>> phone for its connection to silicon valley, it's home to stanford university, the alma mater of president her vert hoover and the institution he founded in 19919. >> this structure is dedicated to the preservation of the books on manuscripts, war, revolution and peace. >> sort of reflecting on the personal sacrifices and the challenges and the roles in which journalists, soldiers and civilians played in the war, how we can build upon understanding of war to prevent war in the future, which is the core of herbert hoover's message. >> join us this weekend, as we look at the history and literary life of this city of about 66,000. saturday at noon eastern, an c-span2's book tev and sunday a 2:00 p.m. on american history tv on c-span3. the c-span cities tour, as we

explore the american story >> next, the house veterans affairs committee looks at combating suicide among military veterans. witnesses include officials from the national institutes of health, veterans affairs department, and the suicide prevention branch of the substance abuse and mental health services administration. this is two and a half hours. >> good evening. i call this hearing to order. first,t, i'd like to welcome ou witnesses this evening, dr. stone from the veterans health administration, dr. alviaoli from the national institutes of health. dr. mckuhne from the substance abuse and mental health services

administration. today's hearing will be the first of many this community will hold as it begins the critical workto to address veten suicide. i think we can all agree how important it is to take care of our veterans, which is why i have made ending veteran suicide my number one priority. sadly, america is facing a national public health crisis that demandsin urgency from e congress, the administration, medical and clinical professionals, veteran service organizations and veterans themselves. this morning, we lost another veteran to suicide at a va hospital. two weeks ago, three veterans committed suicide on va property in just five days. seven veterans have ended their livesve on va campuses this yea. it's clear we are not doing enough to supportrt veterans in crisis. while these incidents may be alarming, they do not tell the full story of veteran suicide in

our country. it is harmful to veterans and overly simplistic solely to blame va for these tragedies. wea must come together as a nation to address this crisis. too many americans have been personally touched by this troubling trend. for me, it was my own uncle, a vietnam veteran, who died by suicide. i still remember the day that i came home i in september, when was 10 years old, to find out that my uncle sabato, a vietnam war veteran, had taken his own . life, and he lived across the street from my own family. his suicide still haunts me from time to time, tom this day. each day, 2020 veterans, servicemembers, reservists and members of the national guard die by suicide. one veteran lost to suicide is one too many, but 20 deaths a

day, totalling more than 7,300 deaths per year is unacceptable. to put this in perspective, that's 1800 more deaths per year than the 5,429 servicemembers who have been killed in action since 2001. both numbers are surprising, and further evidence of a frustrating andur persistent problem thatbl we fail to adequately address. so if i may move this poster closer. when you examine the statistics, barriers to access many veterans face become very clear. only 6.1 of those deaths are veterans accessing services at the va, but 10.6 deaths a day are veterans not using the va at

all, and 3.8 current active duty or members of the national guard are also committing suicide. we all have a responsibility. we all have the responsibility to ilact, because there's no excuse for failing these veterans here at home. my republican colleague, my republican olcolleague, ranking member rowe, often says we haven't moved the needle far enough to reduceav veteran suicide. he'st right. the number was held steady at 20 deaths per day since 2014, for far too long..co it's time to look at this with fresh eyes. in 2015 congress passed the clay hunt suicide prevention for americans act otherwise known as s.a.v.e. act, but this well-intentioned effort hasn't

doneh enough. recently, i met with several members ofal clay hunt's unit, o identified the specific challenges they faced as they transitioned out of thee military. we needd. to understand why thi legislation hasn't done more to prevent suicides. we need to expand our understanding of mental health among veterans.t we need to commit to providing the anresources needed to implementes a comprehensive pla. most importantly, americans must hear from and listen to our veterans. we need to hear from veterans who have attempted suicide, understand their circumstances, and find out what they believe worked and what failed. these veterans have a story to share that can tell us something about our attempt to address suicide, and how response of government, and how responsive government can be to their situation. this committeeee will not be indifferent to the problems veterans face, nor will we turn

a blind eye to the many causes that lead veterans to committing suicide, and i'm glad that we could all come together today to begin to tackle this important issue. ultimately, it'ss up to all of s to reduce and prevent veteran suicide, because this is not a va can solve alone. we know that dedicated doctors, nurses and va employees saved over 240 veterans from committing suicide on va camp uses in recent years. va briefs me on each suicide at a va facility and there's still so much that wemu don't know. we must involve partners at the federal, state and local levels and do a better job of veterans in need regardless of whether that need is clinical or social. by supportingg clinically ffective programs and increasing access to programs that mitt xwigate theog impact

concerns, be they financial, marital, substance abuse related or physical health, veterans will feel the support they seek. va must also ensure that every interaction it has not just in a clinical setting makes veterans feeler supported. one example from vfw struck me when i was reading the statements for the record from the vsos, and i quote, "the vfw is working with a veteran who was rushed to a va hospital during a mental health crisis caused by untreated bipolar disorder and admitted to the inpatientn medical health care clinity for two weeks, despite not being eligible for va health care. va did save his life but now he has a $20,000 bill. his mental health crisis was exacerbated by unemployment and his inability to provide for his

family. with proper treatment, he has been able to return to work, but still lacks the resources to pay the va bill. the vfw is working on having his bill waived, but he will never return to va if he has another mental health crisis." now this is just one more testament to what we already know. when a veteran is faced with the sky-highf costs of medical care that can be a significant barrier to getting help, the help they need. to really combat this crisis, we have to change our mission. we must reexamine our approach suicide prevention, exhaust our research possibilities, break the stigma faced by those seeking mental health services, andse expand the health care an support we offer veterans. like all of those in this room, i believens americans are readyo meet this challenge. countering this crisis will

require to usus shine a nationa spotlight on veteran suicide, and there is still so much that we do not know. we need to better understand the root causes driving veteran suicide, hear from the families who haves lost loved ones, and listen to theis clinicians and social workers who are on the front lines battling to end veteran suicide. as americans, we are proud of the service and sacrifice that they have made for our country, but a "thank you for your service"e" isn't enough for our veterans in crie s in crisis. instead we must thank and honor our veterans with action, work together to provide top quality health care, community support and offer a stable transition out of military service and in to quality, sustainable employment. truly thanking veterans for their service means helping them when they need it most, and to

rise above political opportunism to support veterans in crisis. itit is my hope that together, can curb this crisis. now before i recognize ranking member rowe, i'd like to point out that may is mental health awareness month, and we all have to do our part. i encourage every member of thi committee to record a suicide prevention public service announcement to highlight va's beth there campaign. as the wounded warrior project pointed out, "if a treatment program does not offer a family or a caregiver component, and clinical o through processes when they return home, it may leave the family or caregiver to feel left out in the dark about what occurred." we shall all be doing all that we can to ensure family members and micaregivers not only feel supported but have access to much needed resources, as they help their loved ones recover.

in addition, i would encourage all of you to meet with both veterans who are suicide survivors and speak with families who have lost a loved one toe suicide to better understand how we can work to end this crisis. now at thisth time, i'd like to recognize my friend and colleague, dr. rowe, for five minutes, for any opening remarks that he may have. >> thank you, mr. chairman, and thank you for holding this hearing tonight, and also shining a light on the veteran suicide. tonight's topic is the most important, most confounding and the most heartbreaking one that we will discuss in this committee. while suicidee. is a tragedy no matter where it happens, it is particularlywh painful when it occurs on the groundsds of a facility, with help mere feet away. several weeks have seen four incidents of suicide on va campuses, including one just today in cleveland.

my heart goes out to the surviving family members, and friends of each of these veterans and i i want them to kw they are foremost on our minds herer in this congress. their loved ones are a part of approximately 20 of our nation's veterans, active duty servicemembers and members of the national guard reserve who die by suicide each day.s that rate has remained largely theat same since the 1990s, despite two decades of sincere effort from administrations on both sides of the political spectrum, and substantial increases in funding, staffing, programs, attention and support for mental health care and suicide prevention inside and outside of theat va health care system. sincete 2005 alone, funding for the va mental health care has increased 258% to a high of $9.4 billion in the most recent request. unquestionably too littleun progresso has been made. unquestionably, a "business as

usual" approach to this crisis is not sufficient. to be clear, the tragedy of suicide iss a societal one that is in no way unique to va or to veter veterans. let me just give you an anecdotalan description of why knowri that's true. in my state of tennessee, when i graduated from medical school we had eastern state, central state and western state mental hospital. those are all gone.ho as i went across my district and held town halls and roundtables these past two weeks i met an emt who told me he worked in the er on weekends. one weekend, he had a man there who was in a room waiting for a bed in a mental hospital. he came back a week later and the man wase still in the emergency room. for seniors, we have to transport people from sullivan county, tennessee, you don't know where that is, but to memphis, i can tell you it's 500 miles away. we do not have the mental health infrastructure, not just for va,

but for our citizens in this country anymore, and it's somethingf we're going to have t learn to deal with as a nation. of the 20 suicide deaths per day among our nation's heroes, 14 have not received, as the chairman said, va health care in the two years preceding their ye deaths. this is a clear indication that va alone cannot solve this crisis. i commend president trump for issuing two executive orders in the last two years to rally federal, state and local government agencies as well as non-governmental organizations aroundin this issue. i look forward to the hearing today about how those executive orders arere working and how thr impact will be measured moving forward.d.v i'm also looking forward to delivering and delving into an important concept that secretary wilk and his team including dr. stone and dr. franklin who are both with us tonight have been stressing recently and that is suicide is not exclusively a matter of mental health. it's quite a bit more complex than that, and solving it will require nothing less than

harnessing the collective efforts of every community around in need, long before the crisis point is reached. tonight's hearing would be incomplete if itis didn't inclu a frankom discussion about the role each one of us can play in our districts to stem the tragic tidea of veteran suicide and about the deeper personal and societal issues such as loss of purpose, belonging, and connection that far too many americans, not to mention veterans arere struggling with. our goal should be more than just preventing suicide. it should be helping our veterans to live a life of meaning and joy. i would like to also caution us all in having that discussion, to resist narratives that paint veterans as victims or a tragedy of suicide is insurmountable. we know from research and experience that treatment works, andt recovery is possible, andt is the principle message that i hopepa everyone takes home tonit with them. i'm grateful for all of our witnesses, and audience members for being here this evening, and

i yield back, mr. chairman. >>en thank you, dr. rowe. again, appearing before us tonight isbe dr. shelly avanovo, and she is the deputy director of the national institutes of mental health, dr. richard mckuhne, did i say your name correctly? mckeeon, chief suicide prevention chiefio suicide prevention branch of the substance abuse and mental health services administration, dr. richard stone, executive in charge veterans health administration, department of veteransch affairs, and accompanied by dr. keater ra franklin, national director of suicide prevention, department of d veterans affairs and we'll begin first with testimony from dr. avanovoli, and dr.

