VA Testimony of Robert Jesse before Congress on July 14, 2010

United States Department of Veterans Affairs

HOUSE COMMITTEE ON VETERANS’ AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
JULY 14, 2010
STATEMENT OF ROBERT JESSE, M.D., PH.D.
PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

July 14, 2010

Chairman Mitchell, Ranking Member Roe, and Members of the Subcommittee: Thank you for the opportunity to appear before you today to discuss the Department of Veterans Affairs’ (VA) efforts to reduce suicide among America’s Veterans. I am accompanied today by Dr. Janet Kemp, VA National Suicide Prevention Coordinator. My testimony today will cover four areas: first, data on suicidality in Veterans and VA’s Suicide Prevention Program; second, VA’s National Suicide Prevention Hotline and Veterans Chat (an online resource); third, VA’s outreach and informational awareness efforts to reduce suicide among Veterans; and finally, VA’s impact on reducing the risk of suicide among Veterans.

Let me begin by saying how very important this issue is to VA and all of us in the VA health community. We have initiated several programs that put VA in the forefront of suicide prevention for the Nation. Chief among these are:

Establishment of a National Suicide Prevention Hotline, including a major advertising campaign to provide the hotline phone number to all Veterans and their families;
Placement of Suicide Prevention Coordinators at all VA medical centers;
Significant expansion of mental health services; and
Integration of primary care and mental health services to help alleviate the stigma of seeking mental health assistance.
I will discuss these initiatives in detail later in my testimony.

VA’s Suicide Prevention Program

A suicide by a Servicemember or Veteran is a tragedy for the individual, his or her friends and family, and the Nation. Data indicate that while civilian suicide rates have remained fairly static over the past 30 years, there has been a deeply concerning increase in the suicide rate among members of the Armed Forces over the last 5 years. Eighteen deaths per day among the Veteran population are attributable to suicide. Approximately 50 percent of suicides among VA health care users are among patients with a known mental health diagnosis.

These are staggering numbers, and the data fail to reveal the true cost of suicide among Veterans. In response to this urgent need, VA has been significantly expanding its suicide prevention program since 2005, when it initiated the Mental Health Strategic Plan and the Mental Health Initiative Funding. In 2006, VA supported two conferences on evidence-based interventions for suicide and provided funding to begin integrating mental health care into primary care settings and expanding services at community-based outpatient clinics (CBOC) for treatment of mental health conditions such as post-traumatic stress disorder (PTSD), and substance use disorders (SUD). In 2007, VA began providing specific funding and training for each facility to have a designated Suicide Prevention Coordinator; it also held the first Annual Suicide Awareness and Prevention Day and opened the National Suicide Prevention Hotline in partnership with the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA).

VA also established new access standards that require prompt evaluation of new patients (those who have not been seen in a mental health clinic in the last 24 months) with mental health concerns. New patients are contacted, within 24 hours of the referral being made, by a clinician competent to evaluate the urgency of the Veteran’s mental health needs. If it is determined that the Veteran has an urgent care need, appropriate arrangements (e.g., an immediate admission), are to be made. If the need is not urgent, the patient must be seen for a full mental health diagnostic evaluation and development and initiation of an appropriate treatment plan within 14 days. Across the system, VA is meeting this standard 95 percent of the time. The same year, VA initiated system-wide suicide assessments for those Veterans screening positive for PTSD and depression in primary care, instituted training for Operation S.A.V.E. (which trains non-clinicians to recognize the SIGNS of suicidal thinking, to ASK Veterans questions about suicidal thoughts, to VALIDATE the Veteran’s experience, and to ENCOURAGE the Veteran to seek treatment), and required Suicide Prevention Coordinators to begin tracking and reporting suicidal behavior. In addition, VA added more suicide prevention coordinators and suicide prevention case managers in its larger medical centers and community-based outpatient clinics, doubling the number of dedicated suicide prevention staff in the field.

By 2008, VA had re-established a monitor for mental health follow-up after patients were discharged from inpatient mental health units, developed an online clinical training program, and held a fourth regional conference on evidence-based interventions for suicide. In 2009, VA launched the Veterans Chat Program to create an online presence for the Suicide Prevention Hotline. VA also added a clinical reminder flag to patient records to notify physicians of patients at risk for suicide. This year, VA has already held a Suicide Prevention Coordinator conference and co-hosted a conference with the Department of Defense (DoD) to discuss ways VA and DoD can reduce the prevalence of suicide among Veterans and Servicemembers.

