Statement of
Kayda Keleher, Associate Director
National Legislative Service
Veterans of Foreign Wars of the United States
For the Record
United States House of Representatives
Committee on Veterans’ Affairs
With Respect To
“Veteran Suicide Prevention: Maximizing Effectiveness and Increasing Awareness”
WASHINGTON, DC
Chairman Roe, Ranking Member Walz, and members of the Committee, on behalf of the women and men of the Veterans of Foreign Wars of the United States (VFW) and its Auxiliary, thank you for the opportunity to provide our remarks on veteran suicide prevention.
After examining more than 55 million records of individuals who served in the United States military from 1979 to 2015, VA released its most recent publication of veteran suicide data during summer 2018. This data mostly remained consistent from previous research.
This most recent data showcases that while veterans are 2.1 times more likely to die by suicide than non-veterans, that rate is highest for post-9/11 veterans ages 18-24. Yet, veterans over age 55 and those who served during peacetime experience the overall highest numbers of suicide.
Veteran suicide is an issue that plagues the veteran community. There is no justifiable reason for suicide to be in the top 10 reasons Americans die, let for veterans to be overrepresented in this daunting statistic –– in 2015, veterans made up less than 10 percent of the American population, yet 16.5 percent of all American suicides. Without changing, an average of 20 veterans will continue to die by suicide every day.
In order to address veteran suicide, Congress and the Department of Veterans Affairs (VA) must invest in more research, increase mental health providers employed at VA, and conduct better outreach to pre-9/11 veterans, women and LGBT veterans. There is also more work that can be done to improve the Veteran Crisis Line (VCL).
Research
Data provided by VA, with thanks to interagency cooperation, is critical in the hope of eradicating veteran suicide. A third of veterans, or six of the daily average, who die by suicide were active VA users. Research indicates that veterans who do not use VA for their health care are at an increased risk of suicide. Which comes as no surprise to the VFW, as our members have continuously told Congress they prefer VA health care.
Veterans service organizations, VA, and Congress must know more about the two-thirds of veterans who do not use VA and die by suicide. The VFW urges VA to analyze the demographics, illnesses, socioeconomic status, and military discharges of those 14. There are questions that need to be answered in order to properly address this epidemic. Did those 14 use private sector care? Were they eligible to use VA? Were they among the many who were discharged without due process for untreated or undiagnosed mental health disorders related to sexual trauma or combat? Were they discharged for unjust and undiagnosed personality disorders due to transgenderism or during the era of “Don’t Ask, Don’t Tell?” If veteran suicide is going to be honestly combatted, we must know more about the 14 veterans who die each day without using VA.
As technology continues to improve, VA must continue funding new ways to reach those in need of mental health care. Over time, VA has offered computer and phone applications, such as PTSD Coach, for veterans to conveniently open in their time of need. Yet apps are not the avenue of prevention or intervention all veterans prefer. More must be conducted to find reliable statistics regarding what platforms of technology veterans prefer for all eras and age groups. Those technologies should also be analyzed by VA researchers to further understand key phrases and actions taken by those experiencing mental health crises and/or suicidal ideations. While most people know there are signs of possible suicide, such as an individual beginning to give their belongings away, linguistic psychologists in academia have found there are words used at increased frequency when individuals are experiencing suicidal ideations and mental health crises. These words are not the “cliché” words currently taught to Americans. The VFW urges VA to conduct linguistic psychology research, or to partner with schools, such as Massachusetts Institute of Technology, already doing so.
With the number of VA opioid prescriptions continuing to decrease, and the increased number of providers receiving training on effective psychotherapies specific to post-traumatic stress disorder (PTSD) and military sexual trauma (MST) patients, the VFW believes VA has made great strides in treating this population. Yet, it still has more work to do.
The VFW’s members believe medical cannabis must be researched to determine if it can be a non-pharmaceutical alternative. Conducting such research would not only provide better education for VA clinicians to remain informed and providing the highest quality of care, but it would also provide sound empirical data regarding the medicinal value of cannabinoids. Varying academic and state-funded studies have found preliminary results showcasing that medical cannabis may be helpful for veterans struggling with PTSD or MST, which are closely associated with increased risk of suicide. The VFW strongly urges Congress to pass H.R. 5520.
