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43–052 2009

THE TRUTH ABOUT VETERANS’ SUICIDES 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

MAY 6, 2008 

Serial No. 110–86 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

VACANT 

MALCOM A. SHORTER, Staff Director 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

May 6, 2008 

Page 

The Truth About Veterans’ Suicides ...................................................................... 1 

OPENING STATEMENTS 

Chairman Bob Filner ............................................................................................... 1 

Prepared statement of Chairman Filner ........................................................ 77 

Hon. Steve Buyer, Ranking Republican Member .................................................. 5 

Prepared statement of Congressman Buyer ................................................... 78 

Hon. John J. Hall ..................................................................................................... 7 

Hon. Phil Hare ......................................................................................................... 9 

Hon. Ciro D. Rodriguez ........................................................................................... 10 

Hon. Harry E. Mitchell ........................................................................................... 11 

Prepared statement of Congressman Mitchell ............................................... 79 

Hon. James P. Moran .............................................................................................. 12 

Prepared statement of Congressman Moran .................................................. 82 

Hon. John T. Salazar ............................................................................................... 14 

Hon. Jerry McNerney .............................................................................................. 14 

Hon. Corrine Brown ................................................................................................ 15 

Hon. Stephanie Herseth Sandlin, prepared statement of .................................... 80 

Hon. Shelley Berkley, prepared statement of ........................................................ 80 

Hon. Jeff Miller, prepared statement of ................................................................ 80 

Hon. Ginny Brown-Waite, prepared statement of ................................................ 81 

Hon. Timothy J. Walz, prepared statement of ...................................................... 81 

WITNESSES 

U.S. Department of Veterans Affairs: 

Hon. James B. Peake, M.D., Secretary ........................................................... 15 

Prepared statement of Secretary Peake .................................................. 83 

Michael Shepherd, M.D., Senior Physician, Office of Healthcare Inspections, Office of Inspector General ................................................................ 69 

Prepared statement of Dr. Shepherd ....................................................... 107 

Maris, Ronald William, Ph.D., Distinguished Professor Emeritus, Past Director of Suicide Center, Adjunct Professor of Psychiatry, and Adjunct Professor of Family Medicine, University of South Carolina, School of Medicine, 

Columbia, SC ........................................................................................................ 53 

Prepared statement of Dr. Maris .................................................................... 96 

Rathbun, Stephen L., Ph.D., Interim Head and Associate Professor of Biostatistics, Department of Epidemiology and Biostatistics, University of 

Georgia, Athens, GA ............................................................................................ 55 

Prepared statement of Dr. Rathbun ............................................................... 102 

Rudd, M. David, Ph.D., ABPP, Professor and Chair, Department of Psychology, Texas Tech University, Lubbock, TX ................................................... 57 

Prepared statement of Dr. Rudd ..................................................................... 105 

MATERIAL SUBMITTED FOR THE RECORD 

Video Transcriptions: 

Transcription of CBS News Video entitled, ‘‘Suicide Epidemic Among 

Veterans,’’ aired November 13, 2007 ........................................................... 109 

Transcription of CBS News Video entitled, ‘‘VA Hid Suicide Risk, Internal 

E-Mails Show,’’ aired April 21, 2008 ........................................................... 110 

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Reports: 

CRS Report for Congress entitled, ‘‘Suicide Prevention Among Veterans,’’ 

May 5, 2008, Order Code RL34471, by Ramya Sundararaman, Sidath 

Viranga Panangala, and Sarah A. Lister, Domestic Social Policy Division, Congressional Research Service ......................................................... 111 

Background Materials: 

U.S. Department of Veterans Affairs Pamphlet entitled, ‘‘Suicide Prevention, Men and Women Veterans, Knowing the Warning Signs of Suicide,’’ dated September 2007 ........................................................................ 120 

U.S. Department of Veterans Affairs Pamphlet for VA Employees entitled, ‘‘Suicide Risk Assessment Guide,’’ Issued by the U.S. Department 

of Veterans Affairs, Employee Education System ...................................... 121 

Letters: 

Hon. Michael J. Kussman, M.D., M.S., MACP, Under Secretary for 

Health, U.S. Department of Veterans Affairs, sample of outreach letter 

sent to veterans, informing veterans of the National Suicide Prevention 

toll-free hotline number, 1–800–273–TALK (8255), and pocket-sized 

card with VA Suicide Crisis Hotline phone number/information, as 

well as a Crisis Response Plan .................................................................... 122 

Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking Republican 

Member, Committee on Veterans’ Affairs, to Rick Kaplan, Executive 

Producer, CBS Evening News With Katie Couric, letter dated December 

21, 2007, and response letter dated May 16, 2008, from Linda Mason, 

Senior Vice President, Standards and Special Projects, CBS News ......... 123 

Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking Republican 

Member, Committee on Veterans’ Affairs, to Hon. James B. Peake, 

M.D., Secretary, U.S. Department of Veterans Affairs, letter dated 

December 21, 2007, and response letter dated February 5, 2008, requesting additional data on suicide rates among veterans ....................... 124 

Hon. Bob Filner, Chairman, and Hon. Steve Buyer, Ranking Republican 

Member, Committee on Veterans’ Affairs, to Hon. Robert M. Gates, 

Secretary, U.S. Department of Defense, letter dated December 21, 2007, 

requesting the number of active-duty suicides for each year from 1995 

to 2006; Hon. Robert M. Gates, Secretary, U.S. Department of Defense, 

to Hon. Bob Filner, Chairman, Committee on Veterans’ Affairs, providing preliminary response designating David Chu, Under Secretary 

of Defense for Personnel and Readiness, to address the matter, letter 

dated January 17, 2008; Followup request letters from Chairman Filner, dated May 6 and 21, 2008, requesting DoD to provide response 

to original letter dated December 21, 2007; Response letter from Secretary Gates, designating David Chu, Under Secretary of Defense for 

Personnel and Readiness, to address the matter, letter dated June 

3, 2008; and Followup request letter from Chairman Filner, dated 

June 5, 2008, requesting DoD to provide response to original letter 

dated December 21, 2007. [AS OF SEPTEMBER 25, 2008, THE U.S. 

DEPARTMENT OF DEFENSE HAS REFUSED TO RESPOND TO 

THE COMMITTEE’S REQUEST FOR INFORMATION REGARDING THE NUMBER OF ACTIVE-DUTY SUICIDES FOR EACH 

YEAR FROM 1995 TO 2006.] ................................................................... 132 

Materials Due from the U.S. Department of Veterans Affairs Requested During the Hearing: 

Hon. Michael J. Kussman, M.D., MS, MACP, Under Secretary for Health, 

U.S. Department of Veterans Affairs, to Hon. James B. Peake, Secretary, U.S. Department of Veterans Affairs, Memorandum dated May 

5, 2008, Regarding Blue Ribbon Work Group on Suicide Prevention 

in the Veteran Population ............................................................................ 134 

Table entitled, ‘‘Rates and Risk of Suicide and Other Suicidal Behaviors 

Among U.S. Veterans,’’ Updated April 30, 2008, Prepared by Joseph 

Francis, M.D., MPH, Acting Deputy Chief Quality and Performance 

Officer, Office of Quality and Performance, U.S. Department of Veterans Affairs .................................................................................................. 137 

‘‘The Comprehensive Veterans Health Administration Mental Health 

Strategic Plan,’’ (A Comprehensive VHA Strategic Plan of Mental 

Health Services), dated July 2004 ............................................................... 142 

Table entitled, ‘‘Crosswalking between the U.S. National Strategy for 

Suicide Prevention, the VHA Comprehensive Mental Health Strategic 

Plan and VHA’s Suicide Prevention Actions’’ ............................................. 188 

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Materials Due from the U.S. Department of Veterans Affairs Requested During the Hearing—Continued 

Information Provided by the U.S. Department of Veterans Affairs from 

Discussion with Secretary Peake during Post-Hearing Meeting .............. 189 

Post-Hearing Questions and Responses for the Record: 

Hon. Bob Filner, Chairman, Committee on Veterans’ Affairs, to Hon. 

James B. Peake, M.D., Secretary, U.S. Department of Veterans Affairs, 

letter dated May 21, 2008, and VA Responses ........................................... 208 

Attachments to Chairman Filner’s Post-Hearing Questions and Responses 

for the Record Retained in the Committee files include the following: 

The Medical Inspector Final Report #2008–D–654, entitled ‘‘Quality 

of Care Review, Veterans Affairs Medical Center (VAMC) Dallas, 

Texas, Veterans Integrated Service Network 17,’’ dated May 20, 2008; 

the Course Script entitled, ‘‘VA National Rules of Behavior,’’ Developed 

by the U.S. Department of Veterans Affairs, Office of Information and 

Technology, Cyber Security Service; and Presentation entitled, ‘‘VHA 

Privacy Policy Training, FY 2008’’ 

Hon. Stephanie Herseth Sandlin, Committee on Veterans’ Affairs, as 

forwarded by Hon. Bob Filner, Chairman, Committee on Veterans’ 

Affairs, to Hon. James B. Peake, M.D., Secretary, U.S. Department 

of Veterans Affairs, and VA Responses ....................................................... 236 

Hon. John J. Hall, Committee on Veterans’ Affairs, as forwarded by 

Hon. Bob Filner, Chairman, Committee on Veterans’ Affairs, to Hon. 