VA has adopted a broad strategy to reduce the incidence of suicide among Veterans. This strategy is focused on providing ready access to high quality mental health and other health care services to Veterans in need. This effort is complemented by helping individuals and families engage in care and addressing suicide prevention in high risk patients. VA cannot accomplish this mission alone; instead, it works in close collaboration with other local and Federal partners and brings together the diverse resources within VA, including individual facilities, a Center of Excellence in Canandaigua, New York; a Mental Illness Research and Education Clinical Center in Veterans Integrated Service Network (VISN) 19; VA’s Office of Research and Development; and clinicians.

During fiscal year (FY) 2009, VA’s Suicide Prevention Coordinators reported 10,923 suicide attempts among patients and non-patients, 673 of which were fatal (6.2 percent). There were 9,297 unique Veterans who attempted suicide and survived in FY 2009; 811 of these Veterans made repeated attempts, and 42 died from suicide after they survived an initial attempt during the year. Approximately 47 percent of those who attempted suicide in FY 2009 attempted it for the first time, and more than 31 percent of reported deaths from suicide involved cases where the individual had previously attempted suicide in 2009 or before.

It is not possible to determine if the reported cases are representative of suicidality in VA’s patient population, but we do know that suicidality can be both an acute and a chronic condition. Those who survive attempts are at high risk for reattempting and dying from suicide within a year, so it is essential that we engage survivors in intensified treatment to prevent further suicides. It is precisely because of this concern that VA has initiated the post-discharge follow-up for patients leaving its inpatient mental health units. The data reported above include self-reporting of previous suicide attempts that have not been validated by VA, and all estimates are based on events reported in the Suicide Prevention Coordinator database and may not represent the complete number of suicide attempts among Veterans. Also, the records of suicide attempts for 136 Veterans were incomplete and omitted from this analysis.

This evidence clearly demonstrates that once a person has manifested suicidal behavior, he or she is more likely to try it again. As a result, VA has adopted a comprehensive treatment approach for high risk patients. This includes a flag in a patient’s chart, necessary modifications to the patient’s treatment plan, involvement of family and friends, close follow-up for missed appointments, and a written safety plan included in the Veteran’s medical record. This plan is shared with the Veteran and includes six steps: (1) a description of warning signs; (2) an explanation of internal coping strategies; (3) a list of social contacts who may distract the Veteran from the crisis; (4) a list of family members or friends; (5) a list of professionals and agencies to contact for help; and (6) a plan for making the physical environment safe for the Veteran.

VA’s Vet Centers also fulfill a critical role in reducing the risk of Veteran suicide. The Vet Centers screen all Veterans who visit them for potential harm to themselves or others; in FY 2009, this resulted in 174,700 assessments. Vet Centers intervened in 132 cases of potential suicide or homicide in the Center or in the community. There were no negative outcomes and their engagement potentially saved at least as many lives. All Vet Center staff members have been trained in the Gatekeeper suicide prevention model, based on the U.S. Air Force’s similar approach. Vet Centers also participate in outreach and community education projects with local county, state, Federal and DoD components and can identify Veterans at risk during these events.

Suicide Prevention Hotline and Veterans Chat

Between its creation in 2007 and March 2010, the VA Call Center for the Suicide Prevention Hotline (1-800-273-TALK) has received more than 256,000 calls. Approximately a third of these calls are from non-Veterans. These calls have led to 8,183 rescues of those determined to be at imminent risk for suicide and 30,176 referrals to VA Suicide Prevention Coordinators at local facilities. The VA Call Center has received calls from 3,270 active duty Servicemembers, a little more than one percent of all calls. To address the needs of the active duty population, VA worked with SAMHSA to modify the introductory message for Lifeline (their well-established hotline that feeds calls to the VA Suicide Hotline) developed memoranda of understanding with DoD, and established processes for facilitating rescues, including collaborations with the U.S. Armed Services in Iraq. During 2009, the Hotline services were supplemented with Veterans Chat, which has been receiving more than 20 contacts a day.

The Hotline has 15 active phone lines, 1 warm transfer line, and 151 employees, consisting of 123 Hotline responders, 17 health technicians, 6 shift supervisors, 3 administrative staff, 1 clinical care coordinator and psychologist, and 1 supervising program specialist. There is also a director, a deputy director, and their program support assistant. After receiving a call from a Veteran, Servicemember or family member, the responder conducts a phone interview to assess the emotional, functional and psychological condition. The responder then determines the level of the call, namely whether it is emergent, urgent, routine or informational.

