Transcripts For CSPAN2 Hearing On Military Suicide Prevention 20240713

Programs in the department of defense director of Defense Suicide Prevention Office and the department of defense doctor miller acting director Suicide Prevention program at the department of Veterans Affairs and Suicide Prevention branch chief and deferment of Human Services and doctor kessler professor from the department of Health Care Policy at harvard medical school. Sorryea we are late. The topic is heavy and one that is difficult to discuss but we must address it to ensure the readiness and wellbeing ofut troops and families and veterans. Suicide is a homefront threat tragically rates of suicide for active Duty Service Members increased in the latest reports affecting young men under 30. It is a National Epidemic as a veteran Affairs Committee thats one of my Top Priorities the department of Veterans Affairs improveve capacity and access to Mental Health and the rates of suicide have not decreased. D i see today as an opportunity to understand what more we can do to make a positive impact in this Area Military families are affected and for the first time the department of defense i hope to hear how the dod support spouses and dependents affected by suicide in the future. While a growing challenge unique composition and ensuring adequate care and those of Financial Difficulties and access to healthcare it must be a top Priority Program look forward to hearing from the dod and how they are developing evidencebased Suicide Prevention methods to combat the rise among servicemembers and veterans and their families and also from research and methods and strategies to help combat suicide in the military. Thinking to the witnesses for being here today look forward to your testimony. Thank you for holding this hearing this is a serious and growing problem and to address the factors to all witnesses thank you for sharing your expertise your insight of contributing factors are crucial to support our Service Members and i appreciate as it is critical to understand the military to address those. According to the annual suicide report it has steadily increased over the last six years spiking in 2018 over 6 percent narrative primarily to ptsd combat missions and we must take this very seriously that the report clearly demonstrates that combat missions are not directly correlated to servicemembers who die by suicide. It is complex and individual there are a multitude of factors that can in turn lead to the devastation of suicide military service is very difficult hours servicemembers make sacrifices that are hard for some of us to even fathom when they Enter Service they lose control of where and how often they must relocate, housing, schools their children will attend often impossible to maintain a healthy worklife balance and frequently servicemembers are expected to sacrifice the needs of their families to accomplish the mission our gratitude isnt enough we must recognize the unique burdens they face and those burdens can lead to persistent Mental Health challenges like chronic anxiety. Too often those challenges contribute to suicidal ideations. That isnt her goal to the way the military functions and to ensure servicemembers have Critical Skills and are prepared to serve in a war zone and then to determine what factors are problematic enough that a greater system of support must be provided. To develop more appropriate Strategy Fund strategies so then to spend more and more each year on Suicide Prevention but the results are not good enough i would like to challenge the military leaders to think about military suicide in a more holistic way the factors that contribute to the challenges in suicide. If they understand the servicemembers they can work to minimize those stressors based on the requirements and create a system of support servicemembers need to be successful. This also means taking a real look at the existing systems of support currently there is a policy that requires Mental Health professionals with servicemembers to a commander leading to mistreatment because servicemembers fear the repercussions to their career if they come forward with Mental Health challenges of course dod must have policy that the standards are vague and go much further for civilian Mental Health professional or military chaplains. And for those to suffer in silence to maintain order and discipline i urge the department to review the reporting rules for Mental Health professionals to ensure while protecting those to be around them ever access to Mental Health care and then to make progress at the suicide rate mister chairman we look forward to working with you on this committee and the military and the dod to further support our Service Members. Chairman to listen Ranking Member thank you for the opportunity to appear before you with our colleagues from veterans in menstruation and Harvard University i am with my colleague director of the Mental Program and we are very concerned we look forward to discuss the Suicide Prevention efforts we are worried they are not going in the desired direction each one has a deeply personal story with each death there are families and children and the dod has the responsibility of supporting and protecting them and it is imperative we do Everything Possible to prevent suicide in the military community. So to take meaningful steps the department has expanded with the data this past september we published the first annual suicide report to supplement our long standing report and in the 20 year 18 suicide rates are consistent with the prior two years when compared to the past five years they have been steady for the National Guard they have seen for the active component while hardly acceptable suicide rates are comparable to the Us Population rates after accounting for age and sex differences with the exception of the National Guard we continue to observe heightened risks for National Guard members as part of the asr the Department Published suicide data for military members for the first