[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]


 
                           STOPPING SUICIDES: 
                    MENTAL HEALTH CHALLENGES WITHIN 
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS 

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                           DECEMBER 12, 2007

                               __________

                           Serial No. 110-61

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.



















                            C O N T E N T S

                               __________

                           December 12, 2007

                                                                   Page
Stopping Suicides: Mental Health Challenges Within the U.S. 
  Department of Veterans Affairs.................................     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    66
Hon. Steve Buyer, Ranking Republican Member......................     3
Hon. Stephanie Herseth Sandlin, prepared statement of............    66
Hon. Harry E. Mitchell, prepared statement of....................    67
Hon. Cliff Stearns, prepared statement of........................    67
Hon. Leonard L. Boswell..........................................     5
Hon. Donald A. Manzullo..........................................     6

                               WITNESSES

U.S. Department of Veterans Affairs, Ira Katz, M.D., Ph.D., 
  Deputy Chief Patient Care Services Officer for Mental Health, 
  Veterans Health Administration.................................    48
    Prepared statement of Dr. Katz...............................    84

                                 ______

Bowman, Mike and Kim, Forreston, IL..............................     6
    Prepared statement of Mike and Kim Bowman....................    68
Coleman, Penny, Rosendale, NY, Author, Flashback: Posttraumatic 
  Stress Disorder, Suicide, and the Lessons of War...............    33
    Prepared statement of Ms. Coleman............................    69
Meagher, Ilona, Caledonia, IL, Author, Moving a Nation to Care: 
  Post-Traumatic Stress Disorder and America's Returning Troops..    35
    Prepared statement of Ms. Meagher............................    76
Zivin, Kara, Ph.D., Research Health Scientist, Health Services 
  Research and Development, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    54
    Prepared statement of Dr. Zivin..............................    86

                       SUBMISSIONS FOR THE RECORD

U.S. Department of Veterans Affairs, Michael Shepherd, M.D., 
  Physician, Office of Healthcare Inspections, Office of 
  Inspector General, statement...................................    87

                                 ______

American Legion, Joseph L. Wilson, Deputy Director, Veterans 
  Affairs and Rehabilitation Commission, statement...............    91
Disabled American Veterans, Joy J. Ilem, Assistant National 
  Legislative Director, statement................................    93
Iraq and Afghanistan Veterans of America, Todd Bowers, Director 
  of Government Relations, statement.............................    98
National Coalition for Homeless Veterans, statement..............    99
Vietnam Veterans of America, Richard F. Weidman, Executive 
  Director for Policy and Government Affairs, statement..........   103

                   MATERIAL SUBMITTED FOR THE RECORD

Additional Hearing Material:
    Hon. Michael J. Kussman, M.D., M.S., MACP, Under Secretary 
      for Health, U.S. Department of Veterans Affairs, sample of 
      letter sent to veterans, informing veterans of the National 
      Suicide Prevention toll-free hotline number, 1-800-273-TALK 
      (8255), and pocket-sized card with VA Suicide Crisis 
      Hotline phone number/information, as well as a Crisis 
      Response Plan..............................................   107
    U.S. Department of Veterans Affairs Pamphlet, entitled 
      ``Suicide Prevention, Men and Women Veterans, Knowing the 
      Warning Signs of Suicide,'' dated September 2007...........   108
Post-Hearing Questions and Responses for the Record:
    Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to 
      Hon. Gordon H. Mansfield, Acting Secretary, U.S. Department 
      of Veterans Affairs, letter dated December 14, 2007, and VA 
      responses..................................................   110
    Hon. Harry E. Mitchell, Member of Congress, U.S. House of 
      Representatives, to Hon. James B. Peake, M.D., Secretary, 
      U.S. Department of Veterans Affairs, letter dated February 
      8, 2008, and response letter dated February 27, 2008, 
      following up to request additional information not supplied 
      in earlier VA responses to questions for the record........   115
    Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to 
      John D. Daigh, Jr., M.D., CPA, Assistant Inspector General, 
      Office of Healthcare Inspections, U.S. Department of 
      Veterans Affairs, letter dated December 14, 2007, and 
      response letter dated January 24, 2008.....................   117
    Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking 
      Republican Member, Committee on Veterans' Affairs, to Hon. 
      James B. Peake, M.D., Secretary, U.S. Department of 
      Veterans Affairs, letter dated December 21, 2007, and 
      response letter dated February 5, 2008, requesting 
      additional data on suicide rates among veterans............   121
    Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking 
      Republican Member, Committee on Veterans' Affairs, to Rick 
      Kaplan, Executive Producer, CBS Evening News With Katie 
      Couric, letter dated December 21, 2007, and response letter 
      dated May 16, 2008, from Linda Mason, Senior Vice 
      President, Standards and Special Projects, CBS News........   128


                           STOPPING SUICIDES:
                    MENTAL HEALTH CHALLENGES WITHIN
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                      WEDNESDAY, DECEMBER 12, 2007

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 10:10 a.m., in 
Room 345, Cannon House Office Building, Hon. Bob Filner 
[Chairman of the Committee] presiding.

    Present: Representatives Filner, Snyder, Michaud, Herseth 
Sand- lin, Mitchell, Hall, 
Hare, Berkley, Rodriguez, McNerney, Space, Walz, Buyer, 
Stearns, Boozman, Brown-Waite, Bilirakis, and Buchanan.

    Also Present: Representatives Boswell, Manzullo, and 
Kennedy.

              OPENING STATEMENT OF CHAIRMAN FILNER

    The Chairman. This meeting of the House Committee on 
Veterans' Affairs is called to order.
    I appreciate your attendance, and I appreciate your 
interest in this very important issue of mental illness, 
particularly of the suicides that have occurred in our 
veterans' population, especially those involved in combat 
situations.
    So this is going to be a very tough hearing, an emotional 
hearing. It is an issue the military, the U.S. Department of 
Veterans Affairs (VA) and the American public does not like to 
talk about. Yet, we owe it to our fighting men and women. We 
owe it to their families. We owe it to our future mental health 
as a Nation to explore this issue in as much depth as possible.
    This year, as we try to deal with the influx of veterans 
who are coming from Iraq and Afghanistan, plus the needs of our 
older veterans, which continue, it has been a great challenge 
for this Committee and for this Congress and for this Nation.
    Earlier in the year, and in a series of articles since, The 
Washington Post reporters dealt with the terrible scandal at 
Walter Reed which had the effect, as other local newspapers 
around the country did stories on their military and veterans' 
hospitals, of a wake-up call for all of America. Their 
veterans, their troops coming back from the current war were 
not getting the treatment, the care, the respect, the honor and 
the dignity that Americans thought they deserved.
    Because of that awareness that really spread throughout 
America, this Congress was able to add almost $13 billion of 
new money for healthcare for veterans, an unprecedented 
increase of 30 percent or more, based on the public perception 
that we had to do more.
    The injuries that come from this war are very great, both 
physically and mentally, and yet, America has not really come 
to grips with it.
    One of the television networks, ABC, whose reporter Bob 
Woodruff had suffered a blast injury and traumatic brain injury 
(TBI) in Iraq, opened up that subject to millions of Americans. 
And we know more now about TBI and how to treat it.
    Recently, the CBS network opened up again to millions of 
Americans the issue of suicides amongst our veterans. They had 
a great deal of difficulty getting information from the 
authorities or from the U.S. Department of Defense (DoD) or 
from the Department of Veterans Affairs. That is one of the 
issues we are going to explore today, the issue of information 
and the tracking of these issues. But they had to spend 5 or 6 
months tracking down statistics in different States because 
nobody seemed to be interested in Washington, of understanding 
the statistics.
    Their report of several weeks ago again opened the eyes of 
millions of Americans to statistics, which went way beyond what 
people had thought or imagined as to the number of suicides, 
not only amongst our returning vets but amongst veterans from 
previous wars. I think it is now recognized that as many 
Vietnam veterans have now committed suicide as had died in the 
original war. That is a terrible, terrible statistic and says 
we have to do more.
    So what we are going to do today is try to open up this 
subject which is very difficult for the families involved and 
for our government. We want to talk about the statistics. Why 
doesn't the VA do more about trying to understand the nature of 
the issue? We leave it to citizens like Ilona Meagher, who will 
be testifying later, to keep a Website for tracking suicides, 
of which she is one person with limited resources. This is what 
our government should be doing.
    We want to talk about the stigma of mental illness and how 
we try to deal with this as a Nation. We want to talk about the 
apparent inability of the military to look at mental illness 
and people's honest attempts to deal with it as something to be 
recognized, promoted, encouraged. It is denied. Anybody who 
admits mental illness is threatened with no promotions or no 
jobs in law enforcement when they leave the military.
    It is an issue for all of us in America but particularly 
for those in the military, and we have to face it honestly and 
come to grips with it. That is what we hope to do today.
    We have a brave mother and father who have decided that 
their son's suicide must be talked about and understood to help 
others, and other families, prevent that. We have citizens, 
authors who have dealt very directly with this issue and, of 
course, the professionals within the VA system and those in the 
veterans service organizations (VSOs) who try to help their 
members deal with these issues.
    So we will have a very tough hearing, as I said earlier, 
but it is an important hearing. America must look at these 
issues. We have to decide that we have to deal with them in a 
far more open and dedicated manner, and that is our objective 
today.
    I would yield for an opening statement of the Ranking 
Member, Mr. Buyer.
    [The prepared statement of Chairman Filner appears on p. 
66.]

             OPENING STATEMENT OF HON. STEVE BUYER

    Mr. Buyer. Thank you, Mr. Chairman.
    Some in this room today, including several of our 
witnesses, have been personally devastated by the loss of a 
loved one who has chosen to take their own life. Before I 
begin, I want to personally thank you for testifying about your 
extremely personal and painful experiences. While I know 
nothing can compensate you for the loss of your loved ones, we 
can hopefully find ways to help deter another soldier from 
succumbing to such tragedy.
    I hope that, as we delve into these sensitive matters, we 
do not lose sight of the fact that every case that we will 
discuss here today represents a human life, a veteran, a 
family, and a tragedy. Discussing the tragic circumstances 
surrounding a suicide of one who has worn the uniform should be 
done with great respect and in recognizing also their service 
to our country. We must search for answers and solutions to 
veteran suicide.
    As most of our witnesses will attest this morning, tracking 
suicide rates nationwide is very difficult, and it is clear to 
me that the data we currently have does not give us a 
definitive understanding nor a scope of the problem. There 
seems to be significant variations among the data provided by 
CBS News, the VSOs, the DoD and the VA. These veterans' lives 
were important, and it would be a dishonor to them and to their 
service if information is not accurately portrayed. Accurate 
information is crucial to identifying risk factors, to 
providing better prevention and treatment protocols.
    Therefore, it is imperative that the VA have a better 
method to systematically collect and to track suicides so we 
can get a true understanding and scope of our challenge. It is 
my understanding that the VA is beginning to work with the DoD 
to do this, and I applaud them. But, again, I cannot overstate 
the urgent need to do it quickly. When decision makers do not 
have accurate data, we must rely on anecdotal evidence. While 
this can raise awareness, it does not help us make informed 
decisions on how best to develop strategies to diminish the 
risk and to prevent the events of suicide.
    Notwithstanding the tragic stories that surround this 
hearing, I believe we can point to the steps that the VA and 
the DoD have taken to help veterans and servicemembers deal 
with mental health challenges.
    The VA has already formulated a comprehensive strategy for 
suicide prevention, focusing on the needs of both new veterans 
from Operation Iraqi Freedom (OIF) and Operation Enduring 
Freedom (OEF) and on those of prior conflicts. The specific 
program for suicide prevention is based on public health and 
clinical models and activities both within the VA facilities 
and the civilian medical community.
    The cornerstone of this program is the VA's new 24-hour 
veteran suicide prevention hotline, which opened its lines in 
July of 2007. Since its inception, the VA reports that they 
have made more than 1,300 referrals to suicide prevention 
coordinators and have rescued 317 veteran callers. Veterans 
experiencing thoughts of suicide can call 1-800-273-TALK for 
help.
    We have seen clearly that early intervention and treatment 
has a significant and demonstrated impact and is crucial to 
preventing suicide. It is important to recognize the warning 
signs and to ensure that servicemembers receive the treatment 
they need right away.
    This starts with DoD. I am very encouraged that a new 
training program called BattleMind, developed at the Walter 
Reed Army Institute of Research, is being developed and is 
working to help soldiers transition from the combat zone to the 
home front.
    Mr. Chairman, I would sum this up with this. VA and DoD 
have made strides in the treatment of mental health disorders 
that can lead to suicide. However, until families like the 
Bowmans no longer bear such pain, not enough is being done. I 
welcome their testimony here today, and I hope this hearing can 
help us gain a better understanding of how to offer more 
effective and timely assistance for those troubled 
servicemembers to prevent them from turning to such a tragic 
option.
    On a personal note, as I see the parents sitting in front 
of me, your quest for answers will never end, and probably on 
your last breath there will still be the thoughts of your son. 
At the age of 16, my best friend committed suicide. His 
baseball cap sits in my office. I think people walk in, and 
they think it is my baseball cap, but it is that of a very dear 
friend. I constantly search for answers because none of us 
knew, even as close as we were to him. And, of course, the 
parents would drill us all the time about the signs. What were 
they? And there were no signs. There were no risk factors. It 
was just one of these bizarre strikes of the mind that just--I 
do not have an answer. I just want you to know I carry the pain 
of suicide, and I am in constant search of answers. And I am 
haunted, haunted by suicide. Even among my colleagues--if you 
want to talk about something that is not discussed, in the 15 
years I have been in Congress, it is the number of suicides of 
sons and daughters of Members of the Senate or of the House, 
and it is not discussed--or the attempts. It is that dark side.
    So you know what? It is not just us, and it is not just 
those in the military. You can touch any sector of our society. 
So, as we delve into this issue, we have to also be very 
sensitive, because I recognize there are anti-war advocates who 
also want to say that these individuals who then commit suicide 
and who have worn the uniform are somehow victims, and that is 
not right either, as we are trying to find out actually how can 
we prevent and how can we be helpful to someone who thinks that 
suicide is some form of option that can help them.
    So, on a personal note, I thank you for your bravery to 
come here and to talk about your son, and I know you are doing 
this because you absolutely believe that your testimony here 
today can help someone else.
    Thank you. I yield back.
    The Chairman. Thank you, Mr. Buyer.
    Our first panel will be Mr. and Mrs. Mike Bowman, whose 
son, Tim, an Army specialist in the Illinois National Guard 
from Bravo Troop, 106th Cavalry, committed suicide.
    Before that, if you will allow me, Mr. and Mrs. Bowman, to 
ask our colleague Mr. Boswell if he would just step forward for 
2 minutes. He is the author of Public Law 110-110, the Joshua 
Omvig Veterans Suicide Prevention Act, named after a young man 
in his own district, whose parents have now become friends with 
the Bowmans.
    The Bowmans are being introduced by our other colleague 
from Illinois, Mr. Manzullo.
    Mr. Boswell, please.

          OPENING STATEMENT OF HON. LEONARD L. BOSWELL

    Mr. Boswell. Thank you, Mr. Chairman, Ranking Member Buyer 
and Members of the Committee. I appreciate your holding this 
hearing and your leadership on this issue.
    To Mike and Kim, we extend our hand in friendship, our 
concern and sympathy for the loss of your son, Tim, and we 
pledge to do our best to stop this.
    As we all know, suicide is sweeping through our veteran 
population, and the Committee has shown leadership in 
addressing the issues our veterans face today. I want to thank 
you again for allowing me to speak on this important issue.
    Suicide is an epidemic which is encompassing much of our 
veteran population. For too long, suicide among veterans has 
been ignored, and now is the time to act. We can no longer be 
afraid to look at the facts, and the sad fact is we are missing 
adequate information on the number of veterans who commit 
suicide each year.
    I was shocked, and I am sure all were, when we saw the CBS 
Evening News report focusing on veteran suicides. They found 
that in 2005, over 6,200 veterans committed suicide--120 per 
week. The report also found that veterans were twice as likely 
to commit suicide as nonveterans. These statistics are 
devastating.
    As a result of this report, I immediately introduced H.R. 
4204, the ``Veterans Suicide Study Act,'' which several Members 
of the Committee have co-sponsored. If time had permitted, 
there would be many, many more, because no one--no one--who I 
approached chose not to sign on.
    This legislation will direct the VA to conduct a study to 
get the real facts on the rate of suicide among veterans. It is 
just one step that we must do to ensure that we have adequate 
information so we can treat our veterans as they return from 
combat.
    I would also like to personally thank the Chairman and the 
Ranking Member of the full Committee for their action in 
support of the Joshua Omvig Veterans Suicide Prevention Act 
earlier this year. Now that this crucial piece of legislation 
has been signed into law, I am confident our veterans will 
begin to receive more of the vital care they need.
    While the Joshua Omvig bill puts in place a comprehensive 
approach in treating high-risk veterans, we still need to know 
the facts. So I implore the Committee, and the Congress, to act 
swiftly on H.R. 4204 so we can ensure we have the data we need 
to treat our Nation's heroes. Our veterans have dedicated their 
lives to keep our great Nation safe, and it is now our duty and 
our time to protect them.
    So I want to thank you again for allowing me to share this 
time with you, Mr. Chairman, and I am sorry I have to go to a 
markup. Thank you very much.
    The Chairman. Thank you, Mr. Boswell, for your leadership 
on this issue.
    Mr. Manzullo, if you want to introduce your constituents.
    Thank you for being here with us.

          OPENING STATEMENT OF HON. DONALD A. MANZULLO

    Mr. Manzullo. Thank you, Mr. Chairman. I have the honor 
today of introducing, three constituents who are testifying 
before the Committee today.
    In inverse order, on the second panel is Ilona Meagher. 
Ilona's father was a Hungarian freedom fighter and also became 
a member of the United States Armed Forces, so he is a veteran 
of both the Hungarian and the American Armed Forces. Ilona is a 
tremendous campaigner, a seeker of truth, and she wrote this 
book, ``Moving a Nation to Care,'' about the very subject of 
which we are discussing this morning.
    The other two constituents really exemplify the people 
about whom Ilona Meagher is concerned, and they are the Bowmans 
from Forreston, Illinois. Kim and Mike live about 10 miles from 
my farm in the same county in northern Illinois. Their 
testimony is nothing less than startling and compelling. They 
would rather be anywhere in the world than here today to talk 
about what happened in their lives and to their precious son.
    I encourage the Members of this Committee to continue their 
leadership, to draft legislation or whatever is necessary, in 
order to make sure that the Bowman's testimony is not in vain 
and that their son's life is not in vain and that the lives of 
other young men and women who have taken their lives, will be 
used in order to prevent those situations from occurring in the 
future.
    The Chairman. Thank you, Mr. Manzullo.
    Mr. and Mrs. Bowman, you are recognized for your testimony. 
I had a chance to talk to you yesterday and to understand a 
little bit more about Tim, about the incredible job he was 
doing overseas, about the soldier that he was, about the close 
relationship you had with him, about your patriotism and his. 
So, again, I cannot say I am looking forward to your testimony, 
but I just thank you for having the courage to be here and for 
making sure that Tim's life and death will be used to help 
other people.
    Please, Mr. Bowman.

 STATEMENTS OF MIKE AND KIM BOWMAN, FORRESTON, IL (PARENTS OF 
  SPECIALIST TIM BOWMAN, U.S. ARMY, ILLINOIS NATIONAL GUARD, 
                  BRAVO TROOP, 106TH CAVALRY)