James B. Peake, M.D., Secretary, U.S. Department of Veterans Affairs, 

and VA Responses ......................................................................................... 238 

Hon. Shelley Berkley, Committee on Veterans’ Affairs, as forwarded by 

Hon. Bob Filner, Chairman, Committee on Veterans’ Affairs, to Hon. 

James B. Peake, M.D., Secretary, U.S. Department of Veterans Affairs, 

and VA Responses ......................................................................................... 240 

Hon. Bob Filner, Chairman, Committee on Veterans’ Affairs, to Michael 

Shepherd, M.D., Physician, Office of Healthcare Inspections, Office of 

Inspector General, U.S. Department of Veterans Affairs, letter dated 

May 21, 2008, forwarding questions from Hon. Stephanie Herseth 

Sandlin, and response letter dated July 2, 2008 ........................................ 245 

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THE TRUTH ABOUT VETERANS’ SUICIDES 

TUESDAY, MAY 6, 2008 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 10:03 a.m., in Room 

334, Cannon House Office Building, Hon. Bob Filner [Chairman of 

the Committee] presiding. 

Present: Representatives Filner, Brown of Florida, Snyder, 

Michaud, Herseth Sandlin, Mitchell, Hall, Hare, Berkley, Salazar, 

Rodriguez, McNerney, Space, Walz, Buyer, Stearns, Moran of Kansas, Brown of South Carolina, Miller, Boozman, Brown-Waite, 

Turner, Lamborn, and Buchanan. 

Also Present: Representatives Kennedy and Moran of Virginia. 

OPENING STATEMENT OF CHAIRMAN FILNER 

The CHAIRMAN. Good morning. This meeting of the Committee on 

Veterans’ Affairs of the House of Representatives is now called to 

order. 

I ask unanimous consent that two of our colleagues, Mr. Kennedy 

and Mr. Moran, be allowed to sit with us at the dais. They have 

a longstanding interest in the issues that we will be discussing 

today. Any objection? 

Mr. BUYER. I have no objection. We should follow protocols of the 

Committee. 

The CHAIRMAN. Thank you, Mr. Buyer. 

The hearing today is entitled, ‘‘The Truth about Veterans’ Suicides.’’ I hope we can get to that truth. 

A few months ago, on December 12, 2007, this Committee held 

a hearing that we entitled: ‘‘Stopping Suicides: Mental Health 

Challenges within the U.S. Department of Veterans Affairs (VA).’’ 

Nearly 5 months later, we are holding another hearing on this 

tragic issue and what the VA is doing. But it is brought to us because of data within the VA that seems to dispute what we were 

told in a hearing in December. 

Much of this was occasioned because last year, in November, 

CBS News aired a story called ‘‘Suicide Epidemic Among Veterans,’’ 

and recently, another story called ‘‘VA Hid Suicide Risk, Internal 

E-Mails Show.’’ 

I want to just make sure everybody understands what we are 

dealing with, and I would like to play two brief segments of those 

newscasts on our new video system. 

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[Videos played.] 

The CHAIRMAN. Mr. Buyer raised an interesting point now of how 

we are going to refer to this in the record—a tape. We have not 

exactly figured it out yet. We may have a transcript or referral to 

a Web site. But before the transcript of this hearing is done, we 

will work with you to figure out a way to do this. 

Mr. BUYER. Members, this is relatively new. Often we ask unanimous consent to place letters in the record. This is a first, that we 

actually watch a news program. 

I am willing to work with the Chairman to do something new. 

Either we refer to a Web site, whereby individuals could pull that 

down from a record, actually view the video, because that was how 

it was viewed in the Committee; or do we transcribe what was just 

put in there and put that in the record? 

We are going to work with the Chairman to figure out how we 

handle this. 

The CHAIRMAN. This is a 21st century problem. 

Mr. BUYER. We will work through it. 

Sorry, Mr. Secretary. Housekeeping. 

