . Which actually relates to one thing i think is a fundamental problem that i had not seen anyone fix. Ive always used the example at any time you talk about Mental Health, i have set on a panel and talked about removing the stigma of Mental Health, and when someone whispers to me about a Family Member or friend who has rental health, which by itself stigmatizes and basically perpetuates the stigma. And then dr. Kessler, in your opening statement, you spoke about how a lot of that atrisk signs are in adolescence, when you probably have parents who would write it off as the child going through puberty or teenagers. I think you referred to 13 years old, so how do we work on that, or what work is being done to wear early in someones life, we are identifying it . And then dr. Orbis, how are we making sure that these things that are wellintentioned to identify people who may need to seek help do not have the offset fact of making them feel like they are about to get flagged and perpetuating the stigma . Is a really important question. I will share a little bit about the initiative first. The intent is for peers to help each other. We know our young individuals across the nation are using social media frequently. Statistica recent that over 75 of individuals regularly use social media. We have also done research in the dod that shows inability to disclose when they have suicide ideations or troubles and social media, so this is a tool to help, and if you see your buddy or peers saying these things in social media and may be else sees it, what should you do . What could you say and what resources are available . We are evaluating it now so the training video is complete, but we are doing evaluations with Service Members to understand the efficacy before we roll it out broadly. Add is what i would also and we were talking about this earlier, many times, suicide is so complex and caused by so many are, frankly,here simple things we could do, being connected with one another, having those conversations makes a difference, and that is part of what this particular training is trying to do, open up the avenue to have the conversation to not be afraid of saying, are you thinking about harming yourself . We know that is a misconception. If i say something, i could be at a risk of putting a thought in someones head when they did not have it before. It allows someone to share what they are going through and get that support. Dr. Kessler . It is the 64,000 question. The challenge is, as i said earlier, do we want to repackage it to say things are mild enough that you are building strength . You will have a great resilience . When it is bad enough that you cannot do that anymore, there has got to be a thing where people say, i have been depressed or general comes up and talks about this, or a famous person. It could backfire for many years. The week with the highest suicide rate in america was week after Marilyn Monroe killed herself, and that has been supplanted to the week after Robin Williams killed himself and that is now the highest week of suicide. Horrible,gs life is what hope is there for me . Thing, to have stories of resilience to say, look, i have been through tough times and came out the other end and you may recall rich carmona, a surgeon general, a trauma surgeon at one point, and he was really into real men can get depressed. I have been through hell, and anyone with blood through their veins fit have that situation. Just like real men get scared. Of course i was scared. If you say you were not, you are lying. So the people who are tough admit it upfront. We will have to go through it eventually with this. How to do it in an intelligent way and get from here to there with no hustles along the way, i dont know but it is a way that we have to confront it eventually directly. Recent research has indicated that stories of hope and recovery of people who are encountering difficult times, including suicidal crises, but get through it and can still particularly important in having positive impacts. There has been a lot of concern about depictions of suicide leading to an increase. And safe messaging is important, but the recent research about stories of hope and recovery i think is important, and i also would want to mention that to reiterate something matt had mentioned that it is so important that to the extent we justave this occur in a culture. It is very important within Health Care Systems. If someone dies by suicide, it is really important to take a look at that, but we will not learn from those tragic events. If the psychiatrist or psychologist, physician and social worker are afraid they will be blamed, so we need to look at these situations in a situation for a just culture, for a culture that is not looking to find the fault that caused suicide but hoping to understand it better and to learn from each death to find ways to improve. Sir, if i may add, there was an article coming out of i believe the albany news of senator gillibrand estate today, where they are talking about state leadership and vesting significantly in Mental Health counselors in the schools, elementary, middle schools, and then not just counselors but increasing availability of clinical type care and increasing education about Mental Health and Mental Health issues, and normalizing aspects of it at a young age. I think that is extremely powerful. I think it is a great example of where we need to go, and i think it is an example of the power of the task force and what we can do through prevents by combining the v. A. , the dod with the department of education and taking a look at how to extend this dion the state of new york. Thank you. Senator gillibrand . Thank you, mr. Chairman. We have gone through a few rounds ourselves, and i could go on forever, and we will need to because there will be no one solution. It is an effort that will ,ontinue for many congresses but one thing im interested in and your feedback, and i have questions to submit to the record and hopefully get your , even meager or minor steps that we could be looking at as we prepare and go into next year and look at the next nda, and to the point senator gillibrand brought up, dr. Miller, were in the case where perhaps we have to codify with proper practice is one little thing to make sure command understands how to behave, but any congestions you may have for our considerations as we begin to work on the next part for the National Defense authorization, and anything independent of that, we would be interested in your ongoing feedback and dialogue. I apologize for the hearing and for starting a little bit late. We are very interested and committed to doing everything we can, so i thank you all for being here. We will keep the record open for one week and we look forward to your continued feedback. Committee is adjourned. [indiscernible chattering] [indiscernible chattering] live 2020 cspans Campaign Coverage continues today at 1 45 p. M. Eastern on cspan. Former Vice President joe biden in iowa. At 7 00, time stier is in Iowa Tom Steyer is in iowa. Watch on cspan, cspan. Org or listen on the free cspan radio app. For 40 years, cspan has provided america unfiltered coverage of congress, the white house, the Supreme Court in Public Policy events from washington, d. C. And around the country to make up your own mind. Created by cable in 1970 nine, cspan is brought to you by your local or cable satellite provider. Cspan, your unfiltered view of government. 2020 democratic president ial candidate senator Bernie Sanders spoke with supporters at the National Motorcycle museum and anna moser, iowa. Senator sanders open the event by addressing the killing of the Iranian Military leader by u. S. Forces. And gentlemen, please welcome senator Bernie Sanders. [applause]