time suicide rates for spouses and dependents and calendar year 2017 were comparable to or lower than the Us Population rate after accounting for age and sex based on those findings the department targeted areas of greatest concern the young and enlisted members as well as continuing supporting her familys suicide is a complex interaction we must address those many aspects we are committed to addressing suicide comprehensively to the Common Health approach guided by the Defense Strategy the dod has ongoing efforts underway they support seven key strategies which include identifying and supporting people at risk to have delivery of suicide care teaching coping and problem solving skills with a protective environment to strengthen economic support and to prevent future risk. Take for example identifying and supporting people at risk teaching young servicemembers how to respond to red flags on social media to help those with respect to strengthening suicide care or partnering with the v. A. With the accessibility to Mental Health care during drill weekends. With respect to teaching and coping a problemsolving skills we have interactive Educational Programs to teach foundational skills to help with everyday life stressors and as a final example to protect a creative environment with the campaign to promote social norms to ensure family safety. In our written testimony we have efforts that we pilot and evaluate to aligned to the seven strategies and i will talk about these in more detail the enterprise wide framework to better measure effectiveness and prevention efforts partnership is integral working closely with the federal state and local and other stakeholders to continue and enhance the toolkit to ensure availability Suicide Prevention resources for members and families in closing thank you for your unwavering dedication in the support of men women and families who defend our great nation i welcome your insights input and partnership i fully recognize we have more to do i take this charge incredibly seriously and i look forward to your questions to make chairman and members of the subcommittee thank you for the opportunity to discuss dod Public Health challenge of suicide to be here with the Suicide Prevention director every life lost is a tragedy as a physician and former line officer to be shaken by suicide for me discuss what i have seen military suicide rate was once low when i was at walter reed in 2001 active duty suicide rate was half of a similar population like the rest of america dod has seen a slight increase even with the infrastructure and in large communities active duty suicide rate approaches 25 per 100,000 the National Guard rate is higher. What are we doing . Be transparent we have been working over the past ten years to decrease the suicide rate clearly more needs to be done. How do we reach our goal to ensure all evidencebased is used to be evaluated in regard to suicide outcomes. The v. A. Dod Clinical Practice Guidelines by co champion leeson brenner and doctor bell was recently published of the annals of internal medicine Crisis Response planning as evidence against suicide and on the other hand evidencebased is remaining thin many require the development of intervention is small this means we need to treat a number of people with the treatment that has been proven to work without a single changed outcome we need to translate publichealth successes into the management of suicide dod has opiate crisis of evidencebased practice from intentional and accidental to one fourth of the National Rate along with positive drug screens including hard assessments of policies and screening and pharmacy control implemented policies and procedures from outcomes we need to continue work on suicidal behavior as a line officer i found that they were easily separated placed in financial peril is not hard for them to find trouble today despite drug abuse they still use too much alcohol i never thought mentoring sailors on leadership skills would be a skill that we have to stop sexual trauma and child abuse our partners and kids are a source of strength and sustained military culture. Interventions now are credible those that get help die less by suicide so we transition into v. A. Care when i served at the Healthcare Center in North Chicago shared clinical spaces worked finally to stay focused on the people in front of us suicide can stem from a loss of belonging from us and our families as we protect Freedom Worldwide thank you i look forward to answering your questions. Thank you doctor miller. I appreciate the opportunity. [inaudible] i am honored to be in attendance today as part of the collaborative efforts addressing veteran suicide. Within my position i am 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 to suicide. In my quest to learn what i may have done wrong or missed with john, it has become clear to me that suicide is a complex issue with no single cause. Beyond a National Issue that affects people from all walks of life not just veterans and servicemembers suicide is the result of a complicated combination of risk and factors at the personal communal and societal levels i wholehearted the signed on for heart and mind to the secretaries and executive in charge and the v. A. Top clinical priority of sin is one Suicide Prevention and response of daily action to implement a comprehensive plan to reach all veterans including those that do not see vha Health Services in this context looking to the 2019 National Veteran suicide annual report to inform the current Situational Awareness one of the key ways this is different from those in prior years it places veteran suicide in a broader context of suicide death that american from the report we know the suicide rate is rising alarmingly across the nation the average number of adult suicides per day rose from 86 and 2005 to 124 and 2017 these numbers included 15. Nine veteran suicides per day and 16. Eight per day in 2017 we know suicide is one of the leading causes of death in the United States and as a