Remarks by Secretary Eric K. Shinseki
DoD-VA Suicide Prevention Conference
Washington, DC
June 20, 2012
Good afternoon, everyone. I am honored to be here, and I regret that my friend, Leon Panetta, had to reschedule his appearance for Friday. He and I have worked closely on issues common to both of our departments—five meetings since last July, when he assumed his duties, two last month, and we are hoping to meet again in August. Let me just say that Secretary Panetta's leadership and close partnership on behalf of those who wear and have worn the uniforms of our Nation has been monumental, and, as a result of that, we have brought our two large departments closer together than ever before.
As I often remind our folks at VA, very little of what we do in VA originates in VA. Most everything we do originates in DoD, and we must therefore be collaborative, attentive, and cooperative in supporting DoD's accomplishment of its enormous mission to keep our Nation safe, competitive, and leading. Doing so means that we, at VA, must be situationally aware, agile, and fully capable of caring for those "who have borne the battle" and their families and survivors, long after the guns have fallen silent. Today, we still care for two children of Civil War Veterans, over a hundred spouses and children from the Spanish-American War, about 5,000 from World War I, and the numbers go up from there. The promises of President Abraham Lincoln are being delivered today by President Barack Obama. The same will be true a century from now: VA will be here to deliver the promises of presidents and meet the obligations of the American people to those who have safeguarded us. We, at VA, are proud of our unique mission and of our partnership with the Department of Defense.
So, thank you again for inviting me here today. Our shared commitment to help the most challenged of our men and women find the strength and hope they need to prevail over the issues of suicide is crucial. We must end suicides amongst some of the most dedicated, loyal, tough, and courageous people I've known.
Having said that, suicide is a national concern. The Center for Disease Control's annual report on the top ten leading causes of death among Americans lists suicide as one of the top four causes of death in Americans ages 10–54. More specifically, for age group 15–24, suicides are number three; for age group 25-34, it is the second-leading cause of death among Americans. These also happen to be the recruiting years. Should we be surprised that recruits out of such a population, bearing some level of increased stress for much of the past decade, would experience suicides at some elevated level? Or that the suicide rate among male Veterans appears to be almost twice that of the general population?
Mental health professionals tell me that intervention works. It's important to define what we mean by intervention. If intervention only occurs in the midst of a potential ongoing suicide, our responses will be primarily reactive. In such scenarios, precision and agility become critical since time is of the essence. Recognizing key signs immediately, acting early (sometimes on thin evidence), having the means to intervene, and vectoring help decisively—these are the attributes of success in any crisis, not just suicides. The challenge is knowing when and where to intervene—precision and agility, again. We have demonstrated that we can react well, but is this good enough for the long term?
Each year, around 60 percent of high school graduates go on to college and university—some version of higher education. Of the remaining 40 percent or so, some undergo vocational training; others immediately enter the workforce. A few join the less than one percent of Americans who voluntarily serve in our Nation's Armed Forces.
After basic training and arrival at their first units, they quickly become valued and trusted members of high-performing teams—maybe the best teams they will ever serve on—tough, motivated, and extremely dedicated. With strong leadership, they perform the complex, the difficult, and the dangerous missions—much as they are doing today in Afghanistan, as they did in Iraq, and as they have done throughout our Nation's history. On some days, they are asked to do the impossible, and they don't disappoint. What the current generation has demonstrated has been nothing short of staggering in terms of courage, stamina, determination, and unwavering commitment—without complaint. This is a powerful image we all carry with us of the men and women who enable our way of life.
But there is also a second image: Veterans suffer disproportionately from depression, substance abuse, and they are well up there in joblessness as well—factors which contribute to both homelessness and suicide.
Why these disparate images? To be sure, there are far fewer Veterans in the second image than in the first, but both images are made up of the same youngsters who crossed that high-school graduation stage. They are the same youngsters who entered basic training. How did we fail to continue the kinds of successes they all achieved while in uniform? Why didn't we keep those in the second image from entering that downward spiral towards joblessness, depression, and substance abuse that often leads to homelessness and, sometimes, to suicide?
