Order. Thank you for coming today especially the witnesses we have a number of witnesses available todays hearing is about the issue of suicide. As many people know this month in Americas NationalSuicide Prevention month across the country terrible wasteful loss of life they think john will remember when we first came in three years ago the first bill we passed was a Suicide Prevention bill that passed and if they could get any report they might have on the progress on the implementation in terms of automatic but its very important. I held a hearing at Georgia State university as a member of this committee. As they feel dishing hearing on the issue of suicide th suicidey redesigned it is in that year from leading up to august, 2014, the georgia principal hospital in claremont road i indicator hd three suicides, to oncampus and on the mishandling of available tools for suicide Like Pharmaceuticals and things of that nature and others were like awareness to improve the response to suicide and Mental Health issues. Suicide is a disease and it is preventable. Its been through the safe training for Suicide Prevention. It stands for suicide thinking should be recognized and asks the most important questions of all are you thinking about committing suicide which is a tough thing to address. To encourage treatment and expedite getting help and i can tell you from what we learned in atlanta and in the va, timing is everything as it is in healthcare. You expedite the response and just like the heimlich maneuver safely when somebody was choking and someone else knew how to apply it, just like it helps people that have on timely heart attacks and people that might be drowning more might have drowned and brought back to life, but being aware of the training that is necessary to save a life is critically important. We will see to it that we promote this throughout the va and throughout the government is to it that we are saving lives and helping people recover and restore their life and i want to thank you for your commitment to the Staff Members for having done it and think the members of the committee for their effort as well. We have two panels on the issue, first is the assistant Inspector General for Health Inspections and second days doctor craig bryant at the center for National Veteran studies university of utah and the executive director of the alliance for montana we place all three of you here today you will be allowed to give up to five minutes of testimony. After ten you will be in big trouble. All your statements will be printed for the record and withs episode we will start with you and go down the list from there. Thank you Ranking Member isakson and members of the committee is an honor to testify today on the subject of Suicide Prevention. This topic is important to mr. Russell and all of the staff. We work to ensure veterans of the highest quality Mental Health care. We have reviewed the facts surrounding the deaths of many veterans who took their own lives. Often we find a suffer the effects of chronic Mental Illness and Substance Use disorder. In the aftermath of these deaths, we frequently hear from members of the veteran family, significant friends in pa providers that they would have acted differently if only they had no. After the Virginia Tech incident it impacted the disclosure of medical information that was undertaken. My staff met with and talked with a number of individuals involved in this review. To determine if there were Lessons Learned that could be applied to the va. It seemed too difficult to design but the practices or similar devices may offer a way to improve communication at the critical point when the patient needs help the most. I think there is a chance to improve by expanding the situations under which these and similar devices are used. They thoughtfully derived the model and the question is when thwould an atrisk veteran take action to harm themselves or others. When word intervention be most effective . Research using social media and timely data has shown promise in understanding the human emotional state and therefore may assist in identifying when these atrisk individuals with the most successful. This has great potential. The testimony of others at the table point out that many veterans do not obtain their terror primarily from the va Hospital System and so an effort to reach those veterans who are at risk is most appropriate and essential if we are to make a significant improvement in veterans suicide data. This concludes my testimony and i would be pleased to answer your questions. Mr. Chairman and members of the committee i appreciate the opportunity to discuss advances in recent Suicide Prevention. I will not read in full that i will highlight a couple of key points. The response the va has adopted and implemented numerous measures intended to prevent suicides among veterans. These have led to improved access to care to serve as an example of how an agency can address the cause of Suicide Prevention. The studies reported that these outcomes among military personnel veterans for bush in the past years. Most of the studies in the murder military personnel are applicable to the veteran community as a whole. As summarized in the attachment, all of the interventions reduced suicide but only two are associated with significant reductions in suicidal behavior. The behavioral therapy and crisis respons response planninh are found to reduce the behavior by 60 to 76 . They are the only strategies shown scientifically to reduce suicidal behavior among those that have