father of four young daughters the fact that suicide has become the second leading cause of death within their current age demographic is difficult for me to even comprehend. Amidst the haunting question and the daunting data, there is hope although rates are increasing across the nation we know the rate of suicide is rising more slowly for veterans engaged in vha care compared to those not we know to share a tragic relationship that suicide rates to decrease with a diagnosis of depression with recent vha care. To translate 287 veteran lives saved compared to 2016 although at higher risk for suicide there was not an increase of suicide among female veterans with recent vha care from those recently not using services we know evidencebased treatment can effectively address suicide therefore a National Leader to advance best practice of universal screening for suicide as well the same day access of Mental Health and primary care services. Over 4 million veterans have been screened for suicide within the last year alone over 1 million same day access appointments have been fulfilled in 2018 we know providing aroundtheclock unfailing access to crisis Prevention Service is meaningful often the time to enact suicide and Suicide Attempt or death can be 50 or 60 minutes the v. A. Is a worldwide leader in the provision of Crisis Services to the veterans and military crisis line 1800 calls per day within an average of eight seconds amidst positive anchors of hope and actions we fully acknowledge that more must be done with Suicide Prevention the mission is obviously painfully far from complete one life lost is one too many we appreciate that Committee Partnership with the v. A. And dod to facilitate cross cutting with evidencebased clinical Suicide Prevention strategies this concludes my testimony im prepared to answer any questions. Chairman and Ranking Member and members of the committe committee, thank you for inviting us to participate in this important hearing on Suicide Prevention in american dies by suicide every 11 minutes the tenth leading cause of death in the United States the second between ten and 34 losing 3,702,017 almost the number we lost with opioid overdose for each tragic death there a grief stricken families and friends impacting workplaces and schools in diminishment to our Communities National survey has also shown approximately one. 4 million American Adults before attempting suicide and 10 million report seriously considering suicide. Our concern is intensified by the cdc report it is increasing 49 of 50 states that experience increases of more than 30 percent these have been taken place among men and women federal efforts to prevent suicide increasing over time thus far are insufficient we know our efforts must engage multiple sectors of healthcar healthcare, schools, workplaces and communities and others we have seen a concerted coordinated effort the evaluation of Suicide Prevention grants has shown counties with grants supporting Suicide Prevention activities had fewer Youth Suicide than match counties that were not the greatest impact was counties with the longest period of sustained funding for their prevention efforts this underscores the need for Suicide Prevention in the infrastructure of local government and tribal communities Youth Suicide was reduced by almost 40 percent in arizona imagine they are experiencing suicidal thoughts whenever on the reservation will be seen rapidly by a Trained Community worker also providing grants to provide the zero Suicide Initiative it is a package of interventions uses the most recent evidencebased science on screening and Risk Assessment and safety planning and care protocols and treatments and Care Transitions inspired by the Healthcare System to reduce suicide by more than 60 percent tennessee has shown similar results the state of missouri achieved a 32 percent and death among clients of Community Behavioral Health Centers also working to improve followup after discharge from inpatient psychiatric units in Emergency Rooms the study of youth on medicaid admitted to a Psychiatric Hospital the odds of death by suicide is 76 percent lower for those who had a Mental Health visit within 30 days of discharge in the study that showed rapid telephonic followup after emergency discharge reduces the number of Suicide Attempts similarly the v. A. Study shows a combination of Collaborative Safety planning in the Emergency Department and rapid telephonic followup reduce Suicide Attempts and increase linkage to v. A. Care the study shows that universal streaming in Emergency Rooms led to a doubling of the identification of those experiencing suicidal thoughts and those that were identified right equivalent risk to those seen in the emergency room the Prevention Program that touches the greatest number of people is the national Suicide Prevention lifeline a network of 100 Crisis Centers across the country to answer calls to that the veteran crisis line can be accessed by pressing one last year more than two. 2 million calls were answered by galatian studies have shown the lifeline experience does decrease hopelessness by the end of the call the ftc and the v. A. Have worked together to implement the National Suicide hotline improvement act recommending that they be assigned as a new Suicide Prevention hotline number working together to fund the governors challenge was suicide among all veteran suicide members and their families for states and policy academies to promote comprehensive Suicide Prevention we believe this type of strong interdepartmental effort is necessary to reduce veteran suicide also working together with the federal Suicide Prevention as well as the National Action alliance. The entire federal government engaged in an unprecedented number of Suicide Prevention activities but we all need to do more. But comprehensive public Health Approach and then to both successes and our failures and all those that they have lost to suicide and those that have loved them strive to improve among veterans and servicemembers