Emergent calls require emergency services to keep the caller (or the person about whom the caller is concerned) safe; urgent care requires same day services at a local VA facility; and routine calls require a consultation by the local Suicide Prevention Coordinator. Consults occur if a Veteran consents to a consultation or if emergency services are required. They are simply alerts to the Suicide Prevention Coordinator and do not mean the Veteran is suicidal. Even if the Veteran is already engaged in treatment, a consultation can be done to alert the Suicide Prevention Coordinator to changes in the Veteran’s circumstances or to other needs he or she may have. VA analyzed data from the Hotline and identified the top 10 reasons for calls:

1. Mental Health Needs 59 percent
2. Substance Abuse 28 percent
3. Other 21 percent
4. Loss of Home/Job/Finances 15 percent
5. Physical Health Problems 15 percent
6. Relationship Issues 10 percent
7. Loneliness 7 percent
8. Sleep Problems 6 percent
9. Death of Friend/Family Member/Pet 5 percent
10. Questions about VA 4 percent

The warm transfer line referenced above is a special phone line that is staffed 24 hours a day, 7 days a week and accepts calls from sites or other call centers who want to transfer a caller to VA directly, without having to call the main 1-800 number. VA has pre-arranged agreements to do this with over 20 entities, as well as all other community crisis centers.

The online version of the Hotline, Veterans Chat, enables Veterans, family members and friends to chat anonymously with a trained VA counselor. If the counselor determines there is an emergent need, the counselor can take immediate steps to transfer the visitor to the Hotline, where further counseling and referral services can be provided and crisis intervention steps can be taken. Veterans Chat and the Hotline are intended to reach out to all Veterans, whether they are enrolled in VA health care or not. Since July 2009, when Veterans Chat was established, VA has learned many valuable lessons. First, it is clear that conversations are powerful and capable of saving lives. As a result, opening more avenues for communications by offering both an online and phone service is essential to further success. Second, training and constant monitoring is very important, and VA will continue pursuing both of these efforts aggressively.

The Lifeline and VA Call Center may be the most visible components of VA’s suicide prevention programs, but the Suicide Prevention Coordinators are equally important. Both the VA Call Center and providers at their own facilities notify the Suicide Prevention Coordinators about Veterans at risk for suicide. The Coordinators then work to ensure the identified Veterans receive appropriate care, coordinate services designed specifically to respond to the needs of Veterans at high risk, provide education and training about suicide prevention to staff at their facilities, and conduct outreach and training in their communities. Other components of VA’s programs include a panel to coordinate messaging to the public, as well as two Centers of Excellence charged with conducting research on suicide prevention: one, in Canandaigua, NY, focused on public health strategies, and one in Denver, CO, focused on clinical approaches. VA also has a Mental Health Center of Excellence in Little Rock, Arkansas, focused on health care services and systems research.

Outreach and Awareness of VA’s Suicide Prevention Efforts

As discussed previously, VA’s Suicide Prevention Coordinators do a tremendous amount of work to raise awareness about warning signs associated with suicide and the availability of treatment and support. For example, in February 2010, VA’s Suicide Prevention Coordinators provided 614 informational and outreach programs in their local communities. As a result, VA added 1,511 Veterans to its High Risk List and 1,353 (90 percent) have completed safety plans. In addition to these measures, VA has been aggressively advertising this information and improving outreach to Veterans and family members alike. Perhaps the most notable examples of this outreach are the public service announcements (PSA) featuring actor Gary Sinise and broadcaster and journalist Deborah Norville. All told, these PSAs have been shown more than 17,000 times and represent a significant cost savings. The two PSAs cost approximately $200,000 to produce, while the estimated value of the air time in which they were broadcast is $3.8 million.

Another major effort in this regard is the advertising VA developed and placed on buses and Metro trains in the Washington, D.C. area, resulting in a significant increase in calls to the Hotline from the area. In 2009, VA began an advertising campaign in Dallas, Los Angeles, Las Vegas, Miami, Phoenix, San Francisco and Spokane metropolitan areas (all locations where the suicide rate among Veterans is greater than the national average). The table below contains specific information on the forms and extent of outreach VA pursued in these areas. These advertisements ran for 12-week,non-concurrent periods starting in late spring and ending in early fall 2009. “Units” refer to each specific location, so a bus displaying side, taillight and interior advertisements would count as three units. A second advertising campaign is being pursued through a contract with BluLine Media, Inc. and is producing and displaying suicide prevention advertisements in the interior of public transit buses. This effort has reached 4.3 million daily riders in 124 markets covering 42 states and 21,000 buses. The total cost for these two campaigns was approximately $1.4 million.