    Mr. Bowman. Mr. Chairman and Members of the Committee, my 
wife and I are honored to be speaking before you today, repre- 
senting just one of the families who lost a veteran to suicide i
n 2005.
    As my family was preparing for our 2005 Thanksgiving meal, 
our son Timothy was lying on the floor of my shop office, 
slowly bleeding to death from a self-inflicted gunshot wound. 
His war was now over; his demons were gone. Tim was laid to 
rest in a combination military-firefighter funeral that was a 
tribute to the man that he was.
    Tim was a life-of-the-party, happy-go-lucky, young man who 
joined the National Guard in 2003 to earn money for college and 
to get a little structure in his life. On March 19th of 2005, 
when Specialist Timothy Noble Bowman got off the bus with the 
other National Guard soldiers of Foxtrot 202 who were returning 
from Iraq, he was a different man. He had a glaze in his eyes 
and a 1,000-yard stare, always looking for an insurgent.
    Family members of F202 were given a 10-minute briefing on 
post traumatic stress disorder (PTSD) before the soldiers 
returned, and the soldiers were given even less. The commander 
of F202 had asked the Illinois Guard Command to change their 
demobilization practices to be more like the regular Army, only 
to have his questions rebuffed. He knew that our boys had been 
shot up, had been blown up by improvised explosive devices, had 
extinguished fires on soldiers so their parents would have 
something to bury, and had extinguished fires on their own to 
save their lives. They were hardened combat veterans now, but 
were being treated like they had been at an extended training 
mission.
    You see, our National Guardsmen from the F202 were not 
filling sandbags. They departed in October of 2003 for 6 months 
of training at Fort Hood and Fort Polk. On Tim's 22nd birthday, 
March 4th of 2004, Foxtrot left for Iraq, where they were 
stationed at Camp Victory. Their tour took them directly into 
combat, including 4 months on the most dangerous road in the 
world, the highway from the airport to the Green Zone in 
Baghdad, where Tim was a top gunner in a Humvee. Tim, as well 
as many other soldiers at F202, earned their Purple Hearts on 
that stretch of road known as ``Route Irish.'' We are still 
waiting for Tim's Purple Heart from various military paperwork 
shuffles.
    My wife and I are not here today as anti-war protesters, 
and let me make that very clear. Our son truly believed that 
what his unit did in Iraq helped that country and helped many 
people that they dealt with on a daily basis. Because of his 
beliefs, I have to believe in the cause that he fought and died 
for. That does not mean I do not feel that we lost track of our 
overall mission in Iraq.
    When CBS News broke the story about veterans suicides, the 
VA took the approach of criticizing the way the numbers were 
created instead of embracing it and using it to help increase 
mental healthcare within their system. Regardless of how 
perfectly accurate the numbers are, they obviously show a trend 
that desperately needs attention.
    CBS News did what no Government agency would do. They 
tabulated the veterans suicide numbers to shed light on this 
hidden epidemic and to make the American people aware of this 
situation. The VA should have taken those numbers to Capitol 
Hill, asking for more people, funding and anything else they 
need to combat this epidemic. They should embrace this study, 
as it reveals the scope of a huge problem, rather than complain 
about its accuracy.
    If all that is going to be done with the study is to argue 
about how the numbers were compiled, then an average of 120 
veterans will die every week by their own hand until the VA 
recognizes this fact and does something about it. The VA mental 
health system is broken in function and understaffed in 
operation. There are many cases of soldiers coming to the VA 
for help and being turned away or misdiagnosed for PTSD and 
then losing their battle with their demons.
    Those soldiers, as well as our son Timothy, can never be 
brought back. No one can change that fact. But you can change 
the system 
so that this trend can be slowed down dramatically or even stopp
ed.
    Our son was just one of thousands of veterans that this 
country has lost to suicide. I see every day the pain and grief 
that our family and extended family go through in trying to 
deal with his loss. Every one of those at-risk veterans also 
has a family that will suffer if that soldier finds the only 
way to take battlefield pain away is by taking his or her own 
life.
    Their ravished and broken spirits are then passed on to 
their families as they try to justify what has happened. I now 
suffer from the same mental illness that claimed my son's 
life--PTSD from the images and sounds of finding him and 
hearing his life fade away, and depression from a loss that I 
would not wish on anyone.
    If the veterans suicide rate is not classified as an 
epidemic that needs immediate and drastic attention, then the 
American fighting soldier needs someone in Washington who 
thinks it is. I challenge you to do for the American soldier 
what that soldier did for each of you and for his country: take 
care of them and help preserve their American dream as they did 
yours. To quote President Calvin Coolidge, ``The Nation which 
forgets its defenders will itself be forgotten.''
    Today, you are going to hear a lot of statistical 
information about suicides, veterans and the VA, but keep one 
thing in mind. Our son, Specialist Timothy Noble Bowman, was 
not counted in any VA statistic of any kind. Let me repeat 
that. Our son is not included in any VA count. Now, why, you 
ask? He had not made it into the VA system because of the 
stigma of reporting mental problems. He was National Guard, and 
he was not on a drill weekend when he took his life. Therefore, 
he was not counted as active duty. The only statistical study 
that he was counted in was the CBS News study. And there are 
many more just like him. We call them KBAs, killed because of 
action, the unknown fallen.
    I challenge you to make the VA an organization to be proud 
of instead of the last place that a veteran wants to go for 
help. It is the obligation of each and every one of you and all 
Americans to channel the energies, the resources and the 
intelligence and wisdom of this Nation's best and brightest to 
create the most effective, efficient and meaningful healthcare 
system for our men and women who have served.
    We must all remove the stigma that goes with the soldier's 
admitting that he or she has a mental issue. Let those soldiers 
know that admitting they have a problem with doing the most 
unnatural thing that a human being can do is all right. Mental 
health issues from combat are a natural part of the process of 
war and have been around for thousands of years, but we 
categorize that as a problem.
    Take that soldier who admits a head and mental health 
injury from combat and embrace him as a model for others to 
look up to. Let the rank-and-file know by example that it is 
okay to work through your issues instead of burying them until 
it is too late. Grab that soldier and thank him for saying, ``I 
am not okay,'' and promote him. A soldier who admits a mental 
injury should be the first guy you want to have in your unit, 
because he may be the only one who really has a grasp on 
reality. But instead, he is punished and shunned, and by that 
example, he has become the model for PTSD and suicide.
    While we are at it, why do we call it a disorder? That 
title, in itself, implies ramifications that last forever. It 
is an injury, a combat injury, just like getting shot. And with 
proper care and treatment, soldiers can heal from this injury 
and can be as productive and as healthy as before.
    We, as a country, have the technology to create the most 
highly advanced military system in the world, but when these 
veterans come home, they find an understaffed, underfunded, 
underequipped VA mental health system that has so many 
challenges to get through it that many just give up trying. The 
result is the current suicide epidemic among our Nation's 
defenders, one of which was our son, Specialist Timothy Noble 
Bowman, a 23-year-old soldier and our hero. Our veterans should 
and must not be left behind in the ravished, horrific 
battlefields of their broken spirits and minds. Our veterans 
deserve better.
    Thank you, Mr. Chairman.
    [Applause.]
    [The prepared statement of Mr. and Mrs. Bowman appears on 
p. 68.]
    The Chairman. Mrs. Bowman, do you have anything to add? 
Thank you for being here with Mike. And, again, thank you for 
your courage in being here.
    Mr. Michaud, you are recognized.
    Mr. Michaud. Thank you very much, Mr. Chairman and Mr. 
Ranking Member, for having this very important and timely 
hearing today.
    And it is going to be a tough day going through all of the 
testimonies, but I appreciate your remarks, Mr. Bowman.
    Thank you, Mrs. Bowman, for coming.
    Our soldiers, as you know, put their lives in harm's way to 
protect our country. Not all wounds are physical. The memories 
of the war do not disappear when they take off the uniform. A 
lot of us have seen the casualties of war. Maine recently lost 
one of its sons to suicide. Kyle Curtis, who served in Iraq, 
took his own life, like your son.
    My question is: When your son came back, did he try to get 
some assistance from the VA? Did either one of you notice any 
changes in the way your son was acting? Did you try to see or 
to encourage him to get help?
    Mr. Bowman. Timothy was a very smart kid, for one thing, 
and that gave him the ability to--as soon as he would start to 
open up in a situation where he thought his anger or his 
drinking problem or any sign that he was having trouble was 
going to be visible by us, he would immediately change the 
subject, or if we were sitting around our patio, he would go 
home. He would find a way to leave that situation that was 
putting him in that position, so that he could close that door 
in the back of his mind again and go on to something else.
    He had shown us small signs but not enough to trigger 
anything, because we did not know what we were looking for. And 
we, as National Guard families, are never educated on what to 
look for, because it is volunteer. You know, you show up at a 
readiness group meeting, and there is somebody there who gives 
us a 10-minute briefing. That was 2 months before the guys got 
home. Then you go through the process of the homecoming, and 
you realize that they are going to be changed when they come 
out of combat. That is fact. So then they hit your back door, 
and sure, there are some issues that you see, yet they think it 
is normal, and they portray it as being normal, and they tell 
you that it is normal. ``This is just the way I am now.''
    Now, he showed us one little sign. He showed certain 
friends other little signs. If we had all gotten together, we 
would have seen a larger picture, and we would have known he 
was in more trouble. But he was so good at hiding that that 
nobody knew for sure.
    And he was a model employee. He worked for me in the family 
business. We have an electrical contracting business. He would 
have been the third generation in 40 years. He was an absolute 
model employee. He went to work every morning regardless of 
what happened the night before or anything else. So, you know, 
you would discount any problem he was having at night because 
he did such a good job during the day.
    So trying to read the picture was very, very tough for him, 
especially with our not being educated on what the signs should 
be.
    Mr. Michaud. Not knowing where you live in relationship to 
the VA hospital, other than providing resources to the VA so 
they can hire staff to take care of the need that is out there, 
as well as to provide additional resources so if you live in a 
rural area, they could contract with providers in a rural area, 
do you think it would be helpful if the VA established a 
program for those individuals who might not want to go to the 
VA facility to have counseling online, on a computer?
    With technology today, a lot of individuals, particularly 
our younger individuals, are on the computer all of the time. 
Do you think it would be helpful if the VA established a 
program where someone could actually access help from home, 
whether it is to a clinic or to the VA hospital?
    Mr. Bowman. I would say, yes, definitely. As in the case 
with Tim and with a lot of his unit buddies, they are very 
well-computer-connected. They stay connected with us now via e-
mail and by all kinds of ways through the computer.
    I would think that would be an easy way, especially as long 
as they can enter it anonymously, because you have the stigma 
of, if you walk into a VA clinic, somehow that information is 
going to get back to your commanding officer. And until that 
stigma is removed, that you have just admitted to having a 
mental health issue, they have to be able to find help in some 
way so it is not going to come back to haunt them in their 
careers.
    A lot of these guys who come home from Iraq, a lot of the 
guys in Tim's unit are 10-years-plus in the National Guard. 
They want to get to their 20 years. They do not want to get 
out. So they do not want to have a problem with their careers 
down the road, which means they also do not want to have a 
problem with promotions. And it is a known fact that if you 
voluntarily admit that you have a mental health issue that your 
chance of progression in the military ranks at that point is 
pretty well shot.
    So, with the computer, it is if you can make it anonymous 
and can make it helpful. By ``helpful,'' I mean it is peer-to-
peer counseling.
    We had a discussion this morning about this very issue. The 
Vet Centers were a wonderful idea, but then all of a sudden, 
the VA comes along and they decide they have to have a guy with 
a title and a suit as a counselor at the Vet Center. Now, what 
did that do? That took that soldier who was walking in with 
that issue and made him on the defensive right off the bat. He 
was not talking to his peer anymore. He was talking to somebody 
who was sitting at another level above him.
    If you take a Vet Center and you make it a room with a 
couch and a pop machine and you put guys in there who are not 
in uniform and who are not in a suit or anything else and they 
just sit and talk, you will have veterans opening up. But if 
you take a guy with PTSD and you shove him in a room with a 
doctor in a suit, he is going to shut that door.
    Mr. Michaud. Thank you very much. It has been very helpful.
    Once again, I am sorry for the loss of your son, but I 
really appreciate both of you and your willingness to come 
forward to talk about your tragedy in order to help others who 
have not taken their lives. Hopefully, we will be able to move 
forward in a positive, productive manner.
    So, once again, thank you very much for coming here today.
    Mrs. Bowman. Thank you.
    Mr. Michaud. Thank you, Mr. Chairman.
    The Chairman. Ms. Brown-Waite, you are recognized.
    Ms. Brown-Waite. Thank you very much, Mr. Chairman.
    Mr. and Mrs. Bowman, all of us here who are parents can 
only imagine what it is like to lose a child. It is the 
toughest thing that a parent ever does.
    One of the questions that I was just asking counsel was--I 
do not believe, in many of the Community-Based Outpatient 
Clinics (CBOCs) where they offer mental healthcare, that that 
information gets back to the commanding officer. And I think we 
need to look at that. I know the CBOCs in my district consider 
anyone who seeks mental health or any kind of care as a VA 
case, and it is not reported to the National Guard commanding 
officer or to the Reserves or even if the person is ready 
reserve call-up.
    Tell me why you believe that--tell me why veterans who have 
served believe that the information gets back to the commanding 
officer.
    Mr. Bowman. The 118 soldiers who were in F202 have 
basically all--they have all adopted us. We are their adoptive 
parents now, and they are all our adopted sons. I talk with 
these boys all the time, and they open up to me because they 
know that I will understand about their mental status. They ask 
me questions about Tim.
    I have a list as long as my arm of soldiers in that unit 
who are all seeking counseling of some form or another 
privately, all away from the military, away from the VA, some 
as far as 100 miles away from home, to make sure that that 
information does not get back to their unit.
    Now, you say that that information should be kept 
anonymously by the VA and should never make it back. If that is 
true, then you are not--I am sorry, not ``you''--then they are 
not educating the rank-and-file soldiers to let them know that 
it is safe to go to the VA. You have to change that stigma.
    And I know for a fact that I can call four or five guys 
right now who will tell you the same thing. They are all 
active-duty National Guard. They will not go to a VA center for 
this because they are going back. My son's unit is going to 
Afghanistan in the spring, and they do not want to risk a 
redeployment opportunity by having a mental health issue all of 
a sudden show up on their records.
    Ms. Brown-Waite. Please do not misunderstand me. I am not 
questioning it. I am just saying what I believe is the policy. 
I will certainly check on that, as to if someone goes to a VA 
hospital or to a CBOC, that that information is kept private. 
Certainly, under Health Insurance Portability and 
Accountability Act (HIPAA), for example, which covers the 
privacy of medical records, that would be absolutely prohibited 
unless the patient releases any information.
    So what I am saying is, believe me, I do not think there is 
a person on this panel on either side of the aisle who would 
ever stand for, if that is the policy, its continuing. If it is 
not the policy, I agree with you, it needs to be out there loud 
and clear, absolutely loud and clear, to our military.
    The last casualty in my district happened to have been 
someone who was active-duty who committed suicide. I do not 
believe that the people who are active-duty even are properly 
informed. In this case, the young man was crying, and one of 
his buddies came up to him and said, ``Can I help you? Do you 
need to talk to someone?'' He said, ``Yes.'' So the buddy left 
to go get the chaplain, and in the meantime, this young soldier 
committed suicide. What should have happened was, if it were 
just the two of them, he should have stayed there with him and 
should have gotten, called, you know, just perhaps gone outside 
the door and called for help. So there are certainly ways that 
we could do a better job at suicide prevention.
    Again, thank you very much for coming and for sharing your 
story. And I will follow up on that issue.
    Mrs. Bowman. Thank you.
    Ms. Brown-Waite. Thank you.
    The Chairman. Thank you, Ms. Brown-Waite.
    By the way, I would not just concentrate on the official 
records, on whether they are sealed or not. It is the knowledge 
of when someone walks into a clinic. People talk; their buddies 
talk. The information is there even if the exact record may not 
be held. It is that information and that sense that seeking 
help is itself the problem for the military.
    So, you know, when you are in a small community like this, 
everybody knows what everybody is doing. I would think that 
that is more of the sense than someone's individual record 
being given.
    Would you agree, Mr. Bowman?
    Mr. Bowman. Yes, it very true, especially in a National 
Guard unit because, traditionally, those men are closer than a 
regular military unit because they all live in the same 
neighborhood also.
    The Chairman. Mr. Hare, I know the Bowmans live near your 
district.
    Mr. Hare. Thank you, Mr. Chairman.
    I want to thank the Bowmans for their courage in coming 
today and for telling the story, the chilling story, about your 
son, Tim. I had the opportunity to sit with both of you this 
morning with my friend, Representative Manzullo. I cannot begin 
to express my sorrow for your loss. My son is about the age of 
your son.
    I find it appalling that you have not received the Purple 
Heart for your son, and I want you to know, this morning, 
Representative Manzullo and I will work very hard, and we 
promise you that we will get this situation taken care of 
quickly. I cannot imagine that that is something that has not 
already been done, but we will work on that.
    Your son was a brave young man. He served this country 
honorably. We talked a lot about some of the things, about 
Iraqi veterans and Afghanistan veterans coming back. One of the 
things that you talked about, Mr. Bowman, too, was about how on 
a Monday you are in Iraq and on a Thursday you are home. You 
may be playing soccer or watching your kid's soccer game or 
doing things, but it 
is a very different war, and it has put tremendous stress upon p
eople.
    I just want to ask a couple of things of both of you. We 
talked about this this morning, but I think, for the record, it 
is important.
    You know, the Chairman has a wonderful idea, and that is to 
screen every person who comes back for PTSD. You know, 
Representative Murtha said if you are in combat for more than 6 
months you are a prime candidate. For those particularly in the 
Guard and in the Reserves who have to come out and say, ``Hey, 
I think I have a problem here,'' they are really setting 
themselves up, as you said, for a possible loss of employment, 
a possible loss of being redeployed again in their units. So I 
wonder if you think that makes sense, from a perspective of 
testing everybody.
    But also, I was amazed when you said you only had a 10-
minute briefing prior to your son's coming home. A lot of 
parents--I know Mrs. Bowman this morning was obviously very 
upset. You do not know what to look for. This is not just an 
individual problem. It seems to me, Mr. Chairman, this is a 
problem that affects the entire family. How do you know what to 
look for if you do not know what to look for or know what the 
signs are?
    So it puts you at a handicap, and then the parents and the 
family end up feeling like somehow they could have intervened 
or should have intervened, but if you do not know what you are 
looking for, you are relying upon bits and pieces. Like you 
said, Mr. Bowman, different groups of people had to come up and 
say, hey, Tim said this or Tim said that.
    So I don't know. If you would spend maybe just a couple of 
minutes talking about the need--and I thoroughly agree with the 
Chairman that every person coming back should be screened. I 
think we should look farther down the road, because it does not 
necessarily manifest itself within 30 days of coming home. It 
could be 4 or 5 years. We have seen this.
    Then also, maybe, just how little knowledge you had or the 
families had before your sons and daughters were coming back 
from this war to know even what to look for.
    Mr. Bowman. The redeployment process, basically 
reintegrating back into society--we were talking with Chairman 
Filner last night about the unboot camp, the reverse boot camp. 
It is something that we have lobbied with the Illinois National 
Guard for a long time. 
You cannot just educate the soldier; you have to educate the fam
ily.
    Now, obviously, I am speaking from the standpoint of a 
National Guard parent, but Army Reserves and Marine Reserves 
would pretty well fall into the same category. I have a young 
Marine Reservist who lives right up the road from me who is 
going through the same type of scenario right now.
    You cannot make it optional. Our education meeting from the 
State Family Readiness Group was optional. You did not have to 
be there as a family member. So, out of 118 families, we might 
have had half of them there, so there were 50 families who were 
there. The meeting was about an hour long.
    We spent, I would say, about 10 minutes with a brochure on 
PTSD, and then the rest of the time dealt with the health 
insurance, because, see, a lot of these guys have families. 
They need to know when the health insurance runs out, their 
last check. They need to know all of the financial aspects. 
When does my husband have to go back to work? When does my son 
come off of Federal title and go back onto State title?
    It is all of these questions because, at that point, those 
are much higher on the priority list than PTSD. So you start 
out the meeting talking about health issues, and that gets 
shoved off to the side. Then they hand you a magnet with a 
bunch of phone numbers on it that says, ``Here is where you 
call for help.''
    It does not work because the excitement of the moment, the 
excitement of the homecoming overtakes everything. So you have 
to come back to the issue after they are home. There is a 2-
week period of coming home. Let them be with their families for 
a couple of weeks, and then bring them back. It has been a 
long-talked-about idea through a lot of families. Bring the 
families with them, and do not make it optional. Yes, you are 
going to have to pay for it because a lot of these guys have 
kids, but what would you rather pay for, a couple of weeks in a 
camp where you can educate the family and the soldier or 
looking at another statistic and another news report where you 
have lost another veteran to suicide who took his own life?
    You have to make it appealing to people. You cannot make it 
something that is so absurd or grueling that nobody is going to 
pay any attention.
    Mrs. Bowman. It is one more battle.
    Mr. Bowman. Yes, it suddenly becomes another battle, 
exactly.
    There are ways to do that. You know, you get the right 
people involved in the situation. You look at how you can 
educate kids with cartoons and video games and how they excel 
with that type of training because they relate to it. And that 
is the kind of re-education that not only the soldier needs but 
the families need and all of the family.
    Mr. Hare. Just one final thing. I know I am out of time.
    With regard to the price, the price that your family has 
had to pay, and particularly for those people who have lost 
their lives because they did not know where to go, I do not 
think we even ought to be quibbling over whether or not we can 
afford to do this. This is something that I think we have a 
moral obligation to do for the men and women who serve this 
country.
    So, with that, I yield back.
    The Chairman. Thank you, Mr. Hare.
    Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman. Thank you for holding 
this hearing.
    Let me echo sincerely the comments of my colleagues, in 
which we are very sorry for this tragedy. Having three boys, I 
think anybody who has children certainly identifies with the 
grief that you are going through.
    But I would say to you, in all candidness, that your coming 
here is good for us, but it is probably good for you to talk 
about it and to tell us, in the ways that you are doing, so 
that we better understand. As to the actual telling of it to us 
by you, I think and hope and pray that it helps you too, as you 
mentioned that you have post traumatic stress symptoms 
yourself. Obviously, every death is a tragedy, but losing those 
who fought so bravely to protect us in this room, and in this 
country, is something that we cannot discount and that we 
cannot brush aside.
    In hearing from your testimony that he was one of those who 
spent 4 months on the most dangerous road in Iraq, going from 
the airport to the Green Zone, Members of Congress go to Iraq, 
but we fly by helicopters from the airport to the Green Zone, 
so we are not in that dangerous zone.
    I read also that you indicated that his Purple Heart has 
still not arrived. Is that true?
    Mr. Bowman. That is correct.
    Mr. Stearns. That is something that we will look into, too.
    The thing that struck me about this is--and Members will 
talk about this. Mrs. Bowman, is it possible I could ask you a 
question and get your feeling too? I notice your husband is 
doing all of the talking.
    When you look back at it, do you think the Veterans 
Administration, if they sent people to your home--I know I 
asked the staff here, does the Veterans Administration have 
counseling? It says they provide readjustment counseling and 
outreach services to all veterans who serve in any combat zone. 
Services are also available for their family members for 
military-related issues. Veterans have earned these benefits, 
and these services are provided to them, but, I mean, that 
means you have to go to the Vet Center to get it.
    So, Mrs. Bowman, in retrospect, is there something that the 
Veterans Administration could have told you or something that 
you could have done, where you felt that you just did not have 
the psychological skills or that you did not have the 
education? I mean, is there a void there that we, as Members of 
Congress, could legislate and could tell the Veterans 
Administration that we are not going to wait for the families 
to come to the Vet Centers and that we are going to send the 
people to you once we identify those individuals coming back?
    Mrs. Bowman. Right. It is just like my husband said. If we 
would have been included with Tim in some kind of a program 
where we had to report back to someone, where we had some kind 
of screening or a one-on-one with all three of us or with the 
two of us, as far as what we have seen or have not seen, and 
Tim on his own, so that we could, you know, get together and 
realize there is an issue here and that they could now help us 
deal with this and give us the tools to do that.
    Mr. Stearns. I have been in hearings for something like 
this, and I chaired a Subcommittee on Commerce, Consumer 
Protection and Trade, and we dealt with families who had 
children who took steroids and who committed suicide. So I have 
looked at this.
    What I found is that, if there is employment for the 
individual, that is a big step--but Timothy had employment--and 
if he is adequately compensated and has enough cash flow or 
something so that he at least is not on the edge there. 
Secondly, it is that he has significant counseling by folks, 
and if necessary, he is provided medication.
    Was he provided medication?
    Mrs. Bowman. He did not ask for medication.
    Mr. Stearns. He did not ask. Is there a reason why he did 
not ask?
    Mrs. Bowman. He did not realize he had the problem he did.
    Mr. Stearns. So he did not even realize that this post 
traumatic stress disorder was affecting him, and he was not 
receptive to counseling or to the medication?
    Mrs. Bowman. No.
    Mr. Stearns. Okay. Then the last thing I found was some 
kind of education. Did he have a high school degree?
    Mrs. Bowman. Yes.
    Mr. Stearns. He did. Okay.
    So, once those three are in place, then the building of the 
self-esteem is the key. And the parents somehow have to 
convince him or her that everything is going to be all right; 
we are going to work through it. In this case, it did not 
happen, and it is so tragic and sad.
    I think, as legislators, we can direct the Department of 
Veterans Affairs to not only brief you but to come into your 
house and set up perhaps a casual type of counseling where the 
veterans themselves, who are back and who are, shall we say, 
aware of this problem, can sit down with Timothy and say, 
``Okay, let's shoot the breeze here and talk about it. What is 
happening in life? Who are you dating?'' and things like that. 
So, I mean, that is what you are telling me would have been a 
big step.
    My last thought here is that both of you feel that you 
were--or were not--adequately briefed enough to know how to 
help Timothy. Can you just elaborate on that a little bit?
    Mr. Bowman. No, we were not briefed on what direction to 
send him. The only information we got was, like, of a mandatory 
nature. Before you could do anything, as far as getting him 
help, you had to get him registered with the VA. He had to go 
to the VA office with his DD-214 and get registered there, and 
then you could start the process.
    He came home with a battlefield injury that was going to be 
with him for the rest of his life, a broken hand that was a 
little bit handicapped after combat. So he needed to go to the 
VA because there was some follow-up surgery that was going to 
need to be done in a couple of years. In order to do that, you 
have to register. Well, he finally did that, but he was home 
for about 7 months before he registered.
    A lot of the guys who came out of combat were like that. 
They would not take that step to go get registered at the VA. 
It was almost kind of a mental block that they just kind of did 
not want to do it. Then one of the guys in the unit started 
working at the VA office, and then all of a sudden they all 
started rolling in, because everybody started pushing them.
    Tim had an appointment with the VA that was actually 
scheduled for a couple of weeks after he died. We got a 
reminder letter in the mail that, you know, gave me the 
appointment time and stuff. And I stopped up at the clinic in 
Freeport to see what it was about, and of course, they couldn't 
tell me because of HIPAA, so we don't know if that was about 
his hand. It would have been his first appointment. We don't 
know if that was his hand or what it might be.
    As long as we have brought the VA registration issue up, 
one of the things that has always kind of bugged me about this 
is that a veteran has to go to the VA office with his DD-214. 
Why isn't the VA sitting there when they get off the bus when 
they are coming home from Iraq? There are 118 guys coming off 
of three buses at a National Guard armory. Why don't they have 
somebody at that armory with a computer and a desk, registering 
them before they can go home?
    They are coming out of combat. You know that they are going 
to need help. Sign them up right there. That way, you know 
where they are, you know who they are, and they are in the VA 
system right away. Don't make it so that the soldier has to go 
to the VA. Make the VA go to the soldier.
    [Applause.]
    Mr. Stearns. Thank you, Mr. Chairman.
    Just a point in passing for Members. There are tests, 
written tests, that soldiers can take when they get out that, 
once you take these tests--it is just a question and answer 
over a period--they take this test, it will tell them of their 
post traumatic stress disorder, tell them of their depression 
and their emotional disability. And once they know that I would 
think that would be a step, too.
    The Chairman. But, Mr. Stearns, we have lots of evidence 
that those are not, one, filled out accurately. Because, again, 
the soldier knows if he checks anything he is going to have to 
stay and not get home; two, his deployment is threatened; and, 
three, commanding officers have called in soldiers who have 
made the wrong check on those questionnaires and said you are 
going to have problems unless you change that. So, as I said in 
my opening statement, the whole culture of the military is set 
against him. He is not encouraged nor shown the importance of 
talking about this and getting help.
    Mr. Stearns. Thank you, Mr. Chairman.
    The Chairman. Mr. Rodriguez, who in his former life was a 
professional mental health worker, so we thank you, Mr. 
Rodriguez, for your involvement on this.
    Mr. Rodriguez. Mr. and Mrs. Bowman, first of all, thank you 
very much for your testimony. I know that it is difficult, and 
it is also hard to hear these types of tragedies. But it is 
something that we have to dialogue about and hear about in 
order for us to start doing something about it, and I want to 
thank you for coming forward.
    I have had a situation in Eagle Pass, Texas, where one of 
my soldiers had communicated with his family and seemed in good 
spirits and then the next day committed suicide. And he was a 
soldier. So when you commit suicide and you are in the 
military, that person's body was brought back and was treated 
in a very different way. Here is a soldier who committed 
suicide while in duty.
    And I just had another request from another community on a 
soldier whose parents noticed--this was going to be either the 
third or fourth time they were going to go to Iraq--noticed 
that there was something very different about their son. And I 
made some calls, and I had difficulty trying to see if we can 
just get some treatment for this soldier prior to getting sent 
to Iraq again. And I know the family, so there was no issue as 
it dealt with the courage that was needed in order to go there 
or anything like that. It had to do with some mental health 
problems that they had encountered. And so, somehow, that issue 
of stigma has to be something that we need to work on.
    And as indicated earlier, I know our Chairman, Bob Filner, 
has talked about providing treatment for every single soldier; 
and that way that stigma would not be there for a period of 
time. And sometimes you are not able to pick up on that 
diagnosis initially until much later, and so we have to be able 
to come back a year later.
    And I just wanted to see if you might have any reflections 
on that? How long before you witnessed anything or you were 
able to pick up on something from the very beginning and how 
long was he out from the military before.
    Mr. Bowman. He came home in March of 2005, March 29----
    Mrs. Bowman. Nineteenth.
    Mr. Bowman. Okay--and he died on November 24th of 2005. So 
he was only home for 8 months before his demons took him over.
    And, like I said before, his symptoms, he concealed them so 
well that we could see that there were maybe some problems, but 
you couldn't identify--you couldn't put the pieces together to 
make the picture clear enough to be able to push him toward a 
certain area, certain direction.
    The check-ups--the after-action check-ups when they come 
home, we feel, are extremely important. When they get off the 
bus, get them in the system, get them home for a couple of 
weeks, bring them and the family back, go through the 
demobilization, unboot-camp process with everybody, however 
long that takes.
    But then bring them back in 90 days. Bring them back in for 
1 day, a Saturday, a Sunday, then wait another 90 days, and 
then maybe you stretch it out to 6 months the next time. But 
don't just come to a point and stop and then throw them away.
    We can track a cow with mad cow disease to the middle of a 
pasture in Montana. You have got to be able to track these 
veterans.
    And you don't make it optional, which means you have to pay 
them for it. It goes back to the price, but the price is small 
compared to what the veteran will pay and his family. Bring him 
back in. The symptoms of PTSD will manifest themselves anywhere 
from 30 days to 5 years. So you have got to know what you are 
looking at, and you have to be able to see down the road, and 
the evaluations have to mean something. They can't be that 
four-page test that Tim took when he was at Fort Carson. I have 
got that test. It is a joke.
    Mr. Rodriguez. Let me also thank you for your testimony and 
also indicate--and I want to take this privilege to recognize 
Umberto Aguirre from Del Rio, who is here, and the GI Forum. 
Will the members of the GI Forum please stand?
    I want to personally thank them, because they have been 
working with our veterans. I know we have some homeless 
shelters throughout the country and some training programs and 
these veterans have continued to reach out to a lot of the 
veterans out there. And I want to personally thank the GI 
Forum. Thank you for being there and all the leadership of the 
GI Forum and thank you very much for your testimony.
    The Chairman. Thank you, Mr. Rodriguez.
    Mr. Boozman.
    Mr. Boozman. Thank you, Mr. Chairman.
    I just want to thank you for your testimony. It was very 
helpful. We certainly appreciate the sacrifice of your son and 
sacrifice of your family. My dad did 20 years in the Air Force.
    And, again, it is a matter of resources. We need to put a 
lot more resources in the area. Your son, you know, we can talk 
about, oh, not reporting for a variety of different reasons; 
and, you know, I didn't have the privilege of knowing him. But 
sometimes it is that you are afraid of it being a stigma on 
your report for future promotion or whatever.
    And then a lot of times with guys--and a lot of my friends 
were this way--it is also an admission of a personal weakness 
perhaps that you didn't think you ought to be having. I don't 
mean that as a personal weakness, but the connotation, you 
know, I am having these feelings that I shouldn't have, and I 
am a tough guy and you don't--you know, like I say, tough guys 
are like that.
    So we just need to get it figured out. We need to put a lot 
more resources. Some States are doing a much better job than 
other States right now. We need to look at the States who are 
doing a really good job. And then, again, when it comes down to 
it, require a very high level of care, a very high level of how 
we attack this problem, and then just mandate that we get it 
done and provide the funding.
    So, again, thank you very much for being here. It was very, 
very helpful.
    Mrs. Bowman. Thank you.
    The Chairman. I just want to ask unanimous consent that our 
colleague from Rhode Island, Mr. Kennedy, who is the author of 
the Mental Health Parity Act, be allowed to join us, at the 
dais for the Committee hearing today. Hearing no objection, it 
is so ordered.
    I now recognize Mr. Mitchell, who is Chairman of our 
Oversight and Investigations Subcommittee, and was the first 
one to make sure that we followed up on that CBS News report 
with this hearing, thank you. Mr. Mitchell.
    Mr. Mitchell. Thank you, Mr. Chairman.
    First, Mr. and Mrs. Bowman, I want to offer my condolences. 
I want to thank you for having the courage to come forward 
today and share your son's story.
    You spoke in your testimony about the VA's reaction to the 
CBS News investigation about veteran suicides, and I guess I 
would like to know this. How did you feel when you heard the 
VA's reaction and did it make you feel like the VA was working 
to help families like yours?
    Mrs. Bowman. No.
    Mr. Bowman. My wife can attest to the fact that when I saw 
Dr. Katz's reaction on the TV, the first thing I wanted to do 
was reach through the screen and choke him. That as a family 
member was my reaction to their response to that number. Why 
not take that number and say, you know, oh, my God, we have got 
a problem here. Let us do something about it. This is obviously 
an issue. But instead it is, let us pick on the guy who put the 
number together.
    You know, I don't get it. As a family member, I was 
appalled. I was absolutely appalled. It is just one more case 
where the VA let the veteran down.
    Mr. Mitchell. Thank you.
    The Chairman. Thank you, Mr. Mitchell.
    Ms. Berkley. Again, thank you for your leadership in this 
area.
    Ms. Berkley. Thank you, Mr. Chairman. I appreciate the fact 
that you have scheduled this hearing, and I appreciate Mr. and 
Mrs. Bowman for being here. I know it can't be an easy thing 
for you, but we appreciate it very much.
    When somebody dies from my home State of Nevada in the line 
of duty, I call the family, and it doesn't matter whether they 
live in my district or not. I think it is the only right thing 
to do, to offer my condolences, not only as a congresswoman but 
as a parent and a mother who has sons of her own.
    Earlier this year, I had the occasion of calling a 
grandmother who raised her grandson. He had served one tour of 
duty in Iraq; and he had come home to Pahrump, Nevada, which is 
a very small bedroom community outside of Las Vegas, and was 
emotionally a mess. And he told his grandmother he cannot go 
back. He cannot go back. He doesn't care if goes to jail. He 
doesn't care if this happens, if that happens.
    Now, the military's response to him was to give him Valium 
and send him back. He was back for 24 hours, and he blew his 
brains out. It was in this context that I spoke to his 
grandmother to offer my condolences. Now, I could talk to this 
woman for the rest of her life and I could never heal the hole 
in her heart that she will have for the rest of her life.
    There are so many statistics. I have got pages of them in 
front of me now, and you are living this. And it is important 
for us to recognize, and I think just by holding this hearing 
and bringing this to the attention not only of the American 
people, but of Members of Congress, we are making a giant leap 
forward. Because a generation ago, even a decade ago, this 
conversation could not have taken place.
    Mr. Bowman. You are right there.
    Ms. Berkley. I came from the Vietnam era. That was my war. 
I was in college. Now, I meet with my Vietnam vets all the time 
back in Las Vegas. Most of my homeless in Las Vegas are 
Vietnam-era vets. I talk to them. I have normal conversations 
with them as if I was sitting there talking to you.
    But they came back messed up, and we didn't recognize that 
there is a mental health price to pay for service to our 
country. You can recognize a wound and treat it, but we were so 
ignorant of the fact that people, men and women, are coming 
back with wounds that we cannot see.
    Taking care of these veterans, taking care of our National 
Guard members, taking care of our military is the cost of 
waging war; and this is not an area that can be short-changed. 
It should not be short-changed.
    Now, I had another constituent, Lance Corporal Justin 
Bailey. He returned from Iraq with PTSD. He developed a 
substance abuse problem. And he came from a nice middle-class 
family. His father is a teacher in my district. They are 
normal, average, good Americans that believe in this country, 
believe in the cause and believe that their son was serving his 
country.
    He came back with undiagnosed PTSD. They know it now. He 
developed a serious substance abuse disorder. They begged him 
to get help through the VA. He didn't want to go. They 
convinced him to go. He went. Now, he was on five different 
substances when he checked himself into the VA. The VA gave him 
two more medications, and 24 hours later he was dead at the VA.
    I tell you this because if we don't have--we can pass every 
law in the world here, but if we don't have adequate education, 
if we don't have adequate training, if we don't have adequate 
personnel that can recognize the problem when they see it and 
confront it, nothing we are doing here is going to make much of 
a difference. So I have introduced a Mental Health Improvement 
Act which aims to improve the treatment and services provided 
by the VA to veterans with PTSD and substance abuse disorders; 
and I am hoping that my colleagues, particularly here on the 
Veterans' Affairs Committee, will join me in co-sponsoring this 
legislation.
    It isn't enough to recognize the problem, although we are 
moving forward in that direction, and I think it is good. It is 
not enough to pass legislation. We have to ensure that once 
these young men and women get into the system that the system 
knows what to do with them, and this legislation I hope will 
help that.
    I want to thank you again for being here and hope that your 
tragedy will kick-start this legislative process so that we can 
protect our men and women in the military when they come home 
from their service. Let us eliminate the stigma attached to 
mental health problems and mental health issues.
    And you are so right, and so many of my colleagues that 
have mentioned this, you are right in saying the VA and the 
Department of Defense need to go to our fighting men and women, 
not the other way around. We will save countless numbers of 
lives and improve the quality of their lives for the rest of 
their lives. And I thank you very much.
    Mrs. Bowman. Thank you.
    Mr. Bowman. Thank you.
    The Chairman. Thank you.
    Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    I don't have any questions, really. I just want to thank 
the Bowmans for your courage in coming today, and I think it 
reflects honor upon your son. Now it is our duty to learn from 
your experience and see that some of these changes are 
implemented that will make a difference in people's lives, 
particularly your observation that help should be anonymous and 
helpful, as well as your suggestion that post-deployment 
treatment be mandatory. We will be taking a look at those.
    Thank you for your courage.
    That is all.
    Mrs. Bowman. Thank you.
    Mr. Bowman. Thank you.
    The Chairman. Thank you.
    Mr. Walz, who, I just want to tell the Bowmans, is the 
highest enlisted man ever to be elected to Congress and has 
lots of experience, decades with the Minnesota National Guard. 
And also, they have a program that he might want to describe, 
the Yellow Ribbon Campaign, which tries to deal with the 
returning servicemembers in a way that at least starts on the 
path that you have suggested.
    Mr. Walz, thank you for your efforts.
    Mr. Walz. Thank you, Mr. Chairman; and thank you, Mr. and 
Mrs. Bowman, for being here. There are no words that are going 
to be said here that are going to ease the pain of your loss, 
and we clearly understand that. I have to say, though, 
especially Mrs. Bowman, you occupy one of the highest and most 
respected positions in this society as a Gold Star mother. And 
I have to tell you as a Member of Congress and as a veteran and 
a retired sergeant major and a citizen, I am ashamed that you 
have to come here today, that the idea that you would have to 
come here and ask this Congress to do the right thing for your 
son is absolutely appalling.
    And with all due respect to our news organizations, while I 
am happy they broke that story, there is not a single person in 
this room that doesn't know this was an issue. There are 
Members, there are people sitting behind you, veterans and 
advocates that have fought decades on this very issue; and I 
have worked with them. They have advocated for this, they have 
spoken about it, and we have seen year after year after year 
not addressing this in a real comprehensive manner. And that is 
simply appalling, and it is a shame.
    And I can tell you there is not a Member up here 
especially, and there is not a Member in Congress, that hasn't 
stood in front of soldiers, talked about them, talked about how 
great they are, but time and time and time again this Congress, 
and all of us are guilty of this, have simply failed to move 
things forward that make a difference. And that is an absolute 
shame.
    And I have said that there is no one in this country again 
that should ever allow anyone to stand in front of a soldier if 
they are not going to stand behind him and move this, never. We 
have seen those yellow ribbons. Many of them are very faded 
now, and you can barely read them, and the fact of the matter 
is we haven't done what they said. We haven't addressed these 
issues. We haven't taken this in.
    Senator Dole occupied the same position of both of you, and 
Ms. Shalala, and they sat here and addressed the issue at 
Walter Reed. And Senator Dole was very clear in what he said. 
He said, you spent billions putting them in harm's way. Spend 
billions in whatever it takes to get them out. And that is very 
clear to us what we need to do. So there are things here. And 
Mr. Kennedy is going to speak in a little bit, and I think this 
is an very important piece of this puzzle.
    And both of you with your keen understanding of how this 
works, especially from National Guard families, I can tell you 
this. Having been one of those that came back--we were in 
support of OEF, but sitting there with OEF/OIF veterans when we 
came back, they showed us the Horse Whisperer and told us to be 
nice when we went home, and that was the extent of it. That was 
in 2004.
    Now I am proud to say that, because of the people sitting 
in here and people who came before me, things have changed over 
the last 4 years. They have not changed enough. But Mr. Kennedy 
is following and moving something forward that the late Senator 
from Minnesota, Senator Welch, advocated so clearly, mental 
health parity and this issue of understanding and 
destigmatizing mental health.
    And I being in there and knowing as a first sergeant knows 
exactly what you are saying and watching as people aren't 
trained on this, that there is a discrimination that goes 
against a soldier who has the courage, the fortitude and, as 
you said, the insight to admit this.
    So there are a couple things I want to ask you, because I 
think you do have a keen understanding on this. We started 
noticing this in Minnesota; and the State of Minnesota, under 
the Adjutant General and the Governor, did something that 
actually I guess in letter of the law violated VA 
recommendations. We set up a program that said, do you know 
what? This hands-off policy, it is what soldiers think they 
want. The last thing you want when you come home is to set 
meetings and things like that or to talk to anybody.
    What we found was and what the research shows is that most 
of these patterns of behavior and most of this PTSD gets worse 
in the first 90 days. If you can address it early on, while it 
is fresh, in an environment that is nonthreatening and 
everybody is in it together--we have what we call Beyond the 
Yellow Ribbon Campaign, and we bring them back right away, and 
we reevaluate them, and we do something this Congress is going 
to do now to put forward. We make sure we are testing them for 
traumatic brain injury.
    As many of us know--it was the Blind Veterans of America 
that brought it to our attention earlier--we are starting to 
see a lot of veterans with eye troubles that were actually mild 
traumatic brain injury and those types of things. So we are 
starting to screen them early, we are starting to put them in 
front of the right people, and we are starting to bring their 
families in to understand.
    As you said so clearly, many of us were much older and we 
had children at home. Many of these Guardsmen have not only 
small children, they have teenage children that clearly 
understand what is going on.
    What we are trying to do and will vote on this later today 
is to get the money to do a pilot program to take this thing 
nationwide. My question to you is, do you think this is the way 
to go? Is this the way to address it?
    Mrs. Bowman. Absolutely.
    Mr. Bowman. And you need to bring all the soldiers in. One 
of the stigmas that has always been held up, especially with 
National Guard, is they will bring a chaplain or a counselor in 
for drill weekend. And anybody who wants to see the chaplain, 
he is over in room 105. And everybody looks at who is going to 
walk in that door. They know who is going in that door. And the 
Guard says, you know, they have to come to us. So our thought 
from the very beginning is bring them all in. Everybody gets a 
screening. You don't single out the guy who has a problem. You 
screen everybody. Because half the people who don't walk in the 
door have the biggest problems, and you have to screen 
everybody. That way there is no stigma among the unit. 
Everybody walked through that door and saw that counselor.
    Mr. Walz. Well, once again, thank you. And, again, this 
group behind you, this group sitting out here, they are the 
ones that are going to assure accountability on this. I think 
the time of lip service has pretty much run its course, and 
there is going to be a day of reckoning if we get this thing 
right or we get it wrong. Because we can't continue on like 
this. Especially, as I said, everyone in this room knows it is 
an issue. Now let us fix it.
    I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Walz.
    Mr. Hall.
    Mr. Hall. Thank you, Mr. Chairman; and thank you both, Mr. 
and Mrs. Bowman, for coming here. My condolences for your loss, 
and my thanks to your son for his service to our country. My 
apologies, as my colleague, Mr. Walz, said, that you should 
have to be in this position.
    All of us who represent the different districts around the 
country have veterans come to us, I am sure, with all kinds of 
problems and especially with PTSD; and no small number of those 
are either suicidal impulses or other clearly identified PTSD 
symptoms.
    I have a friend who is a Vietnam vet who was diagnosed with 
post traumatic stress syndrome. At the time, it was called 
PTSS. And you said, Mr. Bowman, you thought that the term 
``disorder,'' it was counterproductive because it seemed to 
describe it as something being wrong with a person, as a 
malady, and it should be more treated as an injury of war so 
that it wouldn't carry the stigma.
    So I am wondering if perhaps a wording change like that, 
that we do--because words do matter. And what the government 
calls things, the labels we put on them as a society or as a 
branch of government or the VA, for instance, or the medical 
community can stigmatize more or less. So I am curious if you 
would think that something like post traumatic stress syndrome 
would be better than, say, disorder.
    Mr. Bowman. I think anything that makes the term something 
that is not permanent. The term ``disorder'' applies to 
muscular dystrophy, multiple sclerosis, something like that, a 
debilitating disease that once you get it, you have got it for 
the rest of your life. Now that doesn't mean that PTSD goes 
away. But it is an injury that, if it is dealt with in the 
first 90 days, again, if you can combat it early enough, you 
can reduce its impact to the point where you have got a 
healthy, fully functioning soldier who is actually better off 
now than he was when he went to combat because he has gone 
through the battlefield, he has gone through the mental anguish 
of war, and now he has found a way to deal with it.
    Mr. Hall. Thank you.
    And I think it is important that, until we are able to do 
that, we not redeploy combat soldiers who have PTSD. So it is 
doubly important that we identify all of them, which would 
reinforce the concept that you have both spoken to, and 
Congressman Walz and others have spoken to, of bringing all 
soldiers in for screening, rather than just say ``go to door 
number five,'' or whatever it is, so that they are watched and 
identified.
    I don't really have more questions for you. I just thank 
you for being here.
    And I want to say that in my short time in office, my staff 
has helped servicemembers, veterans, ranging from 84 years old, 
a World War II veteran, within the last couple of weeks who we 
got 100 percent clarification for PTSD for a soldier who had 
two ships sunk out from under him in the Pacific Ocean in World 
War II and twice found himself floating in the ocean with body 
parts and sharks and other comrades around him and so on and 
was rescued twice. Until 2 weeks ago, having tried repeatedly 
since the 1970s with his friends and with people who were 
trying to help him, and it was just this year that he finally 
was classified.
    On down through Vietnam-era veterans right up to a 25-year-
old, twice-deployed soldier who came back from Iraq and spent 2 
years looking for a PTSD classification. He had all the classic 
symptoms: an exaggerated startle reflex, suicidal tendencies, 
couldn't go to sleep without seeing in his mind's eye the 
picture of his fellow soldiers being killed or of an innocent 
Iraqi girl who was caught in the crossfire in Fallujah and 
other things. They are images that are hard to get out of one's 
mind once you have been through that experience. And we were 
able to get him--because he came forward to us, we were able to 
get him the classification, 100 percent PTSD classification.
    But it is the ones who, because they are trying to be 
strong and because they can hide it, as you said, are hard to 
identify; and that is why I think it is critical that we screen 
everybody. The percentages are running so high that I think 
that is really the only way to be safe and to make sure that we 
don't let soldiers like Timothy slip through the cracks.
    And, once again, thank you for being here; and, Mr. 
Chairman, thank you for holding this hearing.
    I yield back.
    The Chairman. Thank you.
    Mr. Snyder.
    Mr. Snyder. Thank you, Mr. Chairman and Mr. Buyer, for this 
discussion today.
    And I want to thank the both of you, as others have, for 
being part of this national discussion. I hope you are pleased 
with the kind of comments and discussions that you have 
triggered here today.
    I did not know your son. My guess is that he would be 
proud, as a 23-year-old, of what you are doing today. Because 
you are not doing it for him. You are doing it for the sons and 
daughters of everyone else around the country.
    I also appreciate the context that you have put this in, 
which is the absolute finality of devastation of suicide is 
terrible for that person and for the family and friends of that 
person. But in your very last line you say, ``Our veterans 
should and must not be left behind in the ravished, horrific 
battlefields of their broken spirits and minds.''
    Because somebody does not commit suicide does not mean they 
are out of the ravished, horrific battlefields of their broken 
spirits and minds. And there is a lot of human misery that is 
out there, and we know it is out there. I suspect there is some 
in this room or has been some in this room.
    We don't do the thing saying, will everybody who needs 
mental health counseling right now or in the last year please 
stand up and go to the door if you would like to be 
interviewed. Because we all have our private moments of 
devastation. But for some of us human beings that becomes 
something that just eats at you hour after hour, day after day, 
week after week, month after month, year after year and, 
unfortunately, tragically results in suicide in some. But it is 
also tragic if it is untreated for those months and years and 
decades, as you have pointed out in your statement.
    Mr. Kennedy, who I hope we will be hearing from here 
shortly, has recognized through his work for some years now 
that in the private sector, the nonmilitary, nongovernment part 
of our lives, we have not solved this issue of how to deal with 
mental health challenges. A lot of insurance doesn't cover it. 
We have a lot of human misery out there that goes untreated 
because people don't know how to get it and pay for it, and 
that is a problem that we have in this country.
    But thank you for your service and being part of this 
national discussion and debate.
    Mrs. Bowman. Thank you.
    The Chairman. Thank you.
    Mr. Kennedy, thank you for your work on mental health 
parity. You and I have talked about these issues for a long 
time, and I will recognize you for any statement or for 
questions.
    Mr. Kennedy. Thank you, Mr. Chairman.
    I also want to join my colleagues in offering my 
condolences to you for your terrible loss and say that it is 
this personal story that you have offered that I think is going 
to be the catalyst for the change. Tragically, in this country, 
the statistics don't move people, but a personal story like 
yours does.
    The statistics in this country, suicide is twice the rate 
of homicide in this country. We read about murders every day, 
but we don't read about suicides every day. It is the silent 
killer in this country. It is epidemic. But your story here 
today is helping to highlight something that is an untold story 
that is too often the case for so many families and now, 
especially, amongst our returning veterans.
    So you are, as my colleagues have said, really profiles of 
courage in really sharing your story to benefit other families 
from having to go through what you have been through. So I 
really salute you and thank you for your son's service.
    My colleagues have referenced the mental health parity bill 
that Senator Paul Wellstone originally introduced that is now 
actually in the midst of being considered between the Senate 
and the House. And it has a lot to do with your story because 
many of these returning veterans, they are all going to be 
returning to the private work force. And, as you know, the 
stigma continues. And this Committee has set up what are known 
as Vet Centers because of the stigma, because they know many 
veterans won't go to the VA for their mental health services 
because they are afraid it will show up on their record, and so 
they set up Vet Centers for that purpose.
    Because of that, you can understand that many veterans may 
not even choose to avail themselves of anything having to do 
with the VA when it comes to mental health; and they may, as 
now private sector employees, choose to get their mental health 
services through the private sector.
    That is why it is even more important that we pass mental 
health parity legislation. Because all these returning veterans 
will need to be covered as private-sector employees, and we 
have a chance now to pass this sweeping parity bill that 
basically says mental health should be treated like every other 
part of your healthcare in a holistic way.
    And it is so very important because of the facts that I 
have just stated, but I wanted to ask you, with respect to 
families, veterans' families, do you think the VA is doing 
enough to address the families' mental health needs as a means 
to address the veterans themselves, mental health needs? In 
other words, one of the ways that veterans suffer so greatly is 
when they return their families are suffering themselves, 
having had a very difficult time themselves being away from 
their loved one.
    And what ways do you think, also--do you think that peer-
to-peer programs like the vet-to-vet support groups are 
effective? And do you think that the VA ought to be taking 
these programs to scale? Meaning do you think that we ought to 
really ramp them up so that they are not just here and there, 
but they ought to be national, and so that every veteran 
returning gets to talk to another vet, and that we in the 
Congress support these veteran-to-veteran peer support 
programs?
    If you could comment on those?
    Mr. Bowman. As far as the VA help for the families, I have 
never seen a VA person approach me in my entire life. Nobody 
even came to us after Tim died. Nobody offered us family 
counseling. His battalion commander was checking to find out if 
we qualified for family counseling after he died, and there is 
nothing out there for us, even though he gave his--as I feel he 
gave his life for his country.
    So I can't comment on what the VA is doing for families, 
because I have never seen it. And as being in the National 
Guard array with a lot of the kids that I know, they haven't 
seen it either, because they are stretched out. Out of 118 
soldiers in my son's unit, there were from 78 or 79 different 
towns spread across Illinois, Iowa, some small towns, some big 
towns. But nobody has ever jumped up and said, hey, somebody 
came to me with some support information. And we know these 
families because we have stayed in touch with them. So that to 
me is a gray area.
    Mr. Kennedy. And you think the families could be a big help 
to the returning veteran. If they knew in advance when their 
loved one was returning more about mental health because they 
had received some preparation and had gotten some support, they 
might be the greatest resource in that regard.
    Mr. Bowman. Yes. Especially with Guard and Reserve. 
Because, as I said, and we saw it with Tim and I have seen it 
with other Guardsmen. They can suck it up for a weekend drill. 
And they will go in and spend a weekend drill and they will 
look like the most normal human being you ever find. Well, who 
has them for the other 28 days out of the month? The family. 
That is when you are going to see the breakdowns, the 
nightmares, the night terrors, the sweats, the screams, the 
swinging in the middle of the night, sleeping in the closet 
with a 9mm. All those signs are going to be seen by somebody 
other than Guard people.
    So if you educate the family on those signs then at least 
they have a chance to locate some help for them before it turns 
into a disaster.
    Mrs. Bowman. And we ourselves chose to go on our own and 
get counseling. We have been in grief counseling for a year, 
both of us now, as well as our daughter. And it has made a huge 
difference for us.
    Mr. Bowman. And mental healthcare for--well, we discussed 
this earlier. I went to our local mental health association, 
which has offices all over our area. They are supposed to be 
the place to go. And by the time I got done with their initial 
screening paperwork, the financial paperwork, the pre-interview 
with the caseworker and all the other stuff--and I told him 
right up front, I don't qualify for any financial assistance 
whatsoever. I am going to pay for this visit. Just walk me into 
a counselor. And by the time I got all done and I did get to 
the counselor I was so mad at the system of trying to get there 
I told her if I was standing on a ledge right now I would have 
already taken the step because I can't believe what you just 
put me through. And that is what I am supposed to go to as a 
citizen in my own neighborhood.
    Then I go off the grid and find somebody that is a licensed 
private counselor, and she won't work in that system because of 
all that paperwork, and she has got all kinds of patients that 
she sees, and she has been very successful. It is frustrating 
just in the mental health aspect of it.
    Mr. Kennedy. Well, you just made a great case for mental 
health parity; and we will work on that, too.
    The Chairman. Thank you, Mr. Kennedy.
    Mr. Buchanan, do you have any questions?
    Mr. Buchanan. No.
    The Chairman. Mr. Buyer.
    Mr. Buyer. Thank you very much.
    And once again, Mr. and Mrs. Bowman, thank you very much 
for being here.
    I would like to make an association toward the comment of 
Dr. Snyder. And you are absolutely correct. We as a country do 
not do well in not only a tracking system with regard to 
suicides but on the issue on prevention, identifying risk 
factors and things. So, as a country, I agree with you we don't 
do well; and it is a subject matter that we also don't discuss 
much.
    So, as I look at the Center for Disease Control, they put 
out their study, the National Violent Death Reporting System. 
So, as you look into this--now, this is using their reports and 
status from 2001, their latest numbers, among Americans ages 15 
to 24, homicide is the second leading cause of death; homicide 
was contributing, an average, of 14 deaths per day in this age 
group of 15 to 24. Suicide was the third leading cause of 
death; and, on average, we have 10 deaths per day in this age 
group of 15 to 24 for suicides as a country.
    Then when you look at the propensities--I continue on--the 
males take their own lives at nearly four times the rate of 
females. So 78.8 percent of all U.S. suicides are males. Now, 
of all males, suicide is the eighth leading cause of death, and 
it is the sixteenth leading cause of death for females.
    Now when you look at these statistics--and what is kind of 
interesting about statistics and numbers and how you analyze 
these things, you also have to look at this a little bit 
further. Males, when they have made this compulsive decision to 
commit suicide, are more effective. Why? Because they use guns. 
Women don't use guns. Women use pills. And they aren't as 
successful at this compulsive decision to end their life. And 
then it reinforces the other statistic that shows that women 
have a higher statistical average to repeat an attempt on 
suicide.
    So it is interesting when you start reading these 
statistics, yes, they begin to tell a story, but it is not a 
whole story because we don't have a very good tracking system. 
We don't do very good statistics. As a matter of fact, when I 
looked at this national reporting system, really not many 
States report. You can see that.
    So that is why I agree and associate myself with Dr. 
Snyder. He is absolutely correct. We, as a country, on this 
particular issue are not doing well.
    So in your statement when you said when CBS News broke the 
story about veteran suicide, the VA took the approach of 
criticizing the way the numbers where created instead of 
embracing it, well, I just want you to also know that CBS 
News--there are other writings out there that have highly 
criticized CBS News and their story and the way they came up 
with their own statistics. My gosh, you have the New York Post. 
Their headline is--they called it bogus. I mean, they went 
after the way CBS News came up with statistics.
    What I enjoyed about your testimony today is that, 
regardless of statistics and the war of statistics and how you 
come up with them, there is a challenge in front of us.
    I loved your use of the word ``injury.'' And I have heard 
Bob Filner also talk about if you use the word ``disorder'' 
there is a stigma that is attached with it and we have to come 
up with a better language. And he is absolutely correct. That 
needs to be done. And we are going to need to work with the 
great minds of mental health to come up with the right 
language.
    And to my good friend, the Sergeant Major, this is an issue 
that didn't happen just because CBS News broke the story in 
November. We are going to have the testimony coming up here by 
the Inspector General (IG), and the IG is going to talk about 
their report on implementing VHA's mental health strategic plan 
initiative for suicide prevention.
    Sergeant Major, this was started in the year 2004. And I 
would agree with you, Sergeant Major, that the VA was very slow 
in getting this on the ground. And so there I would agree with 
you. We are going to have some testimony coming up on these 
initiatives, and I welcome your participation in that panel.
    I yield back. Thank you.
    The Chairman. Thank you, Mr. Buyer.
    I would offer, since the television program CSI is so 
successful, stress injury is pretty descriptive, but it is hard 
to change such a thing.
    Mr. Bowman. Again, all you have to do to change that term 
is do it right now.
    The Chairman. All right. We will talk about CSI, combat 
stress injury. I think the next panel may be a--have a----
    Mr. Hare. Mr. Chairman, would you indulge me for just 1 
second here?
    Let me just say this to all of you, and I appreciate the 
Ranking Member, but your figures on pieces of paper do not 
reflect people. And, ultimately, just listening to this 
testimony today, families are not brought into this loop when 
it comes to their servicemember having problems. The 
servicemember is not screened when they come back. There is a 
stigma attached to all of this.
    I agree with my friend from Minnesota. What we have to do 
at the end of the day is to say, ``this is enough.'' We have 
hit the wall with this issue here, and we have to look at what 
we are doing. The VA has to be much more proactive than they 
are. These are great cards, but if they don't work they don't 
work, and we have to figure out what does work.
    So I would just again say to you I want to thank you so 
much. I am so sorry about what happened to you. But we have, as 
I said to you in my office, a moral obligation to try 
everything we can possibly try to make this better. And if it 
costs us a few more bucks, so be it. But, ultimately, at the 
end of the day, our job as I see it is to make sure other 
families like yourself don't have to go through the pain that 
you have had to go through. And I think, to be honest, the VA 
has a whole lot of work they could do in educating the parents 
and making sure our troops are not singled out.
    So I just want to thank you so much for coming today, and 
we will get this done one way or another. We will get it done.
    The Chairman. Again, you all have obviously thought a lot 
about this since Timothy's death. You are very articulate, and 
you have helped us all understand this issue.
    Two major things strike me, in conclusion, about your 
recommendations. Number one, I think the President and the 
Administration have been dead wrong in trying to wall off this 
war from public consciousness. They are so afraid of opposition 
that they don't want to educate people as to what is going on.
    If all of us--parents, teachers, ministers, employers--know 
what PTSD is, know what TBI is, traumatic brain injury, we can 
all help Timothy; and that is a public education campaign.
    People all over the country want to help. I sat down with 
the Outdoor Advertising Association of America. If they were 
asked, their billboards would be useful for getting people to 
understand what PTSD is, just knowing where to turn to get 
information. That is a public education campaign that I think 
we have to do. And if the President just called any of these 
people in his office they would do it for free as a service to 
their Nation and to Timothy and his comrades.
    In addition--and I have been trying to get this into this 
year's budget--it is clear from what you say and everything we 
have learned that it should be a part of active duty on either 
return from combat or separation from service--and it has to be 
not only active duty but the Guard and Reserves--go through a 
process. I have called it a ``deboot'' camp. I have called it 
basic untraining, decompression. I am now focused on a heroes 
homecoming camp. That as part of your active duty, for whatever 
number of weeks we can get the VA and DoD to agree to, that 
every soldier with his or her unit, with his or her family, 
gets diagnosed for both PTSD and traumatic brain injury.
    Because, as policymakers, I think we have to assume that 
everybody has it unless we find out they don't, as opposed to 
you prove to us that you have it and then we set up all kinds 
of things. You don't have PTSD, you have personality disorder 
and get rid of you that way. So it has to be mandatory; and 
that allows early treatment, which is absolutely necessary.
    In addition, if you had this heroes homecoming camp, you 
could do job counseling and credentialing and educational 
counseling. All the spouses would be together for mutual 
support. All the soldiers would be together for that kind of 
comradeship, which was so important for them in combat.
    And I think we just have to do this. We expect kids, as you 
said, to be in Baghdad 1 day and taking their kids to soccer 2 
days later. It is absolutely contrary to anything that the 
brain can accomplish.
    So I hope that we can move in those areas. We have to 
change a culture.
    But Dr. Martin Luther King once said, you can't make a man 
love me, but you sure as hell--I don't think he said ``sure as 
hell''--but you sure can make him stop lynching me. That if we 
have certain laws and behaviors, that will contribute to the 
change of the culture.
    I think your testimony has brought us a long way. You have 
a chance for any last-minute statement. You have been here for 
almost 2 hours. That is a long time for congressmen and women 
to stay and talk to you, but it shows how powerful your 
testimony has been. And any last statement we would welcome.
    Mr. Bowman. Just a couple of things.
    One, I truly--we truly are honored to be here today. We 
decided after Tim died that his death was not going to be for 
nothing, that good would come of his death. It is the only way 
that we can deal with his death.
    This has been therapeutical for us. There is no doubt about 
it. Because we know that his name has meant something. We know 
that he has already saved lives.
    On another note, I am an Assistant Illinois State Captain 
for Patriot Guard Riders. If you are familiar with that 
organization, we are the people who stand between funerals and 
protesters. That is my therapy that I have taken on so that I 
can survive day in and day out.
    We have done two funerals in Illinois that were soldiers 
that took their own lives, and I have never been so embarrassed 
by the military in my life as to see the way that those 
families were treated--no honor guard, no flag folders, no pall 
bearers, nothing. Patriot Guard Riders folded the flags. We 
carried the casket.
    There is no reason that every person who served a day in 
the military in this country should not be accorded the 
military funeral rights that every soldier should be given, and 
that includes the most honor you can hand them. Because that 
honor at graveside is what that family will remember. And if 
you want to help that family heal, the country has to remember 
that they need to thank that family for that soldier, and they 
have to thank that soldier. And the only way you have to do 
that is at the graveside and at the funeral.
    And I implore anybody who can work on anything to do that, 
is to make that happen. Because a suicide carries a bad enough 
stigma with it as it is. I was told after our son died, before 
his funeral, do everything you can for him now, and we did. And 
his unit was home. So all of his unit buddies were there. He 
was also a member of the fire department. Between the two of 
them, they coordinated everything and made it just an 
absolutely beautiful service for 2 days.
    But not everybody is that lucky, and I am asking you to 
help those that don't have those connections.
    Thank you.
    The Chairman. Thank you. You have honored your son and your 
family, and we thank you so much.
    We will ask the second panel to come forward.
    Again, thank you, Mr. and Mrs. Bowman. We thank both of you 
for joining us.
    The Chairman. Again, I must introduce you with a personal 
thank you as you all have educated me with your books about 
combat stress injury and suicide.
    Penny Coleman, whose husband, a Vietnam vet, committed 
suicide, is the author of Flashback: Posttraumatic Stress 
Disorder, Suicide and the Lessons of War.
    Ilona Meagher is the author of Moving a Nation to Care: 
Posttraumatic Stress Disorder and America's Returning Troops 
and has taken upon herself to have Web sites which track 
suicides because her government does not.
    The Chairman. With that, you have the floor, which--I don't 
know how you arranged which to go first, but please, Ms. 
Coleman, you are next.

STATEMENTS OF PENNY COLEMAN, ROSENDALE, NY, AUTHOR, FLASHBACK: 
POSTTRAUMATIC STRESS DISORDER, SUICIDE, AND THE LESSONS OF WAR; 
 AND ILONA MEAGHER, CALEDONIA, NY, AUTHOR, MOVING A NATION TO 
 CARE: POST-TRAUMATIC STRESS DISORDER AND AMERICA'S RETURNING 
                             TROOPS

               OPENING STATEMENT OF PENNY COLEMAN

    Ms. Coleman. Mr. Chairman, Members of the Committee, fellow 
panelists, good afternoon.
    I am the widow of Daniel O'Donnell, a Vietnam veteran who 
came home from his war 38 years ago with what is now known as 
PTSD and subsequently took his own life.
    I use the term PTSD grudgingly, like Mike Bowman. It is the 
official term, but it is deeply problematic. My husband did not 
have a disorder. He had an injury that was a direct result of 
his combat experience in Vietnam. Calling it a disorder is 
dangerous. It reinforces the idea that a traumatically injured 
soldier is defective, and that idea is precisely what keeps 
soldiers from asking for the help they need.
    I met Daniel 6 months after he returned from Vietnam, and I 
married him a year later. The man I fell in love with was 
gentle and playful and very funny on good days. But there were 
other days when he would fly into rages over trifles and more 
than a few nights when he would wake up screaming and sweating 
and fighting something terrible that wasn't there. Or he would 
take to his bed with the blinds drawn sometimes for days, and 
all he would tell me was that he didn't want to live.
    I thought that if I loved him enough I could fix him. I was 
wrong. I had no idea what I was up against. After Daniel died, 
I tried to blame him, but I ended up blaming myself.
    For my book Flashback, I interviewed other women who lost 
loved ones to suicide in the wake of Vietnam. In addition to 
their grief, these women, like me, lived with guilt and shame 
and isolation. I now believe that our isolation was exploited 
to help camouflage a terrible tragedy.
    Unlike Agent Orange vets or Gulf War vets, who have never 
stopped demanding that the VA take responsibility for their 
illnesses, in the case of veteran suicides the most logical 
advocates were dead. We, their widows, did not become 
advocates. We believed their deaths were our fault, and we each 
thought we were the only one.
    It is more than 30 years since the war in Vietnam ended, 
and still no one has any idea how many Vietnam veterans have 
taken their own lives because no one has ever tried to track or 
count them. The 1990 National Vietnam Veterans Readjustment 
Study mandated by Congress and government funded, the study 
that proved the syndrome now called PTSD, never even mentioned 
suicide, in spite of the fact that suicide was central to every 
study that preceded it, including those on which it was based. 
No data, no proof; no proof, no problem.
    The United States invaded Iraq----
    Mr. Kennedy. Would you repeat that again?
    Ms. Coleman. Which piece? The last paragraph?
    Mr. Kennedy. What was left out. What was that study?
    Ms. Coleman. The National Vietnam Veterans Readjustment 
Study, which claimed to be the biggest study that had ever been 
done on any demographic group and claimed to address all of the 
issues, the healthcare issues of Vietnam veterans, never 
mentioned suicide or suicidal ideation.
    Mr. Kennedy. Wow.
    Ms. Coleman. It is an astonishing omission.
    The Chairman. And what year was that?
    Ms. Coleman. Nineteen-ninety it was published. The research 
was done between 1986 and 1988, I believe.
    The Chairman. Thank you.
    Ms. Coleman. The United States invaded Iraq in March of 
2003, and by August, so many American soldiers had killed 
themselves that the Army sent a mental health advisory team to 
investigate. Their report confirmed a suicide rate three times 
what the military considers statistically normal. It also 
acknowledged that one-third of the veterans who are being--of 
the psychiatric casualties who are being evacuated had suicide-
related behaviors as part of their clinical presentation. 
Nonetheless, the team's conclusion was that soldiers were 
killing themselves for the same reasons that soldiers, quote, 
typically kill themselves, personal problems.
    A supplement to the report listed things that soldiers most 
often identified as stressors--seeing dead bodies, human 
remains, being attacked, losing a friend. But the report itself 
only mentions marital problems, financial problems, legal 
problems, what they call underdeveloped life coping skills. 
Translation, soldiers are dying because they are managing their 
lives and their affairs badly.
    Every year since 2003, the suicide rate in the military has 
increased; and another team of military psychiatrists have been 
dispatched. Their conclusions are always the same: insufficient 
life coping skills.
    As recently as August, Elspeth Ritchie of the Army Surgeon 
General's Office insisted that, in spite of the suicide rate 
that had reached a 26-year record high, Pentagon studies still 
haven't found the connection between soldier suicides and war. 
There are various possible explanations for the Pentagon's 
refusal to accept that connection, but one of the most 
compelling is certainly budgetary.
    To cite just two examples, soldiers often resort to self-
medication when they are denied or discouraged from treatment, 
and that is commonly used to justify a dishonorable discharge, 
and that means that a soldier will be deprived of healthcare 
benefits. Or VA claims that somehow more than 22,000 soldiers, 
most of whom had already been diagnosed with a post traumatic 
stress injury or a traumatic brain injury, have been dismissed 
from the service with a diagnosis of personality disorder which 
is considered a preexisting condition, which also therefore 
absolves the VA of any responsibility for their future care. 
Such cynical cost-saving measures are devastating to the lives 
of soldiers and their families.
    There is currently no cure for post traumatic stress 
injuries. Though many learn to manage their symptoms, far too 
many will suffer the effect of their combat experience for the 
rest of their lives. They will continue to have nightmares and 
flashbacks. Many will continue to be hypervigilant, have 
startle responses that are often violent. Many will have 
trouble managing their anger and their relationships for the 
rest of their lives. Many will try to self-medicate to help 
them forget. And far too many will die by their own hands.
    But that sad truth cannot be used as an excuse for 
inaction. Our soldiers and our veterans need all the help they 
can get as soon as possible. Their psychic injuries may not be 
curable, but they are treatable. Their lives and the lives of 
their families can be made infinitely less difficult if they 
are given the care and support they have earned.
    They can be assured that their suffering is a normal 
response to an abnormal situation. They can talk to other 
veterans and practice compassion for themselves by feeling it 
for others. They can be taught proven techniques for managing 
their stress and their anxiety. And they can be relieved of the 
added burden of financial worry, all of which may help dissuade 
them from suicide.
    This is a public health issue of monstrous proportion, and 
I am here to bear witness to the fact that military suicides 
are not a new phenomenon. They are old news. This has happened 
before, and it should never have been left to citizens to sound 
the alarm.
    The disingenuous surprise and denial from official sources 
is simply unacceptable. I am deeply concerned that the issue is 
being politicized, that sides are being taken, lines drawn that 
make it appear as though there are two sides to this issue. 
There are not. There can't be. These are our soldiers, our 
veterans. They are also our husbands, our wives, our parents 
and our children; and they are dying by the thousands.
    I am grateful to CBS News that they have finally given us 
some solid numbers. Six-thousand two-hundred fifty-six veteran 
suicides in 1 year. Those numbers are astonishing. They cannot 
be justified or ignored. Our soldiers and our veterans are not 
disposable, and yet that is how they are being treated. More 
than 6,256 veteran suicides a year, and each one of those 
numbers represents an individual beloved face and a life-
shattering experience.
    I know that Daniel came back from Vietnam with an injury 
that finally and directly caused his death. I believe that he 
decided that he deserved to die because he had suffered too 
little or that he wanted to die because he had suffered too 
much. We call his death a suicide, but I have come to believe 
it was either an execution or euthanasia or some tragic 
combination of the two, and that continues to break my heart.
    I am grateful to this Committee for holding these hearings. 
May only good come from your efforts. Thank you.
    [The prepared statement of Ms. Coleman appears on p. 69.]
    The Chairman. Thank you.
    Ms. Meagher.