thank you this concludes my testimony. Thank you for the opportunity to talk to you today suicide is a National Problem and most countries that suicide is fundamentally a Mental Health problem and then with Mental Health problems. Most have the onset of childhood or adolescence in the United States it suggest the median state law does age of those of a mental disorder starts at the age of 13. The military is no exception when we start our studies for the prospective study the vast majority now those early problems are typically mild doesnt exclude somebody from being in service and not what you can get treatment for only a number years later when the problem gets more severe. If it was nipped in the bud it would be much easier. And then to focus on the early end of the spectrum lets not wait until they are jumping off the bridge we can get them into treatment early enough as senator gillibrand said it is a challenge because there is a reluctance to get people to admit relatively mild problems everyone want to stop smoking after they get cancer not before that i could have the enormous payoff these early treatments compare very favorably to cancer Heart Disease or diabetes is tougher when they get to suicide but the relatively mild things the big difference with the physical disorder is only a small number of things that you break your arm you know what to do if you get depressed you can go to social worker Family Doctor or your priest or rabbi the National Center for ptsd the leading Research Center in the world list on their website ten different types of psychotherapy seven different kinds of pills. Each one works for 30 or 40 percent nothing works for everybody and no one is best as a result most treatment is trial and error. You get the first treatment those that have the experience trial and error is the way these things go and those who are depressed there are ways of doing a better job known as Precision Medicine we can do a heck of a lot better and then we are beginning those efforts to get the right treatment to the right people right away. There are other things he can do more concretely that there has been the idea of a new inception survey of everybody does a survey to find people quickly and nip it in the bud. It would also be great to figure out a principled way how do you know which one works we need a commitment to a strong evaluation process for those that develop it dont give you those evaluations so you stick with the good things. We need to integrate the many systems that dod has but there are several things along those lines that are very concrete the v. A. And dod can do this because theyre the greatest Health Care System in the country a high level of expertise they can do this in the way others cant and i urge you to help them do that so thank you again for the opportunity to share these thoughts with you and your subcommittee we will answer your questions. I will miss the next boat because i dont want to miss any of the testimony my staff has been instructed. Senator solomon is not on the subcommittee that he is very much concerned with the trend up in alaska so i am happy to have him speak in my turn. Thank you i appreciate you and senator gillibrand holding this hearing. Let me ask some basic questions but doctor, wyatt is driving the increased rights rates in america corrects this is troubling. I wish i knew. Depression and anxiety disorder seems to be an illness that people in developing countries that are starving dont get depressed and theyre just happy to be alive so theres some of that going on. But theres all kinds of things that we just dont know its clear there are biological factors involved in stressors are involved with vulnerability and things that happen in the environment but as everybody sits here today there is a lot of things going on. The chairman referenced at Fort Wainwright in fairbanks alaska not a huge army base but in the last 18 months they had ten suicides and one attempted suicide that is an astounding number for unit i understand you were informed that the army conducted at Fort Wainwright this summer are there any recommendations you would like to highlight positive or negative from that report . Not just to make a difference at this phase that is struggling because it is a remote to base with cold winters and maybe you are broadly for the military . Thank you what is happening at Fort Wainwright is concerning what the army undertook to understood the amount of time in that installation but in terms of services in particular and those that are they seeing higher concentrations and what sort of factors for that installation we also have with a Steering Committee for Suicide Prevention so those best practices with my office and health of fares but in terms of specific Lessons Learned that we see as risk factors at that installation and those relationship issues. Its where you need factors coupled with the arctic condition the most isolated and remote area to get through those specific challenges are underwa underway. Obviously way up there on deployment that is associated with mood disorders and the other thing is that science that suicide is anti isotropic 4000 folks with the suicide rate one out of 4000 you may get three or four suicides that ten is a huge number we have to run through those stressors. Is very hard to look back and say what it was. We are taking prospective measures in regard regarding Substance Abuse or mood disorders that there is a lot more drinking in the winter than the summer and that is always a concern especially with their impulse in the propensity to be impulsive. And i thank you mister chairman of someone who shared that story with me what stands out is the acknowledgment that it isnt caused by a single condition and i believe we need to do more to the servicemembers and for those who are no longer able to tell us what led them to feel so hopeless and take their lives on to share this story. Brandon enjoying the navy during the Qualification Course family and other members of the unit