Transcripts For CSPAN3 Hearing On Military Suicide Prevention 20240713

And to learn about effective evidencebased Suicide Prevention strategies. To have a panel of experts director for Mental Health programs for overset office at department of defense, the director of defense of Suicide Prevention office for the office of the department of defense and acting director at the department of Veterans Affairs the Suicide Prevention chief of Substance Abuse and Mental Health at the department of Mental Health and Human Services healthcare policy department of Health Care Policy at Harvard Medical School thank you for being here and our topic today is a heavy one that is difficult to discuss but we must address it that the readiness and wellbeing of troops and families and veterans suicide tragically rates of suicide with veteran populations have increased from the reports affecting young men under 30. Veteran suicide as a member of the Veterans Affairs committee of those who die by suicide is one of my Top Priorities the department of defense improved capacity at the rates of suicide have not decrease. With an opportunity to understand more we can do to make a positive impact in this area. Military families for the first time the department of defense with the suicides by spouses and dependents i hope to hear how they are affected by suicide in the future while growing Public Health challenge in the civilian world the composition makes it one of particular importance we must address to ensure adequate care for support for servicemembers and families and veteran veterans with Financial Difficulties and access to healthcare it must be a top priority. I look forward to hearing from evidencebased Suicide Prevention methods with the among servicemembers and veterans and families and also of civilian Research Strategies that could help combat suicide in the military i want to thank all the witnesses for being here today i look forward to your testimony now to Ranking Member gillibrand. Thank you for holding this hearing suicide in the military is a serious and growing problem not enough is being done into all of our witnesses thank you for sharing your expertise of the contributing factors is crucial to help the Committee Support the servicemembers and that you have an expert from the connections and distinctions between military and veteran suicide according to the 2019 report the rate of suicide has steadily increased over the last six years spiking in 2018 it has been a narrative for a long time primarily to ptsd and combat missions and we must take the toll very seriously but the report clearly demonstrates that combat missions are not directly correlated to the servicemembers who die by suicide it is complex and individual a multitude of factors that can lead to the devastation of a suicide the servicemembers make sacrifices when they enter into military service they lose track of the housing they live in what schools their children would attend its often impossible to maintain a healthy worklife balance and they are expected to sacrifice the needs of their families to accomplish a mission the gratitude for their sacrifice is not enough we must also recognize the unique burden that can lead to persistent Mental Health challenges like chronic anxiety and depression and too often those challenges can contribute to Suicidal Ideation of course some of those burdens are intragoal to the way the military functions to ensure servicemembers are prepared to serve in a war zone but it is incumbent upon the leaders to determine when the factors are problematic enough that support must be provided military and civilian leaders determine when factors are disruptive and necessary to accomplish the mission 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 away, understand the factors that contribute to Mental Health challenges and to suicide, if the military is able to understand how the daytoday stressors can Impact Service members they can work to minimize the stressors based on a Mission Requirements and create the systems 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 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 d. O. D. Must have policies to keep their Service Members safe but there is standards for importing the mental standards are vague and it goes much further for civilian Mental Health and civilian chapel,s it is more likely to do nothing to help commanders maintain good order and discipline, i urge the department of defense to urge the rules for Mental Health professionals to ensure that they are allowing for a maximum confidentiality for Service Members but also protecting them, if we can eliminate the barriers that stand between our Service Members and have access to Mental Health care i believe that we can begin to make progress towards addressing our suicide rate, mister chairman i look forward to hearing from our witnesses, i look forward to committee with you and further supporting our law veterans. Chairman tillis and Ranking Member gillibrand thank you for the opportunity to appear before you, with me today is my colleague captain mike the director of Mental Health programs, like you we are very concerned about the suicide rates in our military and we look forward to discussing the department Suicide Prevention efforts, we are disheartened that the rates of suicide in our military is not going in the desire direction, the loss of every life is heartbreaking and each one has a deeply personal story, with each death we know that there are families and often children with shattered lives, the d. O. D. Has the responsibility of supporting and protecting those who defend our country and it is imperative that we do Everything Possible to