avanovoli, you arere recognized for five minutes to give your opening statement. >> thank you. good evening, chairman takano, ranking member rowe and distinguished members of the committee. i am dr. shelly the deputy of the national center of institute of health. it is an hanor to appear before you lttoday, alongside my samsa and the va. given the troubling rise in the national suicide rate in the past decades, suicide prevention research is an urgent priority for thede nih. as the lead federal agency for research on mental disorders, nimh's portfolio includes projects aimed at identifying who is most at risk for suicide, understanding the, causes of suicide risk, developing in interventions, and testing the effectiveness of suicide prevention services in real world settings. in collaboration with our partners, werivate work to translate these research findings into evidence-based ac

practices. today, i want to highlight research that has identified promising suicide prevention toolsve ripe for implementation within health care systems. used effectively, and in combination, these tools may increase the number of lives saved amongmb veterans and amon all americans. health care settings are important for two reasons, access and opportunity. nearly half of individuals who die by suicide had some type of medical visito in the 30 days prior to death, and around 80% did so in the year before death. in addition, about half of people who die by suicide had at least one emergency department visit init the year before deat. nimh-funded research identified a growing number of evidence-based suicide prevention tools that can be used right now in these health care settings. i would liket to walk you throh a scenario that showcases how thegh health care system using some of these tools can identify

more people at risk for suicide, provide effective treatment, and ensure appropriate follow-up care. so let's say you are depressed, and feeling suicidal, but you anyone about these feelings. one day, you have severe abdominal pain and you go to the emergency room. your conversation with the doctor focuses on your physical pain, but because this emergency room screens all patients for suicide risk, the doctor asks you if you have had suicidal thoughts oral attempted suicide. our funded research shows that screening all patients doubles the number of people we can identify who are in need of helf for suicide risk. so when you tell this doctor that you have been considering suicide, the doctor connects you with a social worker. the social worker asks questions to assess your level of risk, discusses treatment options with you, and works with you to develop a personalized safety

plan. this safety plan describes approaches for reducing your access to lethal means, identifies specific coping strategies to decrease your risk, and lists people and resources that could help you in dris crisis. safety planning is an evidence-based intervention and we'ree currently supporting research on the best way to deliver this in various settings andd populations. as part of that safety plan, the social worker links you with a local crisis center that is part of thel national suicide prevention lifeline system. this crisis center works with wi your hospital to keep in contact with you by telephone over the next few months, a very high-risk time for suicide. nimh-funded study has shown this combination of screening, brief prevention, and follow-up contact reduced suicide attempts in the next year by about 30%. a30 growing number of health ca systems are implementing many of these evidence-based practices, but we know there is more we can

do.t through the nationalm action alliance fore suicide preventi, the nimh, samsa, cdc, va and other public and private partners are working towards the goal of zero suicide deaths in health rkcare, in which health systems implement these and other plevidence-based practice. the zero suicide framework includes comprehensive tracking outcomes so we can monitorme progress and identify additional ways to save lives. today, i highlighted just some of the suicide prevention tools our researchers have tested in the health care system. we are committed to working with our partners and stakeholders ti ensure these evidence-based tools are implemented and accessible to all. moving forward, we will continue to provide hope by supporting research to prevent suicide. i want to thank the committee again for bringing us together, and i'm happy to address any questions you may have.

>> thank you, dr. avanovoli. dr. mckeon you're recognized fo. five minutes to give your opening statement. >> thank you, chairman takano, ranking member rowe and members of the committee, thank you for inviting the substance abuse and mental health services administration to participate in thishe extremely important hearg onon suicide prevention for veterans. i'm dr. richard mckeon, chief of the suicide prevention branch at samsa. on american dies by suicide every 11.1 minutes. sue sid is the tenth leading cause of death in the united states, and the second leading cause of death between ages 10 and 34. we lost over 47,000 americans to suicide in 2017, almost the same number we lost to opioid overdoses. for each of theseve tragic deat, there ared grief-stricken families and friends, impacted workplaces and schools, and the diminishment of our communities. samsa's national survey on drug use and health has also shown

that approximately 1.4 million american adults report attempting suicide each year, and over 10 million adults reportrt seriously considering suicide. as painful as these numbers are, our concern has intensified by the cdc's report suicide has been increasing in 49 of the 50 states, with 25 of the states experiencing increases of more than 30%. while federal efforts to prevent suicide have been steadily increasing over time, thus far, they have insufficient to halt this tragic rise. r we can only halt this rise nationally if we are also reducing suicide among the estimated 20 veterans a day who die by suicide, including those not in the care of the u.s. department of veterans affairs. all of us must be engaged in this effort and for this reason, samsa includes language in our suicide l prevention, funding opportunities, prioritizing veterans, and has worked actively with riva on suicide prevention since 2007.

while we have not as of yet been able to halt this tragic rise, concerted, that sustained and coordinated can save lives. one area where such a concerted national effort has beenh mades youth suicide prevention, cross-side evaluate of our garrett lee smith suicide prevention grants shown counties implementing grant-supported suicide prevention activities had fewer youth suicides and suicide attempts than matched counties that were not. however, this life-saving impact fades two years after the activities have ended. this underscores the need to is embed suicide prevention in the infrastructure of states and communities. congress has also provided samsa $11 million to focus on adult suicide prevention with $9 millionn appropriated to the zeo suicide initiative. this is ann effort, as my colleague has expressed, to promote a systematic evidence-based approach to suicide prevention and n health

care systems, using the most recent findings from controlled scientific studies as part of a package of interventions thatge moves suicide prevention if being aig highly variable and inconsistently implemented individual clinicalal activity a emsystematized and prioritize effort. it uses the most recent science on screening, risk assessment, safety planning, care protocolless, and evidence-based treatment. we've also been working through all of our suicide prevention grant programs to improve post-discharge follow-up, since multiple studies have shown that rapid contact after discharge from e.d.s and inpatient units is a time of high-risk. the samsa suicide prevention program that touches the greatest number of people is the jif nal suicide prevention loan line, a network of 165 crisis centers across the country. it luz a special link to the veteransis crisis line which is accessed byy pressing one.

last year, more than 2.2 million calls were answered through the lifeline, and that number has continued to grow at a rate of about 15% per year. however, the increasingcall val the tlifeline system of community crisis centers which are responsible for responding to calls. the va have been working to prevent suicide more recently they have worked together to fund the series of challenges and governors challenges to prevent suicide among all veteran service members and family members.

we have convened cities and states and policy academies intimal mentation academies to promote comprehensive suicide prevention for veterans. multiple public and private partners are engaged in the effort. as an example, the mayor's challenge for the va medical center, the public dental health center they have already developed a coordination referral process to assure that veterans at risk do not fall through the cracks between dha and community system that work is being implemented elsewhere in virginia as part of the governor's challenge. we believe this type of strong continuing departmental effort that incorporates states and communities as partners is necessary to reduce veterans suicide. in summary, an unprecedented amount of suicide prevention activities. what we know we need to do more is to play our role in halting the tragic rise for the loss of life we are experiencing across the country. particularly we know we need to engage in a strong and continuing collaborative effort with the veterans administration and others in order to reduce suicide among our nation's veterans. we must be conscious really looking to improve our efforts and to learn from both our successes and failures and we

owe s it to those in our servic nation and those we have loss as well as to those who love them in order to continually strive to improve suicide among veterans and among all americans is dramatically reduced. >> thank you doctor. we will now hear from doctor stone who will be recognized for five minutes to give his opening statement. >> good evening chairman and ranking members of the committee . i appreciate the opportunity to be here to discuss the critical work the va is undertaking to prevent suicide among our nation's veterans. i am a company today by doctor franklin the executive director of the va suicide prevention program. suicide is a serious public health tragedy that affects communities across this nation and recently the tragedy has occurred on the grounds of our va healthcare facilities in the last six weeks, six veterans have ended their lives on our

healthcare facilities. our facilities are ardesigned t be places of safe haven for those who defended our nation. although less than one half of 1% of suicides occur at both va and civilian healthcare facilities, these events highlight the important discussions that we will have here tonight. all of us at the va feel that these losses as we have dedicated our professional lives to provide healthcare and enhance the resilience of our nation's veterans. the 2018 national strategy preventing veteran suicides is a multiyear strategy that provides a framework for identifying priorities and organizing efforts and focusing community resources to prevent suicides among veterans. this approach has four key areas. first, primary prevention that

focuses on preventing suicidal behavior before this reaches the level of individual self- harm. second, a whole health approach that considers factors beyond mental health. third, application of data and research that emphasizes evidence-based interventions and forth, collaboration. it educates and empowers communities to propagate suicide prevention efforts beyond the va. these efforts should move us from a crisis intervention focus to one that enhances the relational skills and resilience of our heroes. we know that an average of 20 veterans died by suicide every day. this number has remained

relatively stable over the last several years. of those 20, only six have used va healthcare in the two years prior to their deaths while the majority, 14 have not. in addition we note from national data more than half of americans who die by suicide in 2016 had no mental health diagnosis at the time of their death. this is also true for our veterans. we also know that a massive expansion of the va mental health providers and an increase mental health access has done little to reduce the total number of suicides among america's veterans. while there is much to learn there are some things that we know. suicide is preventable, treatment actually works, and there is always hope.

maintaining the integrity of the va mental health care system is vitally important and clearly, this is not enough. the va alone without the help of all of you cannot and veteran suicide, the va has expanded its suicide prevention efforts into a public health approach while maintaining and expanding our crisis intervention services. we ask all of you to help and we appreciate the public service announcement many of you have already recorded. the va is expanding our understanding of what defines healthcare by developing a whole health approach that engages and empowers and equips our veterans for lifelong health , improved resilience, and improved well-being. the va is uniquely positioned to make this a reality for our veterans and for our nation. this effort is about enhancing individual resilience. on march