This is not about them; this is about us. You see, for some—maybe more than just some—these journeys began before the uniforms came off.
A Veteran recently committed suicide some three years after retiring from the military, but he had not elected to convert and continue his Servicemembers Group Life Insurance Policy. As a result, it was determined that he was not insured and his beneficiaries were not eligible to receive payment on a policy he had maintained throughout his active duty service. Much of the resulting public debate centered on VA's having missed his mental illness and its inability to pay off on the insurance policy.
In time, additional evidence allowed the insurance company to pay the claim—multiple affidavits to support his PTSD submitted by friends, former members of his unit, and civilian co-workers at the time of his death. We have since discovered that, while still on active duty, the Servicemember realized he was experiencing mental distress and asked to retire rather than serve a second combat tour. The request was denied, and he was again deployed to Iraq.
After returning from that second tour, he retired after 26 years of service. His military records contain no entries of depression, PTSD, TBI, or mental illness, and his enrollment in VA did not reflect PTSD, TBI, or depression.
While the public dialogue centered on payment of an insurance claim, there was almost no discussion about how we may all have acted to preserve a life—that seems to me to be the issue of substance for this conference. VA should have received ample warning about the mental health burden this Veteran was carrying. There was no handoff between our departments that would have enabled us to track and treat this Veteran—or any other Veteran today.
Are we asking the right questions about suicides? Three years ago in VA, we made ending Veterans' homelessness one of our key major priorities. Why? Because homeless Veterans are evidence that we have gaps in our system of care and benefits. We decided to challenge all our assumptions about homelessness to force us to find and close those gaps.
After all, VA is a large, integrated healthcare system with significant capabilities for treating depression, substance abuse, and suicide ideation. We are also the second-largest educational assistance program in this Nation, and we are the only zero-down home mortgage program in the country, with the lowest foreclosure rate of any of the financial institutions. Last year, we kept 73,000 Veterans who had defaulted on their home loans from foreclosure. If we, with all these tools, are not able to end Veterans' homelessness, who would be able to do that? So we set our goal on ending Veterans' homelessness in 2015.
Many experts on homelessness felt, then, that the primary contributor to Veterans' homelessness was mental illness. After nearly three years of work, they have now concluded that the leading contributor to Veterans' homelessness is, more specifically, substance abuse.
Have we made similar assumptions about suicides over time? Do we know causes, cures, and measures of effectiveness in our treatment regimens of those vulnerable to suicide? Do we have sufficient tools to prevent as well as rescue when dealing with those at risk? Are we asking the right questions to challenge all our assumptions about causes of suicidal ideation? Is it—
- Substance abuse or mental illness, or a combination of the two?
- Control, defiance, or anger?
- Hopelessness or pain?
- Selfishness or feeling that one has become a burden to others?
- Tragic glory inspired by others who end their own lives?
- Or the power of suggestion tempting troubled souls?
I am not a clinician, but I would guess that the professionals in the room would probably conclude, "It's all the above, obviously." I will agree that there is rarely, if ever, a single cause for anything, including suicides. But three and a half years ago, our experts on homeless Veterans were sure mental illness was the leading cause of homelessness, and we have since learned that it is, more specifically, substance abuse. Are there equivalent assumptions regarding suicides?
In VA, we know that when we diagnose and treat, people get better. This is reflected in our suicide treatment data, which show a declining trend between 2001 and 2009—the last year for which we have verified data. But we also know that most Veterans who commit suicide—perhaps as many as two out of three—are not enrolled in the VA healthcare system. As good as we think our programs are, we don't even get a shot at these Veterans. And as hockey great, Wayne Gretsky, says, "I missed 100 percent of the shots I didn't take." The same is true for us at VA. We can't influence and help those we don't see.
So our efforts must focus on both aggressive outreach to Veterans and families and provision of high-quality, cutting-edge mental health treatments to those in need—not waiting for them to find us or to decide they need help, but pushing the availability and quality of our programs. We do this best with warm handoffs between the departments, and yet there are folks still not convinced that warm handoffs are key to preventing suicides.
VA has had tremendous funding support in each of President Obama's four budget requests. Our investments in mental health programs increased by more than one-third in the past three years—from $4.4 billion in 2009 to $5.9 billion in 2012—and our funding specifically for suicide prevention has doubled from $35.8 million in 2009 to $72.8 million in our 2013 budget request, with $6.2 billion overall for mental health.
With that support, we have hired more than 4,000 mental health professionals in the last four years alone, and plan to hire another 1,600 professionals this year, bringing our total mental health clinical staff up to almost 22,000. In 2005, in the midst of heavy fighting in Iraq, 13,000 mental health staff were handling these needs here in VA. And as DoD estimates growth in its mental health patient load, we will hire additional staff to pace the growth in transitioning requirements. But that takes warm handoffs—or else, we are stuck in that primarily reactive response of rescuing them during crisis.
Among the 8.6 million Veterans enrolled in VA healthcare, the number receiving treatment for mental health conditions is up, and of those Veterans being treated, suicide rates are down—an indication that the system is doing a better job of identifying and treating people at risk of suicide. If we diagnose and treat, the outcomes are often positive.
One of our most successful outreach efforts is our Veterans Crisis Line—the creation of Dr. Jan Kemp and her superb team from Canandaigua, New York. DoD knows it as the Military Crisis Line—same number, same trained VA mental health professionals answering the phone, no cost to DoD—an example of our partnering to deliver optimal care to those in crisis. Since start-up in 2007, nearly 600,000 people have called in, including over 8,000 active-duty service members. We've made over 93,000 referrals for care and rescued nearly 22,000 from potential suicide. Again, we react well, but then precision and agility in the midst of crisis become our primary measures of merit, rather than longer-term success through diagnosis, treatment, and strengthening over time.
Some younger Veterans are more comfortable with chatting and texting than talking on the phone, so in 2009 we added an on-line chat service and in 2011 a texting service. Since then, we've engaged almost 54,000 people in on-line chats and another 3,000 by texting. One advantage to these new resources for communicating is they lessen the stigma associated with needing help. That's still an obstacle—shame keeps too many Veterans from seeking help.
I don't claim to understand the motivations of those men and women who are at risk of taking their own lives, but I do know that the victims of suicide also include their survivors—the loved ones left behind to a lifetime of grief, regret, and guilt. Many of you live by a creed that promises—
- I will always place the mission first;
- I will never accept defeat;
- I will never quit;
- I will never leave a fallen comrade.
How do we ensure that our care and concern—our empathy for those at risk—is not mistaken as sympathy for suicide? We must attack that misperception.
And if substance abuse is the leading cause of homelessness, and homelessness, substance abuse, and suicides are all related, do we address substance abuse sufficiently in our consideration of suicides? Are we courageous enough to ask whether our medication policies contribute to homelessness and suicides as well? Several years ago, when I asked whether we over-medicated some of our Veterans at a forum on Veterans' homelessness, that question received a standing ovation from the attendees—the question, not me. They thought it was a serious issue.
In my opinion, these are the assumptions worth reviewing because changes here might drive different approaches to staffing and treatment of mental health and suicides. And I prefer to commit to ending Veteran suicides—not controlling, reducing, or managing those at risk. Let's commit to ending it, and figure out what it will take. That's what we have done with Veterans' homelessness and we seem to be gaining traction there.
VA will continue to work closely with DoD to strengthen our collaboration on behalf of Veterans leaving the Service and reservists returning from operational deployments. We simply must transition them better. Last month, Secretary Panetta and I met to reaffirm our commitment to a fully operational Integrated Electronic Health Record [iEHR] by 2017—a significant challenge. But, as they say in Central Texas, "You can't wring your hands and roll your sleeves up at the same time. You have to do one or the other." He and I have rolled our sleeves up to better pursue the well-being of those who have served the Nation.
Thank you for what you do each day to help prevent military and Veteran suicides. Let's end this.
May God bless those who serve and have served the Nation in uniform, and may God continue to bless this great country of ours.
Thank you.