prevent suicide and our military community, because data informs our ability to take meaningful steps and transparency, on this past september of published our first annual suicide report to supplement our law standing suicide reported and briefly calendar year in 2018 are consistent with the prior two years across all components, one compared to the five past years the rates have been steady for the reserve and National Guard however we see a statistically significant increase for the active component, while hardly acceptable military suicide rates are comparable to the u. S. Population rates after accounting for age and sex differences with the exception to the National Guard, we continue to observe heightened risks for our youngest Service Members, as part of the azar the Department Published suicide data for military members for the first time, suicide rates for military spouses and dependents in calendar year 2017 or comparable to or lower two than the u. S. Population rates after accounting for age and sex, based on the findings the Department Must and will do more to target areas of greatest concerns our young enlisted members and National Guard members as well as continue to support our families. We know suicide is a complex interaction of many factors and our efforts must address the many factors that impact suicide. We are committed to addressing suicide comprehensively through a Public Health approach, guided by the Defense Strategy for Suicide Prevention the d. O. T. Has many ongoing and future efforts on the way. They su these efforts support n key 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 supports and lessening harms and preventing future risk, to provide a few examples, identifying and supporting people at risk, we will be teaching young Service Members how to recognize and respond to suicide red flags on social media and help others who might be showing warning signs, with respect to strengthening access and delivery to care we are partnering with the va to increase the accessibility show Mental Health care via mobile centers during trial weekends, with respect to teaching coping and problem solving skills we are piloting an Interactive Educational Program to teach foundational skills early members career to help with everyday life stressors, as a final example with respect to creating protective environments we are developing a Communications Campaign cheaper more Family Safety with arms we provide additional efforts and evaluating that allowed to the seven strategies i can show you any of these and more detail we also have developed an enterprise ride Program Evaluation framework to check our prevention efforts. This is a drill to reach our goals, we work closely with the federal, state, local and other non governmental stakeholders to continue to advance virtual kid and ensure availability of Suicide Prevention resources for members and their families. In closing i thank you for your unraveling dedication to support of our men, women, and families to defend our great nation. I welcome your insights, and put in partnership. I fully recognize that we have more to do and i take this charge incredibly seriously, i look forward to your questions. Chairman tillis, greg member gillibrand, members of the committee, thank you for discussing the Public Health challenges, suicide. Along with the Suicide Prevention colleagues, every life loss is a tragedy, i have been shaken by suicides so let me discuss what ive seen. Our military suicide rate was one solo, when i was a resident and walter reid our active duty suicide rate was half the rate of a similar population, like the rest of america d. O. D. Has seen the suicides increase, even as we created a centralized Suicide Prevention infrastructure and enlarge community care, are active duty suicide rate now approaches 25 for 100, 000, the National Guard rate is yet higher, so what are we doing . First we are being transparent, we have been working over the past ten years to increase the suicide rate and clearly it shows more needs to be done. How do we reach our goal . By ensuring all evidence based interventions are being used in evaluated in regard to suicide outcomes. Our v. At t clinical practice guideline for risk, shaped with me by lisa brenner, suicide biologist and chairman of public view, board was refereed and synopses, failed evidence for cognitive behavioral therapy, lethal means restrictions as avenues for suicide, are evidence based remains then many domains of intervention require and the in fact size of interventions are small. This means that we need to create a number of people with the treatment that has been proven to work to achieve a single change the outcome. We need to translate Public Health successes from other domains into the management of suicide. D. O. T. Stemmed an Opioid Crisis with its evidence, going from intentional to accidental, along with positive drug screens, our Public Health effort included a hard efforts, screening, pharmacy controls, training ftc. Lamented policies and procedures stem from outcomes and efforts to save lives we need to continue work on the precipitous of suicide behavior like other Young Americans they were easily separated from their money placing them and financial peril there is more way for Service Members to find trouble despite our gains on drug abuse the force still uses too much alcohol and i never anticipate that seafarers on safe relationships would be a skill but we have sexual trauma and child abuse our partners and kids are sort of strength and our children sustained military culture interventions we leverage now are critical veterans who get Health Care Ad via dial us by suicide so transition into va care as we