served in the military. The treatments now serve as a foundation for many studies underway in the va as well as the dod. These not only confirmed the suicidal behavior can be prevented among the military personnel and veterans and shows how to do it. If these studies tell us anything its that they work better than others and simple things save lives. Today will focu we focus on oner barrier. Two studies highlight this issue. The studys researchers found that a Suicide Prevention strategy used was not associated in subsequent reductions in suicidal behavior as expected. The training could actually change this course. The problem is not confined to the va. Tragically it is endemic across the nations Mental Health professional Training System. The recent report from the American Association highlights this issue. The Main Findings are also summarized in the attachment to the testimony. As you can see a shockingly low number of Mental HealthTraining Programs provide any education or training about this fight is too dense. They typically do not require exams were devastation of intervention. The majority of the Mental Health professionals are unprepared to effectively intervene with suicidal veterans. This has critical implications for all veterans cant both within and outside of the va. Weve long talked about the many barriers that stand in the way of a veteran receiving Mental Health treatment and have invested heavily in removing those barriers. What unsettles me the most as a veteran is knowing that when a federal fell in pcs these, sobering and uncomfortable truth is that weve made it easier for the veteran something treatment that doesnt work, especially those who receive services from non pa providers and their communities. If we want veterans to benefit we need to ensure implementation is accompanied by a comprehensive and Robust Training Program and the past few years also led to considerable advances in the most effective ways of teaching these methods to others. Much of this knowledge has been obtained by the va and the research. In order to reverse the trend of a Veterans Society must think bold and be willing to disrupt the status quo. We need to adopt the strategies that have gone with the most support even though they may depart from existing procedures. We need to invest more heavily in Training Clinicians to use these procedures and create new initiatives to incentivize and support their implementation in the critical settings. These should not just target that all clinicians in all settings as well as the universities and their Training Programs that are responsible for the readiness and preparedness of the mentalHealth Professionals. In conclusion, we are at a critical turning point for veteran Suicide Prevention. The answers are clear they have been identified and we must now take the steps needed to ensure the treatments and interventions are easily available to all veterans, both within the va and in our communities. Thank you very much. The appreciate your testimony. Now from the great state of montana. Distinguished members of the committee, on behalf i would like to extend our gratitude for the opportunity to share our views and recommendations. We applaud the committees dedication and addressing the Critical Issues around the veteran suicide as someone who personally lost a Family Member that was a veteran i just want to appreciate my sincere thanks. With 68. 6 per 100,000 visits significantly higher than the suicide rate in the western region. As an organization thats emerged in Suicide Prevention, we think it is very important that you have a framework to understand suicide and the model that we use a combination of biological susceptibility and environmental factors then lead to malfunctioning communications which develop into suicidal behaviors and other symptoms. Examples are the factors of biological susceptibility or genetics and trauma come examples on the environmental side are Emotional Trauma but on the positive, therapy and the support of family. Yofamily. Youll notyou will note that i e covered in lethal means restrictions because i believe that it is incredibly hard to legislate that, but it is an important factor. Montana is a rural state with an average of fewer persons files for this creates unique challenges for Health Care Providers and we are deeply in thneed of more Mental Health providers. Proven to reduce suicide during critical points of the military and veterans experience, montana was influential in bringing awareness and we would like to offer that as a template of something that is proven to work in another population. The second recommendation established a policy goal to improve the diagnostic system, the target that they recommend to the committee is that it hass the va to work with the department of defense, the National Institute of Mental Health, and private partners to identify and prepare to additional brain diagnostic measurements for clinical work in the va by the fall of 2020. The next recordation is to develop a plan for treatment resistant mental conditions. Roughly one third of Mental Health conditions do not respond to traditional treatments and this is a big issue that is not addressed in montana. They have nothing in our state to address treatment, this is personal to me because i lost a dear friend and who was a is a n in september 2015 to resist and to watch his options slowly slip away is one of the hardest things ive ever seen. Montana blue cross and blue shield supports treatment and i do not buy montana va does not. The next recommendation expands access to tell the psychiatry and then makes online behavioral therapy available to all veterans. We also believe that the va should expand the availability of automated suicide risk assessments to do that with a prize to create and update a medical screening tool to determine which patients are at risk of developing side effects from clozapine and develop a public facing Online Research directory for non va resources and create a more synergistic relationship between the va and community Mental Health centers over 1300 community Health Centers across the country, and we should be working with those to care for our veterans. Increase via collaboration with outside researchers and finally, establish a continuity of care pipeline for veterans directly from the department of defense to the kind of Community Providers. Thank you again for the opportunity to provide and your attention to this issue means a lot to me and the entire organization and their families. We appreciate your being here today and what im going to do is reserve my time since we have three members here and i will go straight to the members questions and ask mine later when senator tester returns. Let me start off with the gentleman from arkansas. Thank you mr. Chairman for holding such an important hearing and again also to senator tester i cant think of anything more important to discuss. We all agree that this is a crisis. In arkansas i think we are number ten in the suicide rate overall. Of that group, veterans represent about 8 of the population is represented up 20 of the suicide, so we are a state that is like so much of the rest of the country experiencing significant problems. You mentioned that with recent reports that highlight the inadequacies of the nations medical Health Profession training and in fact i was looking at the charge 15 of psychologists, 25 of social workers, marriage counselors, 28 of psychiatrists only those have received what he called even the oldfashioned training perhaps, not to mention the work that you and others are doing in such a good way. Those are pretty standard. How do we go about unless we have a metric out there how do we go about solving the problem as you are thinking about that and the rest of you can jump in. Once we have done the research and lead to perhaps get in the truck, how do we get that dot talked about but instituted in a timely manner . Good questions. First is a bigger question i will admit this is a huge issue that we are probably requiring in a concerted effort and redefining and reengineering of education and Training System and professional practice of Mental Health. We would need to find ways to incentivize into the initiatives to encourage certain types of curriculum and also partnering and working alongside various accreditation bodies to look at how do we determine. Many of us talk about how we find opportunities to have researchers and scientists work with Communications Experts only to the general public also to other professionals. Of those probabl that we want tt to be using these strategies but also the consumer, so the consumer is educated and understands which treatments work best. So when they go to a Healthcare Provider they can ask direct questions to determine if this is an individual that is likely to be able to help me. Yes sir, go ahead. One of the things we found to be important as getting the research to the states, creating a pipeline to have those conversations with the start of a Research Center in montana to make that happen because of the way that the structures are centralized in the research we probably will never have va research doing much in montana but if that pipeline is adjusted, that gets those conversations started and get people trained. The other thing i would recommend is for the va to make its treatment algorithms for veterans more widely available, i think that transition to the medical record is going to make that more possible. Get those treatment algorithms onto the field so people in the facilities can use them. Is overmedication a problem i would say my response on the overmedication is broad. What we would see for instance a student of mine just finished a dissertation about to publish the results with a larger than expected proportion of veterans that receive diazepam despite being diagnosed with depression and it is not effective treatment for ptsd. Often times, physicians and other prescribers rely on these because the previous treatments have not worked and so they are hoping to provide some kind of symptom relief. The unfortunate aspect is in those cases the veterans are almost three times as likely to die by suicide so theres another risk associated where i dont know if they are overprescribed but im not necessarily certain that in all cases that are intended to prescribers are aware of all the risks and are able to weigh them out with the benefits of those medications. Thank you mr. Chairman. Thank you senator. I would point out one of leaderof theleaders in that bilt book on that in the last congress. Thank you mr. Congress man. I was and hed believed democratic cosponsor along with senator john mccain on the republican side and believe that it was a start but only a first step in this effort and much more needs to be done. Obviously there are steps that have been taken in furthering this effort and i know people here from the doctor later. One of the very important statistics in your testimony is the suicide rate among veterans who do not use the services increased by 39 between 2001 and 2014 was