had professional setbacks his supervisor verbally degraded him even though he was found to have had a history of abusive behavior and was previously relieved for his behavior but there was nothing done to protect him. With a broken collarbone he was forced to remain in this environment for another year then he was so unhappy he walked out of the flightline approach the helicopter apologized to a nearby sailor then jumped into the aircraft tail propeller. They had little hope that anything would change with his mental state given the circumstances of the risk factors he would be experiencing. Its an actuarial matter and stress that things that get you in a box and theres no way out a lot of people commit suicide if they dont die by mistake why did you do it . There wasnt nothing else i could do. It was the last resort. So if you get to those life situations that sense of hopelessness. So actuarially and having bad leaders was top two or three or 45 and whats going on and then ten on the list or Something Like that. But the trick is to say its not the only way out i could tell you other ways you really loved her she will kill yourself how do you prove to her the left ear to have a nice life. But sorry thats it we have to do. Word you agree there is a toxic environment for Mental Health treatment and thats a possibility and a may have dissuaded just when i came here in 2011 for that instruction we sent over a couple days ago. It is a hard question and one we dont always have answers for with the bullying that they are culturally acceptable and to the extent that they happen they are leadership failures in every get into that investigation and remember with the earlier stars meeting to mention those who were better or older or little more mature to that. Bet in that case Mental Health providers are briefed and is it reasonable to think they would understand a patients role in that mission . We have a split fiduciary role as psychiatrist i dont ever remember telling a commander somebody wasnt fit for duty. That we have changed our culture and a mention that before People Struggle especially in this century which also has a Chilling Effect on accessing care but we dont do that anymore. We do obviously have some Mission Imperatives ofs inside in the kelly case some of those concerns were heralded but we need to strike a balance. As a provider that balance usually goes to the patient and i think we get it thats the way we train our residents right now at walter reed but im not surprised to hear that we have fallen short of the market and im sorry about that. Thanks to the chairman and Ranking Member for having this really important hearing today and for everyones testimony i served 26 years in uniform this issue as i think back touches me personally someone in the air force academy in my squad took his own life as we see this trend come all of us know someone or love someone who has been in a Health Crisis or has taken their own life and is someone close to me said after having gone through this that suicide is not and the pain you are feeling it just transfers it to those who survive in the deep wounds for children and other loved ones if they feel they have no other hope. Twenty veterans every day are taking their own lives. Twenty. They deploy, they survive combat and come back to this place the enemy has not taken their life but they take their own. It so important we take all the efforts happening across the federal government and society and at the state and local level at our best efforts to address this issue. Veterans come from society and we see the trend is going up it isnt all combat related but these other factors. A couple of examples in arizona asu did a study veterans are two times more likely overall to commit suicide than the regular population and for the female is three times the rates are way too high and unacceptable. So with a sense of urgency we dont need to just throw more money at the issue but think outside the box. What else can we do a couple of examples in 2015 a 53 yearold veteran with a suicide note and a gun he described his physical pain and the difficulty he had getting treatment that he felt he needed from the v. A. Theres countless stories like that but the vast majority are not even in the v. A. System. So i want to highlight a good news example we have a b connected program in 2017 it started to really work to connect veteran servicemembers and families to whatever support they have that doesnt go back to an immediate crisis but early are on in the chain of events. I have been very impressed by that. I was trying to count how may times you said local and federal and the importance of that relationship between them. That is what i think we can work on together combining the power and resources at the federal level with the local level realizing at the federal level we cannot do it on her own. There is local specific but it can be in other ways and partnered with which we can do and do so well. Thats where taking a look at Suicide Prevention isnt just clinically based that is so important your example is a great one. And to introduce Bipartisan Legislation where instead of veterans spiraling down to take their own life they took their triads to spiral up we need these types of programs in every community. With a suicide risk but there isnt a lot of choices to go to the emergency room they are locked out because they are risk then play inpatient Mental Health where they are high functioning but they need help and they dont fit in with the other population thats the worst place theres not a lot of gray options in that moment but i really think there is a gap for those who are crying out for help. The one option but that would be done but by getting the lifeline so somebody could speak to someone who is talk to and to make that determination what type of help is needed but there are other forms of Crisis Services on this continuum that has things like mobile outreach of somebody being transported to an emergency room to receive that same evaluation