share 130 clinical spaces when i served in North 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 in our families and meeting to another as you protect freedom worldwide, thank you i look forward to answer your questions,. Thank you doctor mueller id like to submit this letter by the secretary without objection i appreciate the opportunity of both created as a veteran i am deeply disturbed by the status of my fellow veterans and im honored to be a net tendencies among of this distinctness panel 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 just suicide, in my quest to learn what i may have done wrong or what i may have missed with john its become clear to me that suicide is a complex issue with no single cars, beyond International Issue that affects people from all walks of life, not just veterans and Service Members. Suicide is often the result of risk and protective factors at the personal, communal, and societal levels, thus eiffel hardily signed on to fully commit heart and mind to the secretaries, through the executive in charge and to the vas top political priority Suicide Prevention. And response and in daily action the va is implementing 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 committee 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 healthcare 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 underway underway. Obviously way up there on deployment that is associated with mood disorders and the other thing is that science that suicide is antiisotropic 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 that ten is a huge number and i think we need to look at the psycho social stressors. It is very hard to look back and say what exactly was and that is one of the frustrating things about suicide. We are taking prospective measures in regard to the treatment of mood disorders, Substance Abuse disorders, things along those lines, but something culturally ive known there is a lot more drinking in the winter than there was in the summer, that is always a concern especially with young folks, visavis positivity, any effect of mood that alcohol has. Thank you mister chairman. Thank you senator sullivan, senator gillibrand. Thank you mister chairman, i want to share a story of someone whose parents share that 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 contributing factors, i believe we have to do more to listen to our Service Members when it comes to the stress factors, and loss in these reports are stories that they can tell, us the crippling factors that led them to feel so hopeless they take their own lives. So i want to share brandons story. Brandon it joined the navy got a broken leg it ended the dream, of court into this the initial setback once announced a supervisor degraded him. This supervise rose found you have a history of abuse of behavior and was previously really for his behavior, they did nothing to protect those in its charge. Brandon attempted to transfer but a broken collarbone man that he knew i had to stay in this environment release another year, on june 25th brandon it was so unhappy and felt so hopeless that he walked out of the flight line and approach to helicopter and apologize to a sailor and ended his life. Doctor, brandon faced personal setbacks combined with daily abuse, had little hope that anything will change. What would be the effect on brandons mental state and what risk factors would he be experiencing . Well the mental state of hopelessness is in fact a mental state and why it is that some people become hopeless in the face of adversity and others not is a tricky thing. Stresses in peoples lives and stresses that seem not are manageable but things they get you in a box and theres just no way out, a lot of people commit suicide if they end up not dying by mistake and you say what were you doing . Why did you do . It they said there is nothing else i could do i tried Everything Else it was a last resort. So the kind of thing where you get in the life situation others know where out is the sense of hopelessness and that sense of hopelessness we know is the two big eaves, financial problems and youre live life. We, have a bad leader is not a good thing but thats not one of the top three or four or five, we have done these big surveys whats going on in your life or release this just suicide theres maybe ten analyst, the trick in a lot of therapy with people who are suicidal is to say to them you know what, its not the only way out i can tell you some other ways, you dont like that you want to prove to her they really loved youre gonna kill yourself how about you prove to her the really love or by going off and try to have a nice life, there are other ways to show them they can move forward. Captain what you agreed that leaders avoiding a top six environment, would and that the possibility of a Mental Health care provider contacting his command may have dissuaded brandon from seeking help . I think that is a great point man and i was actually, just when i came here in 2011 my office promulgated that we send over a couple of days ago. Its a hard question and one that we dont always have answers for, other than we do have a zero tolerance policy. These arent things that are culturally acceptable, and to the extent that they have been our leadership failures and i think whenever we get into the investigation phase in these types of things that is what we see a do want to take one point off of iran, remember in an earlier law star is a meeting mentioned that people with surgeons that are little older or mature seemed to do better than folks who might have hard charging young people who are socially stooge. My view is a child psychiatrist is that military, the best way to raise