5, 2019 the president signed the executive order, 13 861 a national roadmap to empower veteran and and suicide. in order to improve the quality of life to our nation's veterans and to develop the national public health roadmap to lower the veteran suicide rate. this executive order will further the va's efforts to collaborate with partners and communities nationwide and to use the best available information to support all of our veterans. we must partner with, empower, and .energize all communities t engage veterans who don't use the va services and we are committed to advancing our outreach prevention empowerment and treatment efforts and we will continue to improve access to care , our objective however is to give our nations veterans

the top-quality care that they have earned. wherever, and whenever they choose to receive it. mr. chairman, this concludes my statement my colleague and i are prepared to respond to your questions and with your tolerance sir, i would like to do something i did before. i would like everyone who has not done so already to take your phone out, type in the veteran crisis line. one 800-273-88255. 1-800-273- 8255. you will be prompted to press one if you are a veteran then be connected to our professionals and you could also text 838 838255 838255838 838255838255 to connect with a va responder.

mr. chairman, thank you. >> thank you doctor stone. doctor, the full written testimony will be included in the hearing records questions i will begin with myself i recognize myself for five minutes and, my first question, it is for doctor stone doctor stone, the statement provides an example for veterans seeking immediate treatment at a health clinic because "she feared she would take her own life". the front desk worker said she could not be seen immediately because she had to complete the

mental health departments day and it wasn't ready for a week. thankfully the veteran survived despite failing to receive the appropriate care in contrast of the hospitals throughout the country they responded by saving 240 veterans lives when they walk through hospital doors needing our help. let's put ourselves in the shoes of this woman for a moment that interaction with the front desk clerk or nurse or police officer could have led her and her life to her life being saved or led to the veteran going in the parking lot and committing suicide. how should a front desk clerk respond? how is every va employee trained in order to recognize signs of a veteran in crisis? >> clearly this veteran should have been seen and i would be happy to review the events related to that if they could be provided to me by your staff, secondly let me reference the bill that was

created for the veteran you referenced. certainly, i'm very pleased that this veteran was admitted for a two-week period of time or at least that is my understanding and i'm disappointed the first i had heard about it is about this bill is in this hearing. i think that this would have been helpful when i had breakfast when that person two weeks ago, if they could have brought this to my attention then we could have alleviated two weeks of suffering for the veteran and his family. we will be happy to work with this and i could only assume the lack of eligibility for payment for those services ou through our normal budgeting reflections is something in the veteran's background that make he or her ineligible but what should the front desk clerk have done? that front desk clerk is in all likelihood have gone through the same training, training we

give to our nonclinical personnel in order to recogniz these issues that veterans should have been seen and evaluated by the medical professional, this is notable that our police officers go through 30 hours of mental health training in order to recognize the veterans in crisis and also go through approximately 20 hours of actual scenario-based study in which they demonstrate their capability to defuse or de- escalate situations. that has been recognized in our training academy and in a number of federal agencies and police agencies that have sought the training from us i will defer to doctor franklin if she has additional comment. >> the only other people that would add, i appreciate the

context of the question with regard to the front desk because everyone has a role when it comes to preventing suicide and anyone in the hospital system could do the right thing and we are teaching them that the training to teach them to know the signs the symptoms and what the risk is and to take action at that level regardless of the level that is. >> if i were to ask any va employee out of the hospital how they should respond with a veteran crisis walking to the door what answer would i get? >> the answer should be, yes. the answer should always be yes and we welcome veterans to be seen, every e one of our sites, more than 1000 sites have same- day access for mental health services regardless of the veterans status. >> is every employee trained to recognize the signs of a veteran in crisis and treat the veteran with compassion and respect? >> yes. >> so doctor i appreciate that you brought up earlier the issue with the $2000 hospital bill but my question was how

does the va prevent veterans from relapsing into crisis upon discharge including the way in which the va bills the veterans for the care that they receive. my question would be wouldn't a veteran, a $20,000 hospital bill send the crisis into better care? >> we know this is part of my opening testimony, we certainly know many of the issues facing the veterans that lead to suicide relate to relational problems and relationship problems as well as financial problems and this is deeply troubling we would generate this bill if it wasn't a secondary insurance that should have been dealt with. >> so it is important that the va is able to exercise its role as a federal coordinator for care in these cases? >> absolutely, sir. >> my time is up and i would like to turn to her for five minutes.

>> thank you mr. chairman and thank you ranking member and doctors for holding this important hearing and i would like to welcome the panel, thank you for all you do. my question is for doctor stone and if anyone else has any comment, that would be appreciated. there's been a tremendous amount of attention devoted to treat recent incidents of suicide on the va campuses, do you see any connection among these incidents and do you have any evidence that they are symptoms of an increase of suicide among veterans either in general l or on the va property? >> each one of the incidents is a tragedy and each one is an individual that we have lost. what is difficult to understand is that another a number of these incidents have occurred in individuals that we had not seen for a number of years but

yet they arrived on our campus. and under an act of self-harm resulting in their death. clearly as the ranking member is pointing out in his comment the fact that health was a few feet away is deeply troubling. yet, even if we fixed the problem 99.6% of the veteran suicides are not occurring in our campuses. now, what do we know? we know america has a problem on inpatient services especially in psychiatric units when they are not door alarms or alweight alarms that could prevent suicides. we learned that lesson tragically in west palm beach in less than a month ago when the veteran actually timed our nurses walking through to check on them and then committed a

act of self-harm resulting in his death immediately after the nurse walked through to check on him. the lesson from that is that it will replace every door across our system with weight sensors, a perfect thing, no but it's the best we have to correct the issue. what else have we learned? we learned some of the veterans come to our necampuses because and we know this from the notes they have left that they know they will be taking care of and they know that they are families that will be taken care of. there are those that would like to indict the va in this process but i would caution you this is not as easy eaas me having just few more policeman to go through the parking lots or the parking structures. this is about a societal approach that reconnects the veterans that are intensely

lonely. with a feeling of hopelessness that results in these acts inof self-harm. >> does anyone else have comments as my time is running out. >> thank you mr. chairman, i yield back. >> thank you , i would like to recognize the woman who chairs our veterans health subcommittee. >> thank you hemr. chairman and wanted to do a quick follow-up to your line of questioning doctor stone. you gave some very positive responses to the chairman's questions in terms of what the va does the responding to a veteran in crisis but my question is, how do you know that you are 100% correct?

>> because we tabulate on our training management system the amount of training that has been done . we certainly have new employees coming on board who need training but he would think that with the large amount of redundancy in our system that there would be the possibility that each veteran would be able to be taken into our care effectively and without being turned away. >> so training is enough in terms of ensuring that we have a 100% positive response to a veteran in crisis? i understand, there's turnover and that sort of thing but it seems to me as though there needs to be more of that in order to know side-by-side that those things are being --. that's my concern.

>> thank you and i appreciate this it is my concern also. i mentioned amongst our police officers to demonstrate empathy and the ability to de-escalate a crisis situation a is essential. >> thank you. another question i have, the doctor from the nih laid out a program, and evidence-based safety program i think you called it who sbasically quickl summarized screening all patients then a social worker drilling down a little bit more in terms of the screening and then obviously, that screening helped professionals in crisis, and linking with the crisis center, perhaps it's in the va

or in the community i think we could all agree this is a community effort. evidence-based programs, affective, good results, is this what we are doing in the va every single day, screening every single patient having a social worker do the screening and then if need be, linking that veteran to services? >> yes that is what we are doing. we received those results and heaven lamented that implemented that. not only screening mental health but every single clinic across the entire va if someone is seen in podiatry they are screened on suicide, make no mistake. the safety plan across tothe board, this past year we implemented the standardized safety protocol to make sure that every safety plan that was the same with a high degree of rigor and evidence to the model that was raised and the follow-up contact for carrying the outreach, following the research model, yes ma'am. >> thank you. last question i had was, on

military sexual trauma. it is my understanding it's been a while since i read the report. there was a report i think it was in 2018, it talked about the claims, the report, if i recall correctly, it said 60% of the claims were incorrectly denied. so that women and men perhaps were not receiving the benefits that they needed. obviously mst is very much linked to the topic we are talking about this evening. tell me, can you respond to that and let me know what the va is doing about it? >> certainly i represent the vha not the dba and i appreciate the question and to make sure that i have this right we will check and get

back to your staff in order to make sure that we answer this correctly but my understanding is those claims are all being reviewed in order to assure that they are accurate. >> i would like a follow-up . i think it's of your interest and our itinterest, understandably, all of this and the like i think it is important and we need to actually have firm answers and my time is about ton run out but you mentioned in your testimony about the national network of women's health champions which sounds to me like a new program i do not have time to ask questions today but i have not heard about it and i'm interested in order to understand what this is about. i yield back. >> thank you. i recognize this gentleman for the next five minutes. >> thank you mr. chairman i appreciate it and i want to think you for your testimony.

i appreciate the so very much. doctor franklin quickly, what about the screening more intensely for suicide awareness at the dod? any comments on that? the dod, yes. >> yes we have under there was an executive order that was pushed out in the past you not the one that the doctor mentioned in his testimony but an earlier one. the executive order called for increased screening so that when troops are leaving the active-duty site they have eyes on by a medical provider which the results are ltpushed over t our mental health team on the va side so that there is an accurate view on the servicemembers mental health status before they reach active- duty. >> okay very good. >> let me add a little bit to that . i think that this is

correct. in that first executive order the ability for us to interact witho a service member in the years before they leave active- duty is absolutely essential. the authority you have granted us and allowing us to see servicemembers for that first year, after they come off of the active-duty is an absolute risk reduction. i would ask the committee to take a deep look at the work that has been done since the late 1990s in the air force that has actually integrated resiliency, relationship-based training and suicide awareness amongst all active duty and reserve members of the air force, the air force has not seen an increase in the number of suicides and a number of the other uniformed services so this interaction and

potentially modeling after the air force, training, it's absolutely essential. >> very good i would like to work with you, sir, on some legislation owith regard to tha because i think this would make a big difference, i really do. let me ask you another question. i have some knprepared question and i know we don't not have a lot of time but could you tell me, you may not have the statistics on this but prior eras would say the vietnam era, going back to world war 2, give me some statistics with regard to suicide rates. how do we compare to what is going on today, the 20 per day which is obviously much too high as far as i'm concerned. c could you give me any stats with regard to that? for instance, the vietnam era,

as far as the suicide rate is concerned. >> yes, absolutely chairman. the data collection has gotten better over the years so sometimes it is difficult to compare data but we've only recently got more savvy with our data surveillance efforts. what i will tell you is that when we look at our current efforts we see our highest rate of suicide right now amongst 18- 34-year-olds when you look at the rate for 100,000, we see our highest raw number amongst men over the age of 50 fied 55 which we expect comes from that era and the war effort, so we know that we have more veterans in that group or in the category.