               OPENING STATEMENT OF ILONA MEAGHER

    Ms. Meagher. Thank you, Chairman Filner, Ranking Member 
Buyer and other distinguished Members of the Committee. I thank 
you for the opportunity to appear before you today.
    To open, I would like to briefly share my thoughts on why I 
think I am before you.
    I am not only someone who spent 2 years researching and 
writing about post traumatic stress and our returning troops. I 
am also a veteran's daughter. My father was born in Hungary, 
served 2 years in an antitank artillery of a Hungarian 
conscript, fought against the Soviet Union on the streets of 
Budapest during the 1956 Hungarian Revolution, later fled to 
America and in 1958 again became a soldier, this time wearing a 
United States Army uniform and serving as a combat engineer in 
Germany.
    My father's unique experience of having served on both 
sides, both East and West, in such differing armies during the 
Cold War gave him a unique perspective on military life. And so 
growing up, my sisters and I often heard my father say you can 
always tell how a government feels about its people by taking a 
look at how they treat their troops. Looking at our returning 
soldiers and their widely reported struggles with the military 
and with the VA healthcare systems they rely on, of being 
stigmatized from seeking care or of being placed on lengthy VA 
waiting lists when they need immediate help, some even 
committing suicide before their appointment dates arrive, has 
raised this citizen's alarm bells.
    For years, we have had a ``see no evil, hear no evil'' 
approach to examining post-deployment psychological 
reintegration issues, which includes suicide. After all we have 
learned from the struggles of the Vietnam War generation and 
the ensuing controversy over how many of these veterans had or 
had not committed suicide in its wake, why is there today no 
known registry where Afghanistan and Iraq veterans' suicide 
data is being collected? How can we ascertain reintegration 
problems, if any exist, if we are not proactive in seeking them 
out?
    As late as May 2007, the Department of Veterans Affairs 
spokeswoman Karen Fedele told The Washington Post that there 
was no attempt to gather Afghanistan and Iraq veteran suicide 
incidents. Quote, ``We do not keep that data,'' she said. ``I 
am told that somebody here is going to do an analysis, but 
there just is nothing right now.'' That was in May 2007.
    Meanwhile, the Army reported that its suicide rate in 2006 
rose to its highest level in 26 years of keeping such records. 
Last month, at long last, the Associated Press revealed that 
the VA is finally conducting preliminary research. They have 
tracked at least 283 OEF/OIF veteran suicides through the end 
of 2005. I have a note here. I have seen that the VA testimony 
may include a different figure than this, so we are already 
disputing this figure. The Associated Press reported 283 OEF/
OIF veteran suicides in the VA system. That figure was nearly 
double the rate of the additional 147 suicides reported by the 
DoD's Defense Manpower Data Center.
    Looking only at these two suicide figures from the VA, 
283--and from the DoD, 147--there have been at least 430 
Afghanistan and Iraq veteran suicides that have occurred either 
in the combat zone or stateside following their deployments. 
Lost in the VA and DoD counts, as the Bowmans discussed, are 
those veterans who have returned from their deployments, who 
are still in the military and who are not yet in the VA system. 
The DoD says they do not track those incidents, and I assume 
neither does the VA.
    Many of the 430 confirmed suicides that we now know about 
are as a result of our wars in Afghanistan and in Iraq. They 
should, but will not, be listed with the DoD's official OEF/OIF 
death toll, which, yesterday, stood at 4,351. If they are 430 
confirmed OEF/OIF suicides, that translates to an additional 10 
percent of the overall fatal casualty count of these wars that 
are due to suicides, 10 percent. Therefore, dismissing the 
issue of veterans' suicides in the face of this data is 
negligent and does nothing to honor the service and sacrifice 
of our veterans and families and communities that literally are 
tasked with supporting them once they return.
    Yet, prior to last month's CBS News investigation, which we 
have heard about, one additional note in that CBS News 
investigation noted that 20- to 24-year-old Afghanistan and 
Iraq veterans are two to four times more likely to commit 
suicide. They are not the only ones who have talked about its 
being double the rate of suicide for our veterans. There was a 
June 2007 study as well--we could talk about that--that showed 
that the veterans' suicide rate is double the rate of the 
civilian population.
    In my written testimony, I have included 75 suicides that I 
and other citizen journalist colleagues have been tracking 
since September 2005 and which, today, reside in the ePluribus 
Media PTSD Timeline. They offer only a small and incomplete 
sliver of insight into how some of our returning troops are 
faring on the home front, especially in light of the fact that 
at least another 355 incidents could be added among them 
according to the VA and the DoD. I believe they collectively, 
though, tell an even greater tale about the failure of us as 
individuals and as a society to ensure that our returning 
warriors are cleansed completely from the psychological wounds 
of war. They also reflect the failure of our government 
institutions to protect those who protect us.
    While I realize that these distressing stories are the 
exception and not the rule, to our exceptional military family 
members and their having to deal with the deterioration of a 
loved one they thought had safely returned from combat, they 
are the rule. In 1956, the same year that my parents fled to 
this incredible country, the 84th Congress in this very House 
that we sit in today had this to say in a presidential 
commission report on veterans' benefits: ``The government's 
obligation is to help veterans overcome special, significant 
handicaps incurred as a consequence of their military service. 
The objective should be to return veterans as nearly as 
possible to the status they would have achieved had they not 
been in military service, and maintaining them and their 
survivors in circumstances as favorable as those of the rest of 
the people. War sacrifices should be distributed as equally as 
possible within our society. That is the basic function of our 
veterans' programs.''
    Finally, I am not a pedigreed expert or a government 
official. I am shaking in my seat. I am not seasoned in 
testifying before Congress, so I do appreciate the opportunity 
to stand in for the civilian population and to represent them, 
but those who are the professionals and the seasoned, pedigreed 
officials from the U.S. General Accountability Office, the 
Congressional Research Service and even to the Veterans 
Administration have sat in this very seat over these past 
years, and they have told you that we are falling far short in 
providing the resources and programs that our returning 
veterans need and military families need to successfully return 
to their personal lives following their service to this Nation.
    To those who resist hearing the cold, hard truth of where 
we are today, I have only one thing to say: The time is here to 
stop fighting the data. Let us, please, start fighting for our 
troops. This is America. We can do better. We must do better. 
Thank you.
    [The prepared statement of Ms. Meagher appears on p. 76.]
    The Chairman. Thank you both very much.
    Dr. Snyder, do you have any questions?
    Mr. Snyder. I was browsing through your book. I wanted to 
ask: Is it May-ger?
    Ms. Meagher. Mee-ger.
    Mr. Snyder. Meagher. I am sorry.
    Ms. Meagher. That is fine.
    Mr. Snyder. You gave a series in your statement here of 
very specific things. I appreciate what you say, by the way, 
about shaking in your boots. We do that quite a bit here 
because sometimes we are not sure what way to go either with 
some of these things. But one of the issues, in fact, was 
referred to earlier by Representative Kennedy here. You talked 
about outside community-based resources that are available, and 
I recognize that there--I think there are a lot of communities 
that are trying to step forward right now to help families the 
best they can. I think about what happens as the years go by. 
Sooner or later, the war in Afghanistan and Iraq will be a 
historic event, and years will go by, but we know these 
problems that you all are dealing with and talking about, both 
of you, do not go away.
    So we come back to this issue of having services available, 
not just for the individual veteran but also for that veteran's 
family. It may be issues of marital difficulties, of substance 
abuse, of anger management, of the fact that the veteran still 
does not realize that what is haunting him is what happened 
before, and so we still come back to this issue of the 
inadequacy of our mental healthcare system in the United 
States.
    If both of you want to discuss that broader issue, it is 
that which is not just for the veteran, himself, and that we 
expect to give the highest care to the veterans' healthcare 
system or to the military retiree system of healthcare, but it 
is for our system nationwide. I have directed this to Ms. 
Meagher, but I would like you to comment also on it if you 
would, Ms. Coleman.
    Ms. Meagher. I do have some comments because I approach 
this from--of course, I am a veteran's daughter, as I said, but 
I am a concerned citizen, so I am not a journalist. I did what 
is called ``citizen journalism'' because I saw a problem. And 
the problem that I saw was that we were not, first of all, in 
our Nation, called up to pay attention to the issue. Our 
soldiers are returning, and there are no victory gardens being 
planted. There are no war bonds funding drives. There is no 
indication that we are at war. That translates into the same 
things that are happening in communities. While there are 
incredible organizations and people in pockets all across the 
country whom I met while I was on my book tour and learned a 
lot from who are ready and willing to do something, they do not 
have the ability to tap into who the veterans who are in the 
community. So I heard over and over from these incredible 
people doing incredible things that we are ready and waiting, 
but they are not coming in.
    Now, nobody asked them to do these things, and it is 
unfortunate that our leadership did not ask because it would 
have made for a stronger country. I believe that many of the 
things that I comment on cannot be legislated, and I cannot, I 
think, say----
    Mr. Snyder. Did you say ``cannot be''?
    Ms. Meagher. We need to move our society forward and ask 
them to pay attention to this issue and to take it seriously.
    Mr. Snyder. I agree with that. I think of things, though, 
like--you mentioned your father today. My father died, who was 
one of Patton's guys, and he got involved, and he would talk to 
me sometimes. Like after I went into the Marine Corps, we would 
talk about some of this stuff--about the burial details he got 
involved in. He just felt that, someday, one of those guys 
might be him. He would go down into these burned-out tanks and 
would have to bring out these bodies of Americans, and it would 
just haunt him. He could never watch any show on television but 
a game show--no cop shows, no crime shows, no westerns, no war 
movies. It was only game shows because they had no violence in 
them.
    Well, I do not think he knew what was going on, but I think 
it was you, Ms. Coleman, who talked about the person who sleeps 
in his closet or maybe it was the Bowmans or both of you. Okay. 
Well, I also think that there are going to be children in those 
households who are around this stuff, and there are these 
veterans who know that they are having problems that may be 
impacting negatively on those children. Well, we do not have a 
system where the children could go down to the VA hospital 
where they could get good quality mental health counseling for 
a 5-year-old or for a 9-year-old or for a 12-year-old or for a 
15-year-old. Again, we get back to Mr. Kennedy's work here.
    So that is what I was getting at, the community-based 
resources. Even now, you are talking about our not really being 
called forward as a country, but think of where we will be 5 
and 10 and 15 and 20 years from now when memories will have 
faded about our responsibilities, and we are still going to 
have families from these folks who are going to have these 
needs.
    I think it is on the second page where the two of you 
recommend and you talk about complimentary counseling to all 
immediate family members. That is what triggered my thought 
because we need to have a system in this country of providing 
better mental health coverage because that need is going to be 
there for a lot of years for these families, and it may be 
generational. And I think that we are going to be grappling 
with it on this Committee, but we need to be grappling with it 
in our entire healthcare system.
    Ms. Meagher. I do have one suggestion that could be easily 
done, and I would have done it myself if I only had the 
opportunity.
    Mr. Snyder. Yes.
    Ms. Meagher. I think it could be easily done.
    All of these resources that are out there--now, I am from 
Illinois, and the Bowmans are as well. We have National Guard 
troops. They come from the community.
    Mr. Snyder. Right.
    Ms. Meagher. So they know the community. The community 
knows them. And there are resources available to them, but 
there is not a database. There is nothing where somebody who is 
sitting in Texas or in Illinois can simply just go to a 
database to see ``what is available in my community.'' The 
military is not giving the information to the soldiers, and the 
soldiers do not know where to go often. They do not know that 
there are psychologists who are at the ready to donate their 
services. There are programs. There are all types of programs. 
So there could be a database. There could be something that is 
put together that has resources for people.
    Mr. Snyder. In fact, the problem that we run into with our 
Reserve component--and Arkansas has had a lot of Reserve 
component troops, both Guard and Reserve. What they run into is 
they may come from communities where, in fact, the healthcare 
providers there are not part of the military healthcare system 
because they have not had to be. Nobody has come in and said, 
``Do you accept TRICARE?'' Now they are going through, ``What 
is TRICARE? Why is that important to us?'' ``Well, it is, 
because we have been mobilized as a family, and that is now our 
healthcare system because my husband or wife is not on their 
work-related healthcare system anymore. This is our healthcare 
system. If you do not take it, it means I cannot get 
healthcare, and I am going to have to go someplace that takes 
my insurance.'' So we run into those kinds of issues.
    My time is up, Ms. Coleman, but I wanted to give you a 
chance to comment.
    Ms. Coleman. I think that one of the saddest things about 
these wars has been the fact that we have been invited not to 
participate.
    Mr. Snyder. I am sorry. I could not hear you.
    Ms. Coleman. I think one of the saddest things about these 
wars has been that we have been asked not to participate, that 
we have been deprived of the image of funerals and of coffins 
and of tears and of wounds even. I think that has deprived us 
of the opportunity to check in with our consciences, and I 
think it has deprived us of the opportunity to help those who 
have been wounded to carry the burden of their pain. And I 
think it has not contributed to a reinforcement of our social 
fabric, and I think that is too bad.
    Mr. Snyder. Thank you both for being here.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Ms. Herseth Sandlin.
    Ms. Herseth Sandlin. Well, thank you to both of you.
    I was going to pose a question or two with regard to what 
you two have seen or as to, in your conversations with others, 
whether or not there is a difference either in the experience 
or in the numbers of active duty versus the National Guard and 
Reserve. We have done a lot of work on this Committee over the 
last couple of years in examining that question in a lot of 
different contexts.
    On the one hand, you could say, well, perhaps it is our 
national Guardsmen and Reserves because the community itself, 
the entire community, is affected by that or a set of 
communities is by a particular unit's being deployed, and so 
that support network is particularly strong among the families 
during deployment and when those men and women return home, and 
there would be a greater likelihood that they would be somehow 
finding or maneuvering through the community, given the support 
of that community, to find resources to meet their needs. At 
the same time, I hear you saying that there are some 
communities, particularly larger ones, perhaps, and they are 
unlike those that I represent in South Dakota or perhaps some 
in Arkansas, where the unit is from five or six different very 
small communities versus a larger community or a community 
where there is a larger base.
    Have you noticed a difference? How do we best address that 
situation? Perhaps a database is good in terms of the resources 
that are available in a community for National Guardsmen and 
women, but what other issues do we have to get over for active 
duty in response to--of course, we have talked about the stigma 
in the past and the concern that these men and women have as it 
relates to seeking those resources and a fear about how it 
affects their military careers.
    So can either of you talk about the differences that you 
think exist? Are there numbers broken down to suggest that we 
have higher rates of suicide among active duty versus National 
Guard and Reserve, or is it exactly the opposite?
    Are there other hurdles that we can help address based on 
the constituencies that we all represent here and the different 
constituencies that we represent back in our districts to help 
you and to, again, be part of that network within a community 
to facilitate information and to reach out and to know who 
these people are and to make them aware of the services that 
are available to them?
    Ms. Coleman. The information that has been available since 
the beginning of these wars about active duty troops has been 
very hard to get a hold of. Newspaper reporters have had to 
file Freedom of Information Act (FOIA) requests to find out 
what was happening in terms of suicides among active duty 
troops.
    When The Hartford Current did a series of articles in May 
of 2006, by submitting FOIA requests, they got information 
about several suicides. I think when CBS News was trying to 
initiate their report, they also submitted a FOIA request to 
the Department of Defense. And the Department of Defense gave 
them some number of active duty troops, but told them that 
veteran suicides were just something that they were not keeping 
track of. I do not know.
    Ms. Meagher. There are some stats and some specific changes 
and differences as far as Guard and Reserve troops, how their 
experience unfolds.
    According to the DoD, they did a Pentagon task force study 
on the troops in the summer of 2007, and they reported that 38 
percent of soldiers--31 percent of Marines--showed symptoms of 
PTSD, psychological problems. Meanwhile, 49 percent of the 
National Guard and 43 percent of the Reserves did.
    Now, as to some of the reasons that I have seen in the data 
that I have read, there are a few things that are happening 
there. When Reserves are called up, they may have their own 
businesses. Those businesses may go under if they have been 
deployed two or three times. Although the Bowmans spoke about 
their own family support since they are in the same community, 
it is not like a base. There are not specific places where the 
family members can go to get support. So some do not come in 
like that half of the base that did not come in that the 
Bowmans mentioned, and some might come in for these little 
impromptu gatherings, but there is not one 
area where everybody can support each other. So that is signific
ant.
    There are also differences in--I have seen in reports of 
National Guard troops that they may deploy all as one unit, but 
often, especially with individual ready Reserves that are 
activated, they are used as fillers, and so they are going with 
people who they might not have trained with. There are also a 
lot of other issues that revolve around insurance issues, but 
worries about financial--if you have lost your business, that 
is an added stress. It is not PTSD per se, but it is an added, 
additional stressor. There are worries about their families at 
home, and many of them have kids that some of the younger 
active troops do not have.
    Ms. Coleman. One other thing, suicide statistics are 
renowned for being difficult to gather. The Center for Disease 
Control and Prevention (CDC) says that they expect that it is 
somewhere between 10 and 50 percent underreported. If a veteran 
drives the family car into a tree or overdoses or gets into a 
confrontation with a policeman, those are not necessarily going 
to be recorded as suicides, and they are what Mike Bowman 
called a ``killed by'' service. I think that it is very 
difficult to actually get a handle on the number of suicides.
    When CBS News asked State governments to give them the 
number of suicides that they had recorded, those were the 
suicides that family members chose to acknowledge, and a lot of 
States do not consider something as suicide unless there is a 
note that has been left. I think that the numbers that we do 
have are as good as we can get.
    Ms. Herseth Sandlin. Thank you both.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Kennedy.
    Mr. Kennedy. Thank you.
    I just want to follow up on my initial point, when we were 
speaking with the Bowmans, and it was with regard to the family 
issues, the thought that the Bowmans were paying out of pocket 
right now for counseling was really troublesome to me. You 
know, here they are trying to get counseling for the loss of 
their son who suffered as a result of his service, and they are 
paying for it personally rather than the United States paying 
for it. I mean, I think that we owe it to the families to be 
paying for their mental health counseling as a result of the 
loss that they suffer when they lose a father, a spouse, a 
loved one in the line of service. In the case of a suicide, 
certainly, this ought to be extended to families as well, and 
it is just absolutely incredible to me that we do not have this 
extended to family members.
    I would like to ask you to comment on--you know, the Kaiser 
Foundation just completed a study of adverse childhood 
experiences. In California, they have measured the trauma dose, 
basically, of children who come from families where they have 
high doses of Cortisol. Basically, it is a child who comes from 
a family where there is domestic violence. You know, the fight-
or-flight instinct in a human being means you have high doses 
of Cortisol if one is threatened. For children, if they hear 
loud screaming, if they see violence, Cortisol is released in 
the brain just as it would be for any one of us and just as it 
would be for a veteran or for anybody in a situation where it 
is fight or flight. This creates changes in the brain.
    In any event, they have measured this in families where 
children come from homes where there is domestic violence, 
where there is drug or alcoholism, where there are these kinds 
of high-risk situations. These children are at much higher risk 
for suicide themselves, for drug abuse, for a whole list of 
things down the road, and this has been borne out by evidence 
now.
    So what strikes me is not only are we going to see a wave 
of challenges with veterans down the road, but we are going to 
see a wave of challenges with their families. We are talking 
now about a registry for trying to track veterans' suicides. It 
would seem to me we ought to be getting a registry of tracking 
the children of these veterans. Can you comment on that? I 
mean, we have got a whole generation of the children of these 
veterans, and they have been seeing their parents go off for 
two or three tours of duty.
    In dealing with that kind of trauma, what do you think we 
are going to deal with with these kids down the road with their 
parents' coming back and having suffered all that they have 
suffered and the impact on them?
    Ms. Coleman. After the war in Vietnam, 20 years after the 
war in Vietnam, the Australians created what they called a 
``nominal role.'' They got in touch with all of their Vietnam 
veterans, the ones who were still alive, and they have yearly 
contact with them, and they keep track of what is happening not 
only with them but what is happening with their children. And 
one of the things that they found was that those children were 
three times more likely to kill themselves than their peers, 
which was an eye opener and a tragedy.
    Ms. Meagher. That is one of the things, the secondary PTSD 
of the family members. After reading an article about a cluster 
of suicides and of murder-suicides that had taken place at Fort 
Lewis in 2005, that is what brought me into the issue. I read 
in that article that the reporter had listed how many other 
family members--how many wives, how many children--were 
affected, and that is when it really clicked with me that this 
is a larger issue than just the mere data, than just the mere 
stats of the individual people.
    What makes military suicides different than any other 
suicide that might be in the general population is that we have 
a responsibility for these family members. If a person--and I 
have a sister who committed suicide, so I know that that is 
another additional reason why I was emotionally very attached 
to the families who were dealing with this issue, because I 
knew the stigma that our family had to go through. While my 
sister was not a veteran, she was a private citizen, and there 
is no obligation for the government to do anything. There is no 
obligation for the community to care--my family cared--but for 
our soldiers and for our military family members, we have an 
obligation to them. So that is what makes it different.
    As far as things that you could legislate, we have not 
really talked much about what we can do to prevent and to 
protect and to shore up our veterans for this new type of 
warfare that they are in. I know that there is a Psychological 
Kevlar Act. There are only, I believe, ten co-signers. Phil 
Hare, Representative Hare, is one of them, and I am proud to be 
from his State.
    I think we need to look into proactive measures to be able 
to help our troops from basic training onward. We need to push 
the military culture to change and to grow in their idea of 
what it means to prepare a soldier for battle. It is not just 
to pull the trigger. It is also to be able to live with that, 
that work.
    Mr. Kennedy. I appreciate your mentioning the Psychological 
Kevlar Act. That is my bill.
    It seems to me, if we put our soldiers through strenuous 
boot camp, that ought to be not only for the physical but for 
the psychological nature. They ought to be prepared for what 
they are going into, and we ought to have mental health 
literacy as well as physical literacy when we go in.
    I was really struck, Ms. Coleman, by the fact that children 
of veterans of Vietnam in Australia were three times more 
likely to commit suicide than their counterparts. That is 
pretty----
    Ms. Coleman. We do not have those same statistics.
    Mr. Kennedy. We do not have the same statistics here, but 
that is in Australia. Whether this is a question of our 
Veterans Affairs Department, it seems to me it is a question of 
our national interests. It is properly, maybe, an issue that 
has to do more with our U.S. Department of Health and Human 
Services--another area of our governmental policy--but it is an 
issue that we have to address as a Nation and that we should 
address as a Nation.
    Ms. Coleman. Coming off of what Ilona said about it's being 
really important that we focus on preventative care, it seems 
to me--think about this. What if we immediately granted full 
disability to all combat veterans who submit a claim through an 
appropriate VA representative? Those benefits would continue 
until the VA succeeds in denying the claim after all of the 
appeals have been resolved. The VA would then have an incentive 
to streamline their process, but it would also put the emphasis 
on prevention as opposed to diagnostic and curative, which is 
public health. I know that the flagship suicide prevention 
hospital in the VA is the Canandaigua Center for Excellence, 
and all of their literature emphasizes public health outreach. 
It seems to me, if there were not an adversarial relationship 
between veterans and the VA, that that would make it much 
easier for them to get the care they need, and that would 
probably make it much less expensive to take care of them over 
the long run.
    The Chairman. Thank you, Mr. Kennedy.
    Mr. Buyer.
    Mr. Buyer. Ms. Coleman, I would like for you to know that 
information that we obtained to help prepare for this hearing 
we got readily available off the Web, so we contacted the 
Defense Manpower Data Center. Anyone in the country can get on 
the Web, and they can pull down the statistics. So, in your 
testimony to us that they are hiding this information, I just 
want you to know that it is readily available to people.
    Secondly, I would like to add, Ms. Meagher, that I want to 
thank you for your contribution. I think it was therapeutic to 
you, as this experience had to be. Now, as a policy maker, the 
challenge is the many types of disease groups that we deal 
with. Name a disease, and then we have to do this analytical 
overview of populations and their propensities to have come 
down with, say, cancer even if they had not been in the 
military, because then we try to examine, if it was something 
caused by military service, and the causal connection, the 
link, because then there are dollars attached to those kinds of 
things. So we study all of these things.
    On this issue, with regard to suicide, we recognize that as 
a society. I will go back to Dr. Snyder's comment as being 
absolutely correct that, as a society, we have a challenge, and 
it is the propensity of these young adults, 15- to 24-year-old 
males, to committing suicide in our society, and when it is one 
of the top ten killers, we have a problem in our society.
    Then you do the overlay of obligation. I agree with you. 
When you put on the uniform and we do the inculcation and the 
matriculation process, our obligations to care for them will 
continue. The overlay on what we have just discussed and what 
makes it really challenging is what I brought up earlier: There 
are individuals who want to use that data for their own causes 
and antiwar themes. What happens is that we then get away from 
what we really want: What do I want for my comrades?
    What I want for my comrades is I want them to be able to go 
obtain their mental health without a stigma, and that is why I 
really dislike the word ``disorder.'' There is this whole 
balance that we have to go through between the military. Dr. 
Snyder has to struggle with this being on the Armed Services 
Committee. You have got a responsibility here as commanders to 
develop military cohesion that will be effective on the 
battlefield right? If you are effective and you have got the 
cohesion, you are also saving lives because buddies look after 
buddies. Balance that with the privacy then of a soldier. Now, 
commanders also have played an integral role. Because they are 
responsible for military cohesion, they need to know about the 
mental status of their soldiers so they can define the cohesion 
to be successful. So somewhere in here is this challenge of 
providing mental health services so that the commanders can 
also have a comfort zone. It is not only the commanders. It is 
the buddies, the man to their right and left; are they okay to 
carry a weapon? You know, this is very challenging, and I think 
the military is doing a better job today than what they have 
done in the past on their abilities to have soldiers talk about 
their experience when they debrief. It used to be John Wayne. 
You know John Wayne. ``I went in. I did bad things. I feel 
good. I am fine. I am going back to my job.'' No. It is okay to 
talk about it.
    In listening to the professionals--the psychiatrists, the 
psychologists and the counselors--they talk about early 
intervention is, in fact, the best. The reason it is the best 
is that, as to these risk factors that we all are in search of, 
not everybody shows it, and that is what is so hard. You have 
done that through your own life in struggling with, ``What 
could I have seen about my sister?'' I do that about my friend. 
What was there? You know, my brother and I have these 
conversations. We did not know. We did not see. We were with 
him. I never saw it until he did something impulsive.
    So I think the Chairman is on the right track here in 
trying to come up with some form of a classification where 
soldiers and our veterans when they return home--our Guardsmen, 
Reservists--have a comfort zone where it is okay to obtain 
mental health counseling; at the same time, our commanders are 
in a comfort zone that the individual is not imbalanced--do you 
know what I mean, that he is okay? It was okay to talk about, 
when I went into the room, bad things that happened.
    ``Oh, bad things happened? No. What exactly happened?''
    ``I shot and killed two.''
    ``How did you feel about it?''
    ``I did not like it. It was my job. It was my duty. I had 
to do it, but I keep thinking about it.''
    ``Well, what do you keep thinking about?''
    So you are forced to talk that thing through, and that is 
helpful, and commanders are trying to do that kind of thing. 
The more we move to that prevention aspect of it, I think the 
better off we are going to be in the end.
    So I compliment you, Mr. Chairman. I yield back.
    The Chairman. Thank you.
    I wish all commanders were as open as you suggest.
    Mr. Kennedy.
    Mr. Kennedy. Yes. We are working on a network of care--an 
Internet-based, comprehensive resource--for those who can 
access it both for providers and for those trying to get help, 
and that is going to be available, hopefully, throughout the VA 
system. We are working on that. That is a very good suggestion.
    The Chairman. I want to give you both a chance to comment 
on the data question that Mr. Buyer raised.
    It has been my experience that this data is not available. 
We have asked people sitting in your chairs for data. They have 
not provided it from the VA and from the DoD.
    When I read your Web site, Ilona, it brought to mind, you 
know, what if the Pentagon had to raise its money through bake 
sales? You know, you are trying to do something that the 
government should do, and your resources are very limited to do 
that, but the government is not doing it, and it seems 
absolutely necessary that they do. They do not want to know, it 
looks to me. I mean, this could be tracked. We can do this. We 
do not want to know the answer as far as I can tell.
    Would you comment on the availability of data, both of you?
    Ms. 
Meagher. Well, I can say this, that I am just a private citizen 
who, in 2005, was interested in the topic and thought to 
myself, Well, there is this cluster of suicides and murder-
suicides, and some of them were highly decorated in Fort Lewis 
in Seattle. I wanted to see, is it just happening there, or is 
it happening elsewhere?
    So I used simple search engine technology. I just started 
Googling, and I started to find different incidents all across 
the country reported in local media. Now, large Web sites like 
The New York Times and The Washington Post, they are able to 
archive all of their incidents. Small, local communities do 
not. So, a couple of months later, maybe that police standoff--
we are not just talking suicide here. Of course, we are for 
this hearing, but there are a lot of things that are going on, 
and we try to track them all, and it is not meant to 
stigmatize. Obviously, there is a larger portion of troops who 
have the support services that they need, who have the family 
in place to help them, to make the right decisions, to make the 
right calls, but for those families who are having these 
problems--the suicides, the police standoffs, the drunk driving 
incidents, the domestic violence and on and on--those things 
need to be tracked and preserved, not to point a finger but 
just so that we can have some data for them to do some research 
on, have the people who know how to do this research do it, and 
if it is lost, then it is lost, and we lose an opportunity to 
preserve that.
    Mr. Kennedy. So we should track it within the corrections 
system, too?
    Ms. Meagher. Yes.
    Mr. Kennedy. And we are not.
    Ms. Meagher. If I can make one more point about law 
enforcement, there are a lot of things the communities can do, 
and I have already seen them happen. In my area in Dixon, the 
Mayor has tried to be proactive by bringing in law enforcement 
and educational institutions and churches and healthcare 
organizations. Law enforcement needs to be, in many ways even, 
a safe haven. We need to have military families be able to pick 
up the phone--be it to law enforcement or to their healthcare 
providers--and not have to fear that, if they do pick up the 
phone again, there is the stigma.
    If I pick up the phone and if one is having a PTSD episode, 
if a loved one is having an episode, one should not be 
penalized for having to pick up the phone before it gets to 
this pancaking of, you know, one incident after another, and 
then we have a bad record, and then we have lots of problems. 
That just increases stress. We need to think about ways to 
prevent that.
    Mr. Kennedy. In my State, my municipal police academies 
have gotten together and have put their own debriefing and 
program together at their own expense because so many of the 
Guard and Reservists are, obviously, first responders. When 
they come back, if the VA is not doing it, they are going to do 
it themselves to help reintegrate these Guard and Reservists 
back into the first responder community. Of course, the issue 
of those ending up Guard and Reservists and others ending up in 
prison is also something we are doing as a State initiative. We 
are trying to track those who are ending up in our corrections 
system because of the issue of reacting badly because of the 
problems that they are facing emotionally and psychologically.
    Ms. Coleman. In August of 2007, the Army released a 165-
page suicide event report for the year 2006, and that was 
described in all of the reports that I read as a first time 
ever public analysis of what the Army called ``confidential 
data'' submitted by units from across the Army over the past 2 
years. I think it included previously unreleased statistics on 
attempted suicides, and it found hundreds of attempted 
suicides, particularly among active duty soldiers who had 
returned from the war, and an increase in the number of soldier 
suicides in Iraq from the previous year. I do not think those 
figures had been available before.
    The Department of Defense's Web site, up until very 
recently, had two, three, four acknowledged suicides among 
active duty troops, and there were a lot of noncombat 
accidental deaths but almost no suicides. This is a very 
different picture of what has been happening within the 
service.
    The Chairman. We thank you for your testimony. There is a 
lot of movement here because we have votes over on the floor 
for which we have to take about a 30- to 35-minute recess. We 
will decide how we are going to conclude the hearing when we 
get back.
    Both of you have done tremendous work in trying to have 
this Nation understand these issues, in trying to get a sense 
of both raising the consciousness about the issue and speaking 
to our consciences to respond to it. These are our young men 
and women, and we have an obligation to them, and we have to 
understand the extent of the problem and face it squarely and 
then figure out what we are going to do about solving it. So 
you have done a great service to the Nation with your books, 
with your articles, with your Web sites. We look forward to 
working with you when we have any needed legislation that we 
are going to do here. Thank you so much.
    We are going to recess for 35 minutes.
    [Recess.]
    The Chairman. Again, I apologize to our witnesses for the 
recess. And also we tried to, I think, do too much in one day. 
So I think, with the agreement of all the participants, we are 
going to move on to panel five for the Department of Veterans 
Affairs to present its testimony. And then early next year we 
will hold another hearing for other testimony to continue.
    I think the morning testimony was very compelling and took 
a longer time than we had imagined. We thank you for waiting 
this long.
    Dr. Katz, Deputy Chief, Patient Care Services, Office of 
Mental Health in the Department of Veterans Affairs; and Dr. 
Kara Zivin, Research Health Scientist with the Health Services 
Research and Development of the Department of Veterans Affairs.
    You are recognized, Dr. Katz.

STATEMENTS OF IRA KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT CARE 
      SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
           ACCOMPANIED BY ROBERT ROSEN- HECK, M.D., 
  DIRECTOR, DIVISION OF MENTAL HEALTH SERV- ICE AND OUTCOMES 
RESEARCH, VETERANS HEALTH ADMINISTRATION; LAWRENCE ADLER, M.D., 
 DIRECTOR, MENTAL ILLNESS RESEARCH EDUCATION CLINICAL CENTER, 
   VETERANS INTEGRATED SERVICES NETWORK 19, VETERANS HEALTH 
ADMINISTRATION; AND FREDERICK C. BLOW, PH.D., DIRECTOR, SERIOUS 
 MENTAL ILLNESS TREATMENT RESEARCH AND EVALUATION CENTER, ANN 
ARBOR VETERANS AFFAIRS CENTER FOR CLINICAL MANAGEMENT RESEARCH, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
  AFFAIRS; AND KARA ZIVIN, PH.D., RESEARCH HEALTH SCIENTIST, 
   HEALTH SERVICES RESEARCH AND DEVELOPMENT, VETERANS HEALTH 
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS (ON HER OWN 
                            BEHALF)

           OPENING STATEMENT OF IRA KATZ, M.D., PH.D.

    Dr. Katz. Thank you, Mr. Chairman and Members of the 
Committee.
    I want to begin by expressing my most profound condolences 
to Mr. and Mrs. Bowman and to Ms. Coleman. What they have 
spoken of is important to me personally and to all of my 
colleagues. I want to assure them that we have taken their 
words to heart, and so has the Department of Veterans Affairs.
    I want to thank you, Mr. Filner, for holding this hearing. 
The discussion represents an important day for mental health in 
America.
    I want to go over my prepared oral testimony, but to say 
that, especially after the discussion this morning, it is only 
a fraction of what I am personally feeling, and it is also only 
a fraction of what VA is doing.
    There is no question, suicide among veterans is a tragedy. 
The Department of Veterans Affairs recognizes our obligation to 
work to prevent suicide, both in individual patients and in the 
entire veteran population. We are concerned about epidemiology. 
We are more concerned about people and the tragedies that they 
represent. But we focus on epidemiology because findings in 
this area can guide prevention.
    VA has a long track record of research and publication in 
this area. One of our leaders is Dr. Han Kang, who is here. 
Others are on this panel with me.
    One peer-reviewed publication from a long-term, 20-year 
follow-up of Vietnam-era veterans reported that the rate of 
suicide among veterans who were deployed to Southeast Asia did 
not differ statistically from veterans of the same era who were 
not deployed. Another published study of veterans from the 
first Gulf War provided similar findings.
    VA and Dr. Kang have just completed a preliminary 
evaluation of suicide rates among veterans returning from Iraq 
and Afghanistan. From the beginning of the war through the end 
of 2005, there were 144 known suicides among these new 
veterans. This number translates into a rate that is not 
statistically different from the rate for age-, sex- and race-
matched individuals from the general population.
    However, suicide rates among veterans are too high. The 
population receiving care from the Veterans Health 
Administration has more risk factors for suicide than the 
general population. Most veterans are male, and men have higher 
suicide rates. Those who come to the VA for care tend to be 
older, less well-off and more likely to have a mental health 
condition or another chronic illness. Those with the greatest 
need for care are those who are most likely to come to VA. And 
this increased need is associated with increased risks of 
suicide.
    The Chairman. I am sorry to interrupt, Dr. Katz. I just 
don't understand that conclusion, that those with the greatest 
need are those who are most likely to come.
    We have talked for 3 hours about the reasons why people 
don't come. And I could make the same case, since you are 
making a hypothesis here, that there is no real data that the 
people most in need don't come. I could make the very same 
argument.
    So, why do you think that? I don't understand it at all. 
You don't know who is coming or why those who are not coming 
aren't coming. You don't know that.
    Dr. Katz. I will take the question for the record and get 
back to you, post hearing.
    The Chairman. I am just asking. You drew a conclusion which 
I think is wrong, and you can't argue for it? I mean----
    Dr. Katz. Well, those who come--for example, there are the 
demographic issues--age, sex and all. But, most significantly, 
those who come to VA for care are more likely to have mental 
health conditions than others.
    The Chairman. But you are not giving me any basis for 
making that statement. I don't know why that is the case. 
Again, those who have been subject to arguments that, you can't 
come if you are weak and they accept that, no matter how 
difficult--I mean, the suicides we heard about in the morning 
session, they never got in touch with the VA, and they had 
pretty difficult situations. So I just don't know why you would 
just make that assumption.
    Dr. Katz. Well, it is not just an assumption. There is no 
question that there are many people in need who don't come to 
VA for care. That is a problem, and it is a problem that we 
have to solve. But, on a statistical basis, those who do come 
to us have major care needs and, with those major care needs, 
increased risks for suicide.
    The Chairman. But those who don't come could even be in 
greater need. You say the reverse here, and I don't know on 
what basis you are doing that.
    Especially, in light of the little bit of data here, 144 
known suicides. We have heard arguments all morning that your 
data is probably incomplete. There is unreported stuff. There 
is underreported stuff. There is not tracking. I mean, you are 
not anxious, it doesn't seem to me, to go after this stuff. So 
you are basing your conclusions on very suspect data to begin 
with.
    Dr. Katz. Mr. Filner, I would like to get back to you about 
your concerns. But I want to stress that the issue is 
prevention. Arguing about rates isn't the issue. The issue is--
--
    The Chairman. You are the one that is arguing the rates. 
Every one of your paragraphs ends with a thing about the 
rates--every one of them. You are not talking about prevention 
here at all. I read your whole thing, and I couldn't figure out 
what you were doing to stop suicides, frankly.
    Dr. Katz. Well, I will tell you, our suicide-prevention 
activities are based on the principle that decreasing suicide 
requires both enhancing overall mental healthcare and programs 
specifically designed to prevent suicide.
    Part of the training for all staff has been to teach that 
even strong and resilient people can develop mental health 
conditions. We also teach, both within our facilities and in 
the community, that care for these conditions is available and 
must be provided quickly. We also teach that treatment works.
    The VA Suicide Prevention Program includes two centers that 
conduct research and provide technical assistance. It also 
includes a suicide-prevention call center and suicide-
prevention coordinators located in each of VA's 153 hospitals. 
All together, 200 staff members, 200 mental health 
professionals in VA, have suicide prevention as their major 
responsibility.
    The Department is partnered with the Lifeline Program of 
the Substance Abuse and Mental Health Services Administration 
to develop a suicide hotline for VA as part of the national 1-
800-273-TALK system. Since it began, there have been more than 
6,000 calls from veterans, 1,300 referrals to suicide-
prevention coordinators, and more than 300 rescues where police 
or ambulances were called, any one of which may have been life-
saving.
    The Chairman. Any suicides amongst those?
    Dr. Katz. In our current follow-up, we haven't seen any.
    The Chairman. I am sorry?
    Dr. Katz. We haven't seen any.
    The Chairman. You have 6,000 calls and you are giving me 
all this data of 1,300 referrals, 300 rescues. But you haven't 
seen or you don't know if there are any suicides?
    Dr. Katz. We are doing follow-up of those who have called, 
and have been referred to VA facilities and the results from 
the follow-up will be available soon.
    The Chairman. These are obvious questions. I don't know why 
you don't have them before you come in. You give us all this 
data, which is a lot of activity, but I don't know about any 
results. I can't tell from your report that we have any results 
here. You are giving me a whole bunch of numbers, and usually 
that is a reason why you don't----
    Dr. Katz. Mr. Filner, with permission, I could send to you 
the stories of a number of people who have called the hotline, 
so you could see the dedication and skill of VA professionals 
in action.
    The Chairman. I am not arguing that at all. The people who 
are doing this are wonderful people. They are dedicated. They 
are doing their job.
    We heard testimony that something like 6,000 veterans have 
committed suicide last year, or 2005, the year that CBS News 
was doing it. What about that? I mean, there is nothing in here 
that talks about that statistic. I mean, I don't even care if 
it is right. It is somewhere close to the truth. What about 
that? You say you saved 300, but what about the 6,000?
    Dr. Katz. Mr. Filner, VA has a major suicide-prevention 
program, the most comprehensive in the Nation. The numbers, 
frankly, aren't the issue.
    The Chairman. What if it was 3,000? What if it was 1,000? 
What is the difference?
    Dr. Katz. If the number were 300, we would still be doing 
everything possible.
    The Chairman. But you are not referring to why. Why do 
those 6,000 exist, with all this work you are doing? What is 
the measure of your effectiveness if all these people didn't 
know the hotline number, they didn't call the hotline----
    Dr. Katz. Sir, the 6,000 exists because mental illness is a 
real illness, and mental health conditions can be fatal.
    The Chairman. I understand. But to have credibility for 
what you are all doing professionally, you have to address 
these issues, and you are just ignoring them. You don't have a 
word in here about that. I mean, it takes away the sense of 
credibility that you are trying to raise here that you are 
doing all this, because we have both anecdotal evidence and now 
we have more statistical data that we are failing as a Nation. 
Not you individually, not anybody who is on a hotline with 
anybody, but as a Nation we are failing. And you are acting as 
if everything is goodness and light in this effort.
    Dr. Katz. Sir, Patrick Kennedy talked about mental health 
in America, and he is right. VA, in suicide prevention, is 
ahead of the rest of America, as we should be.
    The Chairman. I will accept that. What happens to the 6,000 
veterans who committed suicide last year, the 6,000 who 
committed suicide the year before and the 6,000 the year before 
that? What is going on with them, if we are so successful?
    Dr. Katz. That is why we have the foremost researchers in 
America working on this problem. That is why our mental health 
budget has increased 60 percent since the beginning of the war.
    The Chairman. I understand, but when you ignore these 
issues in a report that is supposed to talk about what you are 
doing, you damage your credibility, you damage whatever we are 
trying to do. Because I have to say, you are ignoring the whole 
problem here with this report. You are using activity as a 
substitute for effectiveness. Just because all these people are 
working doesn't mean they are effective.
    Again, I don't know. We have a National Guard, which you 
are not even discussing here. We have all the people who are 
not enrolled in the VA, which we are not discussing here.
    Mr. Bowman is still here. He made a really interesting 
suggestion: Go meet these kids at the bus when they come off. 
That is what I want to talk about. You heard their testimony. 
Throw this prepared testimony away and talk to the Bowmans, 
talk to Ms. Coleman, talk to Ms. Meagher, and say what we are 
going to do about these issues. You are not doing that. I mean, 
you had the advantage of listening to them. Respond to them.
    You are reading this report, which, you know, had so many 
questions to begin with, but I still don't know what you are 
doing for those people, I still don't understand it.
    You have a National Guard parent whose whole unit has never 
heard anything about how to help address possible suicide. So 
what are we doing about that? If you say, ``Well, we are VA; we 
can't help the National Guard,'' then say that, and then I will 
be happy to figure out legislation that says, you know, how you 
can do that.
    Mr. Buyer. Sir, can we have regular order and permit the 
witnesses to testify, please?
    The Chairman. If they had regular order about how to write 
their reports, we would be okay. I mean, it is not helpful, the 
way you are doing this.
    You can complete your testimony.
    Dr. Katz. Mr. Filner, with your permission, could I yield 
time to Dr. Rosenheck?
    Mr. Buyer. Dr. Katz, would you finish your statement, 
please?
    Dr. Katz. Sure.
    I was talking about the major programs for suicide 
prevention that VA is conducting complementing our major 
expansion of our general mental health programs.
    We have held two VA suicide-prevention awareness days for 
required education for all employees. The first focused on 
enhancing awareness of the issue; the second, training staff on 
how to work with available prevention resources, including the 
hotline and coordinators.
    The coordinators get calls and referrals from the suicide 
hotline, as well as from providers. They educate their 
colleagues. Then----
    The Chairman. Dr. Katz, did you study the well-publicized 
incidents when Marines or soldiers walked into a VA hospital 
saying they thought they had this PTSD thing, which they didn't 
understand, and were having suicidal thoughts? They were told 
that there was nobody available, or an appointment would not be 
available for a month, and they went home and killed 
themselves. Have you addressed that in here?
    I mean, you are telling me about in-service training. That 
is great. What happened about that training when these kids 
came into the hospital and then went out and killed themselves? 
Do you address that?
    Dr. Katz. In this document, no. In fact, the VA has----
    The Chairman. Why not? Well, you are telling me about in-
service training. There are well-publicized incidents when that 
either failed or had not occurred yet. Tell us what happened in 
those cases.
    Dr. Katz. I will send you the case reports from the 
hotline. They are incredible human stories.
    I also want to talk about policy, how, beginning this 
summer, we established a policy that any new request or any new 
referral for a mental health appointment has to have an 
evaluation within 24 hours to determine the urgency. If there 
is an urgent need, care must be provided immediately. If not, 
the patient has to be seen within 2 weeks.
    The Chairman. Did this happen after these incidents? One in 
Minnesota, one in Florida, and, I think, there was another 
State. And 2 weeks wouldn't have saved them anyway. I mean, was 
this in response to that, so it wouldn't happen again?
    Dr. Katz. These policy advances were in response to new 
patients from Iraq and the needs of established veterans.
    The Chairman. Okay. I will let you continue, but, look, if 
you don't deal with these stories and this evidence where we 
have failed our patients, then your credibility of what you are 
doing is zero. It looks like you are just shoving them under 
the rug, you don't want to talk about them, you don't want to 
deal with them, and so you avoid them. Some of us have memories 
about these things, and some of us have policy issues. You 
don't enhance your credibility when you avoid them.
    Finish your testimony, please.
    Dr. Katz. Well, Mr. Filner, you are being somewhat 
dismissive of a major public health effort in suicide 
prevention that VA is doing.
    The Chairman. I am not dismissing the effort. I am 
dismissing the way you are talking about it, as if everything 
is goodness and light, we have no problems, everybody is being 
helped, we saved all these lives. We just had 3 hours of 
testimony that this is not true. Respond to that.
    Dr. Katz. I was profoundly affected by what I heard.
    The Chairman. But you are reading the whole report that you 
wrote before you heard them, as if they didn't testify.
    Dr. Katz. My reaction is thank God we are doing what we are 
doing. I truly believe we are saving lives.
    The Chairman. I don't disagree with that. I want to know, 
what about the lives we are not saving too?
    Dr. Katz. They affect all of us.
    The Chairman. Well, tell us about them. That is all. 
Enhance your credibility by dealing with all of them.
    You may finish.
    Dr. Katz. I do want to end by mentioning that we applaud 
Congress for passing the Joshua Omvig Prevention Bill, recently 
signed by President Bush. We have implemented essentially all 
of the provisions of the bill already, and, in fact, we did so 
before it was passed.
    We continue to do research to develop and implement new 
strategies to improve our ability to save lives by preventing 
suicide. We believe our healthcare system can and must serve as 
a national model for mental healthcare and suicide prevention 
now and in the future.
    Thank you.
    [The prepared statement of Dr. Katz appears on p. 84.]
    The Chairman. Dr. Zivin.

             OPENING STATEMENT OF KARA ZIVIN, PH.D.

    Dr. Zivin. Good afternoon, Mr. Chairman.
    I would like to take this opportunity to express my 
condolences to all the families who have lost a loved one to 
suicide.
    I am honored to provide testimony to the Committee about 
suicide among veterans treated for depression in the VA health 
system. I come before this Committee as a mental health 
services researcher who has conducted research on this topic. 
The views and opinions are expressed on my own and do not 
necessarily represent those of my current employer, the 
Department of Veteran Affairs, or the views of the VA research 
community.
    I am here today to report on findings from a study that I 
conducted, along with my colleagues at the Department of 
Veterans Affairs, National Serious Mental Illness Treatment 
Research and Evaluation Center, SMITREC, and the VA's Health 
Services Research and Development Center of Excellence in Ann 
Arbor, Michigan, where I am a research investigator, as well as 
an assistant professor of psychiatry at the University of 
Michigan Medical School.
    We recently published a paper in the American Journal of 
Public Health examining suicide rates using data from the VA's 
National Registry for Depression for 807,694 veterans of all 
ages diagnosed with depression and treated at any Veteran 
Affairs facility between 1999 and 2004. In all, 1,683 veterans 
in VA depression treatment died by suicide during the studied 
observation period, representing 0.21 percent of this treatment 
population.
    When we calculated the overall suicide rate in this 
population over the 5\1/2\-year study period, it was 88.3 per 
100,000 person years, which is approximately seven to eight 
times greater than the suicide rate in the general adult U.S. 
population.
    A higher suicide rate would be expected among a population 
of patients in treatment for depression than the general U.S. 
population, given that depression is a potent risk factor for 
suicide.
    Because most healthcare systems lack the capability of 
assessing suicide rates among their treatment populations, 
there are few points of comparison with nonveteran treatment 
populations. However, at least one prior study reports a 
suicide rate for men receiving depression treatment in managed-
care settings between 1992 to 1994 of 118 per 100,000 person 
years, a suicide rate which is somewhat higher than that 
observed in this veteran depression treatment population.
    In our study, we observed that the predictors of suicide 
among veterans in depression treatment differed in several ways 
from those observed in the general U.S. population. Typically, 
people in the general population who die by suicide are older, 
male and white and have depression and medical or substance 
abuse issues. In this study, we, too, found that depressed 
veterans who had substance abuse problems or psychiatric 
hospitalization in the year prior to their index depression 
diagnosis had higher suicide rates.
    However, when we divided the depressed veterans into three 
age groups--18 to 44 years, 45 to 64 years, and 65 years or 
older--we found that the younger veterans were at the highest 
risk for suicide. Differences in rates among depressed veterans 
of different age groups were striking: 18- to 44-year-olds 
completing suicide at a rate of 95 suicides per 100,000 person 
years, compared with 77.9 per 100,000 person years for the 
middle-age group and 90.1 per 100,000 person years for the 
oldest age group.
    We did not assess whether individuals had served in combat 
during a particular conflict, although the existence of a 
military service-connected disability was considered.
    In this VA treatment population, men veterans were more 
likely to commit suicide than women veterans. Suicide rates 
were 89.5 per 100,000 person years for depressed veteran men 
and 28.9 per 100,000 person years for veteran women. However, 
the differential in rates between men and women in this 
population of three to one was smaller than that which has been 
observed in the general population of four to one.
    We found higher suicide rates for white depressed veterans, 
95 per 100,000 person years, than for African Americans of 27.1 
per 100,000 person years and for veterans of other races, 56.1 
per 100,000 person years. Veterans of Hispanic origin had a 
lower rate, 46.3 per 100,000 person years, of suicide than 
those not of Hispanic origin, 86.8 per 100,000 person years. 
Adjusted hazard ratios also reflected these differences.
    Surprisingly, our findings revealed a lower suicide rate 
among depressed veterans who also had a diagnosis of post 
traumatic stress disorder, PTSD, compared to depressed veterans 
without this disorder. Depressed veterans with a concurrent 
diagnosis of PTSD had a suicide rate of 68.2 per 100,000 person 
years compared to a rate of 90.7 per 100,000 person years for 
depressed veterans who did not also have a PTSD diagnosis.
    We investigated further to examine whether specific 
subgroups of depressed veterans with PTSD had higher or lower 
suicide risks. We found that concurrent PTSD was more closely 
associated with lower suicide rates among older veterans than 
among younger veterans. This study does not reveal a reason for 
this lower suicide rate, but we hypothesize that it might be 
due to a high level of attention paid to PTSD treatment in the 
VA system and the greater likelihood that patients with both 
depression and PTSD will receive psychotherapy and more 
intensive visits. In general, individuals with depression and 
PTSD diagnoses have higher levels of VA mental health services 
use than individuals with depression without PTSD.
    Interestingly, depressed veterans who did not have a 
service-connected disability were more likely to commit suicide 
than those with a service-connected disability. This may be due 
to greater access to treatments among service-connected 
veterans or more stable incomes due to compensation payments.
    We hope that our findings will help inform clinical 
treatment and policy initiatives to reduce suicide mortality 
among veterans with depression.
    I thank you for this opportunity to testify and will be 
pleased to answer any questions that you have.
    [The prepared statement of Ms. Zivin appears on p. 86.]
    The Chairman. Mr. Mitchell.
    Mr. Mitchell. This question is for Dr. Katz.
    And I have read your testimony. I didn't hear your 
testimony, but I read your testimony. And one of the things I 
am concerned about is, throughout your testimony, you are 
talking about those programs you have in place, which is good, 
and that you are effective for those you have in place.
    But what bothers me is, this morning we heard testimony 
from the parents of Timothy Bowman, whose numbers will not be 
in your figures. He committed suicide. He will not be part of 
the DoD or the VA's numbers. And my concern is, unless somebody 
comes and registers with you, what outreach do you have?
    You know, this is a very serious problem, those who do not 
register. All you have are figures of those who came in and 
registered with the VA. Even in Arizona, this is a growing 
concern. Veteran suicide rates in Arizona have risen 39 percent 
since 2003, and one-quarter of all suicides in Arizona are with 
veterans. This is, I think, an epidemic.
    And I know what you are saying with all of those figures 
that you have there, but my concern is, do you really have 
enough resources to go after the veterans who do not show up 
and are not on your figures, the figures either from DoD or the 
VA? Because I think it is important that we go out and try to 
get the correct figures.
    Am I understanding that you have not really collected 
figures, total figures, on all those returning from Afghanistan 
or Iraq?
    Dr. Katz. Well, I want to begin by--actually it is very 
ironic. We know that Tim Bowman was a person and that his loss 
is terrible, and, as a Nation, we have to mourn him. The 
question is, is he a statistic? Is he counted in VA research? 
And the answer is yes. Dr. Kang's research counts all veterans, 
whether or not they have come to VA for care.
    This raises questions about, the people who don't come to 
VA for care, how are we reaching out to them? Our Vet Centers 
have hired over one hundred peer counselors, ex-vets who go out 
to post-deployment health reassessment, who go to Guard and 
Reserve meetings, and who speak in community centers and 
related venues. There are more than 90 returning veterans 
outreach teams in our medical centers and clinics. We really 
have extensive outreach.
    Is it enough to enroll every veteran? No. Is it enough to 
prevent every suicide? Apparently not.
    We have, thanks to you, considerable funds. And our goal, 
our mission and our challenge is to use these funds 
effectively. We really have to go reaching out to people and 
providing services, where mental healthcare has never gone 
before. We have intensive research going on, and VA has, by 
necessity, become more adept at translating research into 
clinical and public health action than anyone else. Are we 
there yet? Of course not. Have you given us enough resources? 
Yes. Our challenge is to use them to improve lives and save 
lives.
    Mr. Mitchell. So, Dr. Katz, you are telling me that you 
have enough resources to do the job that is necessary to find 
these veterans and to treat these veterans. You have enough 
resources.
    Dr. Katz. Yes, sir.
    Mr. Mitchell. Thank you.
    The Chairman. Mr. Buyer.
    Mr. Buyer. You know, sometimes, Mr. Mitchell, it is not 
just a matter of resources, it is what are you going to do with 
them.
    Mr. Mitchell. Yes.
    Mr. Buyer. When you look back, 3 years ago we gave them 
$300 million, and they couldn't even spend $100 million of it.
    Dr. Katz. Can I comment about that, sir?
    Mr. Buyer. You may.
    Dr. Katz. A year ago, the Committee raised concerns that 
there was underexecution of mental health enhancement funding. 
I guess that is bureaucratic talk for under-spending of the 
resources.
    This past year, there were $306 million allocated for 
mental health enhancements in VA. The actual spending was $325 
million. We overspent and, to be honest, we were congratulated 
by senior leadership for overspending, because nothing is more 
important than mental health.
    Mr. Buyer. I hate to get into the numbers and statistics, 
but I am going to do that for just a second, because, really, 
it is all sort of disturbing to me.
    I look at the Inspector General's (IG) report, and the IG 
says, all right, out of the 25 million veterans in the United 
States, they estimate as many as around 5,000 veterans per year 
are turning to suicide, of the 25 million. Then CBS News, they 
throw out a number of 6,256 in 2005. I mean, since this report 
came out, I mean, there is a difference of 1,200. That is still 
a big number to me.
    But I am curious, do you know how CBS News came up with 
that number if the IG or the VA comes up with a different 
number? Are you familiar with how they--has CBS News shared 
with you the methodology of how they came up with their number?
    Dr. Katz. They shared their algebra but not their raw data. 
We want the numbers. It could help to guide and fine tune our 
prevention efforts. They handed me the numbers when I was 
interviewed, and then they took it back. We requested it from 
the producers. The Inspector General requested it from the 
producers. They are not forthcoming about the numbers. I would 
think that, as a matter of citizenship, CBS News should be 
required to provide these numbers, so VA can translate them 
into prevention.
    Mr. Buyer. Well, the numbers are important in how we get to 
them.
    Let me ask Dr. Zivin, is it important for us to understand 
the gender distribution in these numbers?
    Dr. Zivin. The gender distribution, was that your question, 
sir?
    Mr. Buyer. Yes. Is that important for us to know as 
policymakers.
    Dr. Zivin. It is important for us to know all 
characteristics associated with suicide and how those may be 
similar or different in the VA or among all veterans than the 
general population. And that is something we are studying. We 
have both VA- and NIH-funded research to examine all 
characteristics associated with suicide.
    Mr. Buyer. Have you seen the CBS News report?
    Dr. Zivin. I have seen it, yes, sir.
    Mr. Buyer. And what is your opinion regarding the fact that 
gender distribution would have been left out of their numbers? 
What does that tell you?
    Dr. Zivin. Sir, I would like to ask the members of this 
panel if they would like to comment on this, or perhaps we 
could get back to you about this.
    Mr. Buyer. Well, if anyone here on the panel has an opinion 
on it, please let us know. Because I think it is rather 
bothersome that they would leave out gender distribution. Does 
anyone have an opinion with regard to that?
    Dr. Katz. They controlled for gender but did so in a very 
strange way. Their number for veteran suicides is not, in fact, 
an accurate reflection of the rates of suicide.
    Dr. Rosenheck, you wanted to comment?
    Dr. Rosenheck. Well, actually, I wanted to shift gears a lit
tle bit.
    Mr. Buyer. No.
    Dr. Rosenheck. Okay.
    Mr. Buyer. I get to shift gears.
    Dr. Rosenheck. In direct response, none of us feel we have 
seen a complete report of this data so that we, as professors, 
can judge the validity of the conclusions.
    Mr. Buyer. All right. I am not going to challenge the 
intent of CBS News, because I am hopeful that their intent and 
motivation was pure. And if it was pure, they have nothing to 
hide and should be willing to work with you, with regard to the 
numbers.
    Let me ask this question. The Canadian Government uses the 
term ``operational stress injury''--they don't use PTSD to 
describe their diagnosis. Would that be useful and helpful to 
us, if we would turn to ``operational stress injury'' so we can 
maintain PTSD but come up with another type of description 
whereby it encourages soldiers and veterans to come in to 
discuss this without stigma? Do you have an opinion with regard 
to that?
    Dr. Katz. Well, I think we heard from the world's experts 
about what we call it. And in terms of what it is called and 
how people react to that, the world's experts are the consumers 
and the families. If they want to change the name, we should 
change the name.
    Mr. Buyer. Mr. Chairman, with latitude, I have one last ques
tion.
    One of the concerns is being able to provide mental health 
services to members of the National Guard and the Reserve 
components when they return from their overseas deployments. In 
Indiana, on January 2nd, I will stand with the 76th Brigade. We 
are going to send an entire brigade to war. Not since World War 
II.
    So what outreach programs do you, the VA, have in place for 
the National Guard and the Reserve?
    Dr. Katz. There are peer counselors from the Vet Centers 
who should be there, as should returning veterans outreach 
people from our medical centers and clinics.
    Mr. Buyer. How do we prepare the families while the 
soldiers are gone? What do we do that is proactive?
    I think that is what the Chairman--my interpretation is, 
what are you doing on the prevention side? Let's not just wait 
until they come home. What are we doing to help prepare the 
families?
    We do a lot with the families, not only their care 
packages, and they have their own support groups. But what do 
we do, in being off our heels and on our toes, to be proactive 
on what they should look for? What should they be doing to be 
helpful to them while they are deployed? Are we doing anything?
    Dr. Katz. Vet Centers are authorized to provide outreach 
and education for families under specified circumstances while 
the veteran is deployed. VA is not authorized by law to do so.
    Mr. Buyer. Under specified circumstance. That is telling me 
that is some sort of limited service.
    Dr. Katz. I am actually confessing my personal lack of 
knowledge about the specifics. I am embarrassed. I apologize 
for it. We will have to get back to you.
    Mr. Buyer. I understand that these men and women are 
activated so now they are part of DoD.
    Dr. Katz. Yes.
    Mr. Buyer. But we deal with the consequences of war, the 
consequences. And it is easy to take care of them when we see 
the physical wound, so it is the mental wound that is our 
challenge.
    So this leads to the whole path of how we work 
cooperatively with DoD in trying to get bi-directional, on-
time, real-time mental health data. That is a real challenge.
    But here is what I want to do. I want to do this with you. 
We now know we have a brigade that is going. I am going to work 
with you. I want you to work with myself and the Chairman of 
this Committee, as we also work with DoD, and you tell us what 
we can do that is proactive with regard to this brigade as it 
goes, and what authorities do you need, what do you need from 
us. You probably don't need much authority. A lot of things you 
can do. But tell me what you can't do, and we can break down 
these barriers.
    Will you take that on with us?
    Dr. Katz. Absolutely, with pleasure and with honor.
    Mr. Buyer. All right. Thank you.
    I yield back.
    The Chairman. And I give the same answer, with pleasure and 
with honor.
    Mr. Buyer. All right. Thank you.
    The Chairman. Let me just say a few words.
    Mr. Buyer mentioned that CBS News had 6,000 and IG had 
5,000. That is a big difference. Both of those are a big 
difference, from what I see in this. It is a different 
universe, Iraqi and Afghanistan, since 2005--144. I mean, this 
is a purposeful putting forth the lowest figure that you could 
possibly get to.
    Dr. Katz. No, sir. Those are the full count of suicides in 
returning veterans.
    The Chairman. But you chose a universe on purpose that 
never would touch--how about 5,000 or 6,000? That would get 
people annoyed. 144? Oh, I can live with that. You are giving 
numbers here that do not reflect reality in terms of the 
problem that we have to face and you have to face as 
policymakers.
    And, frankly, your statement, Dr. Katz, that ``CBS News 
should be required to give the statistics''----
    Dr. Katz. Yes.
    The Chairman [continuing]. That is disgraceful from an 
organization, that they have to FOIA, we have to FOIA, a parent 
has to FOIA, to get any information on this.
    I have, from this chair to that seat--and maybe you were 
one who was there, I can't recall now--at least three or four 
different times in the last 7 or 8 months, asked for data on 
suicides from the VA. They always said they will get back to 
me. They have never gotten back to me. You try to get data, you 
get all kinds of different numbers from different universes.
    And besides, the data you use, as we have heard this 
morning, is all slanted anyway. I mean, it is a very specific 
definition of a suicide that you are using that is way 
underreported from the reality.
    CBS News tried to get the data. They didn't want to spend 6 
months going to States and do this thing. They couldn't get the 
data from you because you don't track this stuff. You simply 
don't track it. You don't want to know about it.
    And I had a whole report from Dr. Zivin, who--I never, by 
the way, ever heard somebody on the panel say they are not 
speaking for the Department of Veteran Affairs when you are 
here. I mean, they must have approved this, but you are not 
speaking for them. I don't know, that is strange.
    But you give four or five pages of data. I don't see 
anybody on this panel, in prepared testimony, say what you are 
going to do. How does this inform your treatment? What 
prevention are you doing to do based on this?
    This is a bunch of numbers that is meaningless in the 
context that we are working in today. That is, you had time to 
give this data to somebody to say, ``What are we doing about 
using this data for actual clinical or preventive operations?'' 
And there is nothing. It is just a case of--of ``analysis 
paralysis.'' It is just a bunch of statistics that you are 
going to throw out to us here and say that you have done your 
duty. You guys have not done your duty. You have not given us 
adequate numbers or even an explanation of the problem in 
getting those numbers.
    We haven't talked about, if there are 5,000 or 6,000 or 
2,000 veterans that are dying every year, how are we going to 
get to them? You tell me what you are doing, but you are not 
telling me about the evidence that we have that we are not 
being effective. How are you dealing with that? You have not 
done the job.
    We are going to have another hearing on this.
    [Applause.]
    And I want you to come back with a better report. This is 
not very useful. Again, all you do is compare some things in a 
strange universe that does not come to grips with the issue.
    Dr. Katz. Mr. Filner?
    The Chairman. Mr. and Mrs. Bowman this morning, and the 
other testimony, were crying out for help. I responded to say, 
here is what I am thinking about to respond. I don't know if it 
is good or bad. I said we have to have a public education 
program. I said we have to have mandatory diagnosis of PTSD and 
brain injury. I said we have to do that in a unit with family 
there.
    You didn't come up with anything. You didn't even respond 
to my meager suggestions.
    Dr. Katz. Mr. Filner, I really need to respond to one specif
ic issue.
    The Chairman. Respond to them all. I don't care.
    Dr. Katz. Well, we can provide additional numbers.
    The Chairman. You always say that, and we never get 
anything.
    Dr. Katz. We can provide additional----
    The Chairman. I have done this for at least several years.
    Dr. Katz. You are delivering the message to America that 
there are major problems in VA treatment. I want to deliver the 
message that care is available and that treatment works. We 
have programs in place that can help people.
    The Chairman. How would you have helped Timothy Bowman or 
the Timothy Bowman that is coming tomorrow? Nobody has talked 
to them, nobody has done anything, nobody has counseled them, 
nobody made Timothy aware of anything, and nobody is making the 
Timothys of tomorrow aware. So how are you responding to their 
cry for help?
    Dr. Katz. It is tragic that----
    The Chairman. But what are you doing about it?
    Dr. Katz. We are doing the----
    The Chairman. But it didn't reach these people.
    Dr. Katz. That is tragic.
    The Chairman. Well, then find a more effective way. Don't 
keep telling us you are doing things when they are not 
effective. It is proven not effective. You reach a very small 
percentage of those who need help. Why?
    Dr. Katz. Sir, I really think we want to emphasize the 
message that treatment is available and treatment works. 
Because that message is a matter of public health, and that 
message can be life-saving.
    The Chairman. Well, let me tell you the message that I want 
to send, that we have an epidemic, as has been said before, we 
have a public health crisis. And no matter how hard you are 
working now, we are not doing the job. We need to do more.
    And you need to tell us, rather than how much stuff you are 
doing, what we need to do to be effective. You answered Mr. 
Mitchell that you had sufficient resources. You don't have 
anybody to call up Mr. Bowman to even offer condolences, let 
alone help his counseling. So, I mean, surely some more 
resources would be nice.
    Mr. Mitchell, you have a question?
    Mr. Mitchell. Yes. I would like to follow up on that with 
Dr. Zivin.
    According to your testimony, your study was based on 
veterans who had been diagnosed with depression and were 
treated at VA hospitals or VA facilities.
    What I would like to know is, what about veterans who don't 
fall in either of these categories? What about the veterans who 
have not been diagnosed with depression or who have not been 
treated at VA facilities? What about the veterans who are 
suffering from post traumatic stress disorder or haven't 
visited a VA facility?
    Could you shed any light on the scope of the problem facing 
these and other categories of veterans?
    Dr. Zivin. It is true that we focus in this study 
specifically on depressed veterans treated in the VA 
population, and that represents only a fraction of all veterans 
who either have depression or PTSD or both. And one of the 
things that we are doing as part of our ongoing research and 
what Dr. Katz was just alluding to is that we are now 
collecting and having data on all veterans, with or without 
depression, and rates of suicide.
    One of the other things to mention is that the VA has 
developed a comprehensive strategic plan which is specifically 
focused on treatment for PTSD, suicide prevention and a number 
of other initiatives specifically targeting at-risk veterans.
    And I will ask my colleagues here to comment further, if 
you have other questions.
    Mr. Mitchell. Just one comment to add to that. There are 
some people who come back who don't believe that they have a 
problem, and therefore, they don't register. Maybe they don't 
fill out the forms or tests that I understand are necessary, 
yet they have it. Is there any outreach?
    I understand, Dr. Katz, you said you have programs, but 
there are only programs if somebody comes in. What about the 
people who have not been diagnosed yet who end up with this 
disorder months, maybe years, later? What about those who have 
not registered with the VA?
    What kind of programs do you have in place, not just to 
reach those who have registered and who have been diagnosed, 
what kind of programs do you have in place to go beyond that?
    Dr. Katz. We are in agreement that a major challenge for us 
is reaching more people. We have talked about what we do for 
those who enter our doors, either the Vet Centers or medical 
centers and clinics. We have talked about the outreach that we 
are doing. How do we effectively reach the rest of the 
community?
    Dr. Kussman is writing a letter that should go out this 
week or next to all veterans, raising these issues. Other 
strategies are being developed including additional follow-up 
to the post-deployment health reassessment. We recognize the 
need to do more to reach more people, yet we are working 
intensively--and we are working intensively on how to do it.
    Dr. Rosenheck reminded me of a fact from Dr. Han Kang's 
work that makes this issue very poignant. Among returning 
veterans, among OIF/OEF veterans, the rates of suicide among 
those who come to us don't differ from the age-, sex- and race-
matched individuals, but the rates of suicide among those who 
don't come to us are higher. It is reassuring about what we are 
doing and a clear message about what we should be doing next.
    Mr. Mitchell. Absolutely.
    And one last question, real quickly. Do you believe that 
there is a suicide epidemic?
    Dr. Katz. There is a suicide epidemic in America.
    Mr. Mitchell. Among veterans?
    Dr. Katz. The numbers--what are the numbers? About 18 
veterans kill themselves each day in America. That is too many. 
About four or five----
    Mr. Mitchell. According to CBS News, it was 120 a week.
    Dr. Katz. About the same.
    Mr. Mitchell. That is not higher than the general 
population?
    Dr. Katz. Rates among veterans are somewhat higher than the 
general population because of demographics and increased in 
risk factors for depression, related conditions.
    Mr. Mitchell. I think one way we can find out about that is 
if you have the data. And I think that is--you know, one of the 
people were arguing about earlier was the methodology data that 
CBS News had. And if we had the data, we could certainly refute 
or agree that there is or is not an epidemic and it is more so 
among veterans. I think that is what we have been trying to 
find out.
    Dr. Katz. Some of the Nation's foremost investigators in 
this area are before you.
    Dr. Blow, could you talk about some of the data?
    Dr. Blow. Sure. Among veterans receiving services in VHA, 
so those actually touching the VHA, the rates are about 1\1/2\ 
times age- and sex-adjusted population rates. The rates for 
women are about two times that of that U.S. population overall 
rates for women. So it is much higher for women than for men.
    Mr. Mitchell. Again, these are people in your system.
    Dr. Blow. That is exactly right, the 5.5 million veterans 
who actually we serve.
    Mr. Mitchell. We already heard about someone not in the 
system. That is the purpose of what we are trying to find, 
people who are not in the system being treated.
    The Chairman. Mr. Mitchell, this room has been reserved for 
another Committee, so we have to adjourn this.
    I have one last--you have a last statement.
    Mr. Buyer. Dr. Katz, I want you to go back from here and 
talk with your chief and your team, and I want you to be ahead 
of us. Work with your counterpart in DoD between their 
BattleMind Training initiative that they have, along with your 
initiatives, and we will use that brigade as a cohort. And we 
are going to circle back here next week, okay? But get ahead of 
us. All right.
    Dr. Katz. Thank you.
    The Chairman. Thank you, Mr. Buyer.
    And let me again--I mean, I am very disappointed with the 
testimony. When Mr. Mitchell gave you a chance just to talk 
about outreach, you said that the Deputy Secretary is writing a 
letter. That doesn't do it.
    Look, I will just comment on one thing. We know, we 
absolutely know as a fact--I don't care what any researcher 
tells me--that the images of war in Iraq trigger PTSD reactions 
in people from earlier wars. I could figure out a hundred ways 
for you to go out to those people now. Just take the Vietnam 
vets. Go out, find them and say, ``We are going to help you.''
    You have all this great stuff you are telling me about. We 
know Iraq is going to trigger this from Vietnam vets. Go find 
them. Go to the Vet Centers, go to the Vietnam Veterans of 
America, go to the VSOs who are here. Go to the major cities. 
Set up a place where you can screen people more. Go out to 
communities.
    You are doing this research which doesn't tell us anything, 
and you are not reaching the people who need the help. We said 
it many times this morning. We have an obligation. You are not 
meeting that obligation. You are doing stuff and you are 
spending a lot of money and you have all these professors, but 
we are not meeting the needs. And until we do that, we are not 
going to be satisfied here.
    We are going to take this up early next year. We will 
continue the hearing we started today. But we are going to talk 
to the new Secretary, General Peake, and let him know how 
disappointed we are in this, and hopefully we can move to do 
our veterans a greater service. We are not doing the job now.
    Mr. Kennedy.
    Mr. Kennedy. I would just like to ask that you apply the 
bottom line to the families of veterans so that they can better 
identify these symptoms amongst their own family members. 
Right now they are not given the tools, so to speak, of being 
able to act as the identifier and supporter of their own loved 
one when they come home.
    Am I right?
    Dr. Katz. You are right. Vet Centers, as well as DoD, can 
begin on it. For medical center and clinic staff to do that 
would take an act of Congress.
    Mr. Kennedy. But family members are the ones who spend the 
most time with their loved one. They ought to be brought in and 
made a better and bigger part of this whole process.
    Dr. Katz. Absolutely.
    The Chairman. And acts of Congress is what we do, so just 
tell us what we need to do.
    Mr. Buyer. Mr. Kennedy, that is exactly what we are going 
to try to do.
    Mr. Kennedy. And finally are we tracking--as you said, 
women are twice as likely to have suicide rates within the VA 
as men. Are we tracking women veterans within the VA separately 
from men and their issues, because I understand they have very 
specific and unique issues as to men veterans when they are in 
the VA system.
    Are we doing----
    Dr. Blow. There are many initiatives in the VA to enhance 
services for women veterans with their special needs and 
especially with the special needs that they encounter because 
of their combat exposure.
    Mr. Kennedy. Yes, but are we tracking their women-specific 
issues, around their specific issues, mental health needs, 
issues?
    Dr. Blow. Yes, absolutely. We have many different women's 
mental health initiatives trying to find out what happens to 
them over time, and we try to address their specific needs in 
treatment.
    Dr. Katz. A minor correction. The twofold is women in the 
VA relative to women in the general population. It is still a 
lower rate than men.
    Dr. Rosenheck.
    Dr. Rosenheck. I did want to talk to the Bowmans because I 
am the son of a veteran who committed suicide, and I have been 
now in the VA and have been a psychiatrist and have been a 
professor of psychiatry and epidemiology for almost 40 years, 
and my work is animated every day by the fact that my father 
was a veteran who had committed suicide. I want to tell you 
that my colleagues in the VA come to this work with a personal 
sense of mission. All of us, many of us--more than in any other 
group--are veterans, and more than any other group, we know and 
have been touched by mental illness and by all kinds of 
illness. People do not come to the VA as a simple, professional 
job. People who work in the VA are driven by a sense of mission 
and of caring, and I want to say, in shifting back to my 
capacity as program evaluator and as a scholar--well, I am 
staying with the personal--I started with the VA in 1973. I was 
a first-year resident at the VA in Connecticut, and I was 
seeing veterans coming back from Vietnam. I have worked at the 
VA for my whole career since then, and the change from 1973 to 
now is so astonishing. When I was a first-year resident, I had 
no language. I had no culture. I had no background to 
understand the young men who were coming and sitting in front 
of me right off the battlefield. We had no terms.
    Now, whether you talk about PTSD or PTSI, we have a 
language, and the whole country knows it. I get called by 
reporters, ``Can you get PTSD from watching the war on TV?'' 
Everybody knows about this syndrome, and they know about it 
because of the gift of the Vietnam veterans. Every year, we are 
seeing more and more--I have been tracking it for 10 years, and 
the progress we are making in terms of the numbers of veterans 
we are seeing is astonishing, and the commitment of the 
organization from the bottom to the top to serving veterans who 
served in combat, I can just----
    The Chairman. We thank you for that.
    Mr. Kennedy. I understand that we do not on the women's 
side----
    The Chairman. Mr. Kennedy, we have to end this.
    Mr. Kennedy. We are not tracking women-specific issues from 
the general veterans' population, and I hope that we do a 
better job of doing that.
    The Chairman. Let me just say in conclusion, Dr. Katz and 
your colleagues, nobody is disputing your personal commitment 
or your effectiveness in dealing with veterans. What we are 
saying is how much of a--possibility exists in this country to 
deal with these issues. That is the great disappointment to me. 
We have the ability to do the job for everybody. Although we 
have made progress and we have all of these dedicated people, 
we have not done the job. And until we do the job, we are going 
to keep up the oversight that we have to do.
    This hearing is adjourned.
    [Whereupon, at 2:35 p.m., the Committee was adjourned.]




















                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Hon. Bob Filner,
             Chairman, Full Committee on Veterans' Affairs
    Good morning and welcome to the House Veterans' Affairs Committee 
hearing on Stopping Suicides: Mental Health Challenges within the 
Department of Veterans Affairs.
    Mental health issues have been a focus of this Committee all year 
long and will continue to be at the forefront of our agenda. Public Law 
110-110, the Joshua Omvig Veterans Suicide Prevention Act, was enacted 
in November of this year.
    The House has also passed H.R. 2199, the ``Traumatic Brain Injury 
Health Enhancement and Long-Term Support Act of 2007,'' H.R. 2874, the 
``Veterans' Health Care Improvement Act of 2007,'' and H.R. 612, the 
``Returning Servicemember VA Healthcare Insurance Act of 2007.'' Each 
of these pieces of legislation addresses mental health issues in some 
aspect concerning the well-being of veterans.
    The demands confronting VA today are complex and sometimes 
overwhelming. VA must find a way to ensure quality and efficiency do 
not suffer as they move forward, continuing to treat veterans from past 
wars while adapting to the unique needs of the younger veterans of 
modern warfare who are entering the system for the first time.
    We know that OEF/OIF servicemembers are subject to repeated 
deployments, an intense level of close combat, extended deployment 
lengths and repeated family separations.
    VA has reported that of the 263, 909 separated OEF/OIF veterans who 
have obtained VA healthcare since FY 2002, 38 percent have received a 
diagnosis of a possible mental disorder. Of that population, 48 percent 
have a possible diagnosis of PTSD. The prevalence of mental health 
problems among returning servicemembers is troublesome and should be of 
concern to everyone.
    Recent events have been brought to the attention of this Committee 
through a CBS report on the rising suicide rates among veterans. We 
also know that male veterans are at elevated risk of suicide relative 
to nonveterans. In fact, they are twice as likely to die of suicide 
compared to male nonveterans in the general population.
    Of great concern to the Committee is the recent VA Inspector 
General report that found that nearly 1,000 veterans who receive VA 
care commit suicide every year, and as many as 5,000 a year are 
committed among all living veterans.
    Today we will take a hard look at programs the VA has implemented 
to address the challenges of suicide.
    I look forward to the upcoming testimony.

                                 
          Prepared Statement of Hon. Stephanie Herseth Sandlin
    Thank you to everyone for being here. I congratulate Chairman 
Filner and Ranking Member Buyer for holding today's hearing to examine 
and identify mental health challenges within the Department of Veterans 
Affairs healthcare system.
    As the wars in Iraq and Afghanistan continue to produce a new 
generation of veterans, it is important that Congress evaluate the 
impact of these conflicts on the mental well-being of returning 
servicemembers. We must closely evaluate the ability of the VA to meet 
the mental healthcare demands placed upon it.
    While I am pleased that the VA offers a wide array of mental health 
programs, there continues to be room for improvement. In particular, I 
believe we must do more to meet the mental healthcare needs of our 
rural veterans--who often must travel long distances to reach VA 
healthcare services.
    I am pleased that we have the opportunity to hear from today's 
panelists and am grateful to have the opportunity to hear their 
suggestions and answers to the critical issues involved. I look forward 
to hearing their testimonies.
    Again, I want to thank everyone for taking the time to be here and 
discuss these important matters.

                                 
              Prepared Statement of Hon. Harry E. Mitchell
    Thank you, Mr. Chairman. And thank you for holding today's hearing.
    Last month, CBS News brought some shocking, and critically 
important information to light. Not just that those who served in the 
military were more than twice as likely to take their own life in 2005 
than Americans who never served or that veterans aged 20 to 24 were 
killing themselves when they returned home at rates between two-and-a-
half to four times higher than nonvets the same age, but that the 
Department of Veterans' Affairs wasn't keeping track of veteran 
suicides nationwide.
    The VA is one of the best healthcare systems in the country, with 
literally thousands of professionals working to help veterans with 
mental health needs.
    But with all due respect, if the VA doesn't know the size and the 
scope of the problem, how can we know if they're adequately addressing 
our veterans' mental health needs?
    As disturbed as I was by the CBS' report, I was even more disturbed 
by the VA's response. Instead of reviewing the information and thinking 
critically about whether the VA might need to take some additional 
measures, they immediately attacked the messenger, calling CBS News' 
analysis a ``questionable journalistic tactic.''
    Obviously it would be great to compare CBS' numbers to those kept 
by the VA, but that's precisely the point; the VA hasn't been keeping 
them.
    I think this kind of defensiveness is a disservice to veterans, and 
to all the hardworking employees of the VA who are doing their best to 
help our wounded warriors.
    So, as we begin today's hearing, I just want to say that I hope we 
can get past the name-calling, and hurt feelings and gotcha-fights 
about methodology and do what the American people expect us to do: work 
together to prevent more of these unspeakable tragedies and, if at all 
possible, try to bring some small measure of comfort to those who 
mourn.
    I yield back.

                                 
                Prepared Statement of Hon. Cliff Stearns
    Mr. Chairman,
    Thank you for holding this important hearing today. The statistics 
regarding the rate of suicides among veterans is beyond alarming, it is 
catastrophic. These young men and women are heroes--each and every one 
of them. Veterans returning from war frequently become valued neighbors 
and leaders in their community, giving of their time and themselves to 
help others at home as they did abroad. Their presence reminds us of 
the high cost of our freedom, and inspires us to act for others rather 
than just ourselves. These young men and women who have served our 
Nation in such extreme circumstances--enduring unbelievable amounts of 
the stress of war so that those of us who remain at home can live in 
the peace they protect, deserve the utmost respect--and the utmost care 
that we can provide.
    It is appropriate today that we remember that the problem of the 
traumatic effects of war upon our veterans has been grappled with for 
decades. In fact, only about two hours away lies the battlefield of 
Antietam--the bloodiest single day battle in all of American history 
with almost 23,000 casualties. Many of those that survived left the 
field with more hidden wounds that bandages could not bind. Back then, 
it was called by other names like ``war sickness.'' In World War II it 
was ``shell-shock'' or ``battle fatigue,'' through the years until now 
we refer to it as ``Post Traumatic Stress Disorder.'' From the very 
first shots fired for our independence, those who fought to maintain 
that independence have suffered under the traumatic stress.
    Throughout our battle history, we have learned more and more 
regarding best treatments for this condition, yet more needs to be 
done. I would be interested in statistics that could show clearly the 
leading factors to suicide attempts. Are most veterans who commit 
suicide suffering from PTSD, or from other complicating reasons such as 
substance abuse, or other mental conditions? The better we can identify 
the key indicators and symptoms leading toward suicide attempts, the 
better we can develop and provide treatments. As a co-sponsor of H.R. 
327, the Joshua Omvig Veterans Suicide Prevention Act, I was proud when 
it was signed into law on November 5, 2007. I believe that this is a 
key step toward attacking this problem. I also understand that the VA 
is improving its screening processes, hiring more counselors, and 
developing more ``best practices'' to combat this growing problem. 
However, the clock is ticking, and we need to move quickly to prevent 
the loss of more of our wounded warriors. I look forward to hearing 
from our panel of experts more about this dreadful problem and how we 
are going to work together to prevent the loss of more of our Nation's 
heroes.

                                 
        Prepared Statement of Mike and Kim Bowman, Forreston, IL
(Parents of Specialist Tim Bowman, U.S. Army, Illinois National Guard, 
                      Bravo Troop, 106th Cavalry)
    Mr. Chairman, members of the committee, my wife and I are honored 
to be speaking before you today representing just one of the families 
that lost a veteran to suicide in 2005.
    As my family was preparing for our 2005 Thanksgiving meal, our son 
Timothy was lying on the floor of my shop office, slowly bleeding to 
death from a self-inflicted gunshot wound. His war was now over, his 
demons were gone. Tim was laid to rest in a combination military, 
firefighter funeral that was a tribute to the man he was.
    Tim was the life-of-a-party, happy-go-lucky young man that joined 
the National Guard in 2003 to earn money for college and get a little 
structure in his life. On March 19th of 2005 when Specialist Timothy 
Noble Bowman got off the bus with the other National Guard soldiers of 
Foxtrot 202 that were returning from Iraq he was a different man. He 
had a glaze in his eyes and a 1,000-yard stare, always looking for an 
insurgent.
    Family members of F202 were given a 10-minute briefing on PTSD 
(Post Traumatic Stress Disorder) before the soldiers returned and the 
soldiers were given even less. The commander of F202 had asked the 
Illinois Guard Command to change their demobilization practices to be 
more like the regular Army, only to have his questions rebuffed. He 
knew that our boys had been shot up, blown up by IED's (Improvised 
Explosive Device), extinguished fires on soldiers so their parents 
would have something to bury, and extinguished fires on their own to 
save lives. They were hardened combat veterans now, but were being 
treated like they had been at an extended training mission.
    You see, our National Guardsmen from F202 were not out filling 
sandbags. They departed in October of 2003 for 6 months of training at 
Forts Hood and Polk. On Tim's 22nd birthday, March 4, 2004, Foxtrot 
left for Iraq where they were stationed at Camp Victory. Their tour 
took them directly into combat including 4 months on ``the most 
dangerous road in the world,'' the highway from the airport to the 
Green Zone in Baghdad where Tim was a top gunner in a Humvee. Tim as 
well as many other soldiers in F202 earned their Purple Hearts on that 
stretch of road known as Route Irish. We are STILL waiting for Tim's 
Purple Heart from various military paperwork shuffles. My wife and I 
are not here today as anti-war protesters. Our son truly believed that 
what his unit did in Iraq helped that country and helped many people 
that they dealt with on a daily basis. Because of his beliefs, I have 
to believe in the cause that he fought and died for. That doesn't mean 
that I don't feel that we lost track of the overall mission in Iraq.
    When CBS News broke the story about veterans suicides, the VA took 
the approach of criticizing the way that the numbers were created 
instead of embracing it and using it to help increase mental healthcare 
within their system. Regardless of how perfectly accurate the numbers 
are, they obviously show a trend that desperately needs attention. CBS 
did what NO government agency would do; they tabulated the veteran 
suicide numbers to shed light on this hidden epidemic and make the 
American people aware of this situation. The VA should have taken those 
numbers to Capitol Hill asking for more people, funding, and anything 
else they need to combat this epidemic. They should embrace this study 
as it reveals the scope of a huge problem, rather than complaining 
about its accuracy. If all that is going to be done with the study is 
argue about how the numbers were compiled, then an average of 120 
veterans will die every week by their own hand until the VA recognizes 
this fact, and does something about it.
    The VA mental health system is broken in function, and understaffed 
in operation. There are many cases of soldiers coming to the VA for 
help and being turned away or misdiagnosed for PTSD and then losing 
their battle with their demons. Those soldiers, as well as our son 
Timothy, can never be brought back. No one can change that fact. But 
you can change the system so this trend can be slowed down dramatically 
or even stopped.
    Our son was just one of thousands of veterans that this country has 
lost to suicide. I see every day the pain and grief that our family and 
extended family goes through in trying to deal with this loss. Every 
one of those at-risk veterans also has a family that will suffer if 
that soldier finds the only way to take the battlefield pain away is by 
taking his or her own life. Their ravished and broken spirits are then 
passed on to their families as they try to justify what has happened. I 
now suffer from the same mental illnesses that claimed my son's life, 
PTSD, from the images and sounds of finding him and hearing his life 
fade away, and depression from a loss that I would not wish on anyone.
    If the veteran suicide rate is not classified as an epidemic that 
needs immediate and drastic attention, then the American fighting 
soldier needs someone in Washington who thinks it is. I challenge you 
to do for the American soldier what that soldier did for each of you 
and for his country: Take care of them and help preserve their American 
dream as they did yours. To quote President Calvin Coolidge, ``The 
Nation which forgets its defenders will be itself forgotten.''
    Today, you are going to hear a lot of statistical information about 
suicide, veterans, and the VA. But keep one thing in mind, our son, 
Specialist Timothy Noble Bowman, was not counted in any VA statistics 
of any kind. He had not made it into the VA system because of the 
stigma of reporting mental problems. He was National Guard, and he was 
not on a drill weekend when he took his life. The only statistical 
study that he was counted in was the CBS News study. And there are many 
more just like him. We call them KBA's, killed because of action, the 
unknown fallen.
    I challenge you to make the VA an organization to be proud of 
instead of the last place that a veteran wants to go. It is the 
obligation of each and every one of you and all Americans to channel 
the energies, resources, and the intelligence and wisdom of this 
Nation's best and brightest to create the most effective, efficient and 
meaningful healthcare system for our men and women who have served. We 
must all remove the stigma that goes with a soldier admitting that he 
or she has a mental issue. Let those soldiers know that admitting they 
have a problem with doing the most unnatural thing that a human being 
can do is all right. Mental health issues from combat are a natural 
part of the process of war and have been around for thousands of years, 
but we categorize that as a problem. Take that soldier that admits a 
mental health injury from combat and embrace him as a model for others 
to look up to. Let the rank-and-file know by example that it's okay to 
work through your issues instead of burying them until it's too late. 
Grab that soldier and thank him for saying, ``I'm not okay,'' and 
promote him. A soldier that admits a mental injury should be the first 
guy you want to have in your unit, because he may be the only one that 
really has a grasp on reality. But instead, he is punished and shunned 
and by that example, he has become the model for PTSD and suicide. And 
while we are at it, why do we call it a disorder? That title, in 
itself, implies ramifications that last forever. It is an injury, a 
combat injury, just like getting shot. With proper care and treatment 
soldiers can heal from this injury and be as productive and healthy as 
before.
    We as a country have the technology to create the most highly 
advanced military system in the world, but when these veterans come 
home, they find an understaffed, underfunded, and underequipped VA 
mental health system that has so many challenges to get through it that 
many just give up trying. The result is the current suicide epidemic 
among our Nation's defenders, one of which was Specialist Timothy Noble 
Bowman, our 23-year-old son, a soldier, and our hero.
    Our veterans should and must not be left behind in the ravished, 
horrific battlefields of their broken spirits and minds. Our veterans 
deserve better!!
    Mr. Chairman, this concludes my testimony. Thank you.

                                 
       Prepared Statement of Penny Coleman, Rosendale, NY, Author
 Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of 
                                  War
INTRODUCTION
    The Roman poet Horace said that it is a sweet and fitting thing to 
die for one's country. That sentiment has been offered as comfort to 
widows and orphans for more than 2,000 years. However hollow and 
inadequate it might seem to those who are left only with memories and a 
folded flag, it remains central to the allure and romance of military 
culture. But I have never heard it suggested that there is anything 
sweet or fitting about being a psychiatric casualty for one's country, 
though surely soldiers and veterans who were injured in their minds 
pledged the same and risked as much as their fallen comrades.
    My husband, Daniel O'Donnell, came home from Vietnam in 1969, 11 
years before Post Traumatic Stress Disorder (PTSD) became an official 
diagnostic category. Like most veterans, he simply refused to talk 
about his war experiences, so I had no way of knowing what he had 
experienced or what was going on in his head. In retrospect, I imagine 
he just thought he was going crazy. It must have been terrifying. I can 
only image his despair.
    After Daniel died, it never occurred to me to blame the war for 
what had happened to us. I tried to blame him, but ended up blaming 
myself. If only I had been kinder, more patient, more understanding, 
quicker to notice and identify trouble. I can find more compassion for 
us both from this distance. I can see now that he was just a kid who 
had tried to stay alive in a situation that exploded all the rules he 
had ever lived by, and that he was too sorry and too ashamed to start 
over. And I can see now that I, too, was in over my head in a situation 
I neither understood nor controlled. But at the time, and for decades 
after, I believed his death was my fault, and I crept into a psychic 
lair to hide my shame and lick my wounds in private. I married again 
and had two children, but it was an awful way to live, tip-toeing 
around everybody I loved, trying not to kill one of them by mistake. It 
was a long time before I could find some compassion and forgiveness for 
that young woman who had no idea what she was up against.
    The research I did for my book, Flashback: Posttraumatic Stress 
Disorder, Suicide, and the Lessons of War \1\ included interviews with 
16 widows, mothers, and daughters whose loved ones also took their own 
lives after serving in Vietnam. The story I have just told is only my 
version of a litany that ran through every interview.
---------------------------------------------------------------------------
    \1\ Penny Coleman, Flashback: Posttraumatic Stress Disorder, 
Suicide, and the Lessons of War (Boston, MA: Beacon, 2006).
---------------------------------------------------------------------------
POST TRAUMATIC STRESS DISORDER AND MODERN WARFARE
    Every war in historical memory has produced psychiatric casualties. 
In fact, in every war American soldiers have fought in the past 
century, the chances of becoming a psychiatric casualty were greater 
than the chances of being killed by enemy fire.\2\ So surprise is at 
best a disingenuous response to what is happening yet again. At the 
same time, several issues have emerged that have affected rates of post 
traumatic stress injuries in modern warfare; these include the 
intensity and time a soldier is exposed to combat; unit cohesion, that 
is, the extent to which soldiers have been given a chance to know and 
trust those with whom they are fighting; and the nature of contemporary 
military training.
---------------------------------------------------------------------------
    \2\ Lieutenant Colonel David Grossman, On Killing (New York: Little 
Brown, 1996).
---------------------------------------------------------------------------
    Length of exposure versus unit cohesion: There were two central 
lessons that military psychiatrists took from the wars of the 20th 
century. The first is that soldiers fight for love--not hate. And not 
love of country. They're fighting for the soldier next to them, the one 
they can trust to take their back. The interpersonal bonding that 
happens when soldiers get to know and trust each other is what the 
military calls unit cohesion, and it is known to be one of the most 
effective protections against traumatic stress injuries.\3\ The second 
lesson is that if it is bad enough for long enough, anyone will fall 
apart. Anyone. It's not about how strong you are or how brave you are--
how truly manly you are. There is no such thing as a bullet-proof 
mind.\4\
---------------------------------------------------------------------------
    \3\ Jonathan Shay, Achilles in Vietnam (New York: Touchstone, 
1995).
    \4\ Ibid.
---------------------------------------------------------------------------
    During the Vietnam era, the military took the second of these two 
lessons seriously. The DEROS policy (Date of Expected Return from Over 
Seas) let every soldier know they would be leaving Vietnam exactly one 
year after they arrived. They hoped that a year would be a manageable 
time for a soldier to withstand the stress of the combat environment. 
And indeed, the limited amount of time spent in the combat zone may 
have been the reason that only about 1% of soldiers were evacuated for 
psychiatric reasons, compared to World War II.\5\ At the same time, in 
the interest of efficiency, the military ignored the first rule, about 
the importance of personal loyalty and unit cohesion. After basic 
training, soldiers were inserted individually into the war machine 
according to some bureaucratically efficient system. They were cut off 
from the friendships they had established during training. They were 
sent into terrifying situations surrounded by strangers who they didn't 
know or have any reason to trust. Furthermore, their officers were also 
rotated, serving for only six months with a unit. It has now been 
established that the ways in which DEROS undermined unit cohesion were 
a major contributor to the psychic injuries of the Vietnam war.\6\
---------------------------------------------------------------------------
    \5\ Ibid.
    \6\ Ibid.
---------------------------------------------------------------------------
    Current military policy has turned that on its head. Now, the 
military keeps units together, but ignores the time/intensity rule. 
Soldiers are repeatedly deployed, spending far more time in combat than 
even the generous limits the Army considers safe.\7\ Some units have 
been deployed three or four times in as many years, and it is becoming 
ominously clear that the psychic resources of our soldiers has been 
exhausted.
---------------------------------------------------------------------------
    \7\ Davis H. Marlowe, Psychological and Psychosocial Consequences 
of Combat and Deployment: With Special Emphasis on the Gulf War (Santa 
Monica, California: Rand, 2001).
---------------------------------------------------------------------------
    In 2004, the release of the Abu Grahib photographs broke the 
unforgivable silence in the mainstream press about atrocities committed 
by American soldiers in Iraq. Haditha followed, then Mahmoudiyah, 
Ishaqi, and at this writing, multiple other instances of savage, 
homicidal violence directed against civilians have been reported. More 
recently, there have been the reports of veterans involved in violent 
incidents after coming home.\8\ These acts are being committed by 
American soldiers who are predictably out of control. They are the 
inevitable result of pushing our soldiers way beyond their limits. They 
are not the result of a few bad apples run amok.
---------------------------------------------------------------------------
    \8\ http://timelines.epluribusmedia.org/timelines/
index.php?&mjre=PTSD&table_name=tl_ptsd
&function=search&order=date&order_type=ASC.
---------------------------------------------------------------------------
    I'm not suggesting that American soldiers take no responsibility 
for their actions. I would argue that we must balance outrage at 
criminal and sadistic acts with the insistence that this new generation 
of soldiers and veterans not be asked to take responsibility for the 
terrible and tragic circumstances that led to those acts. Individual 
soldiers cannot be the only ones taking the blame.
    The nature of contemporary military training: Military training has 
been part of the experience of millions of young American men since the 
Revolutionary War. Prior to the Vietnam era, however, that training 
consisted largely of practicing military skills and learning to manage 
military equipment. It is only in the last half century that training 
has evolved into an entirely new phenomenon that makes use of the 
principles of operant conditioning to overcome what studies done over 
the last century have consistently demonstrated, namely, that healthy 
human beings have an inherent aversion to killing others of their own 
species.\9\
---------------------------------------------------------------------------
    \9\ S.L.A. Marshall, Men Against Fire: The Problem of Battle 
Command in Future Wars (Gloucester, MA: Peter Smith, 1978).
---------------------------------------------------------------------------
    War Psychiatry, the army's textbook on combat trauma, notes that 
``pseudospeciation, the ability of humans and some other primates to 
classify certain members of their own species as `other,' can 
neutralize the threshold of inhibition so they can kill conspecifics.'' 
\10\ Modern military training has developed carefully sequenced and 
choreographed elements to disconnect recruits from their civilian 
identities. The values, standards and behaviors they have absorbed over 
a lifetime from their families, schools, religions and communities are 
scorned and punished. Using cruelty, humiliation, degradation and 
cognitive disorientation, recruits are reprogrammed with an entirely 
new set of learned responses. Every aspect of combat behavior is 
rehearsed until response becomes reflexive. Operant conditioning has 
vastly improved the efficacy of American soldiers, at least by military 
standards. It has proven to be a reliable way to turn off the switch 
that controls a soldier's inherent aversion to killing. American 
soldiers do kill more often and more efficiently. Lt. Col. Dave 
Grossman, author of On Killing, calls this form of training 
``psychological warfare, [but] psychological warfare conducted not upon 
the enemy, but upon one's own troops.'' \11\
---------------------------------------------------------------------------
    \10\ Coleman, Flashback, 73-4.
    \11\ Grossman, On Killing, 251.
---------------------------------------------------------------------------
    There are any number of ways that modern training methods both 
support violence, aggression and obedience and help to disconnect a 
reflex action from its moral, ethical, spiritual, or social 
implications. Drill instructors rely on sexist and homophobic labels 
like ``girl,'' ``pussy,'' ``lady'' or ``fairy'' to humiliate, degrade 
and ultimately exact conformity. Recruits are drilled with marching 
chants that privilege their relationships with their weapons over their 
relationships with women (``You used to be my beauty queen. Now I love 
my M-16''), overtly conflate sex and violence (``This is my rifle, this 
is my gun. This is for fighting; this is for fun.''), and treat the 
killing of civilians as humorous (``Throw some candy to the children. 
Wait till they all gather round. Then you take your M-16 now, and mow 
the little * * * * * * * down.'') \12\ Aside from teaching these young 
soldiers to quash their innate feelings about killing in general, they 
are being programmed with a distorted version, not only of what it 
means to be a man, but of what it means to be a citizen.
---------------------------------------------------------------------------
    \12\ Carol Burke, Camp All-American, Hanoi Jane, and the High-and-
Tight. (Boston, MA: Beacon, 2005).
---------------------------------------------------------------------------
    Thankfully, the brainwashing has not yet been developed that will 
override the humanity of most American soldiers. As multiple 
deployments become the norm, however, and as more scrambled psyches are 
sent back into combat instead of into treatment, it is frightening to 
consider that the brainwashing may yet prevail. Given the training to 
which these soldiers have been subjected and the chaotic conditions in 
which they find themselves, it is inevitable that more will succumb to 
fear and rage and frustration. They will inevitably be overwhelmed by 
cumulative doses of horror and they will lose control of their judgment 
and their compassion. It is a credit to their humanity, not a sign of 
their weakness, that these men and women find it hard to live afterward 
with what they have seen and, in some cases, done. The soldiers who, 
following orders, have run over children in the road rather than slow 
down their convoy will never be the same again.\13\ Nor will the 
soldiers manning checkpoints who shoot, as ordered, and kill entire 
families who failed to stop, only to learn later that no one had 
bothered to share with them that the American signal to stop--a hand 
held up, palm toward the oncoming vehicle--to an Iraqi means, ``Hello, 
come here.'' \14\
---------------------------------------------------------------------------
    \13\ Mark Benjamin, ``Military Injustice,'' Salon.com, June 7, 
2005. http://archive.salon.com/news/feature/2005/06/07/whistleblower/.
    \14\ Deborah Scranton, Dir. The War Tapes (Sen Art Films, 2007).
---------------------------------------------------------------------------
    This generation of soldiers wants to tell their stories because 
they want to believe that Americans want to know.\15\ They are not 
looking for absolution, but they want the architects of current policy 
to accept their share of the blame. They have already carried home the 
psychic wounds and the dangerous reflexive habits of violence that will 
always diminish their lives and their relationships. In return, they 
are hoping we will listen to them this time when they ask us to look a 
little harder, dig a little deeper, use a little more discernment.
---------------------------------------------------------------------------
    \15\ http://www.ivaw.org/wintersoldier.
---------------------------------------------------------------------------
    In addition, a number of aspects of deployment and treatment in the 
current situation are directly responsible for adding to the problem of 
PTSD and suicide. These include the failure to screen sufficiently for 
mental health problems, the inappropriate use of drugs, and the re-
triggering of PTSD symptoms among Vietnam veterans.
    Failure to screen: In May, the Hartford Courant ran a series of 
articles exposing the common practice in this army of deploying 
soldiers in spite of serious, documented mental health histories, 
including severe depression, bi-polarity, even autism. On their pre-
deployment health forms, there's a box a recruit can check if they've 
had any kind of mental health issues in the past year. Of the 3% who 
checked the box, 1 in 300 was given any kind of follow-up assessment. 
Some were already on anti-depressants when they were recruited.\16\ The 
use of waivers has meant that individuals with histories of emotional 
problems, problems that have involved them in felonious activities, 
including drug abuse and sale, domestic violence and other violent 
crimes, individuals who would never have been previously accepted into 
the military, are now being enlisted and deployed.\17\
---------------------------------------------------------------------------
    \16\ Lisa Chedekel and Matthew Kauffman, ``Mentally Unfit, Forced 
to Fight,'' The Hartford Courant, May 14, 2006.
    \17\ Mark Benjamin, Out of jail, into the Army. Salon.com, February 
2, 2006. http://www.salon
.com/news/feature/2006/02/02/waivers/.
---------------------------------------------------------------------------
    The inappropriate use of drugs: Self-medication with marijuana and 
heroin by soldiers in Vietnam is legendary; what is less well know is 
that, for the first time, the military made aggressive use of powerful 
tranquilizers and anti-anxiety drugs.\18\ In the short run, those drugs 
were effective, if the definition of effectiveness was boots on the 
ground, but in the long run, they were the moral equivalent of giving a 
soldier a local anesthetic for a gunshot wound and sending him back 
into combat.
---------------------------------------------------------------------------
    \18\ Grossman, On Killing.
---------------------------------------------------------------------------
    It may be that the doctors prescribing in the Vietnam era did not 
realize the effects of those drugs over time, but today's military 
doctors have the benefit of ample evidence.\19\ When soldiers are given 
those kinds of drugs while they are still experiencing the stressor, 
the drugs interrupt the development of normal coping mechanisms--and 
the long-term effects of the trauma are worse. Still, anti-depressants 
that come with warning labels about side effects that include suicide 
are being given to active-duty soldiers with little or no supervision, 
a practice that is virtually playing Russian roulette with their lives.
---------------------------------------------------------------------------
    \19\ Ibid.
---------------------------------------------------------------------------
    The re-triggering of symptoms among Vietnam veterans: Contemporary 
warfare not only creates its own emotional casualties, but reignites 
the symptoms of veterans of previous wars. The Washington Post reported 
a year ago that ``Vietnam veterans are the vast majority of VA's PTSD 
disability cases--more than 73 percent.'' These included ten thousand 
new claims filed by veterans who were entering the system for the first 
time, more than 30 years after their war came to an end.\20\
---------------------------------------------------------------------------
    \20\ Donna St. George, ``Iraq War May Add Stress for Past Vets: 
Trauma Disorder Claims at New High,'' Washington Post, June 20, 2006, 
A01 http://www.washingtonpost.com/wp-dyn/content/article/2006/06/19/
AR2006061901400_pf.html.
---------------------------------------------------------------------------
    Apologists such as American Enterprise Institute scholar Sally 
Satel have accused veterans of memorizing the diagnostic criteria for 
PTSD before going to see a VA doctor. They have accused the VA doctors 
of over-diagnosing and thereby making their patients believe they are 
sick, and the particularly cynical accusation that Vietnam vets who are 
getting close to retirement are angling for ways to pad their old age 
with inflated disability checks.\21\
---------------------------------------------------------------------------
    \21\ Sally Satel, ``Stressed Out Vets: Believing the worst about 
post-traumatic stress disorder,'' The Weekly Standard, August 21, 2006.
---------------------------------------------------------------------------
    Veterans, however, claim that the cause of their applications for 
benefits, far from being fraud, is the daily onslaught of horrific 
images and stories coming out of Iraq and Afghanistan that have 
triggered their flashbacks and reactivated intolerable symptoms. One of 
those is former senator Max Cleland, a triple amputee from the war in 
Vietnam, who was compelled to re-enter therapy at Walter Reed for PTSD 
symptoms that have flared up since the war in Iraq began. Cleland 
recounts that he cannot read newspapers or watch television now because 
both are triggers for PTSD, something that he claims is happening to 
Vietnam veterans all over America.\22\
---------------------------------------------------------------------------
    \22\ http://www.wsbtv.com/news/9747929/detail.html.
---------------------------------------------------------------------------
FACTORS IN THE CURRENT POLICIES THAT ARE TRAGICALLY INCREASING THE 
        INCIDENTS OF SUICIDE
    In November 2007, CBS News released the results of their 
investigation into veteran suicides. Using the clout that only major 
broadcast networks seem capable of mustering, CBS News contacted the 
governments of all 50 States requesting their official records of death 
by suicide going back 12 years. They heard back from 45 of the 50 
States. From the mountains of gathered information, they sifted out the 
suicides of those Americans who had served in the armed forces. What 
they discovered is that in 2005 alone--and remember, this is just in 45 
States--there were at least 6,256 veteran suicides, 120 every week for 
a year and an average of 17 every day.\23\
---------------------------------------------------------------------------
    \23\ http://www.cbsnews.com/stories/2007/11/13/
cbsnews_investigates/main3496471.shtml.
---------------------------------------------------------------------------
    I am grateful to CBS News for undertaking this long overdue 
investigation. And though I am also heartbroken that the numbers are so 
astonishingly high, I am tentatively optimistic that perhaps now that 
there are hard numbers to attest to the magnitude of the problem, it 
will finally be taken seriously.
    Part of taking that seriously will be to acknowledge the ways in 
which the current spate of suicides is being exacerbated by government 
and military policy. In the above section, I presented a number of the 
major factors in the high incidence of PTSD among American soldiers and 
veterans. In this section, I will point to additional factors that 
explain why PTSD so often leads to suicide. A few examples include the 
redeployment of psychically injured soldiers, a lack of sufficient 
medical care professionals, lengthy waits for treatment, complex 
bureaucratic red tape, and a variety of justifications for dishonorably 
discharging traumatized veterans, thus rendering them ineligible for VA 
psychiatric care. It is difficult not to connect all of these factors 
to a tragic prioritizing of budgetary considerations at the expense of 
the lives of soldiers and veterans.
    Redeployment of psychically wounded soldiers: In November 2006, the 
Pentagon released guidelines that allow commanders to redeploy soldiers 
suffering from traumatic stress disorders. Service members with ``a 
psychiatric disorder in remission, or whose residual symptoms do not 
impair duty performance'' may be considered for duty downrange. It 
lists post traumatic stress disorder as a ``treatable'' problem and 
sets out a long list of conditions when a soldier can, and cannot be 
returned for an additional tour in Iraq.\24\ Post traumatic stress 
injuries, under the best of circumstances, are treatable, but not 
curable. Sending soldiers back into the situation that triggered their 
injury in the first place is taking undue, I would say cruel, license 
with their mental health.
---------------------------------------------------------------------------
    \24\ Aaron Glantz, ``Iraq Vets Left in Physical and Mental Agony,'' 
Inter Press Service, January 4, 2007.
---------------------------------------------------------------------------
    Lack of sufficient medical care professionals/Lengthy waits for 
treatment: The Defense Health Board's Task Force on Mental Health has 
reported that there is a shortage of active duty mental health 
professionals. According to the report, ``DoD has already dramatically 
reduced its number of active duty mental health professionals and there 
are proposals to further reduce active duty staffing.'' \25\ As a 
result, according to other researchers, ``doctor-to-patient ratios are 
climbing, waiting periods to see specialists are growing, and the time 
that psychiatrists spend with the most troubled patients--those with 
post traumatic stress disorder, or PTSD--is shrinking.'' \26\ In 
September 2007 a Congressionally mandated report by the nonpartisan 
Government Accountability Office found the Pentagon and VA care for 
service members suffering from PTSD and Traumatic Brain Injury was 
``inadequate'' with ``significant shortfalls'' of doctors, nurses and 
other caregivers necessary to treat wounded soldiers.\27\ The result is 
that soldiers and veterans requesting treatment for PTSD still 
typically are put on waiting lists and wait six months to a year.
---------------------------------------------------------------------------
    \25\ http://www.usmedicine.com/
article.cfm?articleID=1610&issueID=102.
    \26\ Anne C. Mulkern, Denver Post, July 05, 2005.
    \27\ ``Vets Healthcare Not Meeting Standards: Army Has Yet To Fully 
Staff New Units Created To Fix Problems At Walter Reed'' (GAO: 
Washington, DC, Sept. 26, 2007). http://www.cbsnews.com/stories/2007/
09/26/national/main3300260.shtml.
---------------------------------------------------------------------------
    Complex bureaucratic red tape: Since the start of the Iraq war, the 
back-log of unanswered disability claims has grown from 325,000 to more 
than 600,000, with 800,000 new claims expected in each of the next two 
years.\28\ On average, a veteran must wait almost six months to have a 
claim heard. If a veteran loses and appeals a case, it usually takes 
almost two years to resolve.\29\ The number of claims adjusters at the 
VA likewise dropped. It is worth noting that if a service member or 
veteran dies while an appeal is pending, the appeal dies as well.\30\
---------------------------------------------------------------------------
    \28\ Brian Friel, ``Hurry Up And Wait,'' Government Executive, May 
1, 2007. http://www.govexec.com/features/0507-01/0507-01s4.htm.
    \29\ Chris Adams, VA's ability to provide benefits worsens, 
December 1, 2006. http://www.mcclatchydc.com/staff/chris_adams/story/
15238.html.
    \30\ St. George, ``Iraq War May Add Stress.''
---------------------------------------------------------------------------
    Moreover, a veteran applying for compensation for Post Traumatic 
Stress Disorder must submit a 26 page form, the key to which is a 
detailed essay on the specific moments when he or she experienced a 
terrifying event or series of incidents that caused mental illness to 
develop. This is not easy because one of the symptoms of PTSD is for a 
person to try to block out any memory of that event. According to the 
psychiatric guide DSM IV, a person with PTSD often displays a 
``persistent avoidance of stimuli associated with the trauma and 
numbing of general responsiveness.'' \31\ In other words, the last 
thing a person experiencing PTSD wants to do is sit down and write an 
essay on why, and exactly how, they've become mentally ill. A veteran 
must also back that claim up with hard evidence that their PTSD is 
indeed ``service connected''--in essence proving he or she was indeed 
in the place they said they were and that the terrifying incident did 
indeed occur. If the veteran received a medal during the incident the 
job is easier. If not, the vet must track down their service records to 
see if any paperwork was generated as a result of the incident that 
caused the development of their injury. DoD paperwork is notoriously 
difficult to track down, if it exists in the first place. I applaud the 
efforts of Representatives Donnelly and Upton for introducing H.R. 
1490, The Fairness in Veterans Disability Benefits Act, which aims to 
simplify the process for new veterans as they transition out of the 
military and try to provide for their families. It is certainly a step 
in the right direction, but $400 per month is not going to pay the rent 
anywhere in this country.
---------------------------------------------------------------------------
    \31\ Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 
(DSM-IV) (Washington D.C.: American Psychiatric Association, 1994), 
available online at www.psychologynet.org/dsm.html.
---------------------------------------------------------------------------
    Ineligibility for medical benefits: A variety of patterns related 
to PTSD are currently leading to a denial of medical benefits. In some 
cases, soldiers and veterans who have applied for help with PTSD 
symptoms try to manage terrifying symptoms by self-medicating with 
drugs or alcohol; this substance abuse, itself a complication of PTSD, 
is then used to justify a dishonorable discharge, even in cases in 
which a soldier has repeatedly asked for treatment.\32\ In other cases, 
diagnoses such as ``pre-existing conditions'' are used by the military 
to deny its responsibility for treating soldiers suffering emotional 
trauma.\33\
---------------------------------------------------------------------------
    \32\ Daniel Zwerdling, ``Soldiers Say Army Ignores, Punishes Mental 
Anguish,'' ``All Things Considered,'' National Public Radio, December 
4, 2006. http://www.npr.org/templates/story/story.php?storyId=6576505.
    \33\ Joshua Kors, ``How Specialist Town Lost His Benefits,'' The 
Nation, April 9, 2007. http://www.thenation.com/doc/20070409/kors.
---------------------------------------------------------------------------
    One of the saddest consequences of the Bush administration's 
failure to anticipate and plan for an extended conflict in Iraq is the 
billions of additional dollars the VA has discovered it needs to cover 
the shortfall in its healthcare budgets for the past three years. 
Administration apologists such as Sally Satel have kept up a steady 
stream of accusation and innuendo in the media ever since it became 
clear that their new war was going to suck in, chew up and spit out 
devastated soldiers every bit as reliably--and expensively--as the war 
in Vietnam did.\34\ It is worth recalling that, prior to the scandal 
concerning conditions at Walter Reed, President Bush's appointees at 
the Pentagon had strenuously lobbied Congress against funding military 
pensions, health insurance and benefits for widows of retirees. Their 
argument: that money spent on caring for wounded soldiers and their 
families could be better spent on new state-of-the-art military 
hardware or enticing new recruits to join the force. In January 2005, 
Bush's Undersecretary of Defense for Personnel and Readiness David Chu, 
the official in charge of such things, went so far as to tell the Wall 
Street Journal that veterans' medical care and disability benefits 
``are hurtful'' and ``are taking away from the Nation's ability to 
defend itself.'' \35\
---------------------------------------------------------------------------
    \34\ http://www.sallysatelmd.com.
    \35\ Jaffe, Greg. ``Balancing Act: As Benefits for Veterans climb, 
military spending feels squeeze.'' Wall Street Journal, Jan. 25, 2005, 
pA1.
---------------------------------------------------------------------------
    Indeed, what we have seen in the past four years are frantic and 
often tragic attempts to save money, all at the expense of the 
veterans. The military tried charging wounded soldiers at Walter Reed 
for their lunches. Congress made them take that back. They tried 
spinning PTSD as veteran fraud and insisted that 72,000 100% disabled 
vets get themselves recertified. 100% disabled vets are the most 
fragile and the most likely to be further traumatized by a complicated 
bureaucratic process. Congress made them take that back as well, but 
not before at least one overwhelmed veteran took his own life with his 
recertification request papers on his chest.\36\
---------------------------------------------------------------------------
    \36\ Mark Benjamin, ``The VA's Bad Review,'' Salon.com, October 26, 
2005. http://archive .salon.com/news/feature/2005/10/26/suicide/
index.html.
---------------------------------------------------------------------------
    A new study by Columbia University economist Joseph E. Stiglitz, 
who won the Nobel Prize in economics in 2001, and Harvard lecturer 
Linda Bilmes concludes that the war is costing $720 million a day or 
$500,000 a minute.\37\ This total, which is far above the 
administration's prewar projections, attempt to take into account the 
long term healthcare costs for the U.S. soldiers injured in Iraq so 
far. Veterans groups joke the Bush Administration has instituted a 
policy of ``don't look, don't find,'' in order to absolve themselves of 
criminal, financial, and medical liability for their treatment of 
veterans.
---------------------------------------------------------------------------
    \37\ Kari Lydersen, ``War Costing $720 Million Each Day, Group 
Says,'' Washington Post, September 22, 2007. http://
www.washingtonpost.com/wp-dyn/content/article/2007/09/21/AR2007
092102074.html.
---------------------------------------------------------------------------
RECOMMENDATIONS
    The basis for addressing the virtual epidemic of death that 
constitutes suicide among soldiers and veterans much be first to 
acknowledge the problem. While Americans may disagree about current 
American policy in Iraq, surely we can all agree with the motto of the 
VA, ``To care for him [and now her] who shall have borne the battle and 
for his widow and orphan.''
    In August of 2006, Fox News proposed that Congress provide that 
certain types of military service--such as any service in theaters of 
combat, not just actual combat experience, and other forms of hazardous 
duty--automatically qualify veterans for lifetime health benefits. 
There is much to be said for that proposal. Among other things, it 
would eliminate the motivation for unjust dishonorable discharges and 
alternative diagnoses. It would also mean that scientific research 
involving combat veterans might be less politicized and less likely to 
be skewed.\38\
---------------------------------------------------------------------------
    \38\ Steven Milloy ``Politicized Science Produces Bad Public 
Policy,'' August 17, 2006. https://www.foxnews.com/story/
0,2933,209078,00.html.
---------------------------------------------------------------------------
    Less extreme but still vitally needed specific steps include:

      Attack stigma: The ``D'' in PTSD should immediately be 
dropped. To call the psychic injuries of soldiers a disorder reinforces 
the misperception that there is something inherently wrong with the 
soldier. The prejudice that reinforces, in soldiers, veterans, 
caregivers and military officers alike, is in many ways responsible for 
the resistance of sufferers to ask for the help they so desperately 
need. Military personnel at all levels must be educated to understand 
that PTSD is not a sign of weakness or cowardice. Soldiers and veterans 
must be debriefed to help individuals understand and cope with the 
stress that is a normal response to an overwhelming situation. 
Treatment for emotional injuries must be given parity with treatments 
for more visible physical wounds. For example, promoting the 
elimination of stigmatizing questions on security clearance 
questionnaires can set the precedent for culture change within the 
Department of Defense and model similar changes in procedure for other 
employment categories, thus eliminating the risks to future employment 
for individuals in need of treatment for PTSD.\39\
---------------------------------------------------------------------------
    \39\ ``The War inside; troops are returning from the battlefield 
with psychological wounds, but the mental-health system that serves 
them makes healing difficult,'' The Washington Post, June 17, 2007.
---------------------------------------------------------------------------
      Multiply the caregivers: The military's cadre of mental-
health workers is ``woefully inadequate to meet their needs.'' The 
current decline in military mental health professionals must be 
reversed as quickly as possible.
      Provide mandatory and adequate screenings for all 
enlistees and for all returning soldiers: In the first instance, this 
will help to stop the practice of deploying soldiers who are already 
emotionally fragile. It will also serve to create a medical history 
enabling a veteran to later prove service-connection in the event of 
emotional trauma. Finally, because everyone participates, such a 
screening policy would eliminate the shame and stigma.
      Stop redeploying psychically injured soldiers.
      Create a structure for screening soldiers and veterans 
outside of the chain of command.
      Eliminate the wait for soldiers and veterans reporting 
symptoms and requesting treatment and ensure that sufficient emergency 
contacts and treatment options are available.
      Hire and train additional Veteran Service Representatives 
and Veteran Service officers to help veterans navigate the system.
      Streamline application and benefit procedures and make 
them more `vet-friendly.'
      Increase the number and size of Vet Centers, which 
provide flexible and easily accessed programs and resources, and create 
procedures for collaboration between Vet Centers and demobilizing 
troops.
      Hold follow-up interviews with demobilized troops at 30, 
60, and 90 day intervals and then periodically for several years.

CONCLUSION
    I will never know if any or all of the above recommendations, if 
implemented, would have saved my husband Daniel's life. I do know that 
they would have given both of us a better chance. I believe as well 
that, had deaths such as Daniel's been officially acknowledged, 
studied, and counted, not only would our lives as survivors been very 
different, but it would be far more difficult for officials now with 
any credibility deny a connection between combat-related PTSD and 
suicide.
    I find hope in the fact that public attention and better knowledge 
of mental health issues have helped legitimize the psychiatric injuries 
soldiers sustain in every war. Though government apologists still 
shamefully spin and distort the numbers, and though military culture 
still encourages stigmatization, and even punishment, for what they 
insist on calling weakness or malingering, there is still far more 
information about posttraumatic stress injuries available, and that 
makes it less likely that this generation of soldiers and their 
families will experience the same degree of isolation on top of their 
grief that we felt. The difference is that we are talking about it now.

                                 
       Prepared Statement of Ilona Meagher, Caledonia, IL, Author
 Moving a Nation to Care: Post-Traumatic Stress Disorder and America's 
                            Returning Troops
    Chairman Filner, Ranking Member Buyer, and other distinguished 
members of the Committee, I thank you for the opportunity to appear 
before you today.
    To open, I'd like to briefly share my thoughts on why it is that I 
believe I'm here.
    I am not only someone who's spent the past two years researching 
and writing about post traumatic stress in our returning troops, I'm 
also a veteran's daughter. My father was born in Hungary, served two 
years in antitank artillery as a Hungarian Army conscript, fought 
against the Soviet Union on the streets of Budapest during the 1956 
Hungarian Revolution, and later fled to America where, in 1958, he 
again became a soldier, this time wearing a United States Army uniform, 
and serving as a combat engineer stationed in Germany.
    My father's unique experience of having served on both sides--East 
and West--in such differing armies during the Cold war, gave him a 
unique perspective on military life.
    And so, growing up, my sisters and I often heard my father say, 
``You can always tell how a government feels about its people by 
looking at how it treats its soldiers.''
    Looking at our returning soldiers and their widely reported 
struggles with the military and VA healthcare systems they rely on, of 
being stigmatized from seeking care or of being placed on lengthy VA 
waiting lists when they need immediate help--some even committing 
suicide before their appointment dates arrive--have raised this 
citizen's alarm bells.
    We have had a ``see no evil, hear no evil'' approach to examining 
post-deployment psychological reintegration issues such as suicide. 
After all we have learned from the struggles of the Vietnam War 
generation--and the ensuing controversy over how many of its veterans 
did or did not commit suicide in its wake--why is there today no known 
national registry where Afghanistan and Iraq veteran suicide data is 
being collected? How can we ascertain reintegration problems--if any 
exist--if we are not proactive in seeking them out?
    As late as May 2007, Department of Veterans Affairs spokeswoman 
Karen Fedele told the Washington Post that there was no attempt to 
gather Afghanistan and Iraq veteran suicide incidents. ``We don't keep 
that data,'' she said. ``I'm told that somebody here is going to do an 
analysis, but there just is nothing right now.'' \1\
---------------------------------------------------------------------------
    \1\ ``Veterans' Group Emphasizes Suicide Risks,'' Jennifer C. Kerr, 
Associated Press, May 28, 2007.
---------------------------------------------------------------------------
    Meanwhile, the Army reported its suicide rate in 2006 rose to 17.3 
per 100,000 troops, the highest in 26 years of keeping such records. At 
long last, the Associated Press revealed that the VA is finally 
conducting preliminary research. They've tracked at least 283 OEF/OIF 
veteran suicides through the end of 2005, nearly double the rate of the 
additional 147 suicides reported by the DoD's Defense Manpower Data 
Center.
    Looking only at the these suicide figures from the VA (283) and the 
DoD (147), there have been at least 430 Afghanistan and Iraq veteran 
suicides that have occurred either in the combat zone or stateside 
following combat deployment. Lost in the VA and DoD counts are those 
veterans who have returned from their deployments, are still in the 
military and not yet in the VA system. The DoD says they do not track 
those incidents, and I assume neither does the VA because these 
veterans are not yet on their radar.
    Yet, even with this omission, many of these 430 confirmed suicides 
are a result of our wars in Afghanistan and Iraq and should--but 
won't--be listed with the DoD's official OEF/OIF death toll of 4,351. 
It bears mentioning: Currently 10 percent of the overall fatal casualty 
count of these wars is due to suicide.
    Dismissing the issue of veteran suicide in the face of this data is 
negligent and does nothing to honor the service and sacrifice of our 
veterans and the families and communities that literally are tasked 
with supporting them once they return.
    Yet, prior to last month's CBS News investigation, which revealed 
that 120 veterans of all wars committed suicide every week in 2005 and 
that 20-24-year-old Afghanistan and Iraq veterans are two to four times 
more likely to commit suicide than their civilian counterparts, the 
scope of the problem has been largely unknown because no one with 
proper resources and access to do the compiling of data came forward to 
do so.
    In my written testimony, I've included 75 suicides that I and other 
citizen journalist colleagues have been tracking since September 2005 
and which today reside in the ePluribus Media PTSD Timeline.
    Offering only a small and incomplete sliver of insight into how 
some of our returning troops are faring on the home front--especially 
in light of the fact that at least another 355 incidents could be added 
among them according to the VA and DoD--I believe that they 
collectively tell an even greater tale about the failure of us as 
individuals and as a society to ensure that our returning warriors are 
cleansed completely from the psychological wounds of war.
    They also reflect the failure of our government institutions to 
protect those who protect us.
    While I realize that these distressing stories are the exception 
and not the rule, to our exceptional military families having to deal 
with the deterioration of a loved one they thought had safely returned 
from combat, they are the rule. In 1956, the same year that my parents 
fled to this incredible country, the 84th Congress--in the very House 
that we sit in today--had this to say in a Presidential commission 
report on veterans' benefits:

          ``The Government's obligation is to help veterans overcome 
        special, significant handicaps incurred as a consequence of 
        their military service. The objective should be to return 
        veterans as nearly as possible to the status they would have 
        achieved had they not been in military service . . . and 
        maintaining them and their survivors in circumstances as 
        favorable as those of the rest of the people. . . . War 
        sacrifices should be distributed as equally as possible within 
        our society. This is the basic function of our veterans' 
        programs.'' \2\
---------------------------------------------------------------------------
    \2\ U.S. Congress. House, The President's Commission on Veterans' 
Pensions. The historical development of veterans' benefits in the 
United States: A report on veterans' benefits in the United States, 
84th Cong., 2nd sess., May 9, 1956.

    I am not a pedigreed expert or a government official seasoned in 
testifying before you, but those who are from the GAO and the 
Congressional Research Department and even the Veterans Administration 
itself, have sat in this very seat over the years and told you we are 
falling far short in providing the resources and programs our returning 
troops and military families need to successfully return to their 
personal lives following their service to the Nation.
    To those who resist hearing the cold hard truth of where we are 
today, I'd like to say: The time is here to stop fighting the data, and 
to start fighting for our troops.
    This is America. We can do better. We must do better.
    Suggestions to ease the veteran suicide problem:

      Offer all returning veterans immediate compensation and 
treatment support the first six months after their return home. 
Fostering positive coping skills (vs. negative coping skills of self-
medication or domestic violence) must be a key goal of our veterans' 
reintegration programs; veterans forced to wait at least six months for 
VA compensation and treatment benefits to kick in do not feel 
supported, they feel under siege.
      Increase 21st century asymmetrical warfare and 
psychological injury understanding and preparation. The DoD should 
continue to make adjustments in its training to give service members 
the tools they need to counter the modern battlefield's unique 
stressors. The Psychological Kevlar Act of 2007 would push the DoD to 
provide proactive psychological training for veterans from boot camp 
onward; more need to sign on to this legislation and it should be 
passed into law.
      Force the DOD and VA do a better job of communicating 
with veterans on their rights and resources, and making outside 
community-based resources known to them as well. Many vets are unsure 
of what benefits they have earned and what rights they have to them. 
Some are discouraged from using them. Many community programs and 
groups are ready and waiting to assist returning veterans and military 
families, but are unknown to the very people who might benefit from 
them. While Secretary Robert Gates has said it may take up to three 
years to fully implement the PTSD portion of the Dole-Shalala 
recommendations, why are we not utilizing the resources that are 
available in communities across the country?
      Properly and fully fund the Veterans Administration. 
Billions in underfunding translates to long waiting lines, lack of 
funds for PTSD research, and not enough PTSD specialists at each VA 
facility.
      Reduce tour lengths, decrease overall number of combat 
deployments, and increase dwell time between deployments by funding an 
increase in forces. With each successive deployment, troops' 
susceptibility to PTSD increases. Army Chief of Staff George W. Casey 
Jr. testified last month before the Senate Armed Services Committee 
saying that the military must be grown in order for dwell-time to be 
increased, etc.
      Restrict the ability to redeploy troops diagnosed with 
PTSD. No PTSD-diagnosed troops should be redeployed into a combat zone, 
and troops should not be deployed taking psychotropic drugs such as 
Paxil or Zoloft, that have been shown by the FDA to increase suicide 
risk.
      Improve post-deployment assessments. Move away from 
relying on questionnaires and make physicals and one-on-one demob 
consultations mandatory. In February 2006, the VA contracted the 
Institute of Medicine to do a thorough review of scientific and medical 
literature related to the diagnosis and assessment of PTSD; the 
Committee strongly concluded that the best way to determine whether a 
person is suffering from PTSD is with a ``thorough, face-to-face 
interview by a health professional trained in diagnosing psychiatric 
disorders.'' The DoD should follow the same rule.
      Invest more in counseling and support. Rather than 
relying on quick-fix medications to solve returning psychological 
problems, invest time and resources in holistic wellness programs to 
help veterans and their families recover from the experience of war.
      Remove stigma/punishment for those seeking help. One of 
the easiest ways to do this would be to operate under the assumption 
that everyone will need some form of support following combat. Move 
away from a system where those struggling most must somehow find the 
strength to conspicuously come forward on their own.
      Require completion of a `boot camp in reverse' 
transitional training program. Military families who have lost loved 
ones to suicide consistently say there should be a more formal reentry 
program following return from combat, weekly meetings/classes lasting 
from 2 to 3 months. The program should be as required to attend and 
complete by all service members as boot camp.
      Pay special attention in supporting National Guard and 
Reserve forces. Not being a part of a cohesive unit, they are 
especially susceptible to PTSD.
      Stop closing VA Hospitals and Vet Centers. We should be 
providing more opportunities for veterans scattered across the country, 
especially in rural areas, to have access to healthcare benefits.
      Increase funding to community service boards. Many 
troops--especially those with the National Guard and Reserve or in 
rural areas--do not have easy access to health services. Make sure they 
have alternatives to getting the care they need, or fully reimburse 
their private healthcare bills.
      Increase Vet Center program offerings. Offer more 
complimentary group and individual classes for troops and military 
families that explain what PTSD is, how it can be treated and how one 
can forge the tools necessary to move their lives beyond it.
      Provide complimentary counseling to all immediate family 
members. If the service member refuses to seek help, the spouse and 
children should have access to counseling service to help them through 
their loved one's reintegration process.
      Increase personal data security and treatment anonymity. 
Many will not come forward to get the help they need because they worry 
it may come back to haunt them when they're up for a promotion, being 
considered for a mission, or when looking for civilian employment. 
Family members, however, should not be kept in the dark, especially if 
veteran is prescribed psychotropic medication.

Selection of OEF/OIF Veteran Suicides
    The ePluribus Media PTSD Timeline, is a collection of press-
reported cases of post-combat related possible, probable, self-reported 
and/or confirmed incidents of PTSD or broader reintegration 
difficulties. The work is meant to preserve incidents that are at risk 
of being lost to us with the forward movement of time, as small town 
news websites do not archive many of their reports.
    Additional reasons for the existence of the PTSD Timeline include:

      Allowing for ease of study of PTSD and related 
reintegration issues by researchers, reporters, educational and 
government institutions.
      Fostering further discussion and exploration of post-
combat reintegration issues.
      Validating to military family members that we are paying 
attention to their experiences.

    What follows is a brief glimpse at the personal post-war landscape 
for our military families revealed through suicide incidents tracked by 
me and other citizen journalists in the PTSD Timeline since September 
of 2005.

Legend: /ss/=stateside suicide /oif/=OIF combat zone suicide /oef/=OEF 
combat zone suicide

2002
    Following the terrorist attacks of September 11th, Operation 
Enduring Freedom commenced with the invasion of Afghanistan on October 
7, 2001. Fort Bragg, N.C., home of the Army Special Operations Command, 
was the first to experience a cluster of post-deployment reintegration 
issues when three military wives were murdered by their recently 
returned husbands within a span of five weeks. (One additional wife was 
murdered during this same timeframe, but the husband had not deployed 
to OEF).
    On June 11, 2002 /ss/, Rigoberto Nieves (32-year-old Special Forces 
sergeant) fatally shot his wife and then himself in an off-base murder/
suicide after having returned home from Afghanistan in mid-March. On 
July 19, 2002 /ss/, Brandon Floyd (30-year-old Special Ops soldier) 
shot his wife and then himself in an off-base murder/suicide after 
having returned home in January.
    CNN reported at the time: ``Fort Bragg garrison commander, Army 
Col. Tad Davis, is reviewing counseling and stress-management programs 
available at the base. A spokesman said the Army wants to see if there 
is something it could do better. But one military official who had 
previously served at Fort Bragg pointed out that Special Operations 
soldiers may be reluctant to seek help.'' \3\
---------------------------------------------------------------------------
    \3\ ``Fort Bragg killings raise alarm about stress,'' Barbara 
Starr, CNN, July 27, 2002.
---------------------------------------------------------------------------
2003
    On March 19, 2003, Operation Iraqi Freedom commenced.
    Joseph Suell (24-year-old veteran and father of two who'd served in 
South Korea, Kuwait and Iraq) intentionally overdosed on June 16, 2003 
/oif/, the day after Father's Day. Corey Small (20-year-old Ft. Polk, 
La., army private) shot himself in front of others after making a phone 
call home on July 3, 2003 /oif/.
    The following day, on July 4, 2003 /oif/, James Curtis Coons (36-
year-old army master sergeant with 17 years of military service, OIF 
Bronze Star) hanged himself with a bed sheet at Walter Reed Army 
Medical Center; he had been evacuated from Kuwait two weeks earlier 
following an overdose.
    Alyssa Peterson (27-year-old Arabic-speaking interpreter with the 
311th Military Intelligence BN, 101st Airborne), who reportedly 
disagreed with interrogation techniques being used at Tal-Afar prison, 
shot herself on September 12, 2003 /oif/. On October 1, 2003 /ss/, Kyle 
Edward Williams (21-year-old soldier with a clean record who'd served 
in Iraq with the 507th Maintenance Company) shot and killed an Arizona 
man who'd broken into his car and later shot himself.
    Thomas J. Sweet II (23-year-old Ft. Riley, Kan., 5th Field 
Artillery Regiment, 1st Infantry Division sergeant) shot himself on 
November 27, 2003 /oif/, the very day he received word of his 
promotion. Jeffrey Braun (19-year-old 82nd Airborne Division 
paratrooper) shot himself on December 1, 2003 /oif/.
2004
    Alexis Soto-Ramirez (43-year-old 544th Military Police Company 
specialist), who'd been evacuated a month earlier from Iraq due to back 
pain, hanged himself with his bathrobe sash at Walter Reed Army Medical 
Center on January 12, 2004/ss/.
Five days later, on January 17, 2004 /ss/, Jeremy Seeley (28-year-old 
101st Airborne specialist) walked off Fort Campbell, Ky., checked into 
a hotel, and overdosed on household poison.
    Boyd Wicks, Jr. (Marine infantry sergeant) returned from Iraq in 
June 2003 and was discharged in October; he committed suicide on 
February 1, 2004 /ss/, his father saying of PTSD. On March 7, 2004 /
oif/, Matthew Milczark (18-year-old Marine) shot himself in a Kuwaiti 
military chapel. One week later, on March 14, 2004 /ss/, William Howell 
(36-year-old Ft. Carson, Colo., Special Forces chief warrant officer 
with 17 years of military service as a Green Beret) threatened his wife 
with a gun, and then shot himself as police officers moved in on him; 
he'd returned from Iraq a mere three weeks earlier.
    Four days later, on March 18, 2004 /ss/, Brandon Ratliff (6-times 
decorated Army Reserve's 909th Forward Surgical Team executive 
officer), shot himself after writing The Columbus Dispatch, ``I didn't 
think I'd have to fight over there and have to fight these guys, too.'' 
He'd lost a promised promotion and raise following his tour in 
Afghanistan saving injured soldiers on the frontline.
    On March 21, 2004 /ss/, Ken Dennis (22-year-old Marine corporal and 
combat rifleman who'd served in Pakistan, Afghanistan, Somalia, 
Djibouti and Iraq) hanged himself with his belt in his Renton, Wash., 
apartment eight months after returning from Iraq. He'd confessed to his 
father, ``You know, Dad, it's really hard--very, very hard--to see a 
man's face and kill him.''
    Jeffrey Lucey (23-year-old Marine Reserve) hanged himself in his 
basement on June 22, 2004 /ss/, after his parents had involuntarily 
committed him to the local VA; he was released three days later and 
told to stop drinking before they could assess him for PTSD.
    Also on June 22, 2004 /ss/, Adam Kelley (36-year-old Gulf War 
combat veteran) ended his 13-year struggle with PTSD and shot himself 
in his car while sitting in his truck behind a Las Vegas sandwich shop. 
His mother blamed long VA waits, shuffling from one doctor to another, 
prescribing medications that did more harm than good and monthly 
appointments with a physician's assistant rather than weekly 
appointments with a physician's aide as contributing factors.
    Andre Ventura McDaniel (40-year-old Ft. Carson, Colo., Special 
Forces soldier) shot himself six weeks after returning from Iraq, on 
August 28, 2004 /ss/. On September 24, 2004 /ss/, Michael Torok (23-
year-old Ft. Bragg, N.C., communications specialist) stabbed himself in 
the heart in his car parked alongside a rural Illinois cornfield. He 
had visited the Hines VAMC for various ailments following his 
Afghanistan service, but Hines was not screening all returning veterans 
for PTSD at the time. The next day, he told his parents he was going to 
visit a friend and was never seen or heard from again.
    On October 9, 2004 /ss/, Brian McKeehan (37-year-old Fort Euliss, 
Va., soldier) hanged himself with a bed sheet in the Virginia Peninsula 
Regional Jail, one month after returning from Iraq and 12 hours after 
being arrested for assaulting his wife. In the four weeks he was home, 
local police had responded to six domestic violence complaints. Michael 
Jon Pelkey (29-year-old Fort Sill, Ok., captain) shot himself on 
November 5, 2004 /ss/ a year after returning from Iraq. He had received 
a private diagnosis of PTSD, but was told of months-long waits for 
mental healthcare appointments on base.
    Curtis Greene (25-year-old Ft. Riley, Kan., soldier) abruptly went 
AWOL, saying he did not want to return to Iraq; after his wife begged 
him to return, he hanged himself in his barracks on December 6, 2004 /
ss/. Police had previously responded to two domestic violence calls and 
he was being treated for PTSD.
2005
    Andres Raya (19-year-old Camp Pendleton, Calif., Marine) committed 
suicide-by-cop on January 9, 2005 /ss/ four months after taking part in 
the invasion of Fallujah. After telling his family he did not want to 
return to Iraq, he fired on Modesto police in an apparent premeditated 
3-hour ambush in which one police officer was killed and another 
critically injured. Mark C. Warren (44-year-old 116th Armor Cavalry 
Regiment Oregon Army National Guardsman) shot himself in Kirkuk on 
January 31, 2005 /oif/.
    John Ruocco (40-year-old Marine cobra helicopter pilot from 
Newbury, Mass.) hanged himself in February 2005 /ss/, three months 
after returning home from Iraq and a few weeks before he was to 
redeploy. His wife said he worried about the ramifications of seeking 
help, personally and professionally.
    On February 3, 2005 /ss/, Richard T. Corcoran (34-year-old Ft. 
Bragg, N.C. Special Forces soldier who'd served in Afghanistan) shot 
his ex-wife and her boyfriend, and then shot himself.
    Alan McClean (62-year-old decorated Vietnam Purple Heart/Bronze 
Star veteran and minister who'd lost both legs to a landmine) shot 
himself in his Washington State church office on February 11, 2005 /
ss/. Formerly supportive of the war effort, but deeply affected by the 
rising casualty counts, he wrote, ``35 Marines died today in Iraq, only 
slightly more noticed than my legs.'' His daughter said later, ``I 
underestimated the power of the war to take his life and I really feel 
that though my dad's been in Wenatchee, the war in Iraq killed him.''
    Steven Michael Logan (26-year-old Marine intelligence clerk), 
personally reenlisted by Secretary of the Navy Gordon R. England at the 
peak of Mount Suribachi above Iowa Jima a year earlier, shot himself on 
February 28, 2005 /ss/. Samuel Lee (19-year-old 2nd Infantry Division 
soldier) serving in Ramadi shot himself on March 28, 2005 /oif/ and 
Dominic Campisi (30-year-old Delaware Air National Guardsman), who'd 
served in both Afghanistan and Iraq, killed himself on April 17, 2005 /
ss/ only days after returning from Uzbekistan.
    On May 23, 2005 /oef/, Kyle Hemauer (21-year-old 29th Infantry 
Division Virginia National Guard specialist) shot himself in 
Afghanistan. And in Iraq on June 4, 2005 /oif/, the highest-ranking OIF 
death at the time, Ted S. Westhusing (44-year-old colonel and leading 
scholar of military ethics) shot himself in his base trailer. In emails 
to family, he seemed especially upset that traditional military values 
such as duty, honor and country had been replaced by profit motives in 
Iraq.
    Justin ``Paul'' Byers (19-year-old Iowa Army National Guardsman) 
stepped in front of highway pickup truck on June 20, 2005 /ss/ after 
hearing of his 22-year-old brother's death in Iraq. On July 9, 2005 /
ss/, Jeremy Wilson (23-year-old Ft. Carson, Colo., 10th Special Forces 
Group soldier) hanged himself in his barracks a month after returning 
from Iraq. Jason Cooper (23-year-old Mt. Pleasant, Iowa, 308th 
Quartermaster Army Reserve specialist) hanged himself in his basement 
four months after his Iraq tour on July 14, 2005 /ss/.
    Eleven days after being pinned by then Army Chief of Staff Peter 
Schoomaker himself with the Army's new Combat Action Badge, Leslie 
Frederick, Jr. (23-year-old Purple Heart and Bronze Star Ft. Lewis, 
Wash., specialist) shot himself in his Tacoma apartment on July 26, 
2005 /ss/.
    Two days later, on July 28, 2005 /ss/, Saxxon Rech (20-year-old 
Camp Lejeune, N.C., Marine) shot his girlfriend and himself in 
Washington; he had been mysteriously discharged in February. Two days 
later, Robert Decouteaux (24-year-old Ft. Hood, Tx., soldier) shot 
himself on July 30, 2005 /ss/, and another two days later, on August 1, 
2005 /ss/, Robert Hunt (22-year-old Ft. Hood, Tx. 1st Cavalry Division 
radio operator-maintainer) was found dead in his apartment; both 
Decouteaux and Hunt had served in Iraq for a year and were scheduled to 
return in the fall.
    Another two days later, on August 3, 2005 /ss/, Stephen Sherwood 
(35-year-old Ft. Carson, Colo., 2nd Brigade Combat Team soldier) shot 
his wife and then himself nine days after returning home from a year's 
deployment in Iraq. He enlisted in January 2004 to have health benefits 
because his wife was pregnant.
    Bernardo C. Negrete (53-year-old retired brigadier general who'd 
served in Grenada, Panama and Iraq) shot himself on September 16, 2005 
/ss/ after his wife complained that he stop drinking and come to bed. 
Phillip Kent (26-year-old Fort Hood, Texas, 720th Military Police 
Battalion 2nd lieutenant/platoon leader during the hunt for Saddam 
Hussein in Tikrit), after being hospitalized for PTSD following his 
return home and being discharged early, committed suicide on September 
28, 2005 /ss/.
    On October 8, 2005 /ss/, Greg Morris (57-year-old 4th Infantry 
Division Vietnam veteran diagnosed with PTSD) shot himself; by his side 
were his gun, Purple Heart, and a folder of information on how the VA 
planned to review veterans PTSD cases [a plan that was halted following 
public outcry].
    On November 8, 2005 /ss/, Chris Forcum (20-year-old Marine lance 
corporal) killed himself in Oregon six weeks after returning from Iraq. 
His father said at the time that ``they teach soldiers how to fight, 
but they don't teach them how to live when they come home.'' Timothy 
Bowman (24-year-old Illinois National Guard specialist) had joined the 
military after 9/11; he shot himself on Thanksgiving morning, November 
24, 2005 /ss/, eight months after coming home from Iraq.
    Jeffrey Lehner (42-year-old Marine Aerial Refueler Transport 
Squadron sergeant) shot his father and then himself on December 7, 2005 
/ss/, after calling his VA counselor in distress saying he would not be 
coming in the next day. After serving in Afghanistan, the Gulf War 
veteran had returned home at the end of 2004 in need of help, admitting 
himself to a VA hospital for intensive PTSD treatment. Instead, he was 
placed with bipolar and schizophrenic patients because the PTSD ward 
was full. On December 22, 2005 /ss/, Joshua Omvig (22-year-old Iowa 
Army Reverse soldier) shot himself a year after returning from Iraq.
2006
    On January 16, 2006 /ss/, Douglas Barber (37-year-old National 
Guards supply convoy driver), following a two-year struggle with the VA 
over receiving treatment for his PTSD, changed his answering machine 
message to say he was checking out of this world, telephoned police and 
waited for them on his porch; when they would not shoot him, he shot 
himself.
    Chuck Call (30-year Army gunner who'd volunteered to go to Iraq 
with another unit when his was not called up) committed suicide three 
months after returning on February 3, 2006 /ss/. Haunted by nightmares 
and anxiety, he sought VA benefits only to be told he did not qualify 
for them due to his income. On February 20, 2006 /ss/, Jon Trevino (36-
year-old Scott AFB 375th Aeromedical Evacuation Squadron tech sergeant 
who served in both Afghanistan and Iraq) shot his wife and himself.
    In Iraq, Tina Priest (21-year-old Fort Hood, Texas, 4th Infantry 
Division soldier) shot herself on March 1, 2006 /oif/, two weeks after 
saying she was raped by a fellow soldier and days after being diagnosed 
and treated for Acute Stress Disorder consistent with Rape Trauma 
Syndrome.
    Two days later, Donald Woodward (23-year-old army soldier) shot 
himself on his favorite Pennsylvania hiking trail on March 3, 2006 /
ss/. He'd tried killing himself once before by lighting his truck on 
fire and getting inside; his wife pulled him out; afterward, he finally 
agreed to get some help from the VA, which gave him antidepressants and 
scheduled a counseling appointment a month later. He committed suicide 
before the appointment date arrived.
    Three days later, Greg Braun (26-year-old Army Ranger sniper with 
the 128th Infantry of Wisconsin National Guard) shot himself in his 
basement four months after returning home from Iraq on March 6, 2006 /
ss/. He had served in Kosovo as well as tours in Iraq, and was a 
Milwaukee policeman. Eric Ryan Grossman (22-year-old Marine) ran into 
California interstate traffic killing himself when a minivan hit him on 
April 6, 2006 /ss/, only five days after returning from a seven-month 
tour in Iraq.
    James Gallagher (Camp Pendleton, Calif., Marine gunnery sergeant) 
committed suicide eight months after returning from Iraq on May 1, 2006 
/ss/. On July 25, 2006 /oef/, Andrew Velez (22-year-old Army 
specialist) shot himself in Sharona, Afghanistan. Two years earlier his 
brother had died in Iraq and he was said to have ``locked up'' after 
identifying his remains. He suffered flashbacks and held his wife 
hostage between tours.
    At home following a near-suicide attempt in Iraq in which he sought 
the help of his commanding officer, David Ramsey (27-year-old Ft. 
Lewis, Wash., 47th Combat Support Hospital critical care nurse 
specialist) slipped through the cracks stateside as Madigan AMC 
released him from their care, unaware of his near suicide attempt in 
Iraq due to a lack of access to electronic records. Missing his follow-
up appointment, he shot himself on September 7, 2006 /ss/.
    On October 17, 2006 /ss/, Zachary Bowen (28-year-old Army MP who'd 
served in Kosovo and Iraq) strangled and dismembered his girlfriend and 
11 days later threw himself off of the ledge of the Omni Royal New 
Orleans hotel with a suicide note in his pocket. A day later, on 
October 18, 2006 /ss/, Jeanne ``Linda'' Michel (33-year-old Camp Bucca 
Navy medic) shot herself two weeks after returning to her husband and 
three kids. While overseas, she was prescribed Paxil for depression 
without family notification, and taken off the antidepressant, again 
without family notification, when she returned home.
    James E. Dean (29-year-old corporal) killed himself via suicide-by-
cop shortly after learning he was to be redeployed to Iraq. The 
Afghanistan veteran diagnosed with PTSD barricaded himself at his 
father's farm on Christmas Day; a Maryland State Police sharpshooter 
killed him 15 hours later, on December 26, 2006 /ss/.
2007
    On January 16, 2007 /ss/, Jonathan Schulze (25-year-old Marine 
machine gunner) hanged himself following two attempts to get help from 
the Minnesota VA system, once in Minneapolis/St. Paul, the other in St. 
Cloud. He was given a waiting list number of 26 for a counseling 
appointment, but was dead before the date arrived. The following day, 
on January 17, 2007 /ss/, Michael Bramer (23-year-old Fort Bragg, N.C., 
82nd Airborne Division Special Forces Unit paratrooper who'd served in 
Afghanistan and Iraq) shot himself in his home.
    Justin Bailey (27-year-old Marine rifleman), among the first wave 
of the Iraq invasion and diagnosed with PTSD since returning, checked 
himself into a Los Angeles VAMC needing immediate help for prescription 
drug addiction. Yet, the day before his death, he received 
prescriptions for five medications, including a two-week supply of the 
potent painkiller methadone; he overdosed in his VAMC room on January 
26, 2007 /ss/.
    Jessica Rich (24-year-old Fort Carson, Colo., 52nd Engineering 
Battalion Army Reserve heavy equipment operator) drove directly into 
oncoming interstate traffic on February 8, 2007 /ss/; medically 
evacuated from Iraq due to lower back pain and PTSD, she was on a 
waiting list for a specialized PTSD treatment program.
    On February 20, 2007 /ss/, Brian Jason Rand (26-year-old Ft. 
Campbell, Ky., 30th Infantry Regiment sergeant) shot himself at a local 
park seven weeks after returning home to Clarksville, Tenn. He answered 
`yes' to PTSD to the identifiers on his post-deployment questionnaire 
following his second tour; yet, two days after being diagnosed with 
PTSD he was redeployed to Iraq for a third and final time.
    Chris Dana (23-year-old 163rd Infantry Battalion Montana National 
Guardsman) shot himself on March 4, 2007 /ss/ after having canceled his 
appointment for PTSD. His brother said after returning in November 2005 
he seemed to be melting from the inside; his father said his eyes had 
lost their shine, the joy of living.
    Stephen Edward Colley (22-year-old Ft. Hood, Texas, helicopter 
mechanic) committed suicide on May 16, 2007 /ss/. Returning from Iraq 6 
months earlier, his father said he felt he could not get the 
psychological help he needed from the military for fear it would 
jeopardize his future career. On May 27, 2007 /ss/, Brian William Skold 
(28-year-old 151st Field Artillery Minnesota National Guardsman) died 
via suicide-by-cop.
    The ninth Ft. Campbell, Ky., soldier to commit suicide in 2007, 
Derek Henderson (27-year-old Afghanistan and Iraq veteran) jumped to 
his death from a bridge over the Ohio River on June 21, 2007 /ss/. He 
had begun carrying a 12" knife and wanted a gun to ``fight the enemy,'' 
his medical records indicating PTSD five times. On July 25, 2007 /ss/, 
Noah Charles Pierce (23-year-old 3rd Infantry Division soldier) shot 
himself in rural Minnesota. The soldier who had signed up for the 
military after 9/11 wrote in his suicide note that he had killed people 
and now it was time to kill himself.
    On August 29, 2007 /ss/, John R. Fish II (19-year-old Ft. Hood, 
Texas, 41st Fire Brigade ammunitions specialist) shot himself. He had 
returned from a long Iraq deployment in November 2006. Steven D. Lopez 
(23-year-old Ft. Bragg, N.C., Afghanistan and Iraq veteran) shot his 
wife and then himself on November 5, 2007/ss/;
he had sought help from base doctors and was prescribed Paxil.
    On November 20, 2007 /ss/, Joseph Colin Russell (25-year-old two 
tour Ft. Hood, Texas, 1st Cavalry Division, 2nd Brigade soldier) shot 
himself at a friend's house. He was homeless and accused of being 
responsible for the death of another vet following a fight at a 
nightclub.
    Two days later, on November 22, 2007 /ss/--Thanksgiving Day--Tyler 
Curtis (25-year-old two tour Iraq veteran) committed suicide three 
months after returning to Maine following his 2006 discharge from the 
Army. He was torn by grief for the families of those he may have 
killed.

                                 
              Prepared Statement of Ira Katz, M.D., Ph.D.,
     Deputy Chief Patient Care Services Officer for Mental Health,
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Mr. Chairman and members of the Committee, thank you for the 
invitation to appear before you today to discuss the Department of 
Veterans Affairs (VA), Veterans Health Administration (VHA) Mental 
Health program and suicide prevention. Accompanying me today are Dr. 
Robert Rosenheck, Director of the Division of Mental Health Services 
and Outcomes Research; Dr. Lawrence Adler, Director of the Mental 
Illness Research, Education and Clinical Center (MIRECC) in Veterans 
Integrated Service Network (VISN) 19; and Dr. Frederick Blow, Director 
of the Serious Mental Illness Treatment Research and Evaluation Center 
(SMITREC) at the Ann Arbor VA Center for Clinical Management Research.
    Mental illness is a serious disease, affecting not only the 
individual who has the problem, but also his or her family; and the 
community in which he or she lives. The symptoms that characterize 
mental illnesses can cause profound suffering for the patient and for 
others. Moderate levels of the illness are strongly associated with 
problems at work and at home; severe manifestations can lead to 
devastating outcomes such as suicide. While relatively few people with 
mental illnesses die from suicide, the fact that it occurs is a 
constant reminder that these illnesses are real, and that they can be 
fatal.
    The Department of Veterans Affairs is determined to implement the 
findings of the President's New Freedom Commission on Mental Health, 
which require all mental health providers to offer Americans with 
mental health needs world-class treatment focused on early intervention 
and recovery. Our comprehensive Mental Health Strategic Plan, completed 
in 2004, provided a blueprint for us to expand our outreach to veterans 
and to enhance the capacity and quality of our mental health services. 
To implement this plan, we have increased our expenditures for mental 
health services from $2 billion in 2001 to $3 billion in the current 
fiscal year. In addition, we have added more than 3600 new mental 
health staff members to our facilities since 2005, bringing the total 
number of VA employees working in this area to more than 10,000.
    While a significant number of veterans of the conflicts in Iraq and 
Afghanistan have required treatment for mental health conditions on 
their return home, the number is well within our capabilities for 
providing treatment. Approximately 100,500 of the 750,000 veterans of 
this conflict have come to VA with a mental health condition since the 
beginning of the war. This represents only about 10 percent of the 
total number of veterans with mental health issues VA sees in any one 
year. Just less than half (48,559) of those veterans received at least 
a preliminary diagnosis of Post Traumatic Stress Disorder or PTSD.
    The 10-percent increase in patients with mental health conditions 
since 2002 should be balanced against the 50-percent increases in 
expenditures and mental health staffing in VA since 2001. Our new 
resources are adequate for us to address the mental health needs of 
returning veterans, and to enhance our mental health services for 
veterans of all eras. In terms of their suffering and need for 
effective treatment, the number of returning veterans with mental 
health issues is very significant; but our Department is able to meet 
their needs.
SUICIDE PREVENTION
    Suicide among veterans is a tragedy. The Department of Veterans 
Affairs believes that it is our obligation to work to prevent suicide 
both in individual patients and in the entire veteran population. Our 
suicide prevention activities are based on the principle that in order 
to decrease rates of suicide, we must provide enhanced access to high 
quality mental healthcare, and to develop programs specifically 
designed to help prevent suicide. We have trained all VA employees 
about the risk factors and warning signs of suicide, and have offered 
them strategies to help them deal with veterans who may be at risk of 
taking their own lives.
    VA employees have been given the message that even strong and 
resilient people can develop mental health conditions. Care for those 
mental health conditions is readily available and should be timely 
provided. We know that treatment can work.
    VA's suicide prevention program includes two centers that conduct 
research and provide technical assistance in this area to all our 
locations of care. One is our new Mental Health Center of Excellence in 
Canandaigua, New York, which focuses in developing and testing clinical 
and public health intervention. The other is the VISN 19 Mental Illness 
Research Education and Clinical Center in Denver, which focuses on 
research in the clinical and neurobiological sciences. Our system of 
care also includes a suicide prevention call center, also in 
Canandaigua with suicide prevention coordinators located in each of 
VA's 153 hospitals. Altogether, VA has more than 200 mental health 
providers whose jobs are specifically devoted to preventing suicide 
among veterans.
    The Department has partnered with the Lifeline Program of the 
Substance Abuse and Mental Health Services Administration to develop a 
VA suicide prevention hotline. Those who call 1-800-273-TALK are asked 
to press ``1'' if they are a veteran, or are calling about a veteran. 
When they do so, they are connected directly to VA's hotline call 
center, where they speak to a VA mental health professional with real-
time access to the veteran's medical records. In emergencies, the 
hotline contacts local emergency resources such as police or ambulance 
services to ensure an immediate response. In other cases, after 
providing support and counseling, the hotline transfers care to the 
suicide prevention coordinator at the nearest VA facility to ensure 
that follow-up is prompt and appropriate.
    In the five weeks from October 7 to November 10, 2007, 1,636 
veterans and 311 family members or friends called the hotline number. 
These calls led to 363 referrals to suicide prevention coordinators and 
93 rescues involving emergency services. Since the hotline began in 
July, there have been more than 6,000 calls from veterans or families, 
more than 1,300 referrals to Suicide Prevention Coordinators in VA 
medical centers, and more than 300 rescues, any one of which may have 
been life-saving.
    Suicide prevention coordinators receive referrals of those at risk 
for suicide from both the hotline and from providers in their 
facilities, and ensure that care for those at risk addresses their high 
risk status. Coordinators educate their colleagues, veterans and 
families about risks for suicide, provide enhanced treatment monitoring 
for veterans at risk and ensure that any missed appointments are 
followed up on. The coordinators work with the entire staff of their 
medical centers to maintain awareness of those who have previously 
attempted suicide, and ensure that their care is enhanced.
    Prevention coordinators also work with patient safety officers to 
conduct quarterly safety inspections of inpatient psychiatry units, and 
to coordinate staff education programs about suicide prevention. These 
coordinators are in the process of organizing a system of flags in the 
electronic medical record to alert providers about those at high risk, 
and are conducting training for community members who have frequent 
contact with veterans to help them recognize those at risk and 
encourage them to seek treatment.
    Finally, VA has held two National VA Suicide Prevention Awareness 
Days throughout our system to focus all of our 200,000 healthcare 
employees on this issue. The first event focused on enhancing overall 
awareness of the issue, and the second trained all VA staff on how to 
work with available prevention resources, including the hotline and the 
suicide prevention coordinators.
    VA is very much concerned about the epidemiology of suicide among 
veterans, and has used findings in this area to guide our prevention 
programs. As new data on suicide rates, risk factors for suicide and 
regional variations become available, we will use that data to refine 
our programs, and to better evaluate their level of success. In all of 
this epidemiological work, VA uses information from the Centers for 
Disease Control and Prevention's (CDC) National Death Index currently 
available through the end of calendar year 2005.
    VA's Epidemiology Service has published findings from a long-term, 
20-year follow-up on the health of Vietnam-era veterans. The peer-
reviewed, published study reported that rates of suicide among veterans 
who were deployed to Southeast Asia did not differ statistically from 
veterans of the same era who were not deployed. A published study of 
veterans from the first Gulf War provided a similar finding.
    VA has now completed a preliminary evaluation of suicide rates 
among veterans returning from Iraq and Afghanistan. From the beginning 
of the war through the end of 2005 there were 144 known suicides among 
these new veterans. This number translates into a rate that is not 
statistically different from the rate for age, sex, and race matched 
individuals from the general population.
    Taken together, the population of veterans who receive care from 
the Veterans Health Administration have more risk factors for suicide 
than the general population. Although there are increasing numbers of 
female veterans, most veterans are male. Those who come to the VA for 
care tend to be older, less socio-economically well off, and more 
likely to have a mental health condition or another chronic illness. It 
is, therefore, by no means surprising that those receiving care from VA 
have higher suicide rates than those in the general population. Those 
with the greatest need for care are those who are most likely to come 
to VA. This increased need can be associated with increased risks. 
This, in fact, was one of the major factors leading to VA's focus on 
suicide prevention.
    Because of new enrollment criteria for veterans of the Global War 
on Terror, the characteristics of Iraq and Afghanistan veterans coming 
to VA today are different from those for veterans from prior eras. As a 
result, early data being evaluated by VA, suggests that while rates 
among OIF/OEF veterans who come to VHA for care are not different from 
the general population, rates among those veterans who do not come to 
VA appear to be higher. One possible explanation for this finding is 
that VA mental healthcare is effective, and that it can be lifesaving. 
Further research in this area is underway.
    VA's latest data do not demonstrate an increased risk of suicide 
among OEF/OIF veterans compared to the age and gender matched American 
population as a whole. Nevertheless, one suicide among those who have 
served their country is too much. Available information on suicide 
rates and risk factors among veterans are reinforcing the importance of 
the work VA has done to enhance its mental health services since 2001; 
and the usefulness of our comprehensive program for suicide prevention.
    VA has already implemented the key provisions of the Joshua Omvig 
Veterans Suicide Prevention Bill, which was recently signed by 
President Bush, and we continue to do research to develop and implement 
new strategies that will improve our ability to save lives by 
preventing suicide. VA believes that our healthcare system can and must 
serve a national model for suicide prevention, now and in the future.
    Thank you for the opportunity to address the Committee. At this 
time, I would be pleased to answer your questions.

                                 
                Prepared Statement of Kara Zivin, Ph.D.,
  Research Health Scientist, Health Services Research and Development
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good morning, Mr. Chairman, I am honored to provide testimony to 
the Committee about suicide among veterans treated for depression in 
the VA Health System. I come before this Committee as a mental health 
services researcher who has conducted research on this topic. The views 
and opinions expressed are my own, and do not necessarily represent 
those of my current employer, the Department of Veterans Affairs, or 
the views of the VA research community.
    I am here today to report on findings from a study that I conducted 
along with my colleagues at the Department of Veterans Affairs' 
National Serious Mental Illness Treatment Research and Evaluation 
Center (SMITREC) and the VA's Health Services Research and Development 
Center of Excellence in Ann Arbor, Michigan. We recently published a 
paper in the American Journal of Public Health examining suicide rates 
using data from the VA's National Registry for Depression for 807,694 
veterans of all ages diagnosed with depression and treated at any 
Veterans Affairs facility between 1999 and 2004.
    In all, 1,683 veterans in VA depression treatment died by suicide 
during the study observation period, representing 0.21 percent of this 
treatment population. When we calculated the overall suicide rate in 
this population over the 5.5-year observation period, it was 88.3 per 
100,000 person-years (PY), approximately 7-8 times greater than the 
suicide rate in the general adult U.S. population. A higher suicide 
rate would be expected among a population of patients in treatment for 
depression than the general U.S. population, given that depression is a 
potent risk factor for suicide. Because most healthcare systems lack 
the capability of assessing suicide rates among their treatment 
populations, there are few points of comparisons with nonveteran 
treatment populations. However, at least one prior study reports a 
suicide rate for men receiving depression treatment in managed care 
settings between 1992-1994 of 118 per 100,000 PY, a suicide rate which 
is somewhat higher than that observed in this veteran depression 
treatment population.\1\
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    \1\ Simon GE, VonKorff M. Suicide mortality among patients treated 
for depression in an insured population. American Journal of 
Epidemiology. Jan. 15, 1998;147(2):155-160.
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    In our study, we observed that the predictors of suicide among 
veterans in depression treatment differed in several ways from those 
observed in the general U.S. population. Typically, people in the 
general population who die by suicide are older, male, and white, and 
have depression and medical or substance abuse issues. In this study, 
we too found that depressed veterans who had substance abuse problems 
or a psychiatric hospitalization in the year prior to their index 
depression diagnosis had higher suicide rates.
    However, when we divided depressed veterans into three age groups: 
18 to 44 years, 45 to 64 years, and 65 years or older, we found that 
the younger veterans were at the highest risk for suicide. Differences 
in rates among depressed veterans of different age groups were 
striking; 18 44-year-olds completing suicide at a rate of 95.0 suicides 
per 100,000 PY, compared with 77.9 per 100,000 PY for the middle-age 
group, and 90.1 per 100,000 PY for the oldest age group. We did not 
assess whether individuals had served in combat during a particular 
conflict, although the existence of a military service-connected 
disability was considered.
    In this VA treatment population, men veterans were more likely to 
complete suicide than women veterans. Suicide rates were 89.5 per 
100,000 PY for depressed veteran men and 28.9 per 100,000 PY for 
veteran women. However, the differential in rates between men and women 
(3 : 1) was smaller than has been observed in the general population (4 
: 1).
    We found higher suicide rates for white depressed veterans (95.0 
per 100,000 PY) than for African Americans (27.1 per 100,000 PY) and 
for veterans of other races (56.1 per 100,000 PY). Veterans of Hispanic 
origin had a lower rate (46.3 per 100,000 PY) of suicide than those not 
of Hispanic origin (86.8 per 100,000 PY). Adjusted hazard ratios also 
reflected these differences.
    Surprisingly, our initial findings revealed a lower suicide rate 
among depressed veterans who also had a diagnosis of post-traumatic 
stress disorder (PTSD) compared to depressed veterans without this 
disorder. Depressed veterans with a concurrent diagnosis of PTSD had a 
suicide rate of 68.2 per 100,000 PY compared to a rate of 90.7 per 
100,000 PY for depressed veterans who did not also have a PTSD 
diagnosis. We investigated further to examine whether specific 
subgroups of depressed veterans with PTSD had higher or lower suicide 
risks. We found that concurrent PTSD was more closely associated with 
lower suicide rates among older veterans rather than among younger 
veterans. This study does not reveal a reason for this lower suicide 
rate, but we hypothesize that it may be due to the high level of 
attention paid to PTSD treatment in the VA system, and the greater 
likelihood that patients with both depression and PTSD will receive 
psychotherapy and more intensive visits. In general, individuals with 
depression and PTSD diagnoses have higher levels of VA mental health 
services use than individuals with depression without PTSD.
    Interestingly, depressed veterans who did not have a service-
connected disability were more likely to complete suicide than those 
with a service-connected disability. This may be due to greater access 
to treatments among service-connected veterans, or more stable incomes 
due to compensation payments.
    We hope our findings will help inform clinical treatment and policy 
initiatives to reduce suicide mortality among veterans with depression.
    Thank you for this opportunity to testify. I will be pleased to 
answer any questions you may have.

                                 
                  Statement of Michael Shepherd, M.D.,
              Physician, Office of Healthcare Inspections,
    Office of Inspector General, U.S. Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to testify today on suicide prevention and the Office of 
Inspector General (OIG) report, Implementing VHA's Mental Health 
Strategic Plan Initiatives for Suicide Prevention.
                               Background
    In 2004, suicide ranked as the 11th leading cause of death with a 
rate of 11.1 per 100,000 in the general U.S. population and the 3rd 
leading cause of death within the 15-24 age range. It is estimated that 
each suicide intimately affects the lives of at least six other people.
    In any particular suicide, individual and collective proclivities 
tend to combine. Consequently, the attempt to make sense of the 
multiple potential contributions from identifiable psychiatric 
disorder(s), co-morbid medical illness and functional impairments, 
specific personal events, and sociocultural factors has been the work 
of and an ongoing challenge to mental health professionals, 
sociologists, and epidemiologists. This effort has increased knowledge 
about suicidal patients and provided information for utilization in 
their treatment. However, there has been little reduction in overall 
rates through the years, indicating there is more to learn.
    Suicidologists have struggled with standardization issues for many 
years. While it has long been held that the pursuit of valid and 
reliable suicide statistics is important to public health policy, 
establishing the validity and reliability of suicide rates has been a 
notable source of concern. In the U.S. it is widely assumed by mental 
health professionals that the actual suicide rate is higher than 
officially reported. Establishing the validity and reliability of 
suicide rates is complicated by stigma. Other sources of variability 
include limitations of death certificates, variability in the training 
of those tasked with certifying cause of death, use of differing 
guidelines for suicide determination, and the presence of equivocal 
causes such as single car accidents and drug overdoses.
    The 2001 Surgeon General's National Strategy for Suicide Prevention 
identifies steps in a public health model for suicide prevention. 
Collecting data on rates of suicide and suicidal behavior is typically 
referred to as medical surveillance. Data may include information on 
how suicide rates vary by time, geography, age or special populations. 
In addition, data collection may include information on characteristics 
of individuals who suicide, circumstances surrounding suicide events, 
the presence and absence of possible precipitants, and the adequacy or 
accessibility of supportive factors and health services.
    For example, the National Violent Death Reporting System is a 
Centers for Disease Control and Prevention (CDC) effort to develop a 
nationwide, state-based monitoring system for violent deaths. State and 
local agencies use this system to input data from medical examiners, 
coroners, death certificates, police reports, toxicology studies, and 
other sources. At present 17 States are designated to participate in 
the system. Veteran status is one of several uniform data elements 
recorded for input into the system. The data is pooled with the hope 
that it can ultimately be used to answer fundamental questions about 
suicide and to aid participant States in the design and implementation 
of tailored suicide prevention and intervention efforts.
    Suicide is not a single illness with one true cause; it is a final 
common outcome with multiple potential antecedents, precipitants, and 
underlying causes. Interventions that may be more effective for one set 
of patients may differ from those of greatest benefit for a different 
set of patients. Comprehensive suicide prevention programs, those 
employing a portfolio of intervention elements, and particularly those 
that incorporate a range of services and providers, are thought to have 
a greater likelihood of reducing suicide rates. Selecting which 
interventions to implement includes consideration of the needs and 
characteristics of the target population, ways to integrate 
interventions into existing programs, efforts to strengthen 
collaboration, and an analysis weighing the resource requirements 
versus the potential effectiveness of individual interventions.
     Veterans Health Administration's Mental Health Strategic Plan
    In 2003, a VA mental health workgroup was asked to review the 
President's New Freedom Commission on Mental Health's 2002 report, to 
determine the relevance to veteran mental health programs of the 
Commission's goals and recommendations, and to develop an action plan 
tailored to the special needs of the enrolled veteran population. A 5-
year action plan with more than 200 initiatives was ultimately 
developed and finalized in November 2004. Among the action items were a 
number specifically aimed at the prevention of suicide. In addition, 
endorsement and implementation of the goals from the Surgeon General's 
2001 National Strategy for Suicide Prevention, and recommendations from 
the Institute of Medicine's 2002 report Reducing Suicide: A National 
Imperative, were incorporated into the VA Mental Health Strategic Plan 
(MHSP).
  OIG Report on VHA's Implementation of Suicide Prevention Initiatives
    In response to a request from this Committee, the OIG undertook an 
assessment of VHA progress in implementing initiatives for suicide 
prevention from the MHSP. In our May 2007 report, individual MHSP 
initiatives for suicide prevention were categorized and consolidated 
into the following domains:

      Crisis Availability and Outreach.
      Screening and Referral.
      Tracking and Assessment of Veterans at Risk.
      Emerging Best Practice Interventions and Research.
      Development of an Electronic Suicide Prevention Database.
      Education.

    We recommended that:

      VHA make arrangements for 24-hour crisis and mental 
healthcare availability, either in person, or via a crisis line, and 
that at each facility an on-call mental health specialist should be 
available to crisis staff either in person or by phone.
      All nonclinical staff who interact with veterans receive 
mandatory training about responding to crisis situations involving at-
risk veterans inclusive of suicide protocols for first contact 
personnel.
      Healthcare providers receive mandatory education about 
suicide risks and ways to address these risks.
      The requirement of sustained sobriety should not be a 
barrier to treatment in specialized mental health programs for 
returning combat veterans.
      VHA should facilitate bi-directional information exchange 
between VA and DoD for patients with mental illness coming into VHA 
healthcare and/or leaving VHA healthcare for re-deployment to active 
duty status.
      VHA should establish a centralized mechanism to review 
ongoing suicide prevention strategies, to select among available 
emerging best practices for screening, assessment, and treatment, and 
to facilitate systemwide implementation, in order to ensure a single 
VHA standard.
                          Crisis Availability
    Although we found that most facilities reported availability of 24-
hour mental healthcare either through the emergency room, a walk-in 
clinic, or a crisis hotline, this initiative had not achieved 
systemwide implementation and a coordinated toll free hotline was not 
in place at the time of our report. On July 25, 2007, the Department of 
Veterans Affairs subsequently began operation of a 24-hour national 
suicide prevention hotline for veterans. The hotline has reportedly 
received greater than 9,000 calls. Callers include veterans who 
previously would have called a non-VA suicide hotline, veterans who 
would not have utilized a non-VA hotline, family members and friends of 
veterans, and other distressed nonveterans. Several of the veteran 
calls have resulted in 911 emergency rescues and admission to VA 
hospitals. Hotline personnel facilitate referral of distressed 
nonveterans to a non-VA suicide prevention hotline through a 
partnership with the Substance Abuse and Mental Health Services 
Administration.
    I recently visited the hotline, located at the Veterans Integrated 
Service Networks (VISN) 2--Center of Excellence at Canandaigua, New 
York, on less than 24 hours notice. During my visit with hotline staff, 
the phone lines were in use throughout the duration. I observed a call 
from a young veteran who told the hotline clinician that she planned to 
take the bottle of pills that she had next to her. After assessment and 
a lengthy discussion with the caller, the hotline line clinician 
arranged for an emergency rescue. I also observed a call from a 
discouraged Vietnam era veteran who had recently become homeless and 
was calling from his car in which he was living. Hotline staff arranged 
for him to be met by the suicide prevention coordinator at the local VA 
facility.
                    Suicide Prevention Coordinators
    The VA Office of Mental Health Services has been in the process of 
implementing suicide prevention coordinators at all VA medical centers. 
At present, dedicated staff are reportedly in place at approximately 85 
percent of facilities and ``acting'' suicide prevention coordinators 
are in place at remaining sites. Hotline clinical staff told me that 
after requesting a consult for a caller at a VA facility, they contact 
the facility suicide prevention coordinator electronically and/or by 
phone. If they do not hear back within 24 hours, they contact the 
coordinator again. Within 48 hours of the call to the hotline, an 
update on the patient's disposition is to be reported by the suicide 
prevention coordinator to hotline staff. At 2 weeks post call, hotline 
staff contact the suicide prevention coordinator for an update as to 
whether the caller has remained engaged in follow-up in the VA system.
                 Education and Training of VA Personnel
    In terms of initiatives for education on suicide prevention, at the 
time of our May report, we found that only 50 to 60 percent of 
facilities provided programs to train first contact nonclinical 
personnel about crisis situations involving veterans at risk for 
suicide. Only one-fifth of these programs included mandatory 
presentation of suicide response protocols. Almost all facilities 
provide education to health providers on suicide risks, ways to address 
these risks and best practices for suicide prevention. However, at only 
a small percentage of facilities were these programs mandatory. Since 
that time, the VISN 2 Canandaigua Center of Excellence has developed a 
CD and guide for training VA nonclinical personnel and a second CD and 
guidebook for community-based training. The training, titled Operation 
S.A.V.E. (Signs of suicidal thinking; Ask questions; Validate the 
veteran's experience; Encourage treatment and Expedite referral) will 
reportedly be carried out by the facility suicide prevention 
coordinators. A copy of the CDs and guide were provided to me on my 
recent visit. The VISN 2 Center of Excellence leadership report plans 
to subsequently develop a guide and CD for VA clinicians.
   Treatment for Co-Morbid Mental Health and Substance Use Disorders
    In terms of eliminating sustained sobriety as a barrier to 
treatment in specialized mental health programs for returning combat 
veterans, on November 23, 2007, the Deputy Under Secretary for Health 
for Operations and Management issued a memorandum to Network Directors 
that states that ``VHA facilities and providers must never take the 
position that a patient is untreatable because substance use or 
dependence precludes treating mental health conditions while mental 
illness makes it impossible to treat abuse or dependence. Instead, 
services must be designed and available to provide care for veterans 
with substance use disorders and mental health conditions, alone or 
together, regardless of acuity or chronicity.''
         Facilitation of Emerging Best Practice Implementation
    The OIG report recommended that VHA facilitate establishment of a 
centralized mechanism to select among emerging best practices for 
suicide prevention, the VISN 2 Center of Excellence has subsequently 
been organized into a clinical core, an education and training core, a 
VACO initiatives core, and a research core. The clinical core group is 
responsible for the organized development of pilot and demonstration 
projects. The initiative core is responsible for implementation of VA 
Central Office suicide prevention initiatives. The research core is 
focused on performing program evaluation, health services research, and 
intervention effectiveness research in order to expedite the 
dissemination of promising approaches throughout VA.
             Bi-Directional Exchange of Health Information
    Bi-directional information exchange between VA and DoD which 
includes patients with mental illness coming into VHA healthcare and/or 
leaving VHA healthcare for re-deployment is an ongoing issue that has 
been discussed at other hearings.
             VHA Development of a Veteran Suicide Database
    At the time of our inspection, researchers at the VHA Serious 
Mental Illness Treatment Research and Evaluation Center (SMITREC) in a 
joint effort with researchers at the University of Michigan School of 
Public Health in Ann Arbor, Michigan, had been developing a methodology 
by which to create a database of veterans who had utilized VHA care in 
an index year and then stopped utilizing VHA care in subsequent years. 
This database would then be matched with data from the CDC National 
Death Index (NDI), to determine which of these veterans were deceased. 
This data would then be matched with an enhanced version of the 
National Death Index to determine which veterans no longer accessing 
VHA care had died from suicide. In early October, SMITREC researchers 
reported that they have subsequently calculated suicide rates for 2001 
and 2002 among veterans who obtain care in VHA. In recent weeks, they 
reported working on data received from the NDI for calculation of rates 
from 2003-2005.
    At the time of the May OIG report, a template of data elements 
pertaining to suicides and suicide attempts had been piloted in Rocky 
Mountain Network (VISN 19) facilities. In the past few months, VHA has 
reportedly been expanding use of the template to VHA facilities 
nationwide. Clinical providers at VHA facilities nationwide have been 
asked to input data regarding attempts or completed suicides by their 
patients using a template which contains prompts for data elements 
including age, gender, diagnosis, date of attempt, method used, 
outcome, date last seen at VA prior to attempt, among others. The 
facility suicide prevention coordinator is responsible for receiving 
and collating data inputted into the template by clinical providers and 
submitting a spreadsheet to the Center of Excellence at the Canandaigua 
VAMC on the 10th of each month. October was the first month for which 
data was submitted to the Canandaigua Center of Excellence. Most but 
not all VHA facilities submitted data and the extent of provider 
compliance with filling out the templates is presently unclear.
    Since October 2003, the Department of Defense (DoD) Defense 
Manpower Data Center has sent the VA Environmental Epidemiology Service 
a periodically updated personnel roster of troops who participated in 
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), and 
who had separated from active duty and become eligible for VA benefits. 
This data however does not include recently discharged or retired 
veterans who were not deployed in support of OEF/OIF or veterans who 
have served in other eras.
                          The OIG LC Database
    During the past year, colleagues at the OIG Office of Healthcare 
Inspections have diligently pursued creation of a database to 
quantitatively characterize the care transition process from DoD to 
VHA. A September 2007, OIG Informational Report entitled Quantitative 
Assessment of Care Transition: The Population-Based LC Database, 
describes the creation of an analytical database derived from more than 
30 data files acquired from VA and DoD that incorporates details about 
all service members discharged from July 1, 2005 to September 30, 2006. 
The database includes veterans who were deployed, those who were not 
deployed, members of the Reserves and National Guard, those who have 
accessed care in VHA and those who have not. The paper discusses the 
methodology used to create the database, data confidentiality issues, 
its limitations, and analytic potential for research and other 
applications. This unique database may provide background for 
understanding and interpreting ongoing and planned studies pertaining 
to select medical conditions, causes of mortality, and/or healthcare 
access.
                               Conclusion
    Suicide is an unequivocally tragic and often incomprehensible 
event. Preventing suicide is a complex, multifaceted challenge to which 
there is not one best practice but several promising but not proven 
approaches and methods. Since 2004, progress had been made toward 
implementation of the MHSP initiatives for suicide prevention. Progress 
has continued with greater integration and at an accelerated pace since 
the time of the OIG report in May and the enactment of the Joshua Omvig 
Suicide Prevention Act. The full array of suicide prevention 
initiatives has not yet attained systemwide implementation. It is 
therefore incumbent upon VA to continue moving forward toward full 
deployment of suicide prevention strategies for our Nation's veterans.
    Mr. Chairman, thank you again for this opportunity to testify on 
this important issue. I would be pleased to answer any questions that 
you or other members of the Committee may have.

                                 
             Statement of Joseph L. Wilson, Deputy Director
    Veterans Affairs and Rehabilitation Commission, American Legion
    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present The American Legion's 
views on Stopping Suicides: Mental Health Challenges within the 
Department of Veterans Affairs (VA). The VA has the Nation's largest 
mental health program, which is continually implementing various 
programs to accommodate the growing demand for mental health services 
to all veterans.
    Unfortunately, during a time which greatly warrants the development 
of such programs, the increased scrutiny of VA's mental health services 
and budget exist due to the increased demand for mental health services 
from veterans returning from combat in Iraq and Afghanistan, as well as 
veterans from previous eras.
Mental Health Strategic Plan, Initiatives, and Other Recommendations
    Upon the completion of its Comprehensive Mental Health Strategic 
Plan (MHSP), the VA began implementation of mental health initiatives 
in 2005. The Mental Health Initiative (MHI) was instituted to provide 
funding to support the implementation of the MHSP outside of the 
Veterans Equitable Resource Allocation (VERA) model.
    To effectively plan the funding for the MHI, the MHSP was divided 
into four main areas to include: enhancing capacity and access for 
mental health services; integrating mental health and primary care; 
transforming mental health specialty care to emphasize recovery and 
rehabilitation; and implementation of evidence-based care. Under these 
key categories are multiple funded programs, which are also currently 
attempting to accommodate increasing issues, to include suicide, 
amongst our Nation's veterans.
    One of many indicators of increase in suicides is evident in 
recommendations made to VA by the Joint Commission on the Accreditation 
of Healthcare Organizations (JCAHO), an organization formed in 1951 
with a mission to maintain and elevate the standards of healthcare 
delivery through evaluation and accreditation of healthcare 
organizations, and its National Patient Safety Goal (NPSG). Implemented 
on January 1, 2007, JCAHO advised that all VA facilities take the 
following steps to comply with the NPSG:

      Develop and implement strategies to properly assess, 
treat, and manage patients identified at risk for suicide.
      Document the relevant risk factors for suicide in each 
patient's medical record.
      Document treatment and the treatment setting in a manner 
that addresses the presence of (or absence of) relevant risk factors 
that increase risk for suicide and features that may decrease risk for 
suicide.
      Provide the appropriate telephone number(s) for telephone 
calls during working hours and other times, in writing, to at-risk 
patients and/or significant others.
      Instruct patients and their significant others to call 
the facility's Emergency Department or Urgent Care Center if they have 
a crisis situation.
      Ensure that the local or regional mental health hotline 
knows about VA as a resource in case a veteran should contact them.
      Ensure that the safety concerns in the design of the 
inpatient mental health unit (and its furnishings) are addressed.
      Establish and implement a policy stating who is 
responsible for identifying and working with local agencies so that VA 
patients receive emergency support and referral to the VA as soon as 
possible.

    The American Legion supports directives established by the Mental 
Health Strategic Plan and JCAHO, and their intentions to prevent 
tragedies such as suicide. However, there are concerns of adequacy of 
funding for these programs, as well as accommodation, across the board, 
for veterans of previous eras and the ever-increasing number of 
veterans who are returning from Iraq and Afghanistan. The American 
Legion continues to urge the Congress to annually appropriate the 
necessary funds for the Department of Veterans Affairs to ensure 
comprehensive mental health services are available to veterans.
Suicide
    The VA estimates that more than 5,000 veterans take their lives 
each year. Suicide rates are 35 percent higher for Iraq veterans than 
for the general population. Thirty-six percent of the 250,000 Iraq and 
Afghanistan veterans who have sought care in the VA system were treated 
for mental health problems.
    According to research, 283 Afghanistan veterans between 2001 and 
2005 have taken their own lives. It was also reported that awareness 
was intensified nationwide when the United States Army reported the 
increase of its 2006 suicide rate, which rose to 17.3 per 100,000 
troops. Within the past year the Army reported 23 soldiers, then 
currently in Iraq and Afghanistan committed suicide with at least seven 
Iraq and Afghanistan veterans committing suicide since returning home.
    In July 2007, VA opened a 24-hour National Suicide Prevention 
hotline for veterans. Recently, the VA submitted an informative letter 
to veterans disclosing the National Suicide Prevention toll-free 
hotline number included with definitive/probable suicide warning signs. 
The passing of H.R. 327, also titled the Joshua Omvig Veterans Suicide 
Prevention Act, which requires VA to develop and implement more 
programs, such as outreach and education, more than suggests an 
impending crisis amongst the Nation's veterans. During the development 
and implementation of mental health programs, there also arises the 
question of effectiveness.
    Signs of increase is also evident at VA's National Suicide hotline 
center based in Canandaigua, N.Y., in which counselors have taken more 
than 9,000 calls since its inception this year. In addition, the VA 
recently announced plans to provide suicide prevention coordinators at 
each of its 153 medical centers.
    In 2004, VA completed a five-year action plan that included 
implementation of goals from the Surgeon General's 2001 National 
Strategy for Suicide Prevention and recommendations from the Institute 
of Medicine's (IOM) 2002 report ``Reducing Suicide--A National 
Imperative.'' Afterward, the aforementioned were incorporated into the 
VA Mental Health Strategic Plan (MHSP).
    In addition, individual MHSP initiatives for suicide prevention 
were categorized and consolidated, to include:

      Crisis availability and outreach; screening and referral.
      Tracking and assessment of veterans at risk.
      Emerging best practice interventions and research.
      Development of an electronic suicide prevention database.
      Education.

    The warranted emergence of such programs to prevent this dreadful 
tragedy is indicative of a more imminent crisis becoming worse, absent 
effective means of curtailment. The American Legion agrees these 
initiatives are steps in the right direction and continues to remain 
incessant on monitoring the efficiency and effectiveness of programs 
implemented in the MHSP. We also implore the Congress to mirror our 
sentiment as well.
Conclusion
    In response to a call for help from this Nation's veterans, 
programs related to crises such as suicide are continuously being 
implemented. However, in accordance with a 2006 Government 
Accountability Office (GAO) report, there are issues of adequacy and 
accountability in the areas of funding and assessment, which in turn 
leave gaps in this system, therefore allowing veterans in need to fall 
through the cracks.
    It is the insistence of The American Legion that a proactive effort 
be implemented with continuous oversight to ensure complete access is 
available to avert suicides amongst our Nation's veterans. The American 
Legion also urges the Congress to provide annual oversight of VA's 
mental health services to augment deterrence of such tragedies as the 
above mentioned.
    Mr. Chairman and members of the Committee, The American Legion 
sincerely appreciates the opportunity to submit testimony and looks 
forward to working with you and your colleagues to resolve this 
critical issue. Thank you for your continued leadership on behalf of 
America's veterans.

                                 
                       Statement of Joy J. Ilem,
  Assistant National Legislative Director, Disabled American Veterans
    Mr. Chairman and Members of the Committee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
provide testimony at this important hearing focused on preventing 
suicides and meeting other mental health challenges of veterans who 
receive their care from the Department of Veterans Affairs (VA). This 
hearing is especially timely given the series of disturbing reports 
that have appeared recently on these important issues.
    The Department of Defense (DoD) and VA share a unique obligation to 
meet the healthcare and rehabilitative needs of veterans who have been 
wounded during military service or who suffer from readjustment 
difficulties and other consequences of combat deployments. VA recently 
announced it has made suicide prevention a priority and has developed a 
focused program based on increasing suicide awareness, prevention, and 
training to improve the recognition of suicide risk by healthcare 
staff. A national suicide prevention hotline has been established and 
suicide prevention coordinators have been hired in each VA medical 
center. DAV welcomes these efforts but we believe they will be 
fruitless if VA fails to improve the effectiveness of treatment for 
post traumatic stress disorder (PTSD), depression, substance abuse and 
other mental health disorders--which together appear to create the 
greatest threat to rising suicide rates in veterans.
    Suicide is a significant public health problem and should be 
addressed by aggressive efforts in the veteran population. In the 
December issue of the American Journal of Public Health,\1\ VA 
investigators reported the results of their longitudinal study carried 
out from 1999-2004 using nationally representative data to determine 
suicide rates among veterans treated by VA for depression. Of the over 
800,000 veterans studied, 1,683 or 0.21 percent committed suicide. 
Overall, the rates of suicide among depressed veterans were 7-8 times 
higher than the rate for the general population. However, suicide rates 
in depressed veterans were similar to rates found in men receiving care 
for depression in managed care systems. Unlike other studies that 
report higher rates in older adults, this VA study found that depressed 
veterans who were younger were at the greatest risk. One of the 
findings of the study confirmed that veterans with co-morbid depression 
and substance abuse are at very high risk for suicide. Veterans from 
the northeast and central U.S. had lower suicide rates than veterans 
from the south and west. This is consistent with the geographic and 
regional suicide rate variations.
---------------------------------------------------------------------------
    \1\ Suicide Mortality Among Individuals Receiving Treatment for 
Depression in the Veterans Affairs Health System: Associations with 
Patient and Treatment Setting Characteristics. Zivin K, Kim M, McCarthy 
JF, Austin KL, Hoggat KL, Walters H, Valenstein, M. AJPH (2007) 
97(12):2193-2198.
---------------------------------------------------------------------------
    The findings of this study give clinicians important clues to 
characteristics that produce higher suicide risk in veterans suffering 
from depression. Youth, incidence of substance use and geographic 
location are all associated with suicide risk. DAV hopes that further 
studies of suicide risk can increase our understanding and reduce the 
impact on veterans who fought in Afghanistan, Iraq and previous 
conflicts.
    Research demonstrates a clear association between deployment to a 
combat zone and subsequent mental health problems, substance abuse, and 
psychosocial problems such as marital conflict and incarceration. Key 
to our discussion today is the recognition that combat service is 
associated with higher rates of suicide in the early post-deployment 
period. This information is summarized in a report from the Institute 
of Medicine (IOM) entitled Gulf War and Health: Volume 6 Physiologic, 
Psychologic, and Psychosocial Effects of Deployment Related Stress, 
published in November 2007.\2\ The IOM committee studied literature 
covering all deployments in the 20th and 21st centuries including World 
War II, the Korean War, the Vietnam War, the 1991 Persian Gulf War, and 
Operations Iraqi and Enduring Freedom (OIF/OEF). This eminent group of 
experts reviewed the scientific evidence and determined that the 
evidence is sufficient to conclude that there is an association between 
deployment to a war zone and PTSD, other anxiety disorders, depression, 
alcohol abuse, suicide and accidental death in early years after 
deployment, and marriage and family conflict. In addition, the 
committee found that there was suggestive evidence of an association 
between deployment stress and drug abuse, chronic fatigue syndrome, 
fibromyalgia and other pain syndromes, gastrointestinal symptoms, skin 
disorders, increased symptom reporting and unexplained conditions and--
and incarceration. The committee noted that there was insufficient 
investigation by VA and DoD to allow the Committee to draw cause-and-
effect conclusions regarding deployment stress and later physiological, 
psychological and psychosocial conditions. The IOM report states very 
clearly that veterans, young and old, are at increased risk of suicide 
because of their presence in combat.
---------------------------------------------------------------------------
    \2\ Gulf War Health: Volume 6. Physiologic, Psychologic, and 
Psychosocial Effects of Deployment-Related Stress. The National Academy 
Press, Washington DC, 2007.
---------------------------------------------------------------------------
    Military deployments in Iraq and Afghanistan are among the most 
demanding since the Vietnam War over four decades ago. These 
deployments are causing heavy casualties in what are considered the 
``invisible'' wounds of war: PTSD, depression, family dislocations and 
other distress, and a number of other social and emotional consequences 
for those who have served in OIF/OEF. VA reports that OIF/OEF veterans 
have sought care for a wide array of co-morbid medical and 
psychological conditions, including adjustment disorder, anxiety, 
depression, PTSD, and the effects of substance use. Through October 
2007, VA reported that, of the 263,909 separated OIF/OEF veterans who 
have sought VA healthcare since the beginning of those hostilities, a 
total of 100,580 unique patients had received a diagnosis of a possible 
mental health disorder. More than 48,000 enrolled OIF/OEF veterans had 
a probable diagnosis of PTSD; almost 33,000 have been diagnosed with 
depression; and, more than 40,000 reported nondependent abuse of 
drugs.\3\
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    \3\ Department of Veterans Affairs, VHA Office of Public Health and 
Environmental Hazards, ``Analysis of VA Healthcare Utilization Among 
U.S. Global War on Terrorism (GWOT) Veterans: Operation Enduring 
Freedom, Operation Iraqi Freedom,'' October 2007.
---------------------------------------------------------------------------
    According to the recent report of the DoD Mental Health Task Force 
(Task Force), suicide rates have risen among OIF/OEF active duty 
members.\4\ In a finding that is key to this hearing, the Task Force 
also concluded that alcohol abuse contributed in 65 percent of the 
instances of suicidal behavior in military servicemembers. Depression 
and marital and relationship difficulties were seen as additional key 
contributors to suicidal ideology. After receiving these reports, DoD 
is beginning to reinforce suicide prevention efforts, and VA is 
targeting suicidal behavior in the veteran population, including 
establishing a veteran-specific referral procedure when veterans call 
800-273-TALK, the National Suicide Prevention Hotline sponsored by the 
Substance Abuse and Mental Health Services Administration of the 
Department of Health and Human Services. Experts assert that any 
effective suicide prevention effort must offer ready access to robust 
mental health and substance abuse treatment programs, including 
components related to outreach, prevention, stigma reduction, improved 
screenings and early interventions. DAV concurs that these components, 
with the resources to fully support them, are critical to success of 
this prevention effort.
---------------------------------------------------------------------------
    \4\ An Achievable Vision: The Report of the Department of Defense 
Mental Health Task Force, June 15, 2007.
---------------------------------------------------------------------------
    In a study of 315 homeless male veterans and 310 homeless female 
veterans, VA researchers found that 27 percent and 37 percent, 
respectively, reported they had attempted suicide in the past 5 years, 
and an additional 44 percent and 49 percent, respectively, reported 
they had contemplated suicide. The study also found over 80 percent of 
homeless veterans had mental disorders, prominently among them 
substance abuse, and that its degree of severity was a strong predictor 
of suicidality. In men, combat exposure and PTSD were predictive, and 
in women, recent sexual or physical trauma correlated positively with 
suicidality.\5\
---------------------------------------------------------------------------
    \5\ Brenda, BB. Gender Differences in Predictors of Suicidal 
Thoughts and Attempts Among Homeless Veterans That Abuse Substances. 
Suicide and Life Threatening Behavior, 35, (2005) 106-116.
---------------------------------------------------------------------------
    The link between substance abuse and other mental disorders and 
suicide is strong. Earlier this year in a study of over 8,000 veterans 
who received substance abuse treatment, VA researchers found that nine 
percent had attempted suicide in the year prior to VA treatment, but 
only four percent had made suicide attempts in the year following 
treatment.\6\ This would seem to validate the premise that effective 
substance abuse treatment leads to reduction in suicide attempts. A 25-
year study of 641 Vietnam veterans also found that over time, there was 
a strong correlation between suicidality, PTSD and substance abuse.\7\ 
Both these VA studies dealt predominantly with older veterans, but 
experts believe it would be reasonable to expect that similar studies 
focused on younger veteran cohorts, including OIF/OEF veterans, would 
show results consistent with these findings.
---------------------------------------------------------------------------
    \6\ Ilgen, MA; Harris, A; Moos, R; et al. Predictors of Suicide 
Attempt One Year After Entry Into Substance Abuse Disorder Treatment. 
Alcoholism, Clinical and Experimental Research, 31, (2007) 635-642. And 
Ilgen, MA; Jain, A; Lucas, E; Moos, R. Substance Use Disorder Treatment 
and a Decline in Attempted Suicide During and After Treatment. J Stud 
Alcohol and Drugs, 68, (2007) 503-509.
    \7\ Price, RK; Risk, NK; Haden, AH, et al. Post Traumatic Stress 
Disorder, Drug Dependence and Suicidality Among Male Veterans. Drug and 
Alcohol Dependence, 76S, (2004) S31-43.
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    Mr. Chairman, there are rising indications that the misuse of 
substances will continue to be a significant problem for OIF/OEF 
service members and veterans. In a recent study, VA New Jersey-based 
researchers examined substance abuse and mental health problems in 
returning Iraq veterans.\8\ These researchers noted that although 
increasing attention is being paid to combat stress disorders in 
veterans, little systemic focus has been made on substance abuse 
problems affecting this population. In the group studied (292 New 
Jersey National Guard members who had returned from Iraq within 12 
months of data collection) nearly 47 percent of participants reported a 
mental health and/or substance abuse problem. Substance abuse problems 
were found to be higher among veterans with other mental health 
problems. Access to substance abuse treatment both during and after 
deployment was especially low for those needing it (among veterans with 
dual disorders, 41 percent received mental health treatment but only 
nine percent received treatment for substance abuse). Similarly, a 
study of returning Maine National Guard members found substance abuse 
problems in 24 percent of the troops surveyed.\9\ In the most recent 
DoD anonymous Survey of Health Related Behaviors Among Active Duty 
Personnel, 23 percent of the respondents acknowledged a significant 
alcohol problem.\10\
---------------------------------------------------------------------------
    \8\ Kline, A., Falca-Dodson, M., Substance Abuse and Mental Health 
Problems in Returning Iraqi Veterans. VA New Jersey Healthcare System, 
New Jersey Department of Military and Veterans Affairs 2007, 
(unpublished).
    \9\ Wheeler, E. Self Reported Mental Health Status and Needs of 
Iraq Veterans in the Maine Army National Guard. Community Counseling 
Center, 2007 (unpublished).
    \10\ Bray, R., Hourani, L., Olmstead, K., Witt, M., Brown, J., 
Pemberton, M., Marsden, M., Marriott, B., Scheffler, S., Vandermaas-
Peeler, R., Weimer, B., Calvin, S., Bradshaw, M., Close, K., & Hayden, 
D. (2006, August). 2005 Department of Defense Survey of Health Related 
Behaviors Among Active Duty Military Personnel: A Component of the 
Defense Lifestyle Assessment Program (DLAP). Prepared for the Assistant 
Secretary of Defense for Health Affairs, U.S. Department of Defense, 
Cooperative Agreement RTI/7841/006-FR). Research Triangle Park, NC: 
Research Triangle Institute.
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    Substance abuse--common as a secondary diagnosis among newly 
injured veterans and others with chronic long-term illness or injury--
can often be overshadowed by more compelling acute care needs. Mental 
health experts agree that untreated substance abuse can result in a 
variety of negative health consequences for the veteran with marked 
increases in healthcare expenditures, as well as social costs due to 
additional stresses on families from loss of employment and legal 
costs. In both the VA and DoD healthcare systems, current evidence-
based treatment guidelines for substance use disorders confirm the 
substantial body of research supporting the effectiveness of a variety 
of treatments for these problems. VA must continue to educate its 
primary care providers about these proven techniques, including better 
detection of substance use disorders, to ensure that these problems are 
identified early and treated.
    We urge VA to provide a full continuum of care for mental health 
and substance use disorders including more consistent, universal 
periodic screening of OIF/OEF combat veterans in all its healthcare 
facilities and programs--especially in primary care. Outpatient mental 
health counseling and pharmacotherapy should be made available at all 
larger VA community-based outpatient clinics. Also, short-term 
outpatient counseling including motivational interventions; intensive 
outpatient treatment; residential care for those most severely 
disabled; detoxification services; ongoing aftercare and relapse 
prevention; self help groups; and, opiate substitution therapies and 
newer drugs to reduce craving, should be included in VA's substance 
abuse and prevention services program. We believe further investment in 
a comprehensive package of substance-use services will help younger 
veterans during an often difficult readjustment period following combat 
deployments. Hopefully, VA can use preventive approaches that will help 
restore these veterans and to prevent chronic long-term mental health 
consequences that attend drug and alcohol addictions, and thereby also 
lower risks for suicide. These types of VA services could also be 
beneficial to older veterans struggling with chronic addictions.
    Mr. Chairman, war also places great stress on family and social 
relationships. Active duty service members currently are called on to 
make frequent deployments of long duration, in dangerous combat 
assignments. Time at home between these deployments is marked by 
intensive training in garrison and continuous preparations for 
redeployment. Active reservists and National Guard members face 
unanticipated redeployments that disrupt their families and strain 
their financial and employment security.
    We have substantial data and reports that document the strain the 
wars are putting on combat veterans' mental health and their 
relationships with spouses and families. Interpersonal conflict is 
clearly increasing, and recent data suggest that the problems grow 
rather than diminish in the months after service members return home. 
Soldiers also reported more mental health problems and were referred at 
higher rates for mental health services. Of special concern are the 
high rates of alcohol use being reported by soldiers. DAV is very 
concerned about all these reports, and note that these findings do not 
even reflect the full impact of extended deployments, the third, fourth 
or even fifth deployments for some individuals, or the impact of 
redeployed service members who already may be actively suffering from 
untreated PTSD.
    We understand that VA medical centers and their community-based 
outpatient clinics do not routinely provide marital and family 
counseling services. VA's Readjustment Counseling Service, through its 
community-based Vet Center program, is the only major source of marital 
and family counseling services in the VA healthcare system. Vet Centers 
are user-friendly and have high veteran satisfaction, but these vital 
services should be made more generally available at VA's major medical 
facilities to increase access to these important services. Congress 
should ensure that marital and family counseling services are offered 
as a part of the healthcare benefits package, when needed in 
relationship to combat readjustment issues for veterans under care at 
VA.
    In addition to marriage and family counseling services, VA needs to 
improve it's substance use treatment programs. Since the late 1990s, VA 
has seen unparalleled growth in veterans' use of its healthcare system 
however, according to VA mental health staff, the number of veterans 
who received specialized substance abuse treatment services has 
declined since 1998 despite increasing demand from veterans with these 
problems. At a time when substance abuse care needs appear to be rising 
and suicide risk among OIF/OEF veterans is high and so troubling, we 
urge VA to ensure these programs are available to veterans who need 
them.
    These healthcare and psychosocial issues are complex. Therefore, 
VA's approach must be comprehensive and involve long-term structural 
improvements in the care provided to these veterans. We see the need 
for the following actions by VA:

      VA should immediately improve access to substance abuse 
treatment services, particularly early interventions for OIF/OEF 
veterans that are designed to prevent chronic conditions and more 
serious problems.
      DoD and VA must eliminate the stigma attached to service 
members and veterans seeking care for mental illness and substance 
abuse with the same urgency and sincerity that we give to ``medical'' 
illnesses. Otherwise, some veterans will not seek help and may fall 
into despair and be at risk for suicide.
      VA must provide access for OIF/OEF veterans and their 
spouses to marital and family counseling, to help restore relationships 
that deteriorate as a consequence of military deployment and 
separation, and to strengthen the social support system these veterans 
need as they reintegrate into their homes and communities.
      VA must assure that access to comprehensive age-
appropriate mental health services is available to all OIF/OEF 
veterans, and develop services targeted to the new needs of the 
increasing cohort of women veterans who have been exposed to combat 
stress. VA must continue to enhance access to mental health, PTSD and 
readjustment counseling services for all veterans. Enhancements in 
these programs have been initiated, but we should remain vigilant to 
ensure that they are sustained and that state-of-the-art, quality 
healthcare services are delivered, irrespective of a veteran's gender 
or geographic location.
      VA should provide Congress its strategic plan, through 
its Office of Rural Health for OIF/OEF veterans living in rural areas 
far from VA facilities and essentially without access to any form of 
direct VA service in mental health and otherwise. We urge VA and this 
Committee to find acceptable ways for these veterans (many of whom 
served as called-up National Guard members) to gain access to the full 
continuum of healthcare services offered by VA, to address their mental 
health and readjustment needs, and help them restore their marital and 
family relationships after serving.

    Mr. Chairman, we bring to the Committee's attention an issue that 
we believe is of great importance and directly affects veterans' 
suicide risk. Earlier in this testimony, I indicated that a recent IOM 
report had shown that combat service was associated with veterans' 
later incarcerations. Incarceration presents a life-altering 
consequence. There appears to be a link between combat and 
incarceration, mental health decline, substance abuse and elevated 
suicide risk for some veterans.
    The Committee may be aware of a recent front page article in the 
Washington Post concerning the pending prosecution under the Uniform 
Code of Military Justice (UCMJ) of Army Lt. Elizabeth Whiteside. As 
indicated in a Post editorial following publication of the original 
story, ``the 25-year-old Army reservist had a stellar record of service 
but had a breakdown, possibly caused by her service in war-torn 
Baghdad. After a series of stressful incidents, she shot herself in the 
stomach. Despite the unequivocal judgment of psychiatrists that she 
suffers from significant mental illness, her commanders pressed 
criminal charges against her, and she's now waiting to hear whether the 
Army will court-martial her.'' We believe Lt. Whiteside's case 
resonates with the rest of our testimony, and the challenges we face as 
a Nation in dealing with the mental health consequences of war.
    Earlier this year, the Department of Justice's (DOJ) Bureau of 
Justice Statistics issued a report indicating that, while veterans are 
not disproportionately represented in Federal and State prison 
populations compared to nonveterans, OIF/OEF veterans do constitute 
nearly five percent of the total population of incarcerated 
veterans.\11\ Since 2002 approximately 5,000 former military members 
who served in our ongoing wars, individuals who participated at some 
level in U.S. efforts to restore the freedoms of the Iraqi and Afghani 
peoples, have subsequently lost their own personal freedom after 
returning home.
---------------------------------------------------------------------------
    \11\ Noonan, ME; Mumola, CJ. U.S. Dept. of Justice, Office of 
Justice Programs, Bureau of Justice Statistics, ``Veterans in State and 
Federal Prison, 2004,'' May 2007.
---------------------------------------------------------------------------
    Depression, substance use disorders and other mental health issues 
are common in prison. Each of those imprisoned individuals' stories 
deals with unique circumstances and convicted criminal behavior. In 
some instances, sadly, individual failures to readjust and to gain 
access to effective care and services spirals down into impulsiveness, 
emotional breakdown, loss of control, loss of employment, and even 
homelessness and criminal behavior.
    Mr. Chairman, there is another ``hidden'' veteran population, in 
prison and out, that is currently beyond reach of any VA program: these 
are veterans whose behavior while in service led to entanglement in the 
UCMJ, resulting in both imprisonment and/or so-called ``bad paper'' 
discharges. Veterans with less than honorable discharges are not 
defined as ``veterans'' under title 38, United States Code. Thus, they 
are ineligible for any service or benefit from VA. The DOJ report noted 
that 31 percent of veterans in Federal and State prisons have 
dishonorable discharges from military service.
    The DOJ report also indicated that more than 2,000 active duty 
personnel are currently imprisoned in military penal facilities. Once 
their sentences are served, most of them will be issued discharges 
under less than honorable conditions, or they will receive dishonorable 
discharges. In general these persons will not be able to avail 
themselves of federal benefits including VA's programs for PTSD, mental 
health and other readjustment services.
    We believe these subjects should be added to the Committee's 
concerns about mental health and suicide. At this juncture DAV offers 
no specific recommendations for legislation; however, we believe that 
DoD and VA share a responsibility to ensure that war-traumatized 
service personnel and veterans should not be criminalized before an 
effort is made to intervene with therapeutic remedies. We ask the 
Committee to investigate the circumstances of both military and 
civilian justice systems, and to work with your colleagues on the 
Committee on Armed Services, to determine whether DoD and VA are using 
all the tools at their disposal to divert military personnel and 
veterans in trouble to therapeutic solutions rather than allow them to 
be criminalized.
    In summary, many of our active duty service members, veterans and 
their families are experiencing the stressors we have noted in this 
testimony and are experiencing real emotional hardship in their lives. 
To address these challenges, DoD, VA and Congress need to work 
together--and the time to cooperate is now. For a small number of 
veterans, these stressors are having devastating consequences, 
including increased risk of suicide. Taking action now--before their 
problems become more complicated and severe, is in their best interests 
and in the best interest of the Nation. The resources we spend today, 
and the programs that Congress authorizes to promote better mental 
health, will have long term positive benefits for veterans and will 
reduce financial and social costs to the Nation. We owe them nothing 
less.
    Mr. Chairman, thank you for this opportunity for DAV to offer its 
views on these matters. I will be pleased to address your questions, or 
those from other Members of the Committee.

                                 
      Statement of Todd Bowers, Director of Government Relations,
                Iraq and Afghanistan Veterans of America
    Mr. Chairman and members of the Committee, thank you for hearing me 
speak today. On behalf of Iraq and Afghanistan Veterans of America, I 
would like to thank you all for your unwavering commitment to our 
Nation's veterans. The Committee originally invited our Executive 
Director, Paul Rieckhoff, to testify today. Unfortunately, Mr. 
Rieckhoff had a prior engagement that he could not reschedule and so he 
asked me to be here today on his behalf. I will do my best to fill his 
boots this morning.
    I would like to begin by thanking the Committee for the outstanding 
leadership you provided to ensure that legislation combating suicide 
among veterans made its way into law. Specifically, I would like to 
thank you for your efforts to pass the Joshua Omvig Suicide Prevention 
Act. IAVA wholeheartedly endorsed this groundbreaking legislation and 
we are excited about the positive impact it will have on all veterans.
    I was very excited to hear about the nomination of General Peake to 
be the new secretary of the Veterans Administration. General Peake is a 
combat veteran who holds dear the Army's ``Warrior Ethos.'' The Warrior 
Ethos states that ``I will always place the mission first, I will never 
accept defeat, I will never quit, I will never leave a fallen 
comrade.'' I believe we can apply the lessons of combat, and the 
Warrior ethos, to improving suicide prevention at the VA.
    On my second combat tour in Fallujah, Iraq, I was on a patrol with 
my team of six Marines. As we moved through the city we made our way to 
Jolan Park, located in the northwestern portion of the city, to link up 
with our battalion's Executive Officer. Once we arrived at the park we 
found ourselves alone. There were no other Marines in sight. As we 
surveyed the area, I noticed a group of Marines four blocks away waving 
their arms and jumping up and down. By the time I was able to figure 
out that they were telling us we were in danger, it was too late. I 
turned to inform my Captain and, just as I opened my mouth, the 
building next to us exploded. The blast was so strong that it threw me 
backward. Once the dust settled and the ringing in our ears subsided, 
the Marines who were waving at us from down the street made their way 
over to our vehicle. ``What the hell is wrong with you guys!?'' a Major 
screamed at us. Apparently they were utilizing a controlled blast to 
destroy a massive weapons cache used by the insurgents and had called 
in the grid coordinates over the radio to warn all Marines to stay 
clear of the area. We did not get the communication. Our radio had lost 
its encryption.
    The failure to communicate that day in Fallujah nearly killed me 
and six of my fellow Marines.
    I believe communication is also key to success in suicide 
prevention.
    The Army's Field Manual 6-22.5, ``A Leader's Guide to Combat and 
Operational Stress,'' states that ensuring ``communication lines are 
open'' is one of the most ``potent countermeasures to confront combat 
stress and to reduce psychological breakdown. . . .''
    Recently, the VA had made great strides to improve communications 
lines by creating a Nation-wide Suicide Prevention hotline. This 
hotline is available to veterans and their families 24 hours a day, 
seven days a week. This new program has had amazing results. The VA has 
highlighted many stories of veterans who have used the hotline to get 
the help they need. But after talking to many IAVA's members, including 
those in the National Guard and Reserves, we have found that they do 
not know that this service is available. Better outreach is the only 
way to ensure that these new programs are available to all who need 
them.
    But outreach is a difficult task if you do not know where your 
targets are. A national registry of veterans would solve this gap in 
communication.
    The Gulf War Registry was established to inform veterans of changes 
in policy regarding issues specific to the war in the Gulf such as 
exposure to burning oil wells and Gulf War syndrome. Although this 
registry is newly available to Iraq veterans, its potential is still 
limited. Right now, the registry is not open to Afghanistan veterans, 
and is only made available to those who are in the VA system. Only 
about one-third of Iraq and Afghanistan veterans eligible for VA care 
have sought care, so the vast majority of veterans are not eligible for 
inclusion.
    We at IAVA believe that all veterans should be included in a 
registry upon discharge from the military. Currently the tracking 
system for veterans is almost non-existent. Registering veterans, along 
with their deployments to specific conflicts, would help the VA reach 
out to veterans and family members who will benefit from their 
outstanding initiatives and programs, including the suicide hotline.
    Much of the work of suicide prevention, however, must occur much 
earlier in the process. IAVA has strongly endorsed the mandatory pre- 
and post-deployment mental health screening of our service members by 
mental health professionals. This will produce a more accurate 
assessment of the impact that combat has on a service member's mental 
health. Making screening mandatory will reduce the stigma related to 
seeking mental health treatment. I would compare this to the mandatory 
drug testing that the Department of Defense conducts for all service 
members. If all are required to take part, then it becomes a part of 
daily routine and no longer singles individuals out.
    In addition to universal screening, a coherent national anti-stigma 
campaign will help ease the barriers keeping troops from early 
treatment. I am very pleased to announce that IAVA has partnered with 
the Ad Council for the next three years to implement a ``Stigma 
Reducing'' national ad campaign. This campaign will be in print, on 
television and radio and online, and will convey to the American public 
and our Nation's veterans that treating mental health injuries is a 
routine step in reintegration.
    I'd like to close with another personal story of a family in 
Northern Virginia who have experienced first-hand the effects of 
suicide among the veterans' community. They have become my friends and 
are almost like family to me. A few years ago, the father of the 
family, who served in the Army, took his own life. He left behind three 
children. Years later, his family still carries the tremendous 
emotional burden of unanswered and unanswerable questions. What more 
could have been done to save him?
    I ask you, today, to consider that question. What could have been 
done? Would a hotline have been enough? A flier in the mail about the 
signs of suicide? A call from his local Vet Center?
    My friend's family will never know the answer. If we act now, we 
can implement measures that will be a crucial step in reducing suicide 
amongst veterans.
    On the battlefield, casualties are often unavoidable. What is 
avoidable is suicide. If we take the proper steps to combat suicide 
among the veterans community, we can and will win this battle. Thank 
you.

                                 
         Statement of National Coalition for Homeless Veterans
    Mr. Chairman and Members of the Committee:
    We are assembled here to talk about the mental healthcare available 
to, and the reported increase in suicide among, this Nation's 
veterans--and specifically, how the Department of Veterans Affairs (VA) 
is addressing these critical concerns.
    The National Coalition for Homeless Veterans (NCHV) is honored to 
participate in this hearing for several reasons. NCHV, perhaps more 
than any other organization, recognizes the tremendous contributions 
this Committee has made in serving America's former guardians in their 
greatest hour of need. We know that what our member organizations have 
accomplished on behalf of veterans in crisis--men and women who have 
lost everything but life itself--would not have been possible without 
this Committee's guidance, support and courage to act.
    Most importantly, NCHV is proud to stand with you during what we 
believe is a defining moment in the history of this great Nation.
    Never before has the U.S. Congress, and the people it represents, 
been better prepared to address the future needs of America's armed 
forces during a time of war. This Committee knows all too well that the 
cost of our freedom and prosperity necessarily includes tending to the 
wounds of the veterans who sacrifice some measure of their lives to 
preserve it. We understand the Committee's purpose is to serve all 
veterans, but this dialogue most certainly embraces the men and women 
who have served in Iraq and Afghanistan, and all who will follow them.
    The Nation's foremost authorities on mental health--the National 
Institute of Mental Health, National Alliance on Mental Illness and 
Mental Health America (formerly the Mental Health Association), agree 
that the warning signs of increased risk of suicide include histories 
of mental illness, extreme mood swings, changes in personality, 
withdrawal from family members and friends, feelings of hopelessness, 
and depression. Depending on the severity of a person's health and 
economic hardships, self medication on alcohol or drugs increases the 
likelihood of suicide by 30 to 70 percent.\1\
---------------------------------------------------------------------------
    \1\ National Institute of Mental Health, Washington, D.C.
---------------------------------------------------------------------------
    These behaviors, mental health issues, and emotional torments 
characterize the great majority of the clients NCHV organizations 
serve. Approximately 76% of the veterans we treat have histories of 
substance abuse and diagnosed mental health challenges; more than 90% 
of both male and female clients are unemployed. All of them are 
homeless. More than half of the calls we receive on our toll-free help 
line (1-800-VET-HELP) are from veterans who are sick, scared, socially 
isolated, or economically disadvantaged--or from family members asking 
how they can help their loved ones.
    Suicide, a tragic and irreversible act, can most simply be defined 
as the absolute absence of hope.
    The act of willfully ending one's life is most often the result of 
prolonged and deepening mental and emotional stresses, the erosion of 
social supports such as friends and family ties, and the loss of 
intimate relationships.\2\ Veterans--particularly combat veterans--are 
called upon to endure all of these as necessary occupational hazards.
---------------------------------------------------------------------------
    \2\ National Strategy for Suicide Prevention (NSSP), Office of the 
Surgeon General, 2001.
---------------------------------------------------------------------------
    War is arguably the most dehumanizing experience a person will ever 
encounter. Every action tears at the tenets of civilized society; and 
those who serve in a combat unit must disregard the most basic instinct 
of all--self preservation. But the intensity of military training, 
separation from one's social supports, and the inescapable anxiety of 
knowing what their training is preparing them for can potentially be 
just as burdensome to those who serve, whether or not they ever engage 
in combat operations.
    The prospect of multiple deployments, their effect on personal 
finances, and repeated separation from one's family now gripping half 
of the Reservists and National Guard troops serving in the War on 
Terror can only magnify the impact of these pressures.
    The overwhelming majority of America's veterans who have answered 
the call to serve in the military return home to become successful 
business executives, community leaders, captains of industry, public 
servants, and even presidents.
    However, unlike other veteran policy advocates, NCHV is singularly 
concerned about those who do not--our sole purpose is to support the 
men and women who proudly serve but then find themselves unable to 
effectively cope with the challenges life throws at them without regard 
to social standing, economic status, ethnic heritage or personal 
conviction.
    Every day, at more than 280 service organizations across the 
country, we provide services to those who would have no hope were it 
not for the support of Congress, the federal agencies charged with 
helping our most disadvantaged citizens, and the multitude of community 
and faith-based organizations that transform policy into life-saving 
interventions and life-sustaining programs.
VA Mental Health Care
    NCHV is, therefore, well qualified to comment on the availability 
of mental health services through the Department of Veterans Affairs. 
The partnership between service providers that help veterans in crisis 
and the VA is vital to our mission to increase the capacity of service 
providers and to promote effective and cost-efficient collaboration in 
local integrated service networks. This partnership has been credited 
with decreasing the number of homeless veterans on the streets of 
America each night by more than 20% in the last five years.\3\
---------------------------------------------------------------------------
    \3\ VA CHALENG Reports 2003-2006.
---------------------------------------------------------------------------
    Virtually every community-based organization that provides 
assistance to veterans in crisis depends on the VA for access to 
comprehensive health services, and without exception their clients 
receive mental health screenings, counseling and necessary treatment as 
a matter of course. These services are well documented, and case 
managers report this information to the VA as prescribed in their grant 
reports. Follow-up services--counseling, substance abuse treatments, 
outpatient therapies, medication histories and family support 
initiatives--are also monitored closely and reported in client case 
files.
    Despite significant challenges and budgetary strains, the VA has 
quadrupled the capacity of community-based service providers to serve 
veterans in crisis since 2002, a noteworthy and commendable expansion 
that includes, at its very core, access to mental health services and 
suicide prevention.
    The development of the VA Mental Health Strategic Plan from 2003 
through November 2004, and its implementation over the last three years 
with additional funding this Committee fought for, has increased the 
number of clinical psychologists and other mental health professionals 
within the VA healthcare system by nearly 1,000 positions. The 
additional clinical staff have been noted at VA medical centers, 
community-based outpatient clinics (CBOCs) and VA Readjustment 
Counseling Centers (Vet Centers).\4\
---------------------------------------------------------------------------
    \4\ Implementing VHA's Mental Health Strategic Plan Initiatives for 
Suicide Prevention, Office of the Inspector General, Department of 
Veterans Affairs, May 10, 2007.
---------------------------------------------------------------------------
    Media attention to the fact that the VA did not expend the full 
amount of funding authorized to achieve the Mental Health Strategic 
Plan's goals in 2006 did not fairly report that program expansion of 
this magnitude takes time to implement, with respect to both logistical 
and personnel matters.
    Veterans now have access to initial healthcare assessments and 
referrals to VA services through a network that includes 153 medical 
centers, nearly 900 VA community health clinics, 207 VA Readjustment 
Counseling Centers, and about 280 community and faith-based veteran 
assistance programs nationwide--a network that did not exist at the 
close of the Vietnam War. Many of these points of access to mental 
health services have opened within just the last 10 to 15 years. From 
information in our database, we estimate there are more than 3,000 
other organizations--both private and government agencies--that provide 
various services to veterans in need.
    The development of an interagency Suicide Prevention Hotline in May 
2007, a collaboration between the Departments of Health and Human 
Services and Veterans Affairs and staffed by trained counselors on a 
24/7 basis, is a valuable resource for both veterans in crisis and 
family members who are often the ones who call for help.
    The ongoing development of peer counseling initiatives at many VA 
facilities is a replication of successful interventions that have been 
utilized at many community organizations for decades. Plans to provide 
training for VA and community-based organization staffs on effective 
mental health support procedures and suicide prevention beginning in 
early 2008 are another testament to the agency's commitment to ensure 
effective early mental health assessment and intervention strategies 
for veterans of Operation Iraqi Freedom and Enduring Freedom (OIF/OEF).
    VA officials publicly admit there is still considerable work to 
do.\5\ And no one who is professionally invested in this work would 
refute that point. NCHV has been a vocal advocate for enhanced VA 
mental health services for homeless, low-income and recent combat 
veterans since 2001. But a random survey of directors of several of our 
larger member organizations in preparation for this hearing produced 
three significant, and unanimous, conclusions:
---------------------------------------------------------------------------
    \5\ ibid.

    1.  The incidence of suicide among veterans in a community-based 
program in partnership with the VA is ``extremely rare,'' even though 
these clients on admission are often regarded as among the highest risk 
segment of the population.
    2.  Because these programs immediately address a wide range of 
needs, and clients are more likely to receive proper mental health 
treatment, case management and follow-up, the sense of hopelessness and 
low self esteem often associated with suicide quickly subsides.
    3.  Were it not for VA's partnership with community and faith-based 
organizations--and specifically the availability of VA mental health 
services for their clients--the incidence of suicide among veterans 
would likely be much higher.
Recommendations:
    1.  Ensure full implementation of the VA Mental Health Strategic 
Plan--Specific recommendations of the Office of the Inspector General 
include:

        24-hour crisis and mental healthcare availability at 
all VHA facilities, either in person or through a manned suicide/crisis 
hotline.
        24/7 availability of on-call mental health specialists 
for crisis intervention staff.
        Systemwide co-location of mental health services at 
primary care facilities to reduce the stigma associated with seeking 
mental health supports and to enhance service delivery.
        Improve information sharing between the VA and 
Department of Defense for all personnel entering the VA healthcare 
system or leaving it to return to active duty.
        Ensure adequate funding for VA mental health 
professionals to provide training to VA and community-based 
organization staffs on proper mental health supports and suicide 
prevention strategies. This training is critical for all persons 
associated with at-risk veteran populations--clerical staff, intake 
counselors, case managers, peer counselors, and clinical staff.

    2.  Continue this Committee's leadership role in support of, and 
authorize funding to the maximum extent possible for, the VA Grant and 
Per Diem Program. These community-based therapeutic programs, in 
partnership with the VA, provide a wide range of services that greatly 
reduce the risk of suicide among veterans with extreme mental, social 
and economic challenges. Most community-based organizations provide 
follow-up counseling long after clients successfully complete their 
recovery programs. This is widely viewed as a critical component of an 
effective suicide prevention strategy.\6\
---------------------------------------------------------------------------
    \6\ National Strategy for Suicide Prevention (NSSP), 2001.
---------------------------------------------------------------------------
    3.  Simplify and expand access to community mental health clinics 
for OIF/OEF veterans in communities not well served by VA facilities. 
While current practice allows a veteran to apply for a VA ``Fee Basis'' 
card to access services at non-VA facilities, the process is often 
frustrating and problematic, particularly for a veteran in crisis. 
Protocols should be developed to allow VA and community clinics to 
process a veteran's request for assistance directly and immediately 
without requiring the patient to first go to a VA medical facility.
    4.  Extend the period of eligibility for VA medical services for 
Reservists and National Guard troops who serve in Operations Iraqi 
Freedom and Enduring Freedom (OIF/OEF) from two years to a minimum of 
five years. Research indicates, and VA Grant and Per Diem client case 
files over the last 18 years prove, that many emotional and mental 
health challenges emerge or worsen over time. This extension would also 
allow for more precise diagnoses and more effective treatment regimens 
for combat veterans.
    5.  Establish an interactive, 24/7, information and service 
referral website for military members, veterans and their families; and 
ensure that new recruits, Reservists and National Guard troops are 
advised of the site as part of their induction into active duty. This 
would virtually eliminate the problem of not knowing where to ask for 
help regardless of when a service member or veteran becomes aware that 
he or she may need assistance.
Conclusion
    By any accounting, the work of the House Veterans Affairs Committee 
on behalf of this Nation's most vulnerable former service men and women 
over the last two decades has inspired the development and expansion of 
a service provider network that performs miracles every day. Most of 
the accomplishments reflected in this report have occurred in just the 
last five to six years.
    Rekindling hope in those who have no hope is the surest safeguard 
against suicide. NCHV staff and program directors can personally attest 
to this Committee's role in helping transform hopelessness into the 
will to live and prosper for hundreds of thousands of our fellow combat 
veterans. We believe the same can be said of the Department of Veterans 
Affairs.
    On behalf of the veterans we all serve, we implore you to claim 
this moment in American history and make it part of your commendable 
legacy. No veteran should have to lose everything he or she has before 
we, as a nation, offer them a helping hand. Your leadership can make 
sure that doesn't happen to the men and women who serve in Iraq and 
Afghanistan.

                                 
                    Statement of Richard F. Weidman,
          Executive Director for Policy and Government Affairs
                      Vietnam Veterans of America
    Chairman Filner, Ranking Member Buyer, and other distinguished 
members of this committee, Vietnam Veterans of America (VVA) thanks you 
for the opportunity to present our views on suicide and PTSD among our 
Nation's military personnel and veterans. We also want to thank you for 
your consistent concern about the mental health care of our troops and 
our veterans. I should note that Dr. Thomas Berger, Chair of VVA's 
National PTSD & Substance Abuse Committee made substantial 
contributions to this statement, as did Ms. Marsha Four, Chair of VVA's 
National Committee on Women Veterans.
    The subject of suicide is extremely difficult to discuss. It is a 
topic that most of us would prefer to avoid. Accurate statistics on 
deaths by suicide are not readily available because many are not 
reported or are misreported for insurance reasons as well as the desire 
of local officials to avoid the ``stigma'' of suicide in a family. Many 
of us, as veterans of the Vietnam War and as comrades and caregivers to 
our brother and sister veterans, have known someone who has committed 
suicide and others who have attempted to take their life. Unfortunately 
I have personally known many Vietnam veterans who were overtaken by 
despair induced by their deep and intractable neuron-psychiatric wounds 
from the war.
    But as uncomfortable as this subject may be to discuss, it must be 
confronted. It is a very real public health concern in our military and 
veteran communities. A 12-year study published in the June 2007 issue 
of the journal Epidemiology and Health clearly demonstrates that the 
risk of suicide among male U.S. veterans is more than two times greater 
than that of the general population after adjusting for a host of 
potentially compounding factors, including age, time of service, and 
health status. A report released this past May by the VA Inspector 
General noted that ``veterans returning from Iraq and Afghanistan are 
at increased risk for suicide because not all VA clinics have 24-hour 
mental care available . . . and many lack properly trained workers.''
    Media reports of suicide deaths and suicide attempts among active 
duty OEF and OIF soldiers and veterans began to surface back in 2003 
after a spate of suicides in Iraq during the first months of the war. 
Since then, both the military and the VA have stumbled and fumbled in 
their attempts to answer questions about the severity of this malady. 
For example, while all the military services maintain suicide 
prevention programs, the Army in its August 2007 Army Suicide Event 
Report acknowledged that soldiers committed suicide last year at the 
highest rate in 26 years, and more than a quarter did so while serving 
in Iraq and Afghanistan. The report noted ``a significant relationship 
between suicide attempts and number of days deployed in Iraq, 
Afghanistan or nearby countries where troops are participating in the 
war effort.'' The report added that there also ``was limited evidence 
to support the view that multiple deployments are a risk factor for 
suicide behaviors.'' It might be noted here that this report which was 
released only after a FOIA request.
    VVA believes that these deaths are among the most extreme failures 
by the U.S. military to properly screen, treat, and evacuate mentally 
unfit troops. Even a report by the Army released this past October 
suggests that the quality of care, as much as the number of providers, 
is a factor in the rising incidence of suicide among active-duty 
service members. This report notes that more than half the 948 soldiers 
who attempted suicide in 2006 had been seen by mental health providers 
before their attempt--36 percent within just 30 days of the event. Of 
those who committed suicide in 2006, a third had an outpatient mental 
health visit within three months of killing themselves, and 42 percent 
had been seen at a military medical facility within three months. Among 
soldiers who were deployed to Iraq or Afghanistan when they attempted 
suicide in 2005 and 2006, 60 percent had been seen by outpatient mental 
health workers before the attempts. Forty-three percent of the deployed 
troops who attempted suicide had been prescribed psychotropic 
medications.
    The report offered no details on the type or duration of mental 
health care that troops received before they tried to kill themselves. 
A June 2007 Pentagon task force on mental health report, however, 
specifically notes the issue of quality of care, recommending that the 
military develop core training for all medical staff in recognizing and 
responding to service members ``in distress.'' This task force also 
concluded that mental health providers needed additional training in 
treating depression and combat stress.
    To its discredit, the Department of Defense has managed to keep 
what has clearly become what CBS News called a ``hidden epidemic'' 
under the radar of public awareness by concealing statistics about 
soldier suicides. They have done everything from burying suicides on 
official casualty lists as ``accidental non-combat deaths'' to outright 
lying to the parents of dead soldiers. Meanwhile the Army officially 
insists that they have yet to find a connection between PTSD, between 
the stresses of combat and the type of combat waged in Iraq and 
suicide.
    It may be true that, as Will Rogers once said, there are lies, 
there are damn lies, and there are statistics. But even the statistics 
the Pentagon admits to are telling. Unfortunately what is told is a 
grim story indeed, one of willful ignorance and recalcitrance to the 
point of malfeasance on the part of senior officials who do not move to 
correct these problems in both access to mental health care and quality 
of care when access is gained.
    Much of the problem that the VA will in fact be inheriting is 
caused by the failure of the Army Medical Department and the Navy 
Medical Department to properly address neuron-psychiatric wounds of 
war. More than four years into this war, one may well ask ``how can 
this be?''
    Part of the problem with the military is lack of organizational 
capacity caused by the questionable decision to downsize the military 
medical departments as we were going to war. The former Secretary who 
had overall responsibility is now gone, and the Assistant Secretary for 
Health brought in because his entire experience was cutting costs by 
reducing services for HMOs and insurance companies, and who actually 
did the dirty work is also gone. However, the real architect of this 
outrageous and irresponsible policy that has cost soldiers their lives 
and/or their health continues on in his job as Under Secretary of 
Defense. VVA was asked if we hold LTG James Peake accountable for 
creating the situation of too many grievously injured soldiers needs 
chasing too few clinicians and case managers, and we said no, because 
we do not know how hard he fought on the inside. VVA continued in its 
communication with the White House that we do question why David Chu 
still has a job, after all of his public utterances of disdain for 
injured soldiers, survivors of KIA, and more importantly the total 
failure of his policies.
    While VVA now understands that as of early this calendar year the 
Army was given 3,000 additional persons/slots in the Army Medical 
Department, it takes a long time to ``ramp up'' and we wonder how 
successful this all will be as long as David Chu is driving this train, 
aided by his top consultants at the unit of Rand Corporation led by 
Bernard Rostker, who has already done so much damage to Gulf War I 
veterans.
    There is a solution. It requires data collection, training, 
leadership and a cultural mind shift from the military, as well as the 
network of consultants and hangers on that surround the civilian 
officials who are at the head of DOD. Military leaders at all levels, 
beginning with basic trainees, should be taught what their roles and 
responsibilities are when warriors come home. This training should be 
as structured and well thought out as fielding a new weapons system. 
This includes Field manuals, training circulars, incorporation of 
training into Common Test Training (CTT) and Mission Essential Task 
Listings (METL).
    If we change the culture in the military to deal openly and 
honestly about the rigors of war when service members come home, then 
we can begin to mitigate the suicide issue. We don't have a lot of 
time. The longer we delay the worse the problem gets, and it becomes 
more devastating to the all-volunteer military.
    We've got the training for war part down cold. The missing 
component is training to come home. If we do it right, retention and 
recruiting will be high. Soldiers and families will grow and become 
stronger from their experiences.
    However, if we don't put as much emphasis on coming home as we do 
in going to war the implications will be felt for the next 20 to 40 
years. We can't continue to try and force the warriors to figure this 
out on their own, with no help from the command structure and a 
``grateful Nation.'' They have no reference point at which to begin 
recovery and become strong.
    When we begin teaching them how to come home it will become as 
ingrained as field stripping an M4. It will become reflexive instead of 
reactive; it will become proactive instead of passive. It will be 
something that a war fighter has to do as a natural part of going into 
and returning from battle. This will truly begin to remove the stigma 
in the military that has led to situations like that experienced by Lt. 
Elizabeth Whiteside, where the Army is still contemplating whether to 
court martial her for attempting suicide after 10 months in Iraq 
treating grievously injured soldiers, and rendering exemplary service, 
when it all came crashing in on her. Her command structure in Iraq 
created a hostile work environment as opposed to trying to be 
supportive, and getting her counseling help. Compounding this is the 
Command here in the Military District of Washington who even as we 
speak today is still contemplating whether to be vindictive and try to 
punish this fine young soldier by means of a court martial, possible 
jail time, and stripping her of all Army and VA benefits, instead of 
helping her to receive proper treatment. This case exposes just how far 
we have to go to change the military culture in order to stop the 
punishing of war fighters for experiencing psychiatric wounds.
    Words alone won't fix this problem. There is lots of hard work 
ahead. VVA asks that this distinguished panel partner with the 
Committee on Armed Services and others in the House to please convince 
someone in the Pentagon to start listening.
    The Service Chiefs need to launch a Nationwide Anti-Stigma 
Campaign, for starters.
    Active-duty soldiers, however, are only part of the story. One of 
the well-known characteristics of PTSD is that the onset of symptoms is 
often delayed, sometimes for decades. Vietnam veterans are still taking 
their own lives because new PTSD symptoms have been triggered, or old 
ones retriggered, by stories and images from these new wars. Their 
deaths, like the deaths of more recent veterans, are written up in 
hometown newspapers; they are locally mourned, but officially ignored 
because the VA does not track or count them unless they are part of the 
VA registry. Both the VA and the Pentagon deny that the problem exists 
and sanctimoniously point to a lack of evidence they have refused to 
gather.
    In yet another example of dancing around the issue, the VA 
announced last spring that it was setting up a ``suicide prevention 
hotline'' for veterans. This program is headquartered in Canandaigua, 
New York, in cooperation with the National Suicide Prevention Resource 
Center and the Substance Abuse and Mental Health Services 
Administration. As part of its anti-suicide effort, the VA announced 
that it was going to hire ``suicide counselors'' at each of its 153 
medical centers. According to VA hotline administrators, as of late 
November 2007, 92 percent of the now-titled suicide coordinator 
positions had been filled and the national hotline center had handled 
more than 15,000 calls between July 1 and November 17--while also 
admitting that the tracking of calls is voluntary. The VA noted that 
4,900 callers self-identified as veterans, 164 as active-duty military; 
and that 600 calls came from concerned family and friends. Some 1,600 
referrals were made to VA facilities, 100 referrals to Vet Centers.
    At first glance, the call data are impressive and the VA is to be 
congratulated in this endeavor. Yet real questions remain: How many 
suicides have been prevented through this intervention, particularly in 
light of the fact that the hotline call tracking is voluntary? And is 
suicide prevention intervention and care available 24/7 across the VA 
system, including both community outpatient clinics and medical 
centers?
    Finally, much has been made of the recent CBS News investigative 
report on suicides of veterans, especially of the data collection and 
analyses. VVA's concern is not that the reported figures are too high 
or too low. VVA's position on suicide, however, is clear: one soldier/
veteran suicide is one too many, and there have been far too many. 
Let's not quibble about how accurate the numbers are; rather, let's 
focus on the issues of why veterans take their lives and what we, 
collectively, can do to get more veterans into the counseling that 
might save their lives.
    Congress recently passed, and the President signed, the ``Joshua 
Omvig Veterans Suicide Prevention Act,'' which mandates better suicide 
prevention training for VA staff, a referral system to make sure that 
vets at risk receive care, and the opening of a 24-hour veterans' 
suicide hotline. While VVA lauds this bi-partisan effort, we implore 
you to revisit the situation with regularity, and ask hard questions 
that must be answered. With the exception of the creation of the 
suicide hotline, how are the other mandates being translated into 
suicide prevention programs, services, and training? What agency or 
entity is accountable for them? And can DOD and the VA be directed to 
provide truthful, accurate suicide statistics?
    The faceless IED-fueled sniping that is killing and maiming scores 
of our troops, is part of the root cause of the severe psychological 
wounds that grips too many of our troops and veterans. Further, far 
from being nothing like the Vietnam war as alleged by some officials 
who were too busy with other pursuits to join the rest of us who went 
to Southeast Asia, the Iraq war is, as one of our longtime members who 
served as an infantry platoon leader with the 199th Brigade ``Red 
Catchers'' in Vietnam: ``Iraq is Vietnam without water.'' You cannot 
tell who the enemy is in most instances without an electric scoreboard, 
and then only after a particular action is finished. This uncertainty 
and constant pervasive danger causes deep and often chronic stress and 
often leads to Post Traumatic Stress Disorder later on. It is up to all 
of us, with your leadership, to do the very best that we can to 
mitigate the horrors of combat by providing enough help and guidance to 
the men and women who need it most. It is our obligation to continue to 
search for answers, and not utter the empty claims that combat has 
little or nothing to do with the suicides of troops who have 
experienced it.
    The Nation now clearly understands the gaps in care as outlined by 
multiple military commissions. The service chiefs have ensured that our 
service members were taught how to go to war and with the right 
equipment. What remains missing and what we are identifying as a 
fundamental gap in suicide prevention and all reintegration training is 
teaching the force the fundamental skills of ``how to come home.''
    To truly address suicides we must change the way our Nation and the 
Military respond to the trauma of war and the complexities of 
deployment. Moreover, we need to evaluate the way we define and 
understand stress and trauma large scale.
    No veteran should ever feel so left behind that suicide feels like 
a viable option. We owe them so much more than rhetoric. Let's start by 
training them to come home. Then they will be resourced to seek out 
existing service and programs and the stigma of seeking help will be 
minimized.
    The Army's Creed, the Warrior Ethos, and even VVA's motto of 
``Never again shall one generation of American veterans abandon another 
generation''--are meaningless without the doing. And the doing requires 
that we live by and die by our beliefs and the only thing we hold on to 
is the knowledge that our country will be there for us if we need them.
    The Warrior Ethos: written in Soldiers Magazine, July 2006, by 
Peter J. Schoomaker talks about the common thread that has tied us all 
together throughout 230 years of service to our Nation. Since 1775, 
American Soldiers have answered the call to duty. From Valley Forge to 
the battlefields of Gettysburg; from the Argonne Forest to the shores 
of Normandy; from the rice paddies of Korea and Vietnam to the 
mountains of Afghanistan and the streets of Baghdad; our military 
history is rich with the willingness of generation after generation to 
live by the Warrior Ethos. Service members will continue to live by 
these creeds, the question is does the creed extend to them when they 
come home, after the war.
    We thank you for the opportunity to speak to this issue on behalf 
of America's veterans, and we will work with you to find answers that 
our mentally wounded warriors desperately need. I would be pleased to 
answer any questions you may have.
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Department of Veterans Affairs
                                         Under Secretary for Health
                                                    Washington, DC.

                                                 In Reply Refer To:
Dear Veteran,

    If you're experiencing an emotional crisis and need to talk with a 
trained VA professional, the National Suicide Prevention toll-free 
hotline number, 1-800-273-TALK (8255), is now available 24 hours a day, 
seven days a week. You will be immediately connected with a qualified 
and caring provider who can help.

    Here are some suicide warning signs:

    1.  Threatening to hurt or kill yourself.
    2.  Looking for ways to kill yourself.
    3.  Seeking access to pills, weapons or other self destructive 
behavior.
    4.  Talking about death, dying or suicide.

    The presence of these signs requires immediate attention. If you or 
a veteran you care about has been showing any of these signs, do not 
hesitate to call and ask for help!

    Additional warning signs may include:

    1.  Hopelessness.
    2.  Rage, anger, seeking revenge.
    3.  Acting reckless or engaging in risky activities, seemingly 
without thinking.
    4.  Increasing alcohol or drug abuse.
    5.  Feeling trapped--like there's no way out.
    6.  Withdrawing from friends and family.
    7.  Anxiety, agitation, inability to sleep--or, excessive 
sleepiness.
    8.  Dramatic mood swings.
    9.  Feeling there is no reason for living, no sense of purpose in 
life.

    Please call the toll-free hotline number, 1-800-273-TALK (8255) if 
you experience any of these warning signs. We'll get you the help and 
assistance you need right away!

            Sincerely yours,
                               Michael J. Kussman, M.D., M.S., MACP
                               __________
               VA Suicide Crisis Hotline (1-800-273-TALK)
                            Who Should Call?
      Anyone, but especially those who feel sad, hopeless, or 
suicidal.
      Family and friends who are concerned about a loved one 
who may be having these feelings.
      Anyone interested in suicide prevention, treatment and 
service.
                             1-800-273-TALK
      The service is free and confidential.
      The hotline is staffed by trained counselors.
      We are available 24 hours a day, 7 days a week.
      We have information about support services that can help 
you.
                          Crisis Response Plan
    When thinking about suicide, I agree to do the following:

    Step 1:  Try to identify my thoughts and specifically what's 
upsetting me.
    Step 2:  Write out and review more reasonable responses to my 
suicidal thoughts.
    Step 3:  Do things that help me feel better for about 30 min (e.g., 
taking a bath, listening to music, going for a walk).
    Step 4:  If your suicidal thoughts persist, call 1-800-273-TALK
    Step 5:  If the thoughts continue, get specific, and I find myself 
preparing to do something, call 911.
    Step 6:  If I'm still feeling suicidal and don't feel like I can 
control my behavior, I go to the emergency room.

    REMEMBER: The VA Suicide Hot Line is 1-800-273-TALK.

    Get Mental Health Follow-up 1-202-745-8267 for an APPOINTMENT.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 

          POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                  December 14, 2007

Honorable Gordon H. Mansfield
Acting Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Mr. Secretary:

    In reference to our Full Committee hearing on ``Stopping Suicides: 
Mental Health Challenges Within the Department of Veterans Affairs'' on 
December 12, 2007, I would appreciate it if you could answer the 
enclosed hearing questions by the close of business on January 28, 
2008.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
committee and subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,
                                                         BOB FILNER
                                                           Chairman

                               __________

                        Questions for the Record
                   The Honorable Bob Filner, Chairman
                   House Veterans' Affairs Committee
                           December 12, 2007
              Stopping Suicides: Mental Health Challenges
               Within the Department of Veterans Affairs
                       For Ira Katz, M.D., Ph.D.

    Question 1: The Walter Reed Institute of Research recently 
published a study assessing mental health problems among veterans 
returning from Iraq, which found that 42.4 percent of National Guard 
and Reserve-component soldiers screened by the Department of Defense 
required mental health treatment. Given the very real risk of chronic 
health problems and even suicide among this population, we cannot 
afford a business-as-usual approach. What has VA done to provide needed 
mental health treatment to these servicemembers?

    Response: The Department of Veterans Affairs (VA) has expanded its 
mental health programs dramatically since the start of the current 
conflicts. Mental health expenditures in medical centers and clinics 
increased from approximately $2 billion in fiscal year (FY) 2001 to 
over $3 billion in FY 2007. The Veterans Health Administration (VHA) 
developed its Comprehensive Mental Health Strategic Plan in 2004, and, 
by the end of FY 2008, it will have spent over $1 billion in its 
implementation, including hiring over 3,600 new staff to support 
specific programs. VA has established over 90 Operation Enduring 
Freedom/Operation Iraqi Freedom (OEF/OIF) teams to establish post-
deployment clinics in medical centers and to provide outreach and 
education in the community.
    In addition to the OEF/OIF teams, new initiatives have included 
improvements in access and capacity for mental health services 
throughout our system, integration of mental health services with 
primary care in over 100 facilities, transformation of specialty mental 
health services to focus on rehabilitation and recovery, implementation 
of evidence-based practices focused on specific psychotherapies, and 
establishment of a comprehensive national program for suicide 
prevention.
    In addition, VA has hired 100 peer staff for its Readjustment 
Counseling Service (Vet Centers) to provide outreach to returning 
veterans, and is in the process of expanding their staff and increasing 
the number of Vet Centers from 209 to 232.
    For returning veterans, VA provides outreach by sending staff to 
all post deployment health reassessments (PDHRA) and by providing 
education in Guard, Reserve, and community settings. We aggressively 
encourage enrollment through the five-year post discharge period of 
enhanced enrollment opportunity for all returning veterans who served 
in the theater of operations whether or not these veterans require 
medical services at the time. Once veterans are enrolled, we provide 
screening for post traumatic stress disorder (PTSD), depression, 
problem drinking, and traumatic brain injury (TBI), and clinical 
evaluations of those who screen positive to support diagnosis and 
treatment planning.

    Question 2: What additional authority do you need from us to assist 
you in addressing the mental health issues of today?

    Response: VA strongly supported an extension to the post two-year 
enhanced enrollment opportunity for returning veterans who have service 
in the theater of operations. We are most pleased that the recently 
passed National Defense Authorization Act of Fiscal Year 2008 provided 
this by extending the enrollment timeframe to five years post 
discharge.
    Public information campaigns can serve a number of goals including 
increasing awareness of the symptoms of warning signs of mental health 
problems, destigmatizing mental health concerns and help-seeking, and 
providing information about the availability and effectiveness of 
mental health services in VA medical centers, clinics, and Vet Centers. 
The tools available to VA in public information campaigns include press 
releases, public service announcements, and outreach through community 
events. These effective mechanisms can all be continued, and, in fact, 
extended within existing statutory authority.

    Question 3: What is VA currently doing and what more could they be 
doing to reach out to veterans who are at risk for suicide and are not 
currently being seen within the VA healthcare system?

    Response: VA provides outreach to returning veterans through 
participation in PDHRA events, through activities of 100 OEF/OIF peer 
support specialists hired by Vet Centers, and through community-based 
outreach activities of staff from both Vet Centers and medical centers 
or clinics. One important type of outreach is through publicity for the 
1-800-273-TALK hotline. Through this program, a number of veterans have 
been referred to local facilities where suicide prevention coordinators 
have helped them enroll in VHA. Another type of outreach is ``guide'' 
training from suicide prevention coordinators in medical centers. 
Through this program, the coordinators educate members of the community 
who have contact with veterans about symptoms of mental health 
conditions, warning signs and risk factors for suicide, and procedures 
for guiding veterans toward care.
    An important additional activity that is currently under 
development is collaboration with the Department of Defense (DoD) on 
follow-up for those who screen positive on post deployment health 
assessments (PDHA) or PDHRA assessments. There is, by now, good 
evidence that these programs allow the identification of returning 
veterans with symptoms of mental health conditions, and that they 
support referrals for those with mental health problems. However, it 
would be helpful to provide further follow-up to ensure that those 
veterans most in need were, in fact, receiving care. Providing follow-
up to those who report symptoms could help to ensure that they receive 
effective treatment.

    Question 4: VA has recently expanded their suicide prevention 
activities to include suicide prevention coordinators at each facility 
as well as a 1-800 hotline. Could you give us a brief assessment on the 
effectiveness of the program? How are you tracking the effectiveness of 
the program?

    Response: VA's comprehensive program for suicide prevention 
includes increased public awareness of the importance of mental health 
conditions, and both the availability and effectiveness of treatment; 
overall enhancements in the capacity and scope of mental health 
service; centers of excellence for research and technical assistance; 
and a specific prevention system including both the 1-800-273-TALK 
hotline, and suicide prevention coordinators in each medical center.
    The most significant way to evaluate the effectiveness of the 
program will be to follow suicide rates among veterans receiving VA 
healthcare, the entire Nation's veteran population, and the population 
at large. Rates are currently being evaluated and will continue to be 
monitored in the future. Data on mortality and causes of death for 
veterans using medical centers and clinics are available by merging VA 
clinical and administrative records with data obtained from the Center 
for Disease Control and Prevention's (CDC) National Death Index; on 
suicide rates in the entire veteran population in a subset of States 
are available through the CDC's National Violent Death Reporting 
System; and data on suicide rates for the U.S. population are available 
through the National Center for Health Statistics. Although no ``gold 
standard'' is available for evaluating the effectiveness of a suicide 
prevention program, the Air Force's program may serve as a benchmark. 
It was viewed as successful when several years of operation led to a 
reduction in suicide rates by one-third.
    There are also a number of methods that we are using to evaluate 
the prevention system made up of the hotline and the suicide prevention 
coordinators. These include tracking the calls to the hotline, 
referrals to the coordinators, and subsequent care. In addition, VA has 
developed procedures that allow the coordinators to identify 
individuals at high risk for suicide and to track suicide attempts. 
Therefore, other ways to evaluate the impact of further developments in 
our system would be to follow rates of suicide attempts and deaths from 
suicide among high risk patients.

    Question 5: VA recently put out a press release stating that it is 
``accelerating its own research to prevent these tragedies.'' Could you 
tell us what these activities involve?

    Response: VA has a significant infrastructure for the conduct of 
research on mental disorders and their treatment. This includes 10 
mental illness research, education, and clinical centers (MIRECCs), the 
seven divisions of the National Center for PTSD, a Center of Excellence 
of Integrated Care and three on mental illness and PTSD, two centers of 
excellence on substance abuse treatment and education, and two quality 
enhancement research initiatives, one on mental health, and one on 
substance use disorders, as well as a robust program supporting 
investigator initiated research. The MIRECC at Denver and the Center of 
Excellence in Mental Health and PTSD at Canandaigua, New York, focus 
specifically on suicide prevention.
    Ongoing studies are addressing suicide risk factors, validation of 
suicide ideation screening instruments, structure/quality of mental 
healthcare and its relationship to suicide prevention, and risk factors 
for suicide as it relates to depression. Findings from two major 
studies were presented at the House Veterans' Affairs Committee hearing 
on December 12, 2007. One, conducted by VA's Office of Environmental 
Epidemiology, is an investigation of mortality and causes of death in 
returning OEF/OIF veterans. Another, conducted by VA's Serious Mental 
Illness Research Education and Clinical Center, is studying rates of 
suicide, risk factors, and local variability throughout the system. 
Research under development by the Center of Excellence at Canandaigua 
include clinical trials on the effectiveness of peer support for 
suicide prevention, and psychological autopsy studies involving 
linkages of VA medical centers with local coroners or medical 
examiners.
    VA plans to support several additional research programs and 
activities aimed at reducing and preventing suicide, including new 
research solicitations and a periodic update of a literature synthesis 
of best practices for suicide prevention.
    A new research solicitation will be issued shortly seeking studies 
to validate screening instruments and to identify successful strategies 
and interventions for suicide prevention. Of special interest in this 
solicitation are efforts to: improve the continuum of care for 
substance use disorders, improve earlier identification and treatment 
of post-traumatic stress disorders, and implement recovery-oriented 
treatment approaches, particularly evidence-based programs and peer 
support services.
    Examples of specific future research topics include:

      Evaluating strategies to improve earlier identification 
and treatment of PTSD and related mental health disorders (e.g., 
substance use and depression), especially in returning OEF/OIF 
veterans.
      Identifying risk factors and accuracy of assessment of 
suicidality and evaluating best practices for suicide prevention. 
Research on these topics will consider the suicide risks of veterans 
who are experiencing PTSD, especially among OEF/OIF and elderly 
veterans.
      Investigating the effectiveness of evidence-based 
recovery-oriented approaches to mental health treatment, such as 
cognitive-behavioral treatments, family psycho-education, supported 
employment, and social skills training.
      Assessing symptomatic as well as functional changes in 
patients.
      Evaluating evidence-based treatment strategies within the 
context of co-morbid social and medical issues.
      Comparing strategies used in mental health services for 
implementing recovery-oriented treatment programs.
      Assessing outcomes at the patient, provider, and system 
levels.
      Assessing the effectiveness of peer-support programs in 
supporting recovery and community reintegration in veterans with mental 
illness.
      Determining the appropriate mix and organization of 
services (e.g., detoxification, inpatient, residential, intensive 
outpatient, outpatient, psychosocial, and pharmacological) that will 
ensure access to the full continuum of care for patients with substance 
use disorders and varying life circumstances and co-occurring 
conditions.
      Evaluating methods of enhancing the integration and 
coordination of mental health services with substance abuse or medical 
(primary care and specialty) services, including the organization and 
management of services for patients with these co-morbid conditions.
      Improving the effectiveness and efficiency of behavioral 
health screens in VA's healthcare system.

    Question 6: Research has shown that the family is instrumental in 
the recovery of veterans with mental health concerns. Family members 
are affected by the mental health issues, as you heard in previous 
testimony from Mr. Bowman. Currently, VA's authority to provide mental 
health services to veterans receiving readjustment counseling services 
under section 1712 A of Title 38, United States Code, is limited to 
mental health services that are necessary to facilitate the successful 
readjustment of a veteran to civilian life and limited to the provision 
of counseling, training, and mental health services described in 38 USC 
1782 and 1783 (bereavement counseling) for the veterans immediate 
family. If eligibility to receive services were expanded for family 
members, what, in your professional opinion, would be the proper scope 
of these services?

    Response: Vet Centers are authorized to include families in 
readjustment counseling for combat veterans, and to provide bereavement 
counseling for families of fallen warriors. Family members also receive 
the services described in section 1782 (i.e., counseling, training, and 
certain mental health services) when needed for the effective 
readjustment of the veteran. Those same services are available to 
immediate family members of veterans receiving VA medical treatment 
when needed in connection with the veteran's treatment. Under current 
authorization, these services can begin at any time for veterans being 
treated for a service-connected disability, but it can begin only 
during an inpatient hospitalization for others (i.e., for treatment of 
a nonservice-connected disability). Both Vet Centers and medical 
facilities can include families in outreach and education, including 
education programs for veterans with serious mental illness. One modest 
extension to current authorization, included in S. 2162 and H.R. 4053, 
would be to allow the inclusion of families in care for veterans to 
begin whenever it is clinically appropriate, both for veterans with 
service-connected disability and others.
    Further consideration of caregiver support demonstrates a problem 
in defining an appropriate scope for the services that can be provided 
to families. For veterans with significant impairments in day-to-day 
functioning, family caregivers are often essential. Providing family 
members with caregiver effectiveness training, or counseling to reduce 
burn-out are appropriate services, with clear benefits for the veteran. 
Treating caregiver depression could also benefit the veteran, allowing 
a family caregiver to providing more effective support. However, this 
is not currently authorized. It is possible to view psychotherapy for 
depression as similar to counseling for burnout, and to make the case 
that it should be allowable. However, it is less clear if prescribing 
antidepressant medication should be allowable, or blood tests for 
thyroid disease to determine if there were medical causes for the 
depression, or changing medications for other conditions to reduce 
depression as a possible drug side-effect, or . . . The point is that 
there may be no obvious boundary between support for the family as part 
of care for the veteran, limited care for a caregiver, and overall 
healthcare for family members. VA is currently addressing this issue 
through workgroups and funding of pilot studies on caregiver support.
    There is, however, one area in which additional authorization may 
help VA provide more effective outreach to returning veterans by 
working with their families. There are cases, like the Omvig's, where 
families may be concerned about mental health problems, but where the 
veteran may not be willing to seek an evaluation or care. In these 
cases, it may be useful for VA to be able to meet with families to 
evaluate the situation and determine whether there is likely to be a 
mental disorder that requires treatment, to provide education and 
coaching to the family about how to manage problem behaviors, and to 
work with the family to develop a strategy to encourage the veteran to 
seek care. Much of this is being accomplished through programs for 
education and outreach using existing legislative authority. However, 
additional authorization may allow more intensive interactions between 
VA staff and families.
                         For Kara Zivin, Ph.D.

    Question 1: In your testimony, you talked a lot about research that 
VA is currently doing on mental illness and suicide. In your 
professional opinion, what are the gaps in the current research in 
these areas, particularly in how they relate to veterans? What more 
research should VA be doing in these areas?

    Response: VA has the unique opportunity not only to attempt to 
reduce suicide rates among veterans, but also to learn what suicide 
prevention strategies are effective, so that effective rather than 
ineffective strategies can use used for veterans and the U.S. 
population, and by doing so has the potential to advance the science of 
suicide prevention. VA is the only healthcare organization that 
regularly tracks suicide rates, is highly organized, and treats a large 
enough population so the effectiveness of prevention strategies can be 
determined.
    VA is currently making a tremendous effort to prevent suicide. 
There are new and ongoing programs such as those located at the 
Veterans Integrated Service Networks (VISN) 2 Center of Excellence in 
Canandaigua, New York, which encompasses the national VA hotline/crisis 
line active monitoring of suicide prevention initiatives (SPI) and 
extensions of suicide research and education. Research is being 
implemented to examine the hotline's suicide outcomes and the health 
impact including treatment engagement and healthcare utilization. The 
SPI relate to a series of efforts that are unfolding, such as 
implementing suicide prevention coordinators at all VA medical centers, 
cognitive behavioral therapy among high risk inpatients, screening 
efforts pre- and post-deployment, among others. Finally, the 
Canandaigua Center of Excellence is designed to develop new knowledge 
regarding suicide prevention, and is currently focusing on older 
adults, women, people with alcohol problems, and now developing new 
efforts to engage returning OEF/OIF veterans.
    In addition to specific initiatives, the VA's Serious Mental 
Illness Treatment Research and Evaluation Center (SMITREC) in Ann 
Arbor, Michigan, is pursuing major research program and planning around 
suicide prevention. Research and research infrastructure are needed 
across the board, and VA's efforts to promote collaboration across VISN 
boundaries in a coordinated way, and capitalizing on expertise in its 
centers of excellence and MIRECCs is well conceived. It is important 
for VA to conduct ongoing evaluations of these suicide prevention 
programs to refine and improve their effectiveness.
    In particular, we need to learn more about good surveillance tools 
to track changes over time in suicide attempt rates, or hot spots for 
intervention. We need to be able to identify risk factors, regional 
variation, differences in rates and characteristics associated with 
suicide between veterans treated in VA and veterans treated outside VA, 
as well as understanding more about veteran engagement in mental 
healthcare. Continued efforts are essential to educate veterans and 
their families about warning signs for suicide and educate providers on 
suicide prevention and assessment. We need to learn more about how to 
improve the means of suicide prevention as well as best practices 
following suicide attempts. VA is assessing the relative impact of 
specific treatment practices on suicide risks and relative risk periods 
for suicide deaths. VA should also evaluate the effectiveness of 
screening tools, treatment guidelines, incentives, and collaborative 
care models. Ideally VA researchers would assess the unique risk and 
protective factors of the cohort of interest and test interventions.
    With newer cohorts of OEF and OIF veterans, studies of smaller 
groups of veterans could include the National Guard and as well as 
enlisted personnel to better understand their most vulnerable periods, 
key risk factors, and what treatments seem most effective. Families 
should be involved in this research to understand their perceptions of 
risk and how they can be of most support. Evaluation of family and 
patient satisfaction with VA care should be included in this research.
    These efforts should be made in conjunction with VA's research 
program and other well known suicide prevention researchers, so that 
serious efforts to reduce suicide can be accompanied by solid research 
that allows Congress and the U.S. public to determine and use the most 
effective approaches.
    These research efforts originating in VA will benefit both veterans 
and the general U.S. population, because there are few systematic 
studies of any U.S. individuals at risk for suicide over a period of 
time. Such research will help identify periods of vulnerability and 
helpful treatments that prevent suicide deaths or attempts, 
particularly among those who have experienced trauma. We know that 
restricted access to lethal means and physician education are effective 
treatments, as well as psychotherapy and medications for mental 
disorders such as depression and bipolar disorder.
    Because the existing published research on suicide fatalities is 
limited, and conducting this form of research is difficult, VA is 
uniquely positioned to conduct this research and improve our 
understanding of how to best help veterans at risk for suicide.
                    The Honorable Harry E. Mitchell
                       For Ira Katz, M.D., Ph.D.

    Question 1: All documents which contain, refer, or relate to 
requests by any providers of mental health services for veterans, 
including, but not limited to requests by providers in the Veterans 
Integrated Service Network (VISN) to the Veterans Health Administration 
(VHA) for additional resources which were denied, or responded to with 
less than the amount of resources requested, where such resources would 
have been used for any of the following:

    1.  The collection of information relating to veterans at risk for 
suicide;
    2.  The tracking of suicides committed by veterans, including, but 
not limited to veterans who have sought assistance from VA;
    3.  Outreach to veterans who are or may be at risk of suicide;
    4.  Outreach to families of veterans relating to suicide prevention 
and/or benefits for families of veterans who have committed suicide; 
and
    5.  Research into the causes of suicide and/or treatment for 
depression, post-traumatic stress disorder or any other diagnosable 
condition which may increase the risk of suicide among veterans.

    Response: During FY 2007, $306 million was allocated to the Mental 
Health Enhancement Initiative administered by Office of Mental Health 
Services to fund specific programs designed to advance the 
implementation of the Mental Health Strategic Plan and to respond to 
the needs of returning veterans. By the end of the year, substantially 
over $320 million was, in fact awarded. At the beginning of FY 2007, 
overall mental health expenditures for the year were estimated to be 
over $2.8 billion. By the end of the year, over $3.2 billion was spent. 
For FY 2008, approximately $370 million was allocated for the Mental 
Health Enhancement Initiative. All of this was committed for 
continuation of programs initiated in prior years. Based on current 
projections, a substantial increase in enhancement funding is 
anticipated for next year. The Office of Mental Health Services is 
currently developing plans for use of these funds to establish a 
uniform services package for mental health. Last year, $120 million was 
appropriated in emergency supplemental funding for mental health and 
substance abuse. These funds are still being allocated and a number of 
requests for funding are under consideration at this time.
    In general, requests for funding may come from providers or 
investigators to medical centers, centers of excellence, VISNs, or any 
of a number of offices in VA Central Office. Most of VA's research on 
mental disorders and their treatment is funded through investigator 
initiated grant proposals submitted to the Office of Research and 
Development. I am not personally aware of all requests to entities and 
offices other than the Office of Mental Health Services. But as Deputy 
Chief Patient Care Services Officer for Mental Health and Director of 
the Office of Mental Health Services, I am not aware of any proposals 
for programs in any of the above categories for which funding was 
denied.

                                 

                                      Congress of the United States
                                      U.S. House of Representatives
                                                    Washington, DC.
                                                   February 8, 2008

The Honorable James Peake, M.D.
Secretary
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Mr. Secretary:

    I am seriously concerned about the response I received today, more 
than a week after it was due, to my document request relating to the 
House Veterans' Affairs Committee's hearing on December 12, 2007.
    I asked for documents referring or relating to any requests for 
additional resources to track veteran suicides and/or provide mental 
health services for veterans at risk for suicide.
    Instead of documents, I received a response from Deputy Chief of 
Patient Care Services for Mental Health Ira Katz stating that he was 
``not aware'' of ``proposals for any new programs . . . for which 
funding was denied.''
    I specifically asked for documents relating to ``requests . . . for 
additional resources,'' not just ``proposals for new programs,'' nor 
did I request a recap of how much funding Congress appropriated to the 
Mental Health Enhancement Initiative in FY 2007.
    I believe the response I received is incomplete.
    If, for example, Dr. Katz is aware of any requests for additional 
mental health counselors, facilities or equipment, I would like to 
know. I would also appreciate an opportunity to review any related 
documentation.
    I have an obligation as a member of the Committee on Veterans' 
Affairs, and the Chairman of its Subcommittee on Oversight and 
Investigations, to help ensure that the Department of Veterans Affairs 
has the resources it needs to help veterans at risk for suicide.
    I hope the urgency with which the VA has treated my request is not 
a reflection of the priority the VA assigns to this issue.
    Enclosed are a copy of my request as well as the response I 
received.
    I look forward to a complete response as soon as possible. If you 
have any questions, or require further clarification, please do not 
hesitate to contact me.
    Thank you for your assistance.

            Sincerely,
                                                  Harry E. Mitchell
                                                 Member of Congress

Enclosure (1)

Cc:  The Honorable Bob Filner, Chairman, House Veterans' Affairs 
Committee 
David Tucker, Chief Counsel, House Veterans' Affairs Committee

                               __________
                    The Honorable Harry E. Mitchell
                       For Ira Katz, M.D., Ph.D.

    Question 1: All documents which contain, refer, or relate to 
requests by any providers of mental health services for veterans, 
including, but not limited to requests by providers in the veteran 
Integrated Service Network to the Veterans' Health Administration (VHA) 
for additional resources which were denied, or responded to with less 
than the amount of resources requested, where such resources would have 
been used for any of the following:

    1.  The collection of information relating to veterans at risk for 
suicide;
    2.  The tracking of suicides committed by veterans, including, but 
not limited to veterans who have sought assistance from VA;
    3.  Outreach to veterans who are or may be at risk of suicide;
    4.  Outreach to families of veterans relating to suicide prevention 
and/or benefits for families of veterans who have committed suicide; 
and
    5.  Research into the causes of suicide and/or treatment for 
depression, post traumatic stress disorder or any other diagnosable 
condition which may increase the risk of suicide among veterans.

    Response: During FY 2007, $306 million was allocated to the Mental 
Health Enhancement Initiative administered by Office of Mental Health 
Services to fund specific programs designed to advance the 
implementation of the Mental Health Strategic Plan and to respond to 
the needs of returning veterans. By the end of the year, substantially 
over $320 million was, in fact awarded. At the beginning of FY 2007, 
overall mental health expenditures for the year were estimated to be 
over $2.8 billion. By the end of the year, over $3.2 billion was spent. 
For FY 2008, approximately $370 million was allocated for the Mental 
Health Enhancement Initiative. All of this was committed for 
continuation of programs initiated in prior years. Based on current 
projections, a substantial increase in enhancement funding is 
anticipated for next year. The Office of Mental Health Services is 
currently developing plans for use of these funds to establish a 
uniform services package for mental health. Last year, $120 million was 
appropriated in emergency supplemental funding for mental health and 
substance abuse. These funds are still being allocated and a number of 
requests for funding are under consideration at this time.
    In general, requests for funding may come from providers or 
investigators to medical centers, centers of excellence, VISNs, or any 
of a number of offices in VA Central Office. Most of VA's research on 
mental disorders and their treatment is funded through investigator 
initiated grant proposals submitted to the Office of Research and 
Development. I am not personally aware of all requests to entities and 
offices other than the Office of Mental Health Services. But as Deputy 
Chief Patient Care Services Officer for Mental Health and Director of 
the Office of Mental Health Services, I am not aware of any proposals 
for programs in any of the above categories for which funding was 
denied.

                               __________

                                U.S. Department of Veterans Affairs
                                                    Washington, DC.
                                                  February 27, 2008

The Honorable Harry E. Mitchell
U.S. House of Representatives
Washington, DC 20515

Dear Congressman Mitchell:

    This is in response to your recent letter asking for more 
information about requests for additional resources relating to veteran 
suicides. This question has been reviewed once more, and no unfunded 
requests from Department of Veterans Affairs (VA) facilities or staff 
for resources directly related to suicide prevention were identified.
    Your more recent request for information about requests from the 
field for additional mental health counselors, facilities, or equipment 
beyond those specifically related to suicide prevention is more 
complex. In fiscal years 2005 through 2007, the Office of Mental Health 
Services issued a number of requests for proposals to enhance mental 
health programs. These proposals were competitively reviewed, and 
funding decisions were made at times on the basis of need, and at other 
times, on the basis of merit. The office also solicited requests for 
nonrecurring, maintenance funds for space-related needs that are being 
considered at this time.
    As part of its ongoing activities, VA's Office of Research and 
Development regularly receives applications for research awards in 
mental health as well as other areas; these may include requests for 
mental health counselors or equipment to support specific research 
activities.
    Finally, there are mental health components included in a number of 
ongoing evaluations about major renovations and construction for 
facilities. I would appreciate it if you could provide additional 
details about the type of information you require to guide us in 
preparing documents for your review.
    I have been advised that my staff has contacted members of your 
staff to arrange a meeting to respond to any remaining questions or 
concerns. Thank you for your continued interest in our Nation's 
veterans.

            Sincerely yours,

                                               James B. Peake, M.D.
                                                          Secretary

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                  December 14, 2007

John D. Daigh, Jr., M.D., CPA
Assistant Inspector General
Office of Healthcare Inspections
U.S. Department of Veterans Affairs
Washington, DC 20420

Dear John:

    In reference to our Full Committee hearing on ``Stopping Suicides: 
Mental Health Challenges Within the Department of Veterans Affairs'' on 
December 12, 2007, I would appreciate it if you could answer the 
enclosed hearing questions by the close of business on January 28, 
2008.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax at 202-225-2034. If you have any questions, please 
call 202-225-9756.

            Sincerely,

                                                         BOB FILNER
                                                           Chairman

                               __________

                                U.S. Department of Veterans Affairs
                                        Office of Inspector General
                                                    Washington, DC.
                                                   January 24, 2008

The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
United States House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    Enclosed are responses to questions from the December 12, 2007, 
hearing before the Committee on ``Stopping Suicides: Mental Health 
Challenges Within the Department of Veterans Affairs.''
    Thank you for your interest in the Department of Veterans Affairs.

            Sincerely,

                                           JOHN D. DAIGH, JR., M.D.
             Assistant Inspector General for Healthcare Inspections

Enclosure

                               __________
                Questions from the Honorable Bob Filner
                       For Michael Shepherd, M.D.
              Physician, Office of Healthcare Inspections
    Office of Inspector General, U.S. Department of Veterans Affairs
           Before the Committee on Veterans' Affairs Hearing
             ``Stopping Suicides: Mental Health Challenges
              Within the Department of Veterans Affairs''
                           December 12, 2007

1.  In your testimony you stress the need for a comprehensive suicide 
prevention program.

       What is your assessment of the VA's suicide prevention 
program?

    In our report, Implementing VHA's Mental Health Strategic Plan 
(MHSP) Initiatives for Suicide Prevention, the extent of implementation 
was assessed along a spectrum of five stages: no action; in planning; 
evidence of ongoing or completed pilot or demonstration projects; 
implemented throughout an entire Veteran Integrated Service Network 
(VISN) or multiple facilities in multiple VISNs (VISN-wide); and 
systemwide implementation.
    Our findings can be summarized as follows: In terms of crisis 
availability and outreach, we found VISN-wide but not systemwide 
implementation. Initiatives related to referral and tracking of at-risk 
veterans were also at a VISN-wide stage. Those related to screening, 
assessment of at-risk veterans, emerging best practice interventions, 
education, and development of an electronic suicide surveillance system 
were at a pilot stage. Because the VISN 19 Mental Illness, Education, 
Clinical Center (MIRECC) is operational and has evidenced significant 
collaboration with other MIRECC's, the MHSP initiative pertaining to 
research (support for a MIRECC focused on suicide prevention) was 
assessed as having achieved a systemwide level of implementation.

       In your estimation, what changes does VA need to make in 
ensuring an effective suicide prevention program as well as a 
comprehensive one?

    Whereas a public health approach has been applied to prevention of 
coronary artery disease (lowering cholesterol, aerobic exercise) or 
certain forms of cancer (smoking cessation) for more than a quarter 
century, approaching suicide prevention from a public health paradigm 
is a relatively recent development. Just as strategies to prevent lung 
cancer may differ from strategies to prevent cervical cancer, 
interventions that target a depressed elderly man with early cognitive 
impairment may differ from interventions that target a young returning 
veteran with post traumatic stress disorder (PTSD) and co-morbid 
alcohol use. Suicide prevention is thought to require integrated 
strategies, coordinated effort, and steadfast commitment to forward 
progress. In terms of changes VA could make, we would offer the 
following observations:

    Community-Based Outreach--In our report, we noted that while 
several facilities had implemented innovative community-based suicide 
prevention outreach programs, (e.g., facility presentations to New York 
Police Department officers who are Operation Iraqi Freedom/Operation 
Enduring Freedom (OIF/OEF) veterans, participation by mental health 
staff in local Spanish radio and television shows) the majority of 
facilities did not report community-based linkages and outreach aimed 
at suicide prevention. In addition, less than 20 percent of facilities 
reported utilizing the Chaplain Service for liaison and outreach to 
faith-based organizations in the community (e.g., inviting faith-based 
organizations in the area to a community meeting at the VA Medical 
Center (VAMC) to explain Veteran Health Administration (VHA) services 
available, having a VA Chaplain accompany the OIF/OEF coordinator to 
post-deployment events in the community). Although facilities would 
need to tailor strategies to consider local demographics and resources, 
a systemwide effort at community-based outreach appears prudent.

    Timeliness from Referral to Mental Health Evaluation--In our report 
we noted that while most facilities self-reported that three-fourths or 
more of those patients with a moderate level of depression or PTSD who 
are referred by primary care providers are seen within 2 weeks of 
referral, approximately 5 percent reported a significant 4-8 week wait. 
These patients are at risk for progression of symptom severity and 
possible development of suicidal ideation. VISN leadership should work 
with facility directors to ensure that once referred, patients with a 
moderate level of depression or PTSD symptoms are seen in a timely 
manner at any VAMC and Community-Based Outpatient Clinic (CBOC) where 
significant waits are an issue.

    Coordination between VHA and Non-VHA Providers--When patients 
receive mental health treatment at both VHA and non-VHA providers and 
facilities, seamless communication becomes an increasingly complex 
challenge. This fragmentation of care is particularly worrisome in 
periods of patient destabilization or following discharge from a 
hospital or residential mental health program. The Office of Mental 
Health Services should consider development of innovative methods, 
procedures, or agreements, that improve flow of information for 
patients receiving simultaneous treatment at VA and non-VA sector but 
adhere to relevant privacy statutes. In addition, the Readjustment 
Counseling Service and Office of Patient Care Service should pursue 
further efforts to heighten communication and record sharing for 
patients receiving both counseling at Vet Centers and treatment at 
VAMCs and/or affiliated CBOCs.

    Co-Occurring Combat Stress Related Illness and Substance Use--
Alcohol may contribute to the severity of a concurrent or underlying 
mental health condition such as major depression. In addition, the 
presence of alcohol may cause or exacerbate impulsivity and 
disinhibited behavior. Acute alcohol use is associated with suicide and 
suicide completers have high rates of elevated blood alcohol. A recent 
study published in the Journal of the American Medical Association 
(JAMA), Longitudinal Assessment of Mental Health Problems Among Active 
and Reserve Component Soldiers Returning from the Iraq War, in which 
Milliken et al., found that soldiers frequently reported alcohol 
concerns on the Post Deployment Health Assessment and Reassessments 
(PDHA and PDHRA) ``yet very few were referred to alcohol treatment.'' 
Alcohol misuse has been a common factor in OIF/OEF suicide cases that 
we have reviewed.
    Regardless of why a patient begins to abuse alcohol, physiologic 
and psychologic drives become entrained with frequent and/or excessive 
use, until the alcohol misuse ultimately takes on a life of its own 
that is independent of patient history and circumstance. Functional 
ability and quality of life become dually impacted by both underlying 
anxiety and depressive symptoms and co-morbid substance use issues. For 
patients with concurrent conditions, an effective treatment paradigm 
may entail addressing the primacy of not only anxiety/depressive 
conditions but also of co-morbid substance use disorders. Augmenting 
services that address substance use disorders co-morbid with combat 
stress related illness should therefore be given due consideration for 
inclusion in a program aimed at suicide prevention.

2.  In your professional opinion, does VA have the resources to 
implement an effective program?

    The Office of Inspector General has not reviewed VHA's resources 
and we cannot offer an opinion.

3.  In your report you made a number of recommendations about steps 
that VHA should undertake.

       Are there any that you believe VHA has not yet 
undertaken?

    While the VA has begun action on the recommendations in our report, 
the following have not been completed:

    Education of Nonclinical Staff--Subsequent to the OIG report, the 
VAMC Canandaigua Center of Excellence has developed a CD and guide for 
mandatory training of all VA nonclinical staff who interact with 
veterans about responding to crisis situations involving at-risk 
veterans. However, the process of actually disseminating training to 
first line nonclinical personnel is only just beginning.

    Education for Healthcare Providers--Implementation of a mandatory 
education program for healthcare providers about suicide risks and ways 
to address these risks is reportedly in the planning stages but has not 
yet been developed.

    Bi-Directional Information Exchange--Bi-directional exchange of 
health information between VA and the Department of Defense (DoD), 
which includes patients with mental health issues coming into VHA care 
from DoD and/or those leaving VHA care for re-deployment, is an 
unresolved issue that has been discussed at previous hearings including 
the House Committee on Veteran's Affairs October 24, 2007, hearing 
``Sharing of Electronic Medical Records between Department of Defense 
and Department of Veterans Affairs.''

    Establishing a Coordinated Mechanism for Implementing Emerging Best 
Practices--We recommended that VHA should establish a centralized 
mechanism to review ongoing suicide prevention strategies, to select 
among available emerging best practices for screening, assessment, 
treatment, and to facilitate systemwide implementation, in order to 
ensure a single VHA standard. The VA Center of Excellence's structural 
and philosophic organization aligns with the intent of this 
recommendation. The center's capacity, in actual practice, to evaluate, 
select, and facilitate systemwide implementation of emerging best 
practices will only become discernible over time.

4.  I know you are aware of the report by CBS that the rate of suicide 
among veterans aged 20 to 24 is several times the rate among the same 
age group in the general population.

       Do you know whether CBS's numbers are accurate?

    In the absence of underlying data from CBS, which we were unable to 
obtain, we cannot reliably comment on the accuracy of CBS's numbers.

5.  Have you been able to obtain the underlying data from CBS so you 
can determine whether CBS's numbers are correct? If not, why not?

    We requested the underlying data but were not able to obtain it. 
CBS informed us that they could not provide the data to us because of 
contractual arrangements and privacy protection agreements that CBS had 
made with various State vital statistic offices from which it had 
received the data.

6.  What are the data that one would need to determine the rate of 
suicide among veterans as compared to the general population?

    One would need to reliably determine who died by suicide, who is a 
U.S. veteran, and the number of general population at risk. If an 
electronic death certificate system were created that had a field for 
inputting cause of death; fields for salient epidemiologic factors; 
allowed for input from multiple sources including medical examiners, a 
decedent's physician, police reports, etc.; and was standardized across 
States, one might ascertain more accurate and timely data regarding who 
and how many have died by suicide. In addition, from a public health 
perspective, an electronic death certificate system could enhance 
epidemiologic analysis of other causes of mortality. This data could be 
matched to existing data bases of qualified U.S. veterans to determine 
a rate of suicide among more recent veterans. We are not aware of the 
existence of a reliable electronic database that would include 
qualified U.S. veterans who separated prior to 1973-74. Determining the 
number of veterans who separated before the mid-1970's and also the 
total number of veterans in the U.S. would therefore require merging of 
various databases combined with the use of estimative models.

7.  Do you know whether the VA in fact collects the necessary data to 
be able to determine suicide rates among veterans and to compare those 
rates to the general population?

    VHA does not collect data that would enable calculation of a 
suicide rate for all U.S. veterans or that would enable comparison to 
nonveterans on a national basis. VHA collects data to determine suicide 
rates among veterans who receive healthcare at VHA facilities, a 
population that can be accurately quantified using VHA databases.
    For 12 of the 17 States that participate in the National Violent 
Death Reporting System, VHA reported having indirectly calculated 
suicide rates among nonveterans in these States by subtracting veteran 
suicide rates from the rates for the general population. The derived 
nature of this calculation imposes limitations on the reliability of 
this measurement.

                                 

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                  December 21, 2007

The Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Peake:

    On December 12, 2007, the House Committee on Veterans' Affairs held 
a hearing to assess the programs that the Department of Veterans 
Affairs (VA) provides for veterans who are at risk for suicide. This 
hearing raised concerns regarding the discrepancy between the numbers 
of veteran suicides reported by VA as compared to those reported by CBS 
News on November 13, 2007.
    Accurate data is crucial in identifying risk factors and providing 
better treatment and suicide prevention programs. For this reason, we 
respectfully request that the Department of Veterans Affairs share 
their data on suicide among veterans with the Committee.
    Specifically, we request to have the number of veteran suicides for 
each year from 1995 through 2006, reported by year of death, age, race, 
gender and manner of suicide. Additionally, we ask for the methodology 
the Department uses to collect data on veteran suicides.
    Undoubtedly, you share our desire to ensure that every measure is 
taken to prevent our Nation's veterans from committing suicide. We 
would greatly appreciate your willingness to share any information you 
may have regarding this issue with the Committee.
    Thank you for your prompt consideration and attention to this 
request. Should you have any questions, please feel free to contact 
either Committee Staff Director, Malcom Shorter, at 202-225-9756 or 
Republican Staff Director, Jim Lariviere, at 202-225-3527.

            Sincerely,

  Bob Filner
                                                        Steve Buyer
  Chairman
                                                     Ranking Member

                               __________

                                  The Secretary of Veterans Affairs
                                                    Washington, DC.
                                                   February 5, 2008
The Honorable Bob Filner
Chairman
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    This is in response to your letter requesting data on suicide rates 
among veterans and the methodologies used by the Department of Veterans 
Affairs (VA) to collect data on veteran suicides.
    The enclosed information and worksheet contains data on veteran 
suicides from two separate projects. One is an ongoing study of 
mortality in Operation Enduring Freedom and Operation Iraqi Freedom 
(OEF/OIF) veterans being conducted by VA's Office of Environmental 
Epidemiology. Identification of veterans is based on information from 
the Department of Defense and includes all OEF/OIF servicemembers who 
were separated from active duty including National Guard and Reserve 
personnel. The second project is an ongoing study of suicide in 
veterans who have used Veterans Health Administration services from 
2000 onward and who were alive at the start of 2001. The study includes 
veterans of all eras.
    For both projects, information about the time and causes of death 
was derived from the National Death Index. Information contained in 
data files on causes of death from the National Death Index is only 
available through the end of 2005. I have also enclosed the methodology 
used for both projects.
    Your interest in our Nation's veterans is appreciated. A similar 
letter is being sent to Congressman Steve Buyer.

            Sincerely yours,
                                               James B. Peake, M.D.
Enclosures
                               __________
  Study of Operation Enduring Freedom/Operation Iraqi Freedom Veterans
Methodology

    Population: As part of our mortality study of veterans who served 
in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF), 
the Department of Veterans Affairs (VA) obtained the identities of 
490,346 OEF/OIF veterans who served as part of either OEF or OIF and 
were separated or deactivated from military service between October 
2001 and December 2005. This study will assess both overall mortality 
risk as well as cause-specific mortality risk. Among the cause specific 
mortality of particular interest are deaths due to motor vehicle 
accidents and suicides.
    Data Sources: The identities of the 490,346 OEF/OIF veterans, 
military service characteristics, and various demographic data were 
provided to VA by the Department of Defense Manpower Data Center. Vital 
statistics data pertaining to OEF/OIF veterans was determined by using 
VA's database, Beneficiary Identification and Records Locator 
Subsystem, and deaths reported to the Social Security Administration 
Death Master File. The Beneficiary Identification and Records Locator 
Subsystem file has the identities of all veterans who have applied for 
VA benefits (including death benefits), and the Social Security 
Administration Death Master File includes all deaths reported to that 
agency. All veterans were matched against the Beneficiary 
Identification and Records Locator Subsystem and Social Security 
Administration files using Social Security numbers. Cause of death data 
was obtained from the National Death Index. Since 1979, the Office of 
Vital Statistics in each State has reported deaths, including cause of 
death data to the National Center for Health Statistics, where the 
National Death Index is compiled. Causes of death were recorded using 
International Classification of Diseases codes 10th Revision (ICD-10). 
For traumatic deaths, including suicide, part of the ICD-10 codes 
records the method of injury. For suicides, the ICD-10 codes report the 
method of suicide. At the time this study began, the National Death 
Index had cause of death data through December 31, 2005. Using the 
aforementioned databases, VA identified a total of 818 deaths to 
include 144 suicides.
    The attached table has demographic and military service 
characteristics as well as death certificate data and method of suicide 
for the 144 suicides identified in this study.


  CHARACTERISTICS OF 144 SUICIDES AMONG OEF/OIF * VETERANS THROUGH 2005
------------------------------------------------------------------------
              Characteristic                  Frequency     Percentage
------------------------------------------------------------------------
Age at death
------------------------------------------------------------------------
  20-29                                              78            54.1
------------------------------------------------------------------------
  30-39                                              39            27.1
------------------------------------------------------------------------
  40-49                                              14             9.7
------------------------------------------------------------------------
  50-59                                              13             9.1
------------------------------------------------------------------------
Year of death
------------------------------------------------------------------------
  2002                                                7             4.9
------------------------------------------------------------------------
  2003                                               21            14.6
------------------------------------------------------------------------
  2004                                               48            33.3
------------------------------------------------------------------------
  2005                                               68            47.2
------------------------------------------------------------------------
Method of suicide
------------------------------------------------------------------------
  Poisoning                                           7             4.9
------------------------------------------------------------------------
  Hanging                                            30            20.8
------------------------------------------------------------------------
  Firearm                                           105            72.9
------------------------------------------------------------------------
  Jumping                                             1              .7
------------------------------------------------------------------------
  Sharp Object                                        1              .7
------------------------------------------------------------------------
Sex
------------------------------------------------------------------------
  Male                                              141            97.9
------------------------------------------------------------------------
  Female                                              3             2.1
------------------------------------------------------------------------
Race
------------------------------------------------------------------------
  White                                             118            81.9
------------------------------------------------------------------------
  Non-White                                          26            18.1
------------------------------------------------------------------------
Ever seen at VAMC
------------------------------------------------------------------------
  Yes                                                33            22.9
------------------------------------------------------------------------
Branch of service
------------------------------------------------------------------------
  Army                                               73            50.7
------------------------------------------------------------------------
  Marines                                            15            10.4
------------------------------------------------------------------------
  Air Force                                          33            22.9
------------------------------------------------------------------------
  Navy                                               23            16.0
------------------------------------------------------------------------
Rank
------------------------------------------------------------------------
  Officer                                             8             5.6
------------------------------------------------------------------------
  Warrant Officer                                     1             0.7
------------------------------------------------------------------------
  Enlisted                                          135            93.7
------------------------------------------------------------------------
Unit component
------------------------------------------------------------------------
  Active                                             68            47.2
------------------------------------------------------------------------
  Reserve                                            35            24.3
------------------------------------------------------------------------
  National Guard                                     41            28.5
------------------------------------------------------------------------
* These suicides were identified among a cohort of 490,346 OEF/OIF
  veterans selected for mortality follow-up through 2005.

         Study of Veterans Using Veterans Health Administration
Methodology

    Population: The Veterans Health Administration defined the 
population of VA patients at risk for suicide in each fiscal year as 
those who were alive at the start of the year, and who had received VA 
services during either that year or the prior one. This approach to 
identifying VA's patient population was developed in consultation with 
VA mental health leadership and assumes that patients seen in VA 
settings in the prior year would still be considered to be in active VA 
care and part of the at-risk patient population in the following year.
    Data Sources: This study used data from VA's National Patient Care 
Database to identify all veterans with inpatient or outpatient services 
utilization in any VA facility during the relevant years. Measures of 
vital status and cause of death were based on information from the 
National Death Index. The National Death Index is considered the ``gold 
standard'' for mortality assessment information and includes national 
data regarding dates and causes of death for all U.S. residents. This 
information is derived from death certificates filed in the Office of 
Vital Statistics for each State. National Death Index searches were 
performed for cohorts of VA patients who received any VA services 
during the relevant years, and who had no subsequent VA services 
through June 2006. This cost-efficient method for conducting National 
Death Index searches enables comprehensive assessment of vital 
statistics and cause of death among all veterans in the VA patient 
population. The National Death Index data request included Social 
Security number, last name, first name, middle initial, date of birth, 
race and ethnicity, sex, and State of residence. National Death Index 
search results often include multiple records that are potential 
matches. ``True matches'' were identified based on established 
procedures.
    Veterans' age and gender were identified from VA administrative 
files included in the National Patient Care Database. Age at the start 
of Fiscal Year 2001 was categorized as being either less than 30, 30 to 
39, 40 to 49, 50 to 59, 60 to 69, 70 to 79, or greater than or equal to 
80 years. Information regarding race and ethnicity was not consistently 
available in the National Patient Care Database for all VA patients. VA 
identified dates and causes of death using National Death Index data. 
Suicide deaths were identified using International Classification of 
Diseases codes X60 through X84, and Y87.0 (World Health Organization 
2004).
    VA is conducting a comprehensive program for preventing veteran 
suicides, and is conducting ongoing research to guide its prevention 
strategies. The VA Office of Mental Health staff is available to 
provide additional briefings to the Committee on rates, risks factors 
and strategies.

                                            Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                         FY 2001          FY 2002          FY 2003          FY 2004          FY 2005
                           Characteristic                           ------------------------------------------------------------------------------------
                                                                        N       %        N       %        N       %        N       %        N       %
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total *                                                               1403   100       1737    100.0    1600    100.0    1702    100.0    1784    100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total, age 20                                                         1401   100       1734    100.0    1598    100.0    1701    100.0    1781    100.0
  and over
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sex
--------------------------------------------------------------------------------------------------------------------------------------------------------
Male                                                                  1360     97.1    1682     97.0    1559     97.6    1647     96.8    1720     96.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Female                                                                  41      2.9      52      3.0      39      2.4      54      3.2      61      3.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
Age Group
--------------------------------------------------------------------------------------------------------------------------------------------------------
20-29 yrs                                                               26      1.9      44      2.5      38      2.4      50      2.9      38      2.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
30-39 yrs                                                              108      7.7     119      6.9     111      6.9     105      6.2     105      5.9
--------------------------------------------------------------------------------------------------------------------------------------------------------
40-49 yrs                                                              240     17.1     283     16.3     272     17.0     256     15.0     254     14.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
50-59 yrs                                                              359     25.6     437     25.2     407     25.5     424     24.9     470     26.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
60-69 yrs                                                              202     14.4     261     15.1     264     16.5     272     16.0     291     16.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
70-79 yrs                                                              320     22.8     393     22.7     345     21.6     381     22.4     380     21.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
80+ yrs                                                                146     10.4     197     11.4     161     10.1     213     12.5     243     13.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Race
--------------------------------------------------------------------------------------------------------------------------------------------------------
White Hispanic                                                          30      2.1      25      1.4      32      2.0      24      1.4      29      1.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Black Hispanic                                                           2      0.1       1      0.1       1      0.1       2      0.1       2      0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Native                                                                   2      0.1       6      0.3       3      0.2       2      0.1       7      0.4
  American
--------------------------------------------------------------------------------------------------------------------------------------------------------
African                                                                 55      3.9      80      4.6      47      2.9      62      3.6      78      4.4
  American
--------------------------------------------------------------------------------------------------------------------------------------------------------
Asian/Pacific                                                            0      0.0       4      0.2       2      0.1       3      0.2      16      0.9
  Islander
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caucasian                                                              895     63.9    1078     62.2     894     55.9     814     47.9    1142     64.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Unknown                                                                417     29.8     540     31.1     619     38.7     794     46.7     507     28.5
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Includes age <20 years old.



                                            Number of Suicides Among VHA Veterans for Fiscal Years 2001-2005
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                         FY 2001          FY 2002          FY 2003          FY 2004          FY 2005
                           Characteristic                           ------------------------------------------------------------------------------------
                                                                        N       %        N       %        N       %        N       %        N       %
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total *                                                               1403    100.0    1737    100.0    1600    100.0    1702    100.0    1784    100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total, age 20 and over                                                1401    100.0    1734    100.0    1598    100.0    1701    100.0    1781    100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mechanism of Suicide
--------------------------------------------------------------------------------------------------------------------------------------------------------


X60                                                                        Intentional self-poisoning (suicide) by and exposure to non-opioid          5          0.4            4          0.2            8          0.5            5          0.3           12          0.7
                                                                                               analgesics, anti-pyretics, and anti-rheumatics
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X61                                                                    Intentional self-poisoning (suicide) by and exposure to antiepileptic,         39          2.8           49          2.8           38          2.4           43          2.5           53          3.0
                                                                    sedative-hypnotic anti-parkinsonism, and psychotropic drugs, not elsewhere
                                                                                                                                   classified
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X62                                                                     Intentional self-poisoning (suicide) by and exposure to narcotics and         26          1.9           42          2.4           30          1.9           27          1.6           48          2.7
                                                                                   psychodysleptics (hallucinogens), not elsewhere classified
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X63                                                                 Intentional self-poisoning (suicide) by and exposure to other drugs acting         1          0.1            3          0.2            1          0.1            0          0.0            2          0.1
                                                                                                              on the autonomic nervous system
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X64                                                                         Intentional self-poisoning (suicide) by and exposure to other and        100          7.1           97          5.6          103          6.4          112          6.6          102          5.7
                                                                                    unspecified drugs, medicaments, and biological substances
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X65                                                                          Intentional self-poisoning (suicide) by and exposure to alcohol.          2          0.1            2          0.1            5          0.3            0          0.0            1          0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X66                                                                  Intentional self-poisoning (suicide) by and exposure to organic solvents          2          0.1            3          0.2            1          0.1            6          0.4            3          0.2
                                                                                                and halogenated hydrocarbons and their vapors
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X67                                                                   Intentional self-poisoning (suicide) by and exposure to other gases and         34          2.4           62          3.6           35          2.2           59          3.5           50          2.8
                                                                                                                                       vapors
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X68                                                                       Intentional self-poisoning (suicide) by and exposure to pesticides.          1          0.1            1          0.1            1          0.1            0          0.0            0          0.0
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X69                                                                         Intentional self-poisoning (suicide) by and exposure to other and          3          0.2            6          0.3            4          0.3            3          0.2            4          0.2
                                                                                                 unspecified chemicals and noxious substances
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X70                                                                            Intentional self harm (suicide) by hanging, strangulation, and        163         11.6          214         12.3          189         11.8          207         12.2          189         10.6
                                                                                                                                 suffocation.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X71                                                                               Intentional self harm (suicide) by drowning and submersion.         17          1.2           19          1.1           12          0.8           10          0.6           15          0.8
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X72                                                                                     Intentional self harm (suicide) by handgun discharge.        192         13.7          248         14.3          255         16.0          227         13.3          277         15.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X73                                                                     Intentional self harm (suicide) by rifle, shotgun, and larger firearm        145         10.3          174         10.0          150          9.4          171         10.1          170          9.5
                                                                                                                                   discharge.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X74                                                                          Intentional self harm (suicide) by other and unspecified firearm        566         40.4          726         41.9          675         42.2          728         42.8          758         42.6
                                                                                                                                   discharge.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X75                                                                                    Intentional self harm (suicide) by explosive material.          0          0.0            0          0.0            0          0.0            0          0.0            2          0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X76                                                                               Intentional self harm (suicide) by smoke, fire, and flames.          6          0.4            4          0.2            6          0.4           14          0.8           12          0.7
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X77                                                                    Intentional self harm (suicide) by steam, hot vapors, and hot objects.          0          0.0            0          0.0            0          0.0            0          0.0            0          0.0
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X78                                                                                          Intentional self harm (suicide) by sharp object.         34          2.4           33          1.9           33          2.1           35          2.1           28          1.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X79                                                                                          Intentional self harm (suicide) by blunt object.          0          0.0            0          0.0            0          0.0            0          0.0            0          0.0
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X80                                                                             Intentional self harm (suicide) by jumping from a high place.         31          2.2           18          1.0           30          1.9           27          1.6           22          1.2
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X81                                                                 Intentional self harm (suicide) by jumping or lying before moving object.         14          1.0           10          0.6            7          0.4           12          0.7            8          0.4
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X82                                                                             Intentional self harm (suicide) by crashing of motor vehicle.          1          0.1            4          0.2            5          0.3            4          0.2            7          0.4
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X83                                                                                 Intentional self harm (suicide) by other specified means.          7          0.5            6          0.3            3          0.2            4          0.2            2          0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
X84                                                                                     Intentional self harm (suicide) by unspecified means.          5          0.4            6          0.3            4          0.3            4          0.2           11          0.6
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V87                                                                                                        Sequelae of intentional self harm.          7          0.5            3          0.2            3          0.2            3          0.2            5          0.3
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Includes age <20 years old.


                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                  December 21, 2007

Mr. Rick Kaplan
Executive Producer
CBS Evening News With Katie Couric
524 West 57th Street
New York, NY 10019

Dear Mr. Kaplan:

    On December 12, 2007, the House Committee on Veterans' Affairs held 
a hearing to assess the programs that the Department of Veterans 
Affairs (VA) provides for veterans who are at risk for suicide. This 
hearing raised concerns regarding the discrepancy between the numbers 
of veteran suicides reported by VA as compared to those reported by CBS 
News on November 13, 2007.
    Accurate data is crucial in identifying risk factors and providing 
better treatment and suicide prevention programs. For this reason, we 
respectfully request that CBS News share their data on suicide among 
veterans with the Committee.
    Specifically, we request data on the number of veteran and 
nonveteran suicides for each year from 1995 through 2005 reported by 
State with year of death, age, race, gender and manner of suicide. 
Additionally, request the data that CBS News used to define the at-risk 
populations (e.g., veterans/nonveterans, men/women) by age group.
    Undoubtedly, you and the entire CBS Evening News staff, share our 
desire to ensure that every possible measure is taken to prevent those 
who have worn the uniform from succumbing to the tragedy of suicide. As 
such, we would greatly appreciate your willingness to share the 
information you have accumulated with the Committee.
    Thank you for your prompt consideration and attention to this 
request. Should you have any questions, please feel free to contact 
either Committee Staff Director, Malcom Shorter, at 202-225-9756 or 
Republican Staff Director, Jim Lariviere, at 202-225-3527.

            Sincerely,

      Bob Filner
                                                        Steve Buyer
      Chairman
                                                     Ranking Member

                               __________

                                                           CBS News
                                                      New York, NY.
                                                       May 16, 2008

The Honorable Bob Filner, Chairman
Committee on Veterans' Affairs
United States House of Representatives
One Hundred Tenth Congress
335 Cannon House Office Building
Washington, DC 20515

Dear Congressman Filner:

    This is in reply to your letter of last December to Rick Kaplan, 
Executive Producer of the CBS Evening News. It appears that your letter 
was originally lost within CBS and only came to light when a copy of it 
was given to Armen Keteyian, CBS News' Chief Investigative 
Correspondent, at last week's hearing of the House Committee on 
Veterans' Affairs. I apologize for the delay.
    In your letter you request that CBS News provide ``data on numbers 
the veteran and nonveteran suicides for each year from 1995 through 
2005 reported by . . . [and] data that CBS News used to define the at-
risk populations (e.g., veterans/nonveterans, men/women) by age 
group.''
    You are quite right, Congressmen, in stating that we at CBS News 
share your desire to ensure that every possible measure is taken to 
prevent veteran suicide. We believe, however, that the respect in which 
we are best able to serve the interests of veterans and of all other 
segments of the American public is to preserve our ability to do 
effective news reporting; and that to be effective reporters, we must 
maintain our journalistic independence. For that reason we must 
respectfully decline to provide the data you request.
    Insofar as the Committee's request derives from its need for the 
raw data on which CBS News based its reporting, that data is readily 
available to the Committee from State agencies, which are public. If 
the Committee's goal is to review the editorial process by which we 
arrived at our reports' content, we respectfully urge that it would be 
quite wrong of CBS News to submit voluntarily to such governmental 
oversight. Indeed, doing so would fundamentally compromise the 
editorial independence on which we and all news organizations depend.
    I should also point out that obtaining suicide data from the 
various States involved more than just a basic public records request. 
Initially, several States refused to provide their data to CBS News out 
of a concern for the privacy of the veterans involved and their 
families. These States believed that the suicide numbers in some 
categories are small enough so that individuals could be identified and 
their privacy compromised. In order to obtain the data, CBS News had to 
give these States our assurance that we would keep the raw data 
confidential. Some States insisted upon written agreements to this 
effect. Accordingly, we are constrained not only by principle, but by 
these specific undertakings, from providing the Committee with the data 
you have requested.
    I hope you will appreciate Congressmen, that we take the work of 
the House Committee on Veterans' Affairs very seriously and that we 
withhold our cooperation only out of deference to our own 
responsibilities as journalists.

            Respectfully,

                                                        Linda Mason
                                              Senior Vice President
                                     Standards and Special Projects

cc Rick Kaplan
Armen Keteyian