children is catch them being good, you know thats just to address your thing, i think that this is one of the barriers to Mental Health treatment, the duties current rules identifies nine conditions where a Mental Health provider muss reporter treatment. These rules include vague require manage, and prevent a significant challenge for providers, so captain what are the requirements is in the case of harm to mission. There are generally briefed and is a reasonable we think that they would understand a patients role in that mission. As you know maam we have a split fishery world and in that role i dont ever remembering telling a commander that somebody was not fit for duty. We have changed our culture and i mentioned that on law in this room before. A lot of people would struggle and few will its separate that much at a Chilling Effect on accessing care but we dont do that anymore. We do have obviously the submission imperatives around insider threat. I think in the devin kelly case some of those concerns were heralded by we need a strike a balance and as a provider that balance usually goes to a patient and i think that we get it and thats the way we train our residents right now but im not surprised to hear that we have fallen short of the market at times and im sorry about that. Thank you. I just want to say thank you to the chairman and Ranking Members for being here today and everyones testimony, i served 26 years in uniform, this issue as i think it touched me personally when i cut that in my squad took his own life and this is something as we see the trends going on in our society all of us know someone or love someone who has even been in a Mental Health crisis or suicide risk or take in their own lives and as someone close to me said after having gone through this, suicide doesnt transfer the pain sorry doesnt end the pain that youre feeling, just transfers it, in the deep wounds for children and other loved ones in someone feels like they have no other hope and 20 veterans every day or are taking their own lives right now. You know they deploy, they survive combat and come back to this place where the adamant has a dig in their play so this is so important that we take all the efforts that are happening throughout society and at the state and local level. Like our best efforts to try and address this but our veterans come from society, we see the trends, we are a part of whats going on, its not all combat related it sees other factors that are happening, you know there is a couple of examples in arizona where there is a study, veterans or two times more likely overall to commit suicide where population of female is three times, these rates are too high and they are unacceptable, so in a sense of urgency i think we all really need to not just throw more money at the issue but think outside the box, what is not working what else can we do and a couple of examples. In 2015 a veteran drove to the phoenix va, with a suicide note and a gun and shot himself, in the note he described physical pain and it difficulty he was having getting treatment that he felt he needed from the va. There are countless stories like that but the vast majority are not even in the va system. So i want to highlight a good news example in arizona. We have this be connected program in 2017 you know it started and its really working to connect veterans. Service repair leads whatever support they have that goes back to not the immediate crisis but what is going on early on. One example isnt rule arizona disabled veteran called and the question was can someone help me clean up after his pets. In reality once a volunteer showed up they realized carrying the path was actually a barrier for him to get treatment but he wanted to treat and lose his dog so they are able to meet memory was and ensure that he had someone to take care of his job while he actually went and got the treatment that he needed through a program. This is a great example and im anymore and i dont wanna spend all this time where at the local level with local volunteers with federal support we really could be empowering local communities in order to be the neighbor, be the friend, remove those barriers and get people to care they need, what else can we knew do for these types of programs to incentivize them especially for those vast majority veterans that are taking their lives we dont even have them in the va system. I was in arizona two weeks ago and i was working with connected individuals and very impressed by whats occurring there. I was trying to count how many times you said a local and federal and the importance of the relationship between them and that is what i think we can work on to gather is combining the power and the resources at the federal level with the local level realizing that the federal level and the va we cant do it on our own there is a local specific data and resources that we can cover but they cant be covered in other ways and partnered with that which we can do and do so well. That is where taking a look at Suicide Prevention not just from a clinically based perspective but from a Community Based perspective is important and youre examples a great one. Theres another example the veteran treatment courts, to expand these but in arizona where instead of a veteran spiraling down to be behind bars they are given a chance to spiral up with accountability and human support so we need these types of programs i think in every Community Fit for that community the other concern i have is if someone is a crisis and there is a suicide risk, again ive seen this firsthand recently, there is not a lot of choices they go to the emergency room they get locked down or then they get put into an impatient Mental Health board where they are high functioning but they need some help they dont fit in with another population law. I can put them in a worst crisis, theres not a lot of options for someone who is high functioning but needs help. But any other comments on that, i think there is a gap for what people need who are crying out for help but they are high functioning and they just need a path forward. I think that is a great question, you mentioned a couple of things, one option that does not require someone to the emergency room but will be done on the evening it is by contacting the national Suicide Prevention lifeline, someone who can be spoken to our Family Member who is concerned about a loved one can be spoken to you. Where will risk can be assessed and a determination made based on what help is needed without going in the emergency room. But there are other forms of Crisis Services, when there is a comprehensive crisis continuum that has things like mobile outreach so then rather than someone being transported to an emergency room to receive an evaluation, that evaluation can be done where the person is there are also crisis stabilization units, there are some excellent ones in arizona and phoenix and tucson that provides 72 hours of crisis stabilization, where Police Officers can drop someone off if the police need to be involved so i think that improving Crisis Services is one a very important component, not the only component of one very important one of improving our National Suicide efforts. Thank you amway over my time, thank you so much but i know the doctors gonna Say Something a little have to wait for the record. Well that mentioned the coordination between local and national, heres a great example, there is an enormous number of really creative programs that our local that exist one place and nobody else knows they exist so they have the National Perspective to mix and match, the other thing the talent of getting the ray treatment to the right person which is one of the things i mentioned, veterans are much more rule than the rest of americans and the states with the hires proportion are kentucky West Virginia because they all came through there, they joined the military and move back its hard to get to specialize if you live in los angeles they have these ultra special light things. So the kind of thing that richard saying is getting so you can have that a remote and get the right thing to the right person but there is a lot of coordination to figure out how to get a system to work and a coordinated way to take advantage of the ideas that exists that right now in many that we dont really know about and i think we could. Thank you senator, i want to go back in terms of the data i think that i have read that the incidence of suicide adjusted for age and sex is roughly equivalent to civilian society but for the National Guard, is that right . Yes sir so within the va is that roughly the same . It is its a equivalent. Sir its much higher. I guess the question, the first question that i have, you have all talked about programs weve heard state, local, federal weve heard not profit weve Heard Community what effort has there been as a National Effort to try and identify best practices programs with efficacy and in a way to start leading these wellintentioned efforts that may not be achieving the same level of efficacy, you dont want to completely stifle innovation because the next best idea may come out but what sort of National Effort either in your department i know that we are looking at programs within the d. O. D. And the va determined where we should invest our resources but on a National Level what concerted effort if any exists today to try and identify a consistent approach to what are the consistent causes of suicide. Well i would mention a couple of things senator, i think that va is utilizing and then there is a initiative, events based approaches that can be used in Health Care Systems. So improving it is one piece but its only one piece, we know from the National Reporting system that only between 25 and 30 who have died by suicide have received current or recent Mental Health treatment so we need Broader Community efforts there is not nearly as much evidence around this and whats effective so thats a really important area and its incorporated in the u. S. National strategy free Suicide Prevention in, the National Action alliance has made it a priority to try to help strengthen Community Efforts and to look at what may be effective to assist communities and reducing suicides other than ones that take place within the Health Care Systems. As part of a recent meeting at the International Initiative 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 a comprehensively. What were the different components that we are working in different places so that we can all learn from each other so it is critical and we deathly nina comprehensive and Public Health approach but we also need more information about what can be most effective to help in the community. For suicide efforts we try to use both strengthening health care for Suicide Prevention but also strengthening work in the communities. We show some evidence of success for that and our evaluations but theres a lot more work to be done. Doctor miller captain one of the. Im not an expert in this field im trying to learn so that i could we instructed with the level of policy choices but one thing that strikes me is if we have a disproportionately high number of men and women in the national they have a unique circumstance particularly now with the operations being what it is. I dont know if we have data about how many of them were in deployment but in some ways the layperson can draw the conclusion that if that seems to be a true proportionally high number of suicides we know that these suicides among veterans is much higher among those who have no connection to the va or be aj, what does that tell us about what more we need to be doing . The problem is often time there are suicides happening when theyre not on deployment, what are we doing to Better Connect and provide access to our Service Members and veterans, what initiatives are going on that can give us some hope . Historically i believe that we have been speaking from a perspective on accountability, clinically we have been over reliant on a pure clinical perspective and addressing the situation within the walls both metaphorically and literally of a Medical Center sort of setting. I think what we need to continue to do is find ways to engage as iran has says 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, engaging and measuring the effectiveness of Community Based interventions that address broader issues we know are related to suicide and Suicide Prevention. All added as well its certain that the National Guard has unique challenges and locality and whether they are more geographically dispersed is a key factor there. We have a number in addition to the centers which i think is an Exciting New Initiative and its also montreal weekends which is more opportunity to have that regular care. We have been partnering with the National Guard bureau with the approach of providing as many different doors as avenues as we can. So partnering with local resources in the community there is military one source that is getting left prevention if youre having financial challenges parenting challenges the whole host of everyday life challenges. Military wants those available to everyone in all Family Members. We have our military life counselors specific for youth and also more broadly for our military Community Family and they are embedded within communities as well and can be called upon for opportunities if there is a need in a particular community to have additional support. I will pass this to my colleague in a moment where we have a number of avenues in terms of mental care access whether its within the d. O. T. Or partnering with local organizations of free Mental Health care thats available for all of our military members including the National Guard in their family. Ill just add Financial Security and a half care security or big issue i have seen patients from the national our guard or medicaid shortly before patients who didnt have access to health care recently when i was deployed i once saw a young man who had an opioid addiction, its a great treatment its not what he needed to be on but he didnt need to be in the desert on that particular therapy so we need to standardize an optimize care for everyone just as we do for the active duty forces. Doctor mueller Service Members who are transitioning or experiencing a move are particularly vulnerable. They understand that 37. 8 Service Members had died by suicide had either entered or exited service or had experienced a geographical move in 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 cultures shock of transitioning to civilian life both unemployment and civilian rates must be directly impacted by the lack of adequate organizations. In a recent survey rack and afghanistan found that 65 of its members knew a veteran that attempted suicide. Does your office reach out these veterans for insight in advice how you can better serve younger veterans . Yes you are 100 percent correct that at the time of transition it represents a higher risk period for individuals, veterans with regard to this. That track im of transition can be embodied with that that occurs from Service Member to veteran i am optimistic regarding that which we have spent the last year working carefully on with regard to wrap services, three 60 days before separation, i am optimistic about what started on monday of this week which was initiation of executive order which was the va call backs. Within the first month of separation we are contacting every veteran and we receive on the list of those separating, we are introducing them to the va we introducing them to services with the va and we are offering them connection and resources within that conversation we offer them a followup letter and we offer them connection to Mental Health services again that began on monday and we will be monitoring the progress of that within our agency broad goals. I look forward to deposing the results maam. Have you also looked into this issue, we passed and legislation nearly 2019 overmedication a veterans and sometimes veterans are given four or five medications and there is some correlation between increase and suicide, susceptibility because of overmedication, have you began to look at that and have you had any findings up until now . Yes maam i feel like weve been looking at this for a few years at least particularly with opioids and then opioid combinations such as with over diaz opinions we have been monitoring as a whole system opioid prescribing rates, will be weighed and bend so die as being combinations and weve been working on tracking that down however within that there are and mike knows this better than the rest of us there are important Clinical Practice Guidelines to attend to you can exacerbate issues if you taper too quickly or in a way thats not advised so making sure that we are doing this in a way that is consistent with Clinical Practice Guidelines is also important, weve had a significant effort since on that within our system as well. Doctor part of your testimony you said you thought it would be interesting to have a survey since a lot of the data shows that many of our members come in with Mental Health challenges but as i said in my opening remarks a lot of Service Members dont want their commanders to know that they have a history of Mental Illness or that there might be some impediment to Exemplary Service so have you had any thoughts about if we did create a survey how do we allow it to be confidential and im thinking about the fact that our chaplains are able to provide Spiritual Counseling on a confidential basis that number goes to the commander. Is there an argument should be made to allow Mental Health guidance, Mental Health services to be given in a confidential setting including with the survey and then continue that throughout a Service Members career and then again upon separation so that you have an entire continue of care for Mental Health that is outside the chain of command so that there is not that barrier, the fear of being integrated or devalued or being sidelined, you know in the work that weve been doing with new soldiers, were we have surveys that we raid in the reception week the 48 hours weve been getting into service we tell them that this is all confidential, some University Guys doing it and their commanders will never know about it and we find 1 of people told us they try to kill themselves in the past if you admit that anything youre not in the army so all those people didnt say that thats about half of the people that will ever make of Suicide Attempts, they made it before they joined and they on purpose didnt talk about it so its clear that there is stuff going on at that sort as i mentioned before most of these problems are relatively mild but there are some that are pretty severe, what do you do about that . Its a challenge there are several things that weve been working on with College Students its the same kind of age group so you want to be all you can be, you want to be a master of these stresses so we will teach you to be more resilient, youre a winner not a loser so there is rebranding that can be done and probably will do some good its tough to rebrand that you try to kill yourself so the idea of doing something that is more confidential that goes beyond military one source and a lot of people do know that they can go to the chaplains and champions are feeling beleaguered cars are getting a lot of this stuff and it makes not a sense but really as an outsider makes not a sense but you really have to turn it to the folks here as an outsider i really think that has a lot of common sense to me, maam i have a 22nd followup if i may. The most trouble i was in in the military when i was an officer in clinical psychologist is when i did not report that the spouse of an f 16 driver was experiencing Substance Abuse issues when there was an on installation event involving the situation the Commanding Officer was livid at me for not telling him about this i said why would i tell you any said because i want this person to be a driver if i knew that and i said how fair is that, what was really underlying his emotion was the fact that he was afraid that he was going to get in trouble and that fingers were gonna 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 well allow people to take a chance in some cases and use clinical discretion and news and personal discretion and set of blaming on something bad happens as a first resort. Related so we have been working for a long time on trying to deal with military Sexual Violence and you know that more than half of the survivors are a man in terms of raw numbers but the number of men that are willing to report is very low, because they dont want to be devalued or made fun of or just appear that they are not Strong Enough or tough enough for the job so they dont report so they see evidence of untreated sexual trauma and this is one of the leading reasons for suicide among that covert, so one of the things that you face is that we let people report if theyve been sexually assaulted confidentially so they can get access to these services and its not really working because the men still have very low reporting but at least we put that into place and im thinking that to the extent to any of you have thoughts on this issue making a recommendation to the committee about how to create a safe space for Mental Health around. Similar to the allowance we make for military sexual trauma reporting to get services so people dont lose hope and dont decide or fall prey to suicide. I think he was absolutely right when he spoke about not disclosing, he was totally fine on that nondisclosure and i think something along those lines, might not be a bad idea because right now it is just a training issue, its more of a cultural issue of how we practice psychiatrist and psychiatrist. Well id be grateful if youd each do recommendation by letter after youve had some time to think about this because 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 and military sexual traumas. So i would love you recommendations it ways we could implement Something Like this that you think would be productive based on your experience and expertise. I just want to share one thing we are 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 existencetheexistence for a program like 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 head head and they hadnt 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 do cant 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, theres 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 va with 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. [in audible thank you for being here will keep the reckon open for one week and we look forward to continued feedback, committees adjourned. [inaudible conversations]