[A transcription of both the November 2007 and April 2008 CBS 

News videos appear on pages 109 and 110. In addition, the videos 

may be viewed at http://veteransaffairs.edgeboss.net/wmedia/ 

veteransaffairs/videos/cbs_suicide_part_1.wvx (November 2007) and 

http://veteransaffairs.edgeboss.net/wmedia/veteransaffairs/videos/ 

cbs_suicide_part_2.wvx (April 2008).] 

The CHAIRMAN. I think we all know that the first step in addressing a problem is to understand its full scope and extent. In 

the case of the VA and the epidemic of veteran suicides, either the 

VA has not adequately attempted to determine the scope of the 

problem, which I think is an indictment of the competence of the 

VA; or the VA knows the extent of the problem, but has attempted 

to obfuscate and minimize the problem to veterans, Congress, and 

the American people. This is an indictment, I think you would all 

agree, of the leadership of the entire Department. 

In December, Dr. Katz’ testimony before this Committee stressed 

a low rate of veteran suicides, stating that: ‘‘From the beginning of 

the war through the end of 2005, there were 144 known suicides 

amongst these new veterans.’’ In responding to the figures that 

CBS News researched, Dr. Katz stated that: ‘‘Their number for veteran suicides is not, in fact, an accurate reflection of the rates of 

suicide.’’ 

Either Dr. Katz knew that the CBS News figures were indeed an 

accurate reflection of the rates of suicides at that hearing or he had 

a sudden epiphany just 3 days later. 

In an internal e-mail dated December 15, 2007, Dr. Kussman, 

Under Secretary for Health in the Department, referred to a newspaper article and wrote that: ‘‘Eighteen veterans kill themselves 

every day, and this is confirmed by the VA’s own statistics. Is that 

true? Sounds awful, but if one is considering 24 million veterans.’’ 

That same day, Dr. Katz responds, ‘‘There are about 18 suicides 

a day among America’s 25 million veterans. This follows from CDC 

(Centers for Disease Control and Prevention) findings that 20 percent of suicides are among veterans, and it is supported by CBS 

numbers.’’ 

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Just this past February, Dr. Katz sends another e-mail that 

starts with, ‘‘S-h-h. Our suicide prevention coordinators are identifying about 1,000 suicide attempts per month among the veterans 

we see in our medical facilities. Is this something we should carefully address ourselves in some sort of release before someone 

stumbles on it?’’ 

There was silence from the VA. 

As you saw on the viedo, the chief investigative reporter for CBS 

News, Armen Keteyian, characterized the VA’s internal e-mails as 

a ‘‘paper trail of denial and deceit, a disservice to all veterans and 

their families that has rightfully been exposed.’’ 

In April of this year, a Dallas Morning News editorial describing 

a ‘‘recent spike in suicides among the psychiatric patients treated 

at the Dallas VA hospital,’’ stated that ‘‘descriptions of how four 

veterans committed suicide in 4 months, prompting the psychiatric 

ward to close, suggests that patients went to conspicuous and timeconsuming lengths to end their own lives. There seemed to be 

ample time for staffers to stop them, had they been doing their jobs 

better.’’ 

The RAND Corporation, in a recently published study entitled, 

‘‘Invisible Wounds of War,’’ found that since October of 2001, approximately 1.6 million U.S. troops have been deployed, and more 

than a quarter of them have mental health conditions. 

I think it is higher than that. The study estimated that approximately 300,000 of those deployed suffer from post traumatic stress 

disorder (PTSD) or major depression. Among those with PTSD or 

major depression, only half had seen a mental health provider or 

physician to seek help in the past 12 months, and among those who 

sought help, just over half received ‘‘minimally adequate treatment.’’ 

We saw a recent New York Times article that said up to onethird of those diagnosed with PTSD of recent veterans had committed felonies, of which 200 had been homicides, mainly members 

of their own families. 

Something is going on in America. The study that RAND did 

found minimally adequate exposure to psychotherapy as consisting 

of at least eight visits with a mental health professional, such as 

a psychiatrist, psychologist, or counselor in the past 12 months, 

with visits averaging at least 30 minutes. 

I would like to know, how does the VA mental healthcare treatment stack up against this definition of minimally adequate care? 

The RAND study also found that the VA faces challenges in providing access to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, many of whom have difficulty securing 

appointments, particularly in facilities that have been resourced 

primarily to meet the new demands of older veterans. Better projections of the amount and type of demand among new veterans are 

needed to ensure the VA has the appropriate resources to meet the 

potential demand. ‘‘New approaches of outreach would make facilities more acceptable to OEF/OIF veterans,’’ so says the RAND 

study. 