it would be done there are crisis stabilization units in arizona and phoenix and tucson that provide 74 hours of crisis stabilization or they can drop somebody off so improving the Crisis Service is one important component not the only one but to improve the nationals to suicide efforts. Im way over my time to go thank you so much that the coordination is a great example it is an enormous effort that exist one place to have that National Perspective is one thing but the other thing of having the challenge veterans are much more rural. And with kentucky and West Virginia and to join the military and its hard with those ultra specialized things. [laughter] so to get things that you could have get the right thing to the right person there is a lot of coordination to get the system to work to take advantage of those good ideas many of which we dont know about. I think i have read the incidence of suicide and the military is roughly equivalent to civilian society for the National Guard . Yes sir. Is at roughly the same . It is. I guess the first question that i have talking about those problems that are state or local or federal or nonprofit or community, what effort has there been to identify best practices and programs of demonstrable efficacy and a way to start eating these wellintentioned efforts . You dont want to completely stifle innovation that either in your department i know we are looking at programs to determine where we should invest our resources but at a National Level what concerted effort exist to identify a consistent approach . Mentioning a couple of things so with that initiative others that could be in other Healthcare Systems that is one piece but its only one piece italy between 25 and 30 percent of those that die by suicide have received current or recent Mental Health treatment we need more Community Efforts there is not nearly as much evidence so that is an important area that National Action alliance has made it a priority to strengthen Community Efforts and what could be effective to assist communities to reduce suicide within the Healthcare System as part of a recent meeting as part of the International Initiative we meant met with Mental Health leaders to look at what we were doing and how we could approach that comprehensively and the different components so we can all learn from each other. So we definitely need a comprehensive approach but what could be most effective in the community with a suicide efforts we try to use both strength of healthcare and prevention but also work in the communitys list of evidence of success but there is a lot more work on work to be done. Im not an expert in this field of trying to learn with the policy choices and with that high number of men and women on the National Guard they have a unique circumstance and then coming back away from the structure so they could draw the conclusion that seems to be a high number of suicides from the population we know the suicide among veterans is much higher what does that tell us historically, i believe that we have been speaking from a perspective of accountability. Clinically, we have been overreliance on it pure clinical perspective in addressing the situation within the walls both metaphorically and literally of a Medical Center sort of setting. I think that what we need to continue to do is find ways to engage, as ron has said, the right care at the right time for the right person from a clinical perspective, but then in addition, as richard has said, heavily investing in and measuring the effectiveness of communitybased interventions that address broader issues that we know are related to suicide and Suicide Prevention. The National Guard has unique challenges and locality and where there are more geographically dispersed as a key factor. We have a number of in addition to the center that is an Exciting New Initiative and on drill weekends which is an opportunity to have that regular care, i was partnering very closely with the National Guard bureau with the approach of providing as many different doors or absences as we can partnering with local resources within the community. There is military one source available if you are having financial challenges, relationship issues, military one source is available to everyone. We have a military family life counselor for the military Community Family and they are in the Academic Community is outgoing and can be called upon for opportunities if there is a need in a particular community to have additional support. I will pass this onto my colleague in the moment, but a number of avenues in terms of Mental Health care access whetheaccesswhether it is withir partnering with local organizations with a great example of Mental Health care that is available for all of our military members including the National Guard and their family. I would add Financial Security and Healthcare Security are big issues for this cohort. Ive seen patients from the National Guard on medicaid shortly before and patients that didnt have access. When i was deployed i saw a young man that had an addiction and was on beauty morphine which is great treatment he needed to be on that he didnt need to be in the desert on that particular therapy, so we need standardized and optimized care just as we do for the forces. Senator gillibrand. Doctor miller, Service Members that are transitioning are experiencing the move and to seem particularly vulnerable. For the department of statisti statistics, Service Member who died by suicide have either entered or exited service or had experience in geographical moves the last 90 days or would be in the coming 90 days. Service members who are exiting the service are dealing with a number of very stressful factors as well as the Culture Shock transforming to a transitioning. Unemployment and suicide rates must be directly impacted by the lack of adequate coordination between the dod and va as military members are exiting service. They found 65 of the members knew a fellow post9 11 veteran that attempted suicide. You are 100 correct at time of transition to peace and the high risk period for individuals that are in servicemembers with regards to suicide. From Service Member to veteran. I am optimistic with regards to Wraparound Services and about assorted what started on the va pullback. We are contacting every veteran and introducing them to services and offering resources and the conversation. We offer a followup letter and we offer them connection of Mental Health services. Again that began on monday and we will be monitoring the progress of that within our agency goals and i look forward to the positive results. Theres some correlation between the susceptibility have you begin to look at that . Particularly with opioids we have been carefully monitoring opioid prescribing rate and we are working on tracking down and addressing the. However, there are important Clinical Practice Guidelines you could exacerbate if you taper to quickly so making sure that it is consistent with Clinical Practice Guidelines is also important and weve had an emphasis on the system as well. Part of the testimony was all that it would be interesting to have a survey since the data shows many coming of Mental Health challenges have a lot of servicemembers dont want their commanders to know that they have a history of Mental Illness or that there might be an impediment to be exemplary services. Do you have any thoughts about if we could create an inception survesurvey how to allow it to e confidential coming and im thinking about the fact that our chaplains are able to provide guidance and Spiritual Counseling on a confidential basis that never goes to the commander is there an argument to be made to allow the services to begin in a confidential setting included in the perception survedeception surven continue that throughout the servicemembers kabir and again upon separation so you have a continuum of care so that there isnt that barrier of being sidelined. We tell them this is all confidential, the commanders will never know about it and they told us they try to kill themselves in the past. If you admit that, all these people didnt say that its about half the people who ever make an attempt and on purpose they didnt talk about it. Most of the problems are my old some are pretty severe. Weve been working with college students, the same each group. We are teaching you are a winner for going in and getting help so there is a great branding that can be done. The idea of doing something thats more confidential and goes beyond the military source a lot of people do know that they can go to the chaplains and they are feeling beleaguered now because they are getting gettit of this stuff. It makes a lot of sense but you have to turn to the folks here. I ha have a 22nd followon. The most trouble i was on in the military when i was in office were clinical psychologist is finite not report the spouse of a 16 driver was experiencing when there was an installation involving the situation the Commanding Officer was livid at me for not telling him about this. He said hes a good signhe saidd the driver to be if i knew that. And what was underlining his emotion is the fact he was afraid he was going to get in trouble and fingers were going to get plaintiffs have asked all levels i think we also need to take a look at the culture in which th we blame and point fins and allow people to take a chance in some cases and use clinical discretion instead of blaming when something happens as a first resort. We have been working for a long time on trying to deal with the scourge of the violence and did you know that more than half of the survivors are men in terms of raw numbers but the number of men willing to report is very low because they dont want to be devalued or made fun of or appeared they are not Strong Enough or tough enough for the job so they dont report. And we have seen some evidence that untreated sexual trauma particularly among men is one of the reasons among that cohort. One of the reforms you put in place a long time ago is we want people reported they had been assaulted confidentially so they can get access to the services. It isnt really working because they have low reporting but at least we put that into place. And i am thinking that to the extent any of you have thoughts on this issue making a recommendation to the committee about how to create a safe space for Mental Health reporting similar to the military sexual trauma reporting to just get services into these people so that they dont lose hope or fall prey to suicide. Policy wise he was fine on the nondisclosure and i think something along those lines codified in the law might not be a bad idea because right now it is a training issue and a cultural issue of how we practice. After he had time to think about this, i do believe having a requirement by the chain of command to report any Mental Health issue is a significant barrier to seeking treatment and we have seen it in the military sexual trauma context. I loved your recommendations about ways you could implement Something Like this that you think would be productive based on your years of experience and expertise. I just want to share one thing we are doing and the panel has spoken to the importance of trying to change the culture around how we view Mental Health and a suicide. One of the initiatives we are working on is a program focused on trying to talk about the concerns of the security clearance or privacy concerns into different resources they could use in addition to Mental Health professionals to seek help. That is an Important Initiative that we are using to help break the concern. Maybe im not aware of the various portals of where i can reach out for support and resources. Thank you. I want to connect to your Opening Statement. We 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 it for the existenctheexistence for a proge that is known could it have the unintended consequences of having other people try to do everything they can which relates to one thing that is a fundamental problem i