City	Media Form	Number of Units
Dallas	Bus: Side, Taillight, and Interior Ads	275
Los Angeles	Bus: Taillight and Interior Ads	1,700
	Bus Shelter Ads	40
	Rail Car Ads	105
Las Vegas	Bus: Side, Taillight and Interior Ads	1112
	Bus Shelter Ads	150
Miami	Bus: Side, Taillight, and Interior Ads	310
	Rail Station Ads	22
	Rail Car: Interior Ads	136
Phoenix	Bus: Side, Taillight and Interior Ads	950
	Bus Shelter Ads	25
San Francisco	Bus: Taillight and Interior Ads	1,265
	Rail Car Ads	336
	Rail Station Ads	140
Spokane	Bus: Side, Taillight, and Interior Ads	348

VA is continuing to conduct assessments of these programs. The Center of Excellence at Canandaigua is reviewing the associations between exposure to public health media messaging, knowledge of Hotline use among those known to the participant, and self-reported likelihood of Hotline use if in need. The current evaluation strategy aims to collect data from three random samples of approximately 500 community members from each of the 2009 media campaign implementation sites. To identify any long-term associations between exposure to media messaging and likelihood of Hotline use, data are collected at baseline (the time the campaign was initiated), and 6 and 12 months following the start of the campaign. This study is not complete, but preliminary data indicate an increase in the number of calls originating in the areas where these advertisements were deployed. Phoenix, for example, saw a 234 percent increase in calls from the 602 area code within 30 days of the start of the media campaign. This change is all the more notable due to the contrast between it and the more modest change or even decrease among calls originating from other Arizona area codes during those same time periods. Based on these promising efforts, in FY 2011 VA will pursue a “next generation” of suicide prevention outreach based on a comprehensive strategy developed with “social marketing” experts and implemented through a newly created national outreach contract.

VA’s Impact on Reducing Suicide

On the macro level, one way to evaluate the impact of VA mental health care and its suicide prevention program is to evaluate suicide rates. However, before addressing this issue, it is important to consider who accesses VA health care. For this, it is useful to refer to findings on those Veterans returning from Afghanistan and Iraq who participated in the Post-Deployment Health Re-Assessment (PDHRA) program administered by DoD. Between February 2008 and September 2009, approximately 119,000 returning Veterans completed PDHRA assessments using the most recent version of DoD’s form. Of the more than 101,000 who screened negative for PTSD, 43,681 came to VA for health care services (43 percent). Among 17,853 who screened positive for PTSD, 12,674 came to VA for health care services (71 percent). These findings demonstrate that Veterans screening positive for PTSD were substantially more likely to come to VA for care. Findings about depression were similar. Both sets of findings support earlier evidence that those Veterans who come to VA are those who are more likely to need care and to be at higher risk for suicide. The increased risk factors for suicide among those who came to VA is often referred to as a case mix difference.

Working with the Centers for Disease Control and Prevention’s National Violent Death Reporting System, VA recently calculated rates of suicide for all Veterans, including those using VA health care services and those who do not. This analysis included data from 16 states for individuals aged 18-29, 30-64, and 65 and older for the years 2005, 2006, and 2007 (during the period of VA’s mental health enhancement process). The year 2005 marked the beginning of enhancement, while the year 2007 is the most recent one for which data are available.

Suicide rates for Veterans using VA health care services aged 30-64, and those 65 and above were higher than rates for non-users, and they remained higher from 2005 to 2007, probably a reflection of the case mix discussed above. However, findings for those aged 18-29 were quite different. In 2005, younger Veterans who came to VA for health care services were 16 percent more likely to die from suicide than those who did not. However, by 2006, those younger Veterans who came to VA were 27 percent less likely to die from suicide, and by 2007, they were 30 percent less likely. This difference appears to reflect a benefit of VA’s enhancement of its mental health programs, specifically for those young Veterans who are most likely to have returned from deployment and to be new to the system.

Because the number of Veterans from the 16 states in this group is relatively low, the rates are, for statistical reasons, variable. Nevertheless, they demonstrate important effects. In 2005, 2006, and 2007, respectively, those who came to VA were 56, 73, and 67 percent less likely to die from suicide. Those who utilized VA services, to some extent, showed a lower rate of suicide with an effect that appeared to increase during the time of VA’s mental health enhancements. More broadly, the rate of suicide among Veterans receiving health care from VA has declined steadily since FY 2001; specifically, the rate declined more than 12 percent during this time. From a public health perspective, the decline in rates is significant, corresponding to about 250 fewer lives lost as a result of suicide. A chart detailing the VHA suicide rate from FY 2001 through FY 2007 is attached.

Conclusion

Mr. Chairman, as my testimony demonstrates, VA has taken a number of steps to provide comprehensive suicide prevention services, and the data indicate our efforts are succeeding. But our mission will not be fully achieved until every Veteran contemplating suicide is able to secure the services he or she needs. I thank you again for your support of our work in this area, and for the opportunity to appear before you today. I will be happy to respond to any questions from you or other Members of the Subcommittee.