>> in 2016, veterans over 75 years old . and i add the 55-74 to that first group that i mentioned which adds up to over 60% of the suicides amongst veterans in this nation. clearly, we need to recognize the fact that of the 20.4 million veterans in this nation, 77% have experienced combat and the long-term effect on these veterans can't be underestimated. now, i grew up in a generational home. multiple generations had didn't in that home, everybody on that street were generational homes,

i could not walk out the front door as a young child but yet i had 20 mothers msthat were up a down that street, think about the neighborhood that each of us lived in today, recognizing the isolation that many of us feel, i have lived in my current neighborhood for four years and i know the neighbors on either side and have been in their homes and no one else. >> counter that to the on-base housing i experienced on active duty when my family and i moved into a home, every single family in the neighborhood came to bring us food, to make sure we were all right that if we needed anything, every weekend after that for weeks, we were welcomed into their homes until he became firm members of the community. this is a profound difference we are seeing in all age groups of that trend, certainly the 18

years of combat we have experienced in the current environment has taken a tremendous toll on veterans under the age of 35 but make no mistake, the increased suicide rate amongst veterans affects all age groups. >> thank you doctor stone let's try to keep our comments within the five, we have a lot of people to get to but this was compelling what you were saying. let's move on to mrs. rice for five minutes. >> thank you mr. chairman. and thank you all for being here to testify tonight. i want to talk about an issue that i don't think that we could adequately address the issue of suicide amongst veterans without talking about guns, firearms. if you look at there is no question of firearms being one of the most common themes of

leading suicide amongst the general population and 69% of veterans who have come pleaded completed suicide via firearms, the veterans are more likely to utilize firearms in an attempt or completion of suicide in their civilian counterparts, it's been proven that restricting access to firearms may reduce suicide rates. this is for anyone on the panel. has the va studied gun violence and the veteran population, what research is currently available on gun violence and connection? i'm well aware that we have not, are going to find a study in order to look beat the overall reason for the epidemic of gun violence in the country but since we are talking about the va i am asking about the va. is this an issue that warrants research to shed light on why the firearms are the most commonly utilized.

and what resources are va offering to veterans that could limit their access to firearms? so anyone who would like to answer that. >> to put this in a national context let me mention a couple of things, there's clearly an important issue, the collaborative safety plan that the doctor spoke to includes part of paying attention to access when working with an individual who is suicidal. the frequently, this may include firearms and things like access to large amounts of pharmaceuticals or other dangerous substances. our prevention resource center has an online course on counseling about access. this is within the context of someone who is suicidal or trying to reduce access to lethal means on a temporary basis and i mentioned another

of the grantees are doing work with the firearm owning groups in things like the gunshot projects working with them, and with other groups to try to have this collaborative effort in order to educate suicide warning signs so people know how to respond. >> the only other thing i would add from the va side working hand and hand with those initiatives that the doctor spoke about we also trained on mental health providers with the hispecial training on acces to lethal means and how to talk with veterans about the issue. we have a partnership with the national shooting in sports foundation. a partnership that helps us execute training in local communities with gun shop owners on signing finding symptoms of suicide risk. we work on the issue around putting time and space between the person at risk with any means that are lethal and certainly firearms are a top thing in our society.

you mentioned before, ineligibility, i think it's the most insane policy that there is many any man or woman in a uniform in this country, and iss , i don't care what they did, is ineligible for some kind of, for access to healthcare. i wonder, doctor, if you could tell us what specific risks are there other than audible discharges are other than the limited access to the va mental health care services, specifically women veterans more likely to have experience ptsd and likely to have received a bad paper discharge as retaliation for reporting mst before the two-year mark when they would be eligible for the va healthcare.

so this is an issue we need to talk about in terms of, i don't think there should be a veteran ineligibility that should go hand-in-hand. >> i think that you are exactly correct congresswoman, one of the biggest problems we had as the chairman identified in his opening statement is never activated guides in a reservist, a federal service or technically they aren't a veteran. i'm not eligible to welcome them into the system now we've tried to overcome that by using our vet centers and combining working successfully with the guard bureau and army reserve to try to move our vet centers and into drill weekends but many of the suicides we are seeing are and never activated guardsmenei and reservists are between the ages of 35 and 54. so they are long since their service days. and how to reconnect with them or to give us the authority to

engage them it seems to me if i could accept a veteran with other than honorable paper, we ought to be able to accept the never activated guard in reserves who account for about 2 1/2-3 of the daily suicides we are seeing. >> thank you we should continue to have this conversation and thank you mr. chairman. >> this was a great question you recognize for five minutes. >> thank you for having this hearing. just quickly, there something i should bring up you know, this came up over the last question. losing one veteran, to suicide, it's tragic and we don't take this lightly. that said this is in the second amendment, right? the ability to take that right away from them, it won't stop

one of them from attempting suicide, in fact, it may discourage them from seeking help through the va or through other means if they believe they might lose that right. i think this is a concern depending on where you are at in the country but i know where i come from and many have expressed that concern to me as well. we are committed to preventing suicide. and i'm dedicated teto ensuring that we are appropriately educating at-risk servicemembers and veterans. and their families without firearm safety without meaningful support to overcome the struggles they face but we need to be very careful but doctor stone you answered part of this, you reference in your testimony, from last year, i want to thank him for deciding that what i want to ask you, what, if any outcomes or lessons have been learned since this was signed especially when the veterans are getting screened for benefits from the

va and going on through the programs, what are we gleaning from that? what we are learning and i mentioned about the air force experience, it's incredibly, it's intriguing. we also learned the more veterans and servicemembers learn about our services the more they engage us and it is the right thing to do for us to be engaged with them, well before they get out of uniform. certainly, when you're sitting at the discharge station getting ready to get out, and that 6-12 months before it's time for us to engage in the active service as we've all been great just gracious giving staff time to talk about the access as well as the risk for that service member a year

after they leave the service. i discussed this earlier, the difference in american society and the civilians side versus american society in uniform. dramatic changes for the service member who may have experienced 10, 15, or 20 of these years in uniform. >> believe me i'm not criticizing when i go down the next path, okay? i'm trying to figure this out as a member of the committee and i'm sure the co-committee is acting as this, the va once again before is telling us the combat veteran suicide is a top priority for the va as budgets continue to increase the suicide prevention money we are getting more money citowards th. what actual results could be seen on the level we are putting l out there. we are not changing it, we are still at the 20 per day. we have to come up with the ideas that truly change this

and we have to figure out. if we are not increasing programs that we have change it, how do we become and bring those numbers down? i know that you brought up the fact of the age, the concern of the age is where are we at when they commit suicide, what other things could be going on in their lives do we monitor that? do we know the statistics? and how do we bring this now? every year we could come back and talk about it but if we don't change numbers we could raise money every year but we don't change numbers, we aren't helping them. >> i cannot disagree with your statement, congressman, but the message here is this was 10 years ago this would have been

a $4 billion budget and i would have half the number of mental health providers that i have today. we have the same day access to mental health services but we have not changed the numbers. there are those that would argue that maybe we have, maybe this would be worse as a crisis if we did not have 24,000 mental health professionals ready to see you today as a veteran, if in fact, this is not the answer then we have some hard looks at each other and hard looks at ourselves in the mirror about what society has become i mentioned that as intergenerational home i had mentioned earlier, these are tough discussions to have we do know the high rates of the military sexual trauma and intimate partner violence, substance abuse, mental health disorders, they lead to a dramatic escalation in the

female veterans as was mentioned by some of your colleagues earlier. we know also amongst all veterans that it is in the two weeks before becoming homeless, the rates for suicide go up dramatically.th we know for veterans that are involved with the justice system , the month after they have been incarcerated, after they are out from incarceration, dramatic levels of suicide, this is true across all of american society, frankly that is a worldwide phenomenon. . thank you. >> thank you. i now recognize mr. lamb for five minutes. >> thank you mr. chairman. i want to thank you for mentioning the health program in your testimony and for being a supporter of those. i have also been struck by the potential in the va's whole health program with a chance to

visit the program dc hospital. it's a promising area and i commend the va for pursuing it and being innovative and risk- taking with that. what struck me about this was not just the value of the services themselves because i think what we saw was acupuncture, meditation, yoga, and a couple of other things. you used the term empowering veterans it gives veterans an active role in managing their own healthcare and basically gives them a bunch of great nontraditional somewhat unusual options that pick from these yourself, whichever one you like or you find valuable will keep coming back. that is how they were running it. you could tell from that community arose and some veterans would keep coming back to these same classes as they were able to and were able to

get to know each other and look for out out for each other. mostly older veterans but there were potential to use the program to attract some of the younger veterans because of military members on active duty are being trained in some of the same stuff the dod has been good at getting these things out there so they have been used to it. so, i've introduced legislation to expand the availability of whole health and the v ability. i was hoping either you or doctor franklin could talk about any connection that you believe exists between the availability of the whole health program and your suicide prevention efforts, how those hcould go hand-in-hand, thank you. >> as we modernize the va, congressman, the effort is to expand across the entire enterprise of the whole health model one of the things our colleagues has an understanding

of the role of the physical exercise for the participation in team-based sports. and there's dramatically preventative activity introducing the suicide risk and i will defer to doctor franklin. >> i appreciate your thoughts and i'm eager to execute this as it started with the entities, one of those you may have visited. this is well underway for full execution across the enterprise and the notion of focusing on the determinates of how and thinking about veterans in the context of biological and sociological, psychological, and spiritual, allowing them to drive their care into the future of the organization i appreciate. >> thank you i yield back. >> thank you, you are recognized for five minutes. >> thank you mr. chairman and

thank you to everyone for being here. this is a subject i know us all take seriously. i'm not sure which one of you gave the following extent and i apologize for that, the second leading cause for death in the age group of 18-34, what is the number one, three, and for any ideas?a >> in that age group number one is accidents. number three, it is homicide, it's either the third or fourth, but i don't remember exactly but we could certainly get that for you. >> and also, with that, regardless of what is one, two, three, and four, how many quotes or standpoint big numbers or finite data, is there any huge percentage difference, now accidents or accidents. but is there any significant percentage differences in like three, four, just to drop off?