I think many of us believe that the VA healthcare system has 

been pushed to the edge in dealing with mental healthcare needs 

of our veterans. I believe we are witnessing either an inability to 

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address this problem or a purposeful attempt to minimize the problems faced by veterans and the VA, and sweep this epidemic of suicides under the rug. 

This morning we are going to attempt to get a better idea of the 

scope of this epidemic and what the VA is doing to respond to it. 

What specific steps has the VA taken since December, steps not 

previously planned, to get a better idea of the scope of what problem; and what has it done to begin to address the problem? 

Finally, I think we must seek real accountability from the VA. 

Mr. Secretary, we are looking to you to provide that. 

[The prepared statement of Chairman Filner appears on p. 77.] 

The CHAIRMAN. Let me just say, for the record, that was my prepared, controlled statement. My uncontrolled statement goes something like this, Mr. Secretary: 

We should all be angry at what has gone on here, at what looks 

like posturing before this Committee by not telling us the truth 

and talking about how to deal with statistics without informing 

this Committee. Our oversight function has to work, and can only 

work, with mutual respect for each other. We both, presumably, 

want to do the best job we can for veterans. We have to have mutual respect for each other, and the facts; and, I believe your staff 

exhibited neither. 

If the testimony that Dr. Katz gave was wrong, being questioned 

3 days after we went through a back-and-forth that was very difficult to do for both of us, why weren’t we notified? Why didn’t you 

say, ‘‘we found new statistics and we’re checking them out?’’ You 

never told us anything after your chief doctor in charge of mental 

health testified differently. 

What we see is a pattern, Mr. Secretary, a pattern that we have 

seen going back to the days of atomic testing, through the Agent 

Orange controversies of Vietnam, depleted uranium, and more recently, Persian Gulf War Illness, PTSD, traumatic brain injury 

(TBI), suicides, and homelessness. The same pattern that really reveals a culture of a bureaucracy. 

The pattern is deny, deny, deny. Then, when facts seemingly 

come to disagree with a denial, you cover up, cover up, cover up. 

When the cover-up falls apart, you admit a little bit of a problem 

and underplay it: It’s only a few people, only 1,000 veterans got exposed to that gas; Agent Orange didn’t affect very many; atomic 

testing, well, nobody knew what was going on. 

Then, finally, maybe you admit it’s a problem and then, way 

after the fact, try to come to grips with it. 

We have seen it again and again and again. It is not just dealing 

with numbers, as your whole testimony does, Mr. Secretary. You 

are talking about numbers as if that is all it is. It is a bureaucratic 

situation. 

This is not a bureaucratic situation with just numbers. This is 

a matter of life and death for the veterans that we are responsible 

for. 

I think there is criminal negligence in the way this was handled. 

If we do not admit, if we do not assume there are problems, if we 

do not know what the problem is, then the problem will continue, 

and people will die. If that is not criminal negligence, I don’t know 

what is. 

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Mr. Secretary, we had a discussion right after you were confirmed. I came up to see you to congratulate you on your new role 

as Secretary. I asked you a question. I said, Are you going to just 

be a caretaker for the last year of this administration, or are you 

going to do something real and have a legacy? I said, I hope it is 

the latter, and I will help you do that. 

I will tell you how you deal with this issue will determine how 

we see your role. There is clear evidence of a bureaucratic coverup here. 

One of the people in the e-mails is Dr. Kussman and I don’t even 

see him here. I guess he had a previous engagement. He ought to 

be here. I also don’t see the public relations guy that was one of 

the people in the other e-mail. They should be here to talk about 

what happened. 

I want to know, since I don’t see it in your testimony and I see 

only vague references to the e-mail, how are you going to ensure 

accountability? Are you going to ask for the resignations of Dr. 

Kussman, Dr. Katz, and anyone else who participated in the coverup of the data? 

I want to know if you are going to really take your role seriously 

and if there is going to be accountability for what has gone on here. 

This is not just an abstract discussion, this is not just a hearing 

to say, ‘‘We got you.’’ This is about our veterans and whether they 

have a life ahead of them or not. 

I will tell you I have talked to the Members of this Committee 

and they are pretty angry with what is going on. I think you need 

a better answer than your prepared statement, which just goes into 

bureaucratic details. 

Now, we will have opening statements. 

Mr. Buyer, you are recognized. 

OPENING STATEMENT OF HON. STEVE BUYER 

Mr. BUYER. Thank you, Mr. Chairman. I think those of us who 

have friends or family members that have committed suