Were live at the Senate Veterans affairs committee, where the success tear will testify about preventing veteran suicides as the committee looks into what congress can do to prevent them. Senator Johnny Isaacson chairs the committee. John tester is the top democrat on the committee. This is live coverage on cspan 3. We call this hearing to order. I thank all of you for coming today, especially our witnesses. We have a number of members on the way, but were in the interest of your time were going to get started. Todays hearing is about the issue of suicide. This month in america is National Suicide e Prevention Month across the kocountry. Suicide is a terrible, terrible, terrible loss of life. John will remember when we came in as a committee our first bill we passed was the Suicide Prevention bill. Passed this committee 990. It will ask to give us a report on the progress on the implementation of the act but its a very important act. And in august of 2014 i held a hearing at Georgia State university as a member of this committee. The reason i did was because in that year the months leading up to august 2014, georgia principal of the va hospital had three suicides, two on campus. A mission handling of available tools Like Pharmaceuticals and things of that nature. Others for a lack of awareness and lack of capacity. That was the real thing that concerned me. We began working in the clairemont hospital innen atlanta to improve vas response to suicide and to Mental Health issues. Suicide is a disease. It is preventable. There are many things we can do to set the example. Our staff director did a great job of seeing to it that every member of the staff has been through the training for Suicide Prevention. Is stands for signs of suicide thinking should be recognized. Ask the most important question of all, are you thinking about committing suicide, which is a tough thing to address, but the key question to ask. Validate the experience and encourage treatment and expedite getting help. I can tell you from what we learned in atlanta and the va timing is everything as it is in health care and most things. The goal we know about in health care, but when someone is contemplating suicide, its not something you put off for an appointment on wednesday or another day. Its something deal with immediately and quickly and expedite the response to it. I want to thank the staff for going through the training. Just like the heimlich maneuver has saved me a life, somebody was choking and somebody else knew how to apply that maneuver and just like cpr has helped people with untimely heart attacks, cpr helped people who might have drown and brought back to life. But being aware of the training thats necessary to save a life is is critically important. Were going to see to it we promote that training throughout the va and throughout the government to see to it we are saving lives and helping people to recover and restore their life. I want to thank bob for his commitment to being on the staff and all the Staff Members for having done it and thank the committee for their effort as well. We have two panels on the issue. The first is john day,en assistant Inspector General for health inspections. And dr. Matthew fits from montana. We appreciate all three of you being here today. Youll be allowed to give up to five minutes of testimony. We dont have a whistle that blows, but after ten youll be in big trouble. With that said, well start with you dr. Day and your testimony and go down the list from there. Welcome. Thank you, chairman isaacson, Ranking Member, members of the committee, its an horror to testify before you today on the subject of Suicide Prevention. This topic issen important to all of the staff at the oig. We work to receive veterans receive the highest quality Mental Health care. We have reviewed facts surrounding the death of veterans that took their own lives. We find they suffered the effects of chronic Mental Illness and Substance Abuse disorder. In the aftermath of these deaths, we hear from members of the veterans family, c significant friends that they would have acted sooner or differently only if they had known. After the Virginia Tech incident shootings, a serious review of the privacy laws that impacted disclosure of medical information was undertaken. My staff met with and talked with a number of the individuals who were involved in this review to determine if there were Lessons Learned that could be applied to va. Changes to law seemed too difficult to design, however, changes in practice that utilize advanced directives or similar devices may offer a way to improve communication at the criticalen point when a patient needs help the most. I think there is a chance to improve communication by expanding the situations underwhich these and similar devices are used. Va is thoughtfully derived to predict who may suicide. The question is when would a veteran take action to harm themselves or harm others . When would intervention be most effective . Research using social media and other more timely data has shown promise and understanding the human emotional state and therefore, may assist in identifying when intervention for these atrisk individuals would be most successful. I think pilot studies and this has great potential. The testimony of others at this table point out that veterans do not obtain their care primarily from the va hospital system. So an effort to. Reach those veteran who is are at risk is most appropriate and essential to make a significant improvement in veteran suicide data. This concludes my oral testimony. I would be pleased to answer your questions. Mr. Chairman, mr. Ranking member and members of the committee, i appreciate the opportunity to appear here today to discuss recent advances in veteran Suicide Prevention. I want to read my written testimony in full, but will highlight a number of key points. The response to rising suicide rates the va has implemented numerous measures to prevent suicide among veterans. These efforts have led to improved access to care and serves as how they can prevent suicide. Several new studies reporting related outcomes among military personnel have been published in the past two years. While most of these studies their findings are applicable to the veteran community as a whole. As summarized in the attachment to my testimony, all the interventions reduce suicide. But only two are associated with significant reductions in suicidal behavior. Brief behavioral therapy are found to reduce behavior by 60 to 76 . Its those who served in the military. These treatments now serve as a foundation for several studies currently underway in the va and the dod. These latest findings not only confirm that behavior can be prevented among military personnel and veterans and shows how to do it. If these studies telt us anything, its that some strategies work better than others and simple things save lives. Tragically few veterans are likely to receive these treatments for a number of reasons. Today ill focus on one particular barrier. Inadequate training in Mental Health professions. In these studies researchers found that a key Suicide Prevention strategy used was not associated with subsequent reductions as was expected. The lack of effectiveness was attributed to poor quality implementation. Of note, the personnel did not implement the liability or specifici specificity. Researchers from both studies concluded that the results pointed to insufficient training and additional training could change this course. The problem of training is not confined to the va, though. Tragically deficient training is indem ic across the mental healh system. A recent report from the American Association of suicide highlights this issue. The Main Findings of that report are smarz ed in the attachment o my testimony. As you can see a shockingly low number of Training Programs provide any education or training about suicide to its students. Further more, state licensing boards, the very bodies charged with protecting the Publics Health and safety from unqual y unqualified professionals do not require any exams or demonstration of competency in risk assessment. The complications are disturbing. The vast majority of our nations Mental Health professionals are unprepared to effectively intervene with suicidal veterans. This has critical implications for all veterans, both within and outside the va. We have long talked about the many barriers that stand in the way of a veteran receiving Mental Health treatment and invested heavily in removing those barriers. What unsettles me the most is knowing that when a fellow veteran overcomes these barriers, he or she is unlikely to receive the treatments that are most likely to save their lives. A sobering and uncomfortable truth is we have made it easier for veterans to obtain treatment that doesnt work, especially those who receive services from nonva providers in their communities. If we want veterans to benefit from the most recent advances in Suicide Prevention research, well need to ensure implementation is accompanied by a robust training program. Luckily the past few years have led to considerable advances in our understanding of the most effective ways of teaching these methods to others. In order to reverse the trend, we must be willing to disrupt the status quo. We need to adopt the newest strategies that have garnered the most support, even though they may depart from existing procedures. We need to invest in training to use these procedures and create new initiatives to incentivize and support their implementation and clinical settings. These changes should not just target the va and dod but all settings. As well as our universities and Training Programs that are responsible for the readiness and preparedness of the Mental Health professionals. In conclusion, we are at a critical turning point for Suicide Prevention. Answers are now clear and effective strategies have been identified. We must now take the steps needed to ensure the treatments and interventions are easily available to all veterans both within the va and our communities. Thank you very much. Chairman, Ranking Member and distinguished members of the committee, on behalf of montana i would like to extend our gratitude to share our views and recommendations. We applaud the dedication in addressing the Critical Issues surrounding veteran suicide as someone who has lost a Family Member that was a veteran and just want to appreciate my sincere thanks. Montana has the highest suicide rate in the country. This is significantly higher than the National Veterans suicide rate and the western region. We think its important you have a framework to understand that the suicide, the model that we use is the stress model in which a combination of biological susceptibility that lead to malfunctioning neuron communications, which. Develop into behavior. The therapy and the support of family. Youll note that i will not be coming restriction because i believe its incredibly hard to legislate that, but it is an important factor. This creates unique challenges for our Health Care Providers and we are deeply in need of more Mental Health providers. Ill move on to our recommendations. Our first offer of intervention is proven to reduce suicide during critical points of military and veteran experience. It was influential in bringing the youth aware Mental Health program to the United States and we would like to offer it as a template of something thats proven to work in another population and would be perfect to bring over to this one. Second recommendation, establish a clear policy goal to improve the diagnostic treatment system. The target that we recommend to the committee is a task to work with the department of defense, the National Institute of Mental Health and the private partner to prepare two additional brain diagnostic measurements for clinical work in the va by the fall of 2020. Our next recommendation is to develop a plan for treatment resistant Mental Health conditions. Rough ly a third of mental healh conditions do not respond to traditional treatments. And this is a big issue and its an issue thats not addressed in montana. The va has nothing in our state to address treatment resistant depression. This is very personal to me because i lost a dear friend and it was a veteran in september of 2015 to treatment resis tapt depression and to watch his options slowly slip away was one of the hardest things i have ever seen. Montana blue cross and blue shield supports tms treatment for depression. I do not know why the va does not. Expand access to psychiatry and make online behavioral therapy available to all veterans. We also believe the va should expand availability of automated suicide risk assessments, develop a prize to create and validate a medical screening to determine which patients are at risk of developing side effects, develop a public facing Online Research directory for nonva resources. Create a relationship between the va and community Mental Health centers. There are over 1300 Community HealthCenters Across the country and we should be working with those to care for our veterans. Increase the vas collaboration with outside researchers and finally establish a continuity of pipeline for veterans directly from the department of defense to va and Community Providers. Thank you again for the opportunity to testify in front of this committee. Your attention to this issue means a lot to me, our entire organization and their families. Thank you, we appreciate you being here today. What im going to do is reserve my time. We have different meet thags are going to take place. Im going to go to members and their questions and ill ask mine later when senator test returns. Hes doing another presentation. Let me start off with john. Thank you very much, mr. Chairman. Thank you for holding such an important hearing and also to senator tester. I cant think anything thats more important to discuss. Certainly we all agree this is a crisis. In arkansas i think were number ten in suicide rate overall. Of that group, veterans represent about 8 of the population but represent 20 of the suicides. So we are a state that is like so much of the rest of the country. In fact, the rest of the country period is experiencing significant problems. Dr. Brian, you mentioned that recent reports have highlighted the inadequate sis of the Mental Health professional. And in fact i was looking at the chart 25 of social workers, 2 to 6 of marriage counsellors. Those have received what we call even the Old Fashioned training perhaps. Not to mention the work that you and others are doing in such a good way. Those are are pretty staggering. Unless we have a metric out there, how do we go about solving that problem . I will admit also as youre thinking about that, and the rest of you can jump in too. Once we have the new research, once we perhaps get a metric, how do we get that not talked about but instituted in a timely manner . Both very good questions. The first it would probably require a concerted effort in it redesigning and reengineering our education and Training System and professional practice of Mental Health. We would need to find ways to incentivize graduate Training Programs to sure that not only is that training scientifically supported. This can be established in a a number of ways looking at grants and other federal incentives and initiatives to encourage certain types of curriculum and training opportunities. To look at how do we determine whether or not an educational system is meeting minimum standards for the practice of Mental Health across these disciplines. If we work with those organizations, i think we will be able to see some very dramatic shifts in curriculum. For your second question regarding dissemination and implementation. I think one of the challenges that many of us have as scientists is a scientist not to be very good at communicating their ideas to nonscientists. And so many of us in the dissemination field have talked about how do we find opportunities to have researchers and scientists work with Communications Experts on how to convey this information not only to the general public but also to other professionals. Those who we want to target to be using these strategies, but we also need to target the consumer. So the consumer is educated and understands which treatments work best. So when they go to a health care provider, they can ask the right questions to determine if this is an individual thats likely to be able to help me. One of the things we found to be important is getting the research to the states. Creating a pipeline to have those conversations. We had to start up our Research Center in mo