>> one thing to remember for example is that while accidents may be at times, very random, i don't want to waste time on accidents. >> the bigger point here is the relevant perspective on where this sits and causes of death as we talk to people and other entities and figure out where to put the finite resources towards solving the problems and an example, isolation, we know this causes potential suicide ideation that when some of us with gray hair, entered the military, there were military barracks you had communal living where you had your bunkmate now we have private rooms if you will, once you reach may be, e4 or e5. we are not able to have time

around our fellow military remembers regardless of differences when it comes to generationally talking about the community or neighborhood, know your neighbors or you don't know your neighbors. well, do you know your platoon mates? or do you know w the people aft you leave? there are differences societally as we look at dealing with mental health. state-sponsored programs, do states have different programs that you could refer to as examples of how this is being done well? some states versus others not that we need to know but other best practices shared when it comes to, the one-size-fits-all when it comes down to washington dc may not resonate in northern michigan or isolated areas or somewhere where are more rural. but are

there any, things that you do to compare and contrast and take best practices? >> i would mention a couple of things. many states are making the strong effort for suicide prevention. an example of that is what is called the colorado national collaborative which the cdc has been very engaged in the idea there, it is to try to promote suicide prevention in a comprehensive and public- health way to bring it down to the local level and again, it sounds like this is being driven by the states and communities, federal funding that is being utilized >> my time is running short and i have a couple more questions as long as we could see the best practices being captured and put out so that we gain from it not just a one-size-

fits-all perspective , as far as the requirement for veterans to make contact with in the year after leaving the active- duty did i get the right? any idea of what percentage of the veterans are still in the individual reserve because when you talk about that 18-34 group a lot of those are still in that timeframe where they have the four-year commitment, who is doing that and how is that related? >> so, we talked about the army guide and army reserve who has the largest reserve, individually. >> young soldiers, when they leave active-duty they are under dod and the responsibility is not to have 32 so the point is, who is taking care of those folks in the individual reserves? >> that is a difficult thing to say. >> will you could take that for the record i would suggest mr. chairman, that would be interesting around the table

for us to talk about because there is significant differences given the age group we are talking about here, it's the number two leading cause of death. and i yield back. >> thank you. i appreciate your suggestion. you are now recognized for five minutes. >> thank you mr. chair and doctor stone and witnesses were here today, i spent a couple weeks in the district with a chance to tour some of our va clinics in anticipation of the hearing coming up and i had the opportunity to ask professional va's what are some of the things that we could do collectively in order to reduce suicide. one of the things that was mentioned to me on several occasions was focusing more on that transition. out of the department of defense active-duty life and into the va. and how we could do a better job coordinating. i know that we touched on this

a little bit. but, are there ways because my understanding, i'm not a veteran, but as you are coming out of active military, there's a lot of information thrown at you. one of the va professionals likened this to a phrase i'm familiar with, drinking from a fire hose. so, what kind of coordination efforts are taking place between the dod, the va, and is the dod being cooperative in assisting the va? to reach a veteran and that 6- 12 month period prior to getting out of active duty? >> the answer is yes, the dod is a great partner in this process. we like to have more timewe to spend with the vetera because the more time we spend with the veteran the more likely they are to engage with us after they get of service. secondly, are we effectively outreaching in that year after they get off of active duty,

you have funded us very graciously and will spend about $200 million this year. in outreach efforts of various types, everything from electronic billboards to websites in which we are reaching out to even directly links with 500,000 letters in december of last year and we were able to capture how well over 1000 veterans could come in and cs but this depends on the individual and most importantly depends on when the individual is really open to hearing our message. there's no doubt that we are the most integrated healthcare system when it comes to mental health and the ability for us to interact with that veteran and provide ongoing services is essential to the well-being of the future. >> thank you for that. th

one of the interesting programs i had heard about from the va region that i represent. i'm not sure if you're familiar with something called free the keys have you heard of this before? >> i have not but doctor franklin may. >> no. >> okay touching on the conversation earlier about gun violence so the region in upstate new york they talked about a program there implement and called free the keys where they take the keys of a gun storage cabinet, a veteran might own a firearm, they keep the storage cabinet locked and will take the keys from the storage cabinet and put it into a cup and put water in the cup entries the cup and it's in a freezer so when the veteran has an impulse they may want to get the firearm to commit suicide and they actually have to get the key out of the frozen cup which creates more time n for them to think about the act they may take and this is

perhaps a cup with a picture of a loved one or the veterans crisis suicide number on it or something that might give them more time as an impulse, when you want to take your life this may give them more time to think about before they actually are able to get the key out of the ice and go to the storage cabinet with a firearm then commit suicide. >> this is one of the most troubling factors in survivors v of suicide, and about 25% the distance between the decision to commit an act of self-harm and to actually committing the act's five minutes. in about half is less than 60 minutes. anything that puts distance between that decision and an attempt to de-escalate

crisis has value whether it is putting keys in a freezer or a picture of a loved one or the phone ringing of a loved one saying i have been thinking about you, it's a chance to de- escalate. >> thank you and i certainly encourage you to think of the wonderful program they are utilizing and what i represent for the practice that we could possibly use across the country to give more time to make that decision. >> thank you. mr. banks you are recognized for five minutes. >> thank you mr. chairman, doctor stone i've got a quick question for you on the outset, what are you and the secretary doing to create a culture of urgency at the va with veteran suicide? >> congressman, i think there's a culture of urgency. i think that this is the secretary's and mine number one priority, to do everything that

we can to reduce or eliminate veteran suicide but as i said in my opening comments we can't do this alone and we need the entirety of the american society to dedicate themselves along with us and support us and as i mentioned to your telephone call to a veteran or somebody you have not seen, somebody from your faith group, to pick up the phone, one of the things that we recognize in your state, your state has some of the lowest suicide rates in the nation both amongst civilians an and veterans, there is something unique that goes on in your state, it may be the small towns, the faith-based communities but there is something unique with the suicide rates in your state that have dramatically lowered them compared to other areas. the other thing we recognize in

popular states like california or new york, there are reduced suicide rates over in rule states if i go to montana or south dakota the rates are higher is this about loneliness . is this about being disconnected? or loneliness? the answer is yes. >> could you point to examples of ways within the bureaucratic organization where you are creating this better than before? >> i think so. i'm really proud of the 24,000 mental health providers and their staff. i think the way we show that is by accessibility on the same day basis. in places that are going to just open access to get veterans in. we will see almost 22 million ambulatory visits for mental

health. we are very proud of it and will continue to retain and track behavioral health providers. the increase in our medicine work will remove from 30% from veterans this year but 20% of veterans eligible. gible or able to participate in tele- mental health is extraordinary. i think this demonstrates our commitment. but as i said earlier, simply hiring more mental health providers will make access better and won't fundamentally change the problems of homelessness or fundamentally change the problems of financial challenges or relationship changes. in the last 18 years, the department of defense has done wonderful work showing the problems that you can't go out for 15 months to combat, especially combat that is intense every single day, go

back to the vietnam era. one of your colleagues earlier asked. people went out for a week and came back and decompressed. these words, you are in combat every single day. in the time that i spent in afghanistan, the medical cord gets every bad it was a flow of casualties every single day, you cannot underestimate the fact that the human mind and the human body must be compressed from that, and when you go out for 15 months and come home for a year and go out again, it is an operational phase with an all volunteer force.>> let me shift gears with a quick, president trump signed authorization that would require the secretary to conduct a study of 5 years of data analytics of the veteran

crisis, he confirmed that the process has begun or tell us of any progress about that today?>> i can't, but dr. franklin may be able to. >> yes, there was a number of recommendations that came from that, we have successfully closed out those recommendations.>> this was mandating a study of 5 years using data analytics, to study the effectiveness of the veteran crisis line. >> okay, forgive me, but absolutely, we can check on that and get back to you for the record.>> thank you, my time has expired. >> think you mr. banks, i appreciate your questions. we will take a look at the response to the nature of the deployment and how they differ. then i will recognize mr.

christopher pappas for five minutes. >> thank you very much , and your thoughts here today as we confront this critical issue for our nation and for all our veterans and their family members. i wanted to build off of one thing that dr. stone was discussing, that was the va police force, and you indicated a little bit of the training that goes in, in terms of identifying the signs, i think that is a really important discussion to have and ensuring that they have that experience under their belt we should be treating this as any other medical issue. so, knowing the signs of mental illness should g be just like knowing the signs of a stroke, for somebody walking into the facility experiencing. beyond that, as we look at the ig report around va policing, if you would have any other comments you would like to offer in terms of the recommendations, there was concern about ensuring that police units were appropriately staffed at the facilities around the country. and if you

don't have anything further to add right now, we can follow up and have a further discussion following this hearing. >> i do, i think there are a number of things that are troubling in the way we structure and police management, we are actually going through a process of restructuring regional management, there is very little career mobility in the va police force, it is pretty much run as a police force out of an individual healthcare facility. because of that, it is hard for us to retain police officers. in addition, we have graded police officers, and our ability to retain very high quality officers is really challenged. there is a number of areas i would be happy to take off-line with you that i think we could do a much better job of retaining these great officers that we have.

>> thank you, i appreciate that, we will certainly be following up. as you know, on april 12, the administration's ban on trans servicemembers went into effect, i have concern for that group, as you know, transgendered veterans are known to experience suicide at high rates. and, i'm wondering what thoughts have been given to the handle as these folks leave service, in terms of making sure that they are getting the care that they need.>> so, there has been no change in the va's posture, and that is that we continue to welcome all servicemembers to care, we provide all care regarding transgendered work, the only thing we don't do is the surgery, and, so, but, we welcome all transgendered members and we will continue to do so.