Throughout the years, research on mental health issues associated with combat or sexual trauma, such as PTSD and traumatic brain injury (TBI), has allowed providers and researchers to understand and diagnose mental health disorders in ways never before possible. This has been advanced by extensive genomic research conducted by VA for varying risk factors such as the SKA2 gene and RNA deficiencies. The VFW also urges VA to complete recruitment of the Post-Deployment Afghanistan/Iraq Trauma Related Inventory Traits study, which will provide a pool of 20,000 veterans of Iraq and Afghanistan to identify possible genetic variations that may influence risk of PTSD and TBI.
Increase Access
The entire nation is experiencing a critical shortage of mental health providers. In addition to this deficiency, applications to work at VA have significantly dropped since the 2014 crisis in Phoenix. The Office of Inspector General determined that in fiscal year 2018, the Veterans Health Administration’s number one shortage was psychiatrists, with psychologists as the fourth largest shortage. Congress must provide VA with the assets necessary to increase hiring and retention of mental health care providers, and to assure they are appropriately included in graduate medical education improvements passed in the MISSION Act. The VFW also urges Congress and VA to establish and monitor quality assurance metrics to hold non-VA community care providers accountable to.
Mental health providers within VA have continued to receive extensive training in areas such as prolonged exposure and cognitive processing therapy, which are the most effective and empirically proven therapies to treat PTSD. Medication treatments are also offered and, thanks to the VFW-supported Jason Simcakoski Memorial and Promise Act, medications are being more closely monitored. Through VA’s Opioid Safety Initiative, opioids are being prescribed on a less frequent basis for mental health conditions and are better monitored for negative consequences such as addiction.
The VFW has long advocated for the expansion of VA’s peer support specialists program, and thanks Congress for passing H.R. 4635. VA peer support specialists are healthy and recovered individuals with mental health or co-occurring conditions who are trained and certified by VA standards to help other veterans with similar conditions and/or life situations. Veterans who obtain assistance from peer support specialists continuously sing their high praises. Peer-to-peer programs are also critically important for minorities, LGBT and woman –– or any group within the veteran community which makes up a smaller population and can at times feel ostracized or as though nobody within their community understands them. This is instrumental in helping veterans avoid loneliness, which can lead to suicidality.
The VFW urges Congress to make sure VA has the resources required to continue expanding this effective, low-cost form of assistance. To ensure VA is offering a holistic approach in effectively addressing PTSD, VA must have the ability to provide peer specialists outside of traditional behavioral health clinics. Veterans overcoming homelessness, seeking employment, or in mental health crisis would benefit from these services. For these reasons the VFW calls upon Congress to pass H.R. 2452, and to further expand this program to other specific populations.
Aside from veterans receiving support from fellow veterans who have recovered from similar health conditions and experiencing the bond and trust veterans share, peer support specialists also greatly assist in destigmatizing mental health conditions such as PTSD. For a veteran to become a peer support specialist, they must have actively gone through treatment, and be living a relatively healthy lifestyle. This allows veterans who may be struggling to see that their condition is treatable, manageable, and not something that has to negatively impact or control their lives.
Outreach to Women, Minorities, and Older Veterans
Outreach works. In August 2017, an entertainer named Logic performed a song on live television about suffering from suicidal ideation and mental health crisis, but then eventually getting help and recovering. The song was titled “1-800-273-8255” –– the National Suicide Prevention Lifeline. In the days following the performance, the National Suicide Prevention Lifeline saw a 50 percent increase in callers. This is just one example showing that VA must conduct more strategic outreach.
Short of producing music, the VFW has partnered with VA and other non-government organizations for our Mental Wellness Campaign. Beginning in fall 2016, this outreach campaign was launched to raise awareness, foster community engagement, improve research and provide intervention for those affected by invisible injuries and emotional stress. Over the last two years more than 200 VFW posts and 13,000 volunteers have successfully reached 25,000 people through our annual Mental Wellness Campaign Event. This event consists of the VFW, VA, and other partners conducting community service, spending time with veterans, their families, and people in the community educating. Participants learn the five signs of emotional suffering –– personality change, agitation, being withdrawn, poor self-care and hopelessness. VA also provides information about programs and opportunities for assistance from VA and local community partners.
In today’s society, it seems as though many people assume veterans at the highest risk of suicide are men who were in combat roles and served during the post-9/11 era. That is where society is wrong. Veterans with the highest number of suicide are males over the age of 50, and women veterans who do not use VA.
Studies also show survivors of sexual trauma are among the highest for increased risk of suicide. With nearly a third of women who serve experiencing some degree of sexual assault in the military, and LGBT veterans being overrepresented in that as well, care for survivors of sexual trauma must remain a priority.
The rate of female veteran suicide since 2001 has increased by nearly 100 percent for women who do not use VA. Currently, women veterans are twice as likely to die by suicide as non-veteran women. While tracking of LGBT suicide data is not currently done by VA, there is data showcasing that LGBT veterans experience depression and suicidal ideations at twice the rate of heterosexual veterans. These numbers are atrocious and completely unacceptable.
The VFW urges Congress and VA to continue expanding telemental health programs. These programs are often invaluable in decreasing risk of suicide for sexual trauma survivors –– who are overrepresented within the female and LGBT populations –– wanting to use group therapy for mental health linked to sexual violence. In VA facilities where there may not be enough women or other individuals comfortable participating in group therapy, telemental health provides an alternative.
Better outreach must also be conducted to veterans who served prior to 9/11. Veterans who are age 50 or older make up approximately 65 percent of the total population of veteran suicides. More must be done to reach this population. Post-9/11 veterans are more likely to enroll in VA and VA has really excelled at providing access and conducting outreach to this population. Now it is time to expand these outreach initiatives and increase their access.
Joint Action Plan
VA is the largest integrated health care system in the United States. The number of veterans using this system to seek treatment for mental health care has also continued to increase as more veterans who served in Iraq and Afghanistan leave the military. This is part of the cost of war. Congress and VA must ensure those seeking treatment are provided timely access to VA care.
This year, at the request of the current administration, VA, the Department of Defense (DOD), and the Department of Homeland Security began implementing the Joint Action Plan to improve mental health care access for service members transitioning out of the military for their first year out of uniform. This plan was set in place with the hope of annually reducing veteran suicides for a population at increased risk.
The plan focuses on universal access to mental health care for all veterans during their first year as civilians. Additional framework was also built for more support of veterans identified to be higher risk. This way of identifying varies from algorithms already set in place at VA to identify veterans using VA health services who are among the highest risk of suicide. The overall goals, which are still being implemented, include better assurance that all service members leaving DOD know how to access VA, and streamlining access to their first year of mental health care.
There are also provisions in the plan that calls for increasing partnerships between VA and private sector providers. The VFW agrees that sometimes there is a need for care to be supplemented within the community, but also firmly believes that these non-VA providers must be held to a high standard of care. Current reports show the care provided by non-VA providers is of lower quality, and that these providers prescribe veterans opioids at an alarmingly higher rate than VA. When a veteran does require community care, empirically proven forms of therapy must be done, medical and pharmaceutical records must be shared with VA, and the non-VA providers must meet or exceed the same standard as VA. This is particularly true for mental health, as VA’s suicide data shows that non-VA users are more likely to die by suicide.
Veterans who have deployed to a combat zone, but do not have a service connected disability, still earned the benefit of having access to VA for up to five years after leaving the military. The VFW supports all veterans having access to mental health care at VA for their first year out of service, but watches steadily to assure other veterans who may be older or combat hardened do not suddenly have to overcome new found access standards. For this reason, the VFW asks for proper congressional oversight of the Joint Action Plan and for VA to provide more transparency during this time of implementation.
Veterans Crisis Line
In 2007, VA established the Veterans Crisis Line (VCL). The hotline was established to provide 24/7 suicide prevention and crisis intervention to veterans, service members, and their families. The VCL provides crisis intervention services to veterans in urgent need, and helps them on their path toward improving their mental wellness. The VCL plays a critical role in VA’s initiative of suicide prevention and ongoing efforts to decrease veteran suicide. The VCL has answered millions of calls and text messages. It has also initiated the dispatch of emergency services nearly 100,000 times. Since opening its doors in 2007, VCL has expanded to three locations –– Canadaigua, N.Y., Atlanta, and Topeka, Kan.
If a veteran currently calls a VA Medical Center or most Community Based Outpatient Clinics the veteran will receive the option to dial the number seven for an automatic transfer to the VCL. This technology has been successful, but the expansion is another example of VA struggling to keep up with modernized technology due to lack of funding and prioritization. The VFW believes all VA facilities, including Vet Centers, must have this capability sooner rather than later.
The VFW is pleased with other technology modernizations the VCL has made throughout 2018. This summer, Apple and Android smartphones developed the capability for Siri and Google Assistant to connect individuals to the VCL through voice command. Now a veteran can just say, “Call the Veteran Crisis Line” and be connected even if the number is not saved to their contact list. There will also be a three number dial-in, similar to 911, which will connect dialers with the VCL. Current estimates anticipate this new technology will launch in early 2019.