havent seen anybody to. I use the example anytime you talk about Mental Health and i sat on a panel talking about removing the stigma and then i get off the panel and somebody comes up to me and whispers about a Family Member or friend that has Mental Health which by itself is stigmatizing in perpetuating the stigma. In your Opening Statement you were talking about how a lot of the signs or adolescence and that they would write it off as going through puberty boy teenage years i think you referred to about 13yearsold so how do we work on that or what work is being done where early in someones life we are identifying it and then how do we make sure they dont have the opposite effect and therefore perpetuating the stigma. It is for peers to help each other. We know that the young individuals across the nation are using social media and a frequent standing. There was a statistic that 55 of our young individuals across the nation regularly use social media. Weve also done a search that has shown individuals to disclose when they are having suicide troubles in social media so this is a tool to help if you see your peer saying things on their social media and maybe no one else is seeing it, what should you do, how can you reach out and what resources are available. We are evaluating it right now so the training video is complete but we are doing evaluations of Service Members to understand the effectiveness and efficacy before we roll it out broadly. I think what i would also add is we were talking about this earlier many times suicide is so complex and cost by so many different factors, and there are simple things we can all 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 is opening 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 at risk of putting the thought in someones hea head and they hadt thought about it before and we know its helpful and allows the release of someone to share what they might be going through to get the connectedness and support. Doctor kessler for doctor mckeon. Its the 64,000dollar question. The challenge is to leave onto as i said earlier repackage it to say things my old enough you are going to have a great resilience. When its bad enough you can dot do that anymore, theres got to be something where people say ive been depressed before, ive had ts. A general comes up and talks about this or a famous person but as said it can backfire. For many years the week of the highest suicide rate was the week after Marilyn Monroe killed herself and that has been supplanted now, the week after Robin Williams is now the highest. If he thinks worth isnt worth living but hope is there for me so it is a tricky thing. To have stories of resilience ive been through tough times and i came out the other end. You might recall a Surgeon General at one point, he was h. , search and and was into men can get depressed. Ive been through hell. Anybody that has blood running through their veins would be pushed in a situation. Just like real men get scared. Of course i was scared. If you say youre not youre lying. The people Strong Enough for those that admit. We have to go there eventually with this. How to do it in an intelligent way out to get from here to there and not have potholes along the way i dont know but its got to be something that we confront in a direct way. Recent research has indicated stories of hope and recovery of people encountering difficult times including suicidal crisis could get through it and can still thrive are particularly important in having positive impacts. In the Suicide Prevention field theres been a lot of concern about the depictions of suicide leading to an increase and safe messaging is important that the recent research about the stories of hope and recovery i think is important and i would also want to mention that to reiterate something mac had mentioned its so important to the extent we can see this occur within the just culture and not one of claim its important in the Healthcare Systems. If someone dies by suicide, its important to take a look. But we wont learn from those tragic events if everyone is iffy. If a psychologist, psychiatrist, physician, social worker or afraid they will be playing. We need to look at the situations in a situation with a culture that isnt blaming or looking to find fault. Thats hoping to understand it better and to learn from each to find ways that we can improve. Sir, if i may add, there ths an article coming out i believe it is in the albany news of senator gillibrand state today where they are talking about state leadership investing significantly in Mental Health counselors in the schools, elementary, middle schools and then not just counselors and increasing availability of clinical type of care, but also increasing education about Mental Health and Mental Health issues and normalizing aspects at a very young age. I think that is extremely powerful. I think it is a great example of where we need to go, and i think its an example of the power of the task force by combining the cea width of the department of education and taking a look at how to expand beyond the state of new york. Thank you, sir. As you can see we have gone through a few rounds ourselves. We are going to need to because there isnt going to be any one solution. Its an effort we will continue for congress. I do have feedback and questions for the record we will submit. The senator brought up the case where perhaps we need to codify what youre doing which is proper practice, one little thing we can do to make sure the command understands how they should behave but any suggestions that you may have for the consideration as we get to work on the next National Defense authorization and anything independent of that is interested in the ongoing dialogue and feedback and again i apologize for the hearing starting a little bit late and i think you see the members that came here have expressed an interest. We will keep the record open for one weekend look forward to your feedback. The committee was adjourned. [inaudible conversations]