>> dr. franklin? >> i would just add, so much so, we have recently developed a toolkit for all of our medical providers, it is on the website, and it really speaks to how to engage with this unique population and exactly what you know, the increased risk for sewage -- suicide. a 19% increased risk for this population, we got in front of that as early as we could, we developed the stoke it -- the toolkit. >> thank you very much, i'm glad you handed out these cards come of this has been an important resource to our district office as we get calls from that in the state of new hampshire and i'm hoping that you will continue to look for ways to elevate this resource as we implement the national strategy for preventing veteran suicide. as you explained, there are well followed practices and procedures that are in place when a veteran calls who is in crisis, who is experiencing suicidal thoughts. i wondered

if you could comment on other situations that might come up on the line emma veterans who may be experiencing depression or mental illness. and how those cases are handled. and i'm wondering, what resources are available, local suicide coordinations to help these individuals, and i'm thinking particularly around transportation. >> absolutely, that is a good question because not all the calls are crisis related, but all the calls are important and we tackle them in the same way, so we assess and triage and get folks to care, and in some cases that might be a warm handoff to a center, in some cases it might be a handoff into a community-based organization or one of our own medical centers and on crisis capacity. you are thinking about transportation, transportation

can absolutely be a barrier to care, we have a number of entities where we are funding transportation capabilities. we are also partnering with a number of agencies, there is a good example happening in massachusetts where they are partnering with the local police force or off-duty police officers and maybe you are familiar with it, part of the homebase capability that is connected to mass general whereby retired police officers and off-duty police officers are helping do that transportation piece of it, making sure that doesn't become a barrier for people getting into care when they need it most.>> thank you very much.>> thank you, now i recognize mr. dan meuser for five minutes. >> thank you mr. chairman, and thank you very much to our witnesses, i appreciate very much your service. clearly, you are very, very experienced and capable to be handling these

important jobs. i just really want to thank you for your service. i do represent pennsylvania's ninth compression, we have over 50,000 veterans, we also maintain army training facility as well as the lebanon va. 70% of the 20 suicides deaths per day, among our veterans which is absolutely heart wrenching, have not received healthcare we have been discussing, in the previous 2 years. conversations that i have with the lebanon va have made it clear that we need to work on meeting veterans where they are, for example, the va has partnered with local colleges, veteran oriented campus groups, the va provides instruction for college faculty to identify challenges and have va staff

contact points for veteran students who on a volunteer basis, who are willing to help. so, dr. franklin, i will ask you, can you speak about the importance of community engagement, the need for such outreach, is this something that is encouraged and is regularly practiced? >> yes, and i think it is something that has been practiced even more so in the last year and a half, this idea of partnering with the community, at the national level, putting the right memorandums into place so that we solidify those relationships so that they span the test of time. and also informal relationships and i appreciate the fact that they are doing that right out in pennsylvania because we are teaching at the national level for them to do the same thing locally. what we are doing is we are asking them to use their data and to use their data to define where to go to for partnerships. when we look at the data, and

we see the highest rate between 18 and 34-year-olds, we are asking them to work with veterans where they work, live, and thrive, and we believe they might be in university settings, so the fact that you know that they are developing partnerships, trying to get after suicide outside of the four walls of our va system, and they are doing it with community partnerships like universities tells me they are on track and that is the future of the organization, we are really trying to push for broad partnerships and focus on the fact that the chairman said that we can't do it alone. and, we need to increase our partnerships and community engagement.>> thank you. the lebanon va also makes its grounds very inviting, it creates a social atmosphere for the veterans, and in many cases, their families, they have a military museum within the facility. is this something that is encouraged and other va's, dr. stone? >> yes, sir.

it is encouraged across the system, many veterans find this welcoming place, a place of social connection. and, that is the big key to what we are discussing, it is why for the veteran that wants it, we have chapels on our campuses, we have various veteran related memorials, and these all seek to connect the veteran back to us and bring them into the system.>> yes, that is very much in line to what you are referring to a couple of times today, so i'm glad to hear that. do you consult with the dav, vfw and the american legion? i remember that many of the members are here today as well, on these issues, get their ideas and what they think should be done? >> we do, in fact, i just finished a series of meetings with as many of the sros who'd would be willing to meet with

us. the specific question was, how to solve this problem. it is my belief, as you have figured out already from my earlier comments, that belonging, being a part of something has huge value. therefore, i believe this membership is protective. now, we can't demonstrate that because nobody keeps numbers on that, or very few of the vs those two, but we believe it has huge value. >> thank you, and clearly by your words and donations, your dedication, all of you, so thank you on behalf of veterans in my district and everywhere, thank you.>> thank you. miss elaine luria, you are

recognized for five minutes. >> thank you, dr. stone, in fy 2019 annual performance plan, strategic objective 2.2 states that the va ensures at risk and underserved veterans receive what they need to eliminate veteran suicide and includes three recommended interventions and follow-up care. are you familiar with this objective and you know what the percentage was for satisfactory performance? >> i am not but dr. franklin might be.>> dr. franklin? >> i'm not sure exactly, i know that you might be talking about our reach intervention. >> it was the only metric in the 2019 performance plan in the entire va that i could find that was related to suicide. it stated that you would have recommended interventions and follow-up care. and, so, in the performance plan, it said that you would seek to achieve the 65% of the

time, yet, dr. stone earlier in your remarks, you said this was your number one priority and that you are putting all efforts behind being 100% effective in this area. so, seemingly, the 65% is a relatively low measure of effectiveness for your number one priority, would you agree?>> congresswoman, i must admit with you, i am not familiar with this and i would be more than happy to take a look at it and get back to your staff in the next 48 hours to talk about it. >> i appreciate that, i would like to follow up about that metric. it was the only one in the plan that refers to suicide.>> if i might just go on for a minute, many of these, i came back to the va in july, and this might be a document that was created before i came back. but, we will resolve this for the committee and i apologize to you for not being able to answer the question. >> i understand, i look forward to the follow-up. dr. franklin, last week i had

the pleasure of meeting with a veterans outreach specialist and several counselors from one of our vet centers, and they were incredibly dedicated to their mission and specifically focused on helping to put an end to veteran suicide, and the specialist explained how he gets at this problem of reaching veterans in the community and the veterans, do you find this particular role within these centers and being effective? >> yes, absolutely, this is a critical role, and i appreciate the fact that you are mentioning barbershops because we are pushing them toward nontraditional partnerships, and certainly our partnerships, we want them locally to reach out to people that connect, that we have already mentioned on this panel today. one of the things i have been pushing the workforce towards is to reach out to partners who

are nontraditional. >> i understand the effectiveness of that tactic, i'm just wondering, are we requesting enough funding and do we have enough personnel in this role to do this effectively across the country? >> we have 300 that centers, and i think we have enough personnel, i spoke earlier today with the chairman and discussed the fact that we must begin to move too much smaller engagement units and i think the vet center is within that model. please remember, it took the vietnam veteran about 10 years to decide if they would come in for therapy, they didn't want to come in -- >> i only have one minute left and i wanted to touch on one thing which was your outreach budget. and, looking at last year, only $1.5 million, 6.2 million allocated are slightly less than 25% spent towards that ever. for fy 19, budgeted 47.5 million in suicide prevention, how much of that do you plan to

use for paid media?>> so, if you break down the actual budget , one of the problems we had that you reference is that prior to 2019 budget, we lumped all of this together, and was very hard to track. so when i arrived, we broke this out into six separate buckets so that we can track it. there is $206 million in those buckets. we expect to spend all of it. >> we are about halfway through the fiscal year, would you anticipate that we are on track based on the time remaining in the year two spend all of it effectively this year? >> we are. as of march 30, just under 50%, we have some additional obligations, especially in our centers of excellence and our devastation projects. although, we have obligated the money, there is about $8 million that

we pushed out to the field. those obligations have not come back in, but we do expect to obligate all of that money. >> okay, very quickly, what measures of effectiveness do you have? are you tracking the engagement, and have you any way to report back if that is effective? >> certainly, i am not an expert in advertising or how they measure this. but, as the measures that are beginning to come back, indicate that they have been quite effective, the question is, will they change behavior and dr. franklin may have additional comments. >> specifically, can you tie that to increased calls to the crisis hotline or any other tangible metrics that you will be able to report and track overtime and provide back to it, based off of that spending?>> absolutely, we are doing it with two primary metrics. >> i'm going to ask you to get that back to her.

we have to move on. >> certainly, yes.>> thank you. andy barr for five minutes. >> thank you for holding this very important hearing, and thank you to the witnesses for focusing on this national crisis. i did want to ask dr. stone about the topic that mr. mike bost was talking about, in terms of the increased commitment to the va since 2005, approximately 250 p percent increase, and yet we do continue to see unfortunately a rate of suicide at over 20 per day. you mentioned a couple things that i wanted to explore and unpack, what is going on? why we haven't seen a decline in the total numbers? and, you noted that there were

a total number of deaths by suicide among middle-aged and older adult veterans as the highest category. but, we do also see from your suicide did a report that the rates of suicide are highest among the youngest veterans. so, the rates are higher among the youngest veterans and i did note from the iraq and afghanistan testimony that veterans aged 18 to 34, the post-9/11 generation has the highest rate of suicide, is that the explanation for why the numbers are still elevated? even though we have made an additional financial commitment to addressing this national crisis? and if not, what is the cause of that? >> maybe some of my colleagues can, but i don't think i have a full answer to that question, except i absolutely believe that not all of this is about mental health. i think significant amounts of this relate to personal, financial, and relationship- based problems and loneliness

and isolation. secondly, you and i both know that the post-9/11 generation of veterans joined the military knowing that they were going to combat. that is a unique individual in america that has not only joined but understands they were absolutely going to war. and, the effect of that, i've already discussed. and, the effect of recurrent deployments and what he does to ongoing relationships. >> thank you. recently, my hometown of lexington, kentucky reached an important milestone in ending veteran homelessness after a collaborative effort, the va certified an effective ending to veteran homelessness in our community. this milestone is important because as many of us are aware, homeless veterans are at a higher risk of suicide than

non-homeless veterans. dr. stone, dr. franklin, i noticed that many prevention resources that the va provides are available online or by phone or via mail. given the higher suicide homeless, the higher rate of suicide homeless veterans, how is the va reaching homeless veterans who obviously don't have access to those resources? >> yes, we have 444 suicide prevention coordinators with a surge underway to add a number of 246 more, and they do in person outreach engagements where they are out in communities. we have a metric for them to do at least five face-to-face outward engagement with people just like you mentioned. and many times, when i do my checks and i go out to do visits at the va, they talk with me that they do many more than five, five is the requirement. but, they are out, they are helping veterans where they are

in these communities and they are familiar with shelters and local entities where the veterans are, they are doing face-to-face outreach engagements. >> another quick question about the national guard. obviously, certain national guard members never federally activated or are not eligible for services yet, they may go to a va for help in a time of crisis. how does the va handle these cardmembers? >> we do not turn them away, we treat them, we bring them in, we give them care immediately, right away, barrier free, access free, dr. stone signed an am away this year to have our mobile that centers out at every drill this weekend, and we did a one to one match with every drill to assign it to a mobile vet center so they are getting care early and consistently over time. >> in the remaining time, we see this in central kentucky, dr. franklin, any of the

witnesses here, what is the evidence in support of these adaptive therapies? >> so, we have a center that focuses on alternative therapies, or nonpharmacological therapies, what we find for most of this work is that they share components that are relevant to treating mental illness or suicide risk. i'm not as familiar with this therapy but it does have key components to things like mindfulness and connection and attachment that are key components of a lot of our evidence-based therapies like cognitive behavioral therapy. >> thank you, my time has expired.>> i now recognize mrs. lee for five minutes. >> thank you, and thank you all for being here. first of all, i appreciate the approach that you are taking and i wanted to address what

you said, mr. stone, it is not all about mental health, and in the cdc report that was included in our packet, you reported that more than half the people who died by suicide did not have a known mental health condition. and went on to say that many of these deaths were preceded by economic losses, physical health problems and housing stress. and, it further said that it went on to identify seven strategies for helping deal with those individuals who are identified as high risk. the number one strategy was economic support. given that the highest were seeing a biggest increased in the younger veterans, and we are seeing a big increase in suicides across the country in our young members of our society, my question is, have you done any tracking on access to economic benefits to the veterans benefits, you know, has there been any tracking in terms of risk, in terms of who

has committed these suicides? have they had trouble accessing the va benefits, etc.? >> so, we do know anecdotally that there is financial problems related to a number of recent on-campus suicides. but, i cannot create a pattern for you. this relates to what i believe is anecdotal. we do know, however, that at the point of impending homelessness, the incidence of suicide rate, which in veterans is just over 30 per 100,000 dramatically goes up to about 80 per 100,000 population. so, financially, stability is an absolute risk factor. >> i want to get into tracking and what you are doing also

with respect to the department of defense, and the executive order and the electronic health records, as the chair of the subcommittee. i understand that you are collaborating on the screening tool for the new electronic health records system. what is the status of that collaboration? >> it is an active collaboration at this time, as we try to create a common platform that will allow not only access to data but common clinical pathways that allows us to capture information in the same way. >> are there specific aspects of dod policy and practice that you are incorporating and vice versa?>> yes. >> active collaboration and the ipo that works with us to collaborate is actively engaged in this, as are the work committees who have 18 different committees that are working to collaborate. >> seeing that the ipo is not fully formed, that is sort of a

problem, and the fact that, you know, the department of defense has not agreed to come to a roundtable that we had discussed about this, i mean, i don't see evidence of the ipo. >> the ipo has been in existence for a fair length of time, we have been working together for years, as we work through this. both secretaries committed to enhancing the ipo, and we are still working our way through those processes. but, as i stated earlier, i have found dod a wonderful partner in this. >> so, when the electronic health record goes live next spring, will suicide risk be a flag that is immediately available?>> yes. >> and, are there any flags that will not be available? >> i would have to bring the

work group leads that are actually working with, i would be attending in kansas city next month, one of the work groups, myself, to work through this process and observe it. we have had four separate meetings that have brought leaders together in order to make these decisions. the fifth will occur in the next couple weeks and then i will be out at work group 6 to work our way through this. >> okay. one final question. what data will be collected from the health telenet platform and how will it be used for further development of effective interventions? >> we will have to take that for the record, in terms of specific data, for telenet mental health? >> yes, thank you. >> thank you, mr. cunningham, you are recognized for five

minutes. >> thank you mr. chair and think you to everyone of you for attending tonight, suicide prevention coordinators are critical to the va's efforts to prevent veteran suicides. i wanted to see if you all could speak, in your opinion, as to what shortcomings the va has with suicide prevention coordinators as far as mistakes they make or any issues or weaknesses found in that particular employment? >> i can take that. we have 444 suicide prevention coordinator's around the nation, i would note that we are the only hospital system that has employed full-time suicide prevention coordinators to get after those issues. we are in the process of hiring up another 246 this is based on the analysis that was done over the past year that recognized the effect that we added our crisis centers, as you know,

and then we also created a new capability called reach veteran which is a predictive algorithm that produces a red flag and looks at variables and provides the functions of others in the hospital system to do care and outreach to veterans with high risk. that has created an additional workload and burden on this capability that was stood up over 11 years ago, as well, it is a time to continue to reset and refresh the community. we offer a training for them every other year, in collaborate was with dod, we do an ongoing assessment of their needs and we make sure that we are training them with the latest evidence-based practices and we are supporting them. they are taking care of our nations veterans who are at most high risk. we care for them as well and we want to make sure that we are providing them the best care possible. we have recently also conducted an analysis to further advance

public health entities other than just suicide prevention coordinators that are doing clinical work, we want to make sure we are doing additional work outside the community with our reach. it is a holistic approach.>> and of those additional ones, how many are vacancies, if any? >> those are not vacancies, those are additional, above and beyond. we don't have the vacancy rate, but we have it with our mental health, which includes our social workers and psychologists and others, the vacancy rate is around 10%, i don't know if dr. stone might want to add to that.>> because we are working with a segment of healthcare delivery then nobody else has ever done before, we are still figuring this one out. and when i say that, the average suicide prevention coordinator would have a cohort of about 90

patients. but yet, not all of them are they contacting every day. in some instances, especially in those people coming out of our emergency rooms that are at risk, they are being contacted by the nurses or actually even the provider. we implemented, as was mentioned by my colleagues, a post suicide attempt, suicide prevention contract, that i have spoken about previously here today. in previous testimony. it has been pretty dramatic in reducing future suicide rates. but, the individuals that are interacting with that at risk veteran, either the nurses or the actual provider that cared for them in the emergency room. so, adding the additional personnel is a recognition that we continue to grow in our engagements and our veteran crisis line as well as identifying at risk veterans by going through what we call our reach veteran program.

we have 30,000 veterans that we consider at substantial risk of future suicide in making positive contact with them is essential. >> i appreciate that, dr. stone. one final question for you as i'm trying to understand, what you testified to here today, let's say you are king for the day, and for every extra dollar of funding that you have received, how much of that what you put into addressing mental health within the va hospital and, you know, suicide prevention coordinators, addressing the issue head on? and what percentage of that dollar would you allocate towards the issues you previously identified with, the homelessness or economic, basically this underlying factor. >> having sat through the last couple hours with me, you understand very well my answer, this is not a financial problem. this is a problem of the

society we live in, this is about the interpersonal connections that we each have to each other as a society. i can hire another 20,000 mental health providers, and what i can say to you is that people in crisis will get great care, and they will come in and be seen in the same day that they are today. i can hire additional people for that, but this is about moving to the left, moving towards the fact that we need to reduce risk, and it goes back to your colleague's comments earlier about whole health, and identifying what connects us as humans to other humans and finding stabilization as a society. that is much different than it was for those veterans that came home 30, 40, and 50 years ago. >> i appreciate your time and i appreciate the service that each of you provide. >> thank you, mr. cunningham.

mr. gil cisneros ? >> thank you, mr. chairman. dr. stone and dr. franklin, i sat down and had a conversation with the director of the va medical center, and he mentioned the program that they're running called the veterans medical evaluation team, have you heard of it? >> no. >> for those of you that don't know, this program is a partnership between the department of veterans affairs and long beach and also law enforcement, local law enforcement, to proactively reach military veterans in trouble. even if they are not connected with the va system. they train local police officers, even va clinical technician will often go with the law enforcement officer on calls when it is regarding a veteran. he touted, this is a very successful pilot program that they are running, and we heard about several examples of successful pilot programs at local va hospitals as well.

just this evening. how does the va collect this data from this? obviously, you are encouraging local va hospitals to go out and to run community programs. but, how is the va overall collecting this data, and then deciding if these programs are successful? and implement them out on a larger scale? >> that is a very good question , i appreciate the example that is happening in your area because we have 24 sittings cities that are working with us, and seven states, and they are implementing as you described, creative, evidence- based approaches that involved trained community members. we bring them in and collaboration with our colleagues here to train them on these approaches. so that they can execute these, and we monitor them over time through a technical assistance

arm that is offered through my colleague, and we do it together, we host a series of monthly calls with local mayors and governor county teams to learn the best practices and we created an online i.t. platform where we call it a community of practice where they can input their best practices and data into this platform. anybody across the va can go in and look, share, and learn. i want to have him share because he is helping on this effort. >> this is a very important initiative, really trying to promote comprehensive approaches to suicide prevention at the local level, which is what we think is really needed. so, we look forward to our continued partnership with the veterans administration around this work, both in the cities and the rural areas and among states.

>> we are sharing best practices, which is great, but there has been an example of a program where you have said, we need to implement this nationwide because it is working? >> yes, i will give you one example under the leadership of dr. stone, that involves our er work. it was an early study that spoke to the importance of aftercare, they are getting simple intervention around outreach to veterans when they leave the emergency room. it pointed towards significant reduction in suicide, and we had done it in seven of our facilities, we tracked data over time in a small pilot, and when dr. stone got in the seat of the executive director, we had a series of meetings to put it on a fast track to full implementation across the entire system, every er.>> this is specifically directed at survivors of suicide attempt,

and was mentioned earlier by our colleagues, they had seen a 30% reduction, we are seeing a 50% reduction in future suicide attempts.>> you know, i agree with you, basically it is going to take a village, the va can't do it by itself, everybody needs to get involved, working with local law enforcement, local officials as well, to make this all happen. the last thing i have, you had mentioned the program that you have been working with, with the air force. you have been able to work with the air force to help minimize the numbers. that is the first i've heard of this program, i would love to see more information about that and i would really, if it is being so successful with the air force, why haven't we been able to implement it with the other services? >> i would not speculate, sir, on what the other services have done or not done, i have been

out of uniform since 2014, i can tell you that we are incredibly intrigued with the fact that the air force has taken it as far back as 1996. the integration of suicide prevention strategies and integrated them into virtually every level of officer and enlisted training. and in response to 18 years of warfare, they have seen almost no increase in air force veterans, or air force active service members of suicide rates. >> my time is expired, but if you could make that program, that information available to us, i would appreciate that. thank you.>> thank you, mr. chair. >> ms. underwood, you are recognized for five minutes. >> annual reviews of va suicide prevention and mental health services have found that most veterans get good mental health

care from the va. despite that, the suicide rate for veterans in my home state of illinois is almost double the rate of the population. we reviewed the medical research on the subject. i would like to walk through some of that research briefly with you today. suicide attempts for service members are more likely to result in death than they are for civilians, is that correct?>> yes, ma'am. >> let's talk about the research that might contribute to that, so we are using evidence-based policies. you are aware that both men and women have higher rates of firearm ownership and easier access to firearms in the general population, is that correct?>> yes. >> veterans are more familiar and comfortable with firearms than the general population. so, we know that both men and women veterans are more likely than civilians to use firearms then other measures for suicide. this is especially more dangerous because of tempting suicide with a firearm is more deadly than with any other method.>> absolutely.>> i want

to call to attention, it is integral to preventing veteran suicide. since 2008, the va has offered free gun locks to veterans in an effort to reduce suicide. is that correct? >> yes. >> the va has an educational campaign as well, i saw a flyer myself back home last week. that obviously veteran suicide remains at a critical level. va health professionals received training on providing lethal means counseling to veterans, is that corrects? >> yes, we do. the training is focused on how to talk to the veterans in a firearm better friendly way, we don't want to turn them off by using the wrong term or to have them begin to talk about this issue in a way that brings it into the public square and is a

potential political issue. we teach our clinicians that it is about safety and the training is focused on protecting the environment as is the last question of the safety plan, that both of my colleagues here mentioned. it is about assessing the environment for all causes in a manner of safety issues, and we focus the training on putting time and space between the person at risk and the identified means, which are many of the things that we talked about this evening. whether it is the freeze method or storage of firearms or having a peer involved and having a peer hold the weapon while a veteran is at risk. >> so, who receives the training? you know, you mentioned that the professionals do get it, but which category? >> mental health professionals.>> okay. in the written testimony, it talked about how many veterans received primary care, and many of these screenings are done by the primary care providers, do you see any utility in training

them in these methods? >> yes, if it were up to me, we would train the entire va, it is a short training, it is available online, it is easy to take, and we will monitor it overtime and continue to make a better. yes, ma'am.>> is that a resource constrained that they mandated or required to undergo this training? >> i think it is about getting their commitment and getting them on board to do it. we have a lot of work to do to make sure they are prioritizing that and training in platforms, if you will. >> i think this committee would support elevating that among the priority measures, and if there's anything we can do to accelerate that, i think it would be useful. we want to make sure that all healthcare professionals are armed with the resources that they need in order to properly service our veterans. has the va engaged at all with firearm dealers and ownership

groups to find ways to increase their involvement with veteran suicide prevention? >> absolutely, that is why we have a partnership with the national shooting and rifle foundation, it is not just with my single program, it is between the whole va md american foundation for suicide prevention which is another nonprofit that is heavily engaged in research in this space. it calls for the three agencies to work together to bring firearms owners, dealers, and even trade organizations to the table and teach them about signs and symptoms of risk. the state of new hampshire has had success in this, and as has the state of colorado. >> would you say bring together, are you hosting these meetings? >> we are not hosting them at the national level but they are hosting them locally, and they are going door to door to firearm dealers and people that sell and they are talking about suicide risk.

>> in numerous states, this kind of work is going on with funding, it goes to states, and has been used in a number of different states to fund this activity. >> thank you so much for sharing this information, i think there might be some utility as we explore evaluating these types of partnerships and seeing if there is a direct role that these agencies play and if we can be helpful to accelerate that. we stand by to do so. thank you.>> thank you so much for being here today. dr. stone, dr. franklin, i can see that you are deeply committed to this issue. my fear is that there are some things, as you mentioned, that are out of our control. and i'm saying this as somebody that went to afghanistan 6 years ago, and one thing is our

operational tempo and my question today centers around the effects of these issues on suicide. i will read off some statistics to you. a report published in 2008. the uniformed services university, it is showing that those who served 12 or fewer months before their first deployment were approximately twice as likely to attempt suicide during or after their second appointment. also, those redeployed within six months or less were 60% more likely to attempt suicide. we are aware of these statistics? >> i am. >> have you seen any further causal relationship between the number of deployments and the intensity of deployments? >> particularly the post-9/11 combat veterans. >> certainly, there are some deeply troubling issues regarding operational pace that

you bring up, and i referenced earlier in testimony, and that is not only the intensity of ongoing combat, in a 12 to 15 month deployment, as well as the dwell time when we bring servicemembers back, that would be extensively studied in the army stars program, it was also a point of interest as the vice chief of staff of the army who spearheaded a number of studies on relationship-based effects related to the amount of suicides in both the army and marine corps. all of that work was done in cooperation with the marine corps.>> as you see further evidence relating deployments and tempo of suicides, amongst young men and women, do you think it is within your purview to make recommendations to the active-duty army as to what they should change, and note

that if they do not change those things, they are creating an avoidable and what i would argue, incredibly wrong risk of suicide amongst veteran populations? do you think that is within your purview to make those recommendations to the active- duty army?>> i think that identifying data, and sharing that data with our uniform colleagues is entirely appropriate. i am not the decision-maker. >> of course not, but i'm talking about recommendations. would you recommend to the active-duty army, would you say that is responsible to redeployed soldiers with less than six months? >> the active component must make that decision. >> i am asking the healthcare professional. >> and i'm saying, those are decisions that the active component must make. we can share data, we have a

cooperative environment in which we as healthcare professionals are discussing this, but you can go back through the 20 years of this war and really look at the push and pull between the size of the ground force, and the relationship between the medical professionals that were advising senior leaders, and decide for yourself how that has been handled. i was in uniform for 23 years, i served on the army staff, i had my chance to say what i needed to say, and was welcomed by senior leaders and was proud to work alongside the ground combat forces. that said, my job at this point is to take care of 20 million veterans that want to see us. and, to take care of their problems. the decisions on dwell time, combat time, are certainly in a discussion between you and those active leaders. >> okay. i understand.

moving onto national guard soldiers. presently serving in the national guard, how do you explain, what is your understanding of this crisis with suicide amongst national guard soldiers who have not deployed? and do you think that the training tempo has any connection to this? and the fact that it has increased dramatically in the last 20 years?>> i think there are some deeply troubling spots of the national guard, and i referenced this earlier in testimony when i said that everyone of these service members joined knowing that they were probably going to combat. this is a different national guard, it is simply a guard that takes care of the state -related problems of floods, and hurricanes and tornadoes. this combat force is an area of debate that has been highlighted recently in a book called signature wounds, is the pace too much for the ground

combat forces of the guard? these are individuals that have served tremendously well, in combat. but, the stress on that force is significant, and one that i think we all need to consider. >> do you think it is within your purview to make recommendations to the national guard? >> we have entered in with the national guard, the national guard has been a wonderful partner, the general has been great in our meetings about discussing and trying to do everything he possibly can to reconnect. one of the things that we see is that there is a lower rate of suicide in guard members than there is in reserve members, and despite of the fact that the guard is much larger, there is something protective about the connection within states. remember that the army reserve is a force

that you might travel 400, 500, or 600 miles in order to do your reserve service. the guard has something protective about it that we need to study more and i can tell you that the leadership of the guard and the army reserve has been great about entering in these conversations openly and with a sense of self- examination.>> thank you very much for your time, and for your service.>> thank you mr. rose for your questions. mr. watkins, you are recognized. >> thank you, mr. chairman. thank you to the panel for being here, these questions would go to anybody who would like to answer. having served, or lived and worked both in service and as a paramilitary contractor for 8 years in iraq and afghanistan, i know firsthand some of the challenges servicemembers face when they go back home, and my question is, the metric of 22

suicides per day, i want to take a closer look at that for a deeper understanding is that metric hinting and suggesting this narrative, am i learning right that a lot of those are vietnam era veterans? >> 21% of the national veterans suicide number is over age 75. 37% is between age 55 and 74. 27% is between age 35 and 54. and 15% is 18 to 34. >> thank you. is the va open to, alternative is a loaded phrase, but, other means of therapies aside from psychotherapy, for example,

transmittal meditation? >> absolutely, there are a number of treatments, i don't know that the when you specifically mentioned are on our list, but we can get back to you on that. we are open to all forms of treatment plans, yes.>> and, do you have data that can measure the efficacy of those as compared to the more traditional psychotherapies? >> we don't have data specifically when those are implemented alone, what happens is they are traditionally implemented as part of a broader care system. for example a client might get cognitive behavioral therapy with additional complement tree care and it is typically evaluated as a part of the full system of care, the full treatment plan, if you will. >> are they using those approaches? >> it appears as though they are open to those. they are

using yoga and other forms of therapy.>> are reserve commanders open to those approaches as well? >> i think there has been tremendous progress in the openness of active leaders to these, because they can keep soldiers in the fight and the soldiers do very well with these types of training. i think the early intervention and the embedding of both behavioral health provider with the active component formations has shown tremendous value in both special operations as well as traditional ground forces. >> should those take a bigger role in soldiers basic trainings? >> i think that making servicemembers aware of the role of complementary medicine is tremendously valuable. probably the hardest data we

have really relates to organized sports activities and a protective effective organized sports activities, and i think an hour, our last report, it was really a demonstrable effect. >> great, thank you so much, i have no doubt there would be many more suicides if it weren't for your efforts, so thank you for your service.>> thank you mr. watkins. >> thank you for holding this hearing, this is a very important issue. particularly in my district, it is very large veteran population , i had an opportunity during the district work period to

have several meetings with the veterans service organizations and other nonprofits that are leading in this and related issues. i wanted to ask another question about the intersection of guns and suicide. in the national report, the veterans affairs calls for a continued focus on innovative crisis intervention services. one crisis intervention tool that 15 states have adopted is called an extreme risk law. when somebody is showing warning signs, these laws around this ask a judge to temporarily restrict their access to firearms. it cited 14% reduction in the states firearm suicide rate. and in the 10 years after its law went into effect in indiana, it cited 75% reduction

. the impact of an intervention tool like this can be magnified for the veteran population because not only do veterans have a higher rate of suicide and the general public, they are more likely

to hear from all stakeholders including the families of those veterans that have committed suicide and those veterans that have survived suicide and the many other professionals and stakeholders that have insights to help this committee take action and to really make a difference in reversing this trend that we see in veteran suicide. i understand lee minority does not wish to make a closing statement the minority does not wish to make a closing statement. to the veterans that are watching this hearing and to those struggling with the thoughts of suicide, a grateful nation cares for you. both your service and life are valued and your continued existence is necessary to

advancing the causes for which you so selfishly served. you sacrificed everything to preserve our freedoms. we as a nation are committed to preserving your life. if you or someone you know is contemplating suicide, or are in need of additional assistance, please call the suicide prevention lifeline at 1-800-273-8255. when you call that number, press the number one to get in touch with a professional that is waiting to assist you. all members will have two revise and extend their remarks

and include extraneous material. again thank you for all of the witnesses for appearing today before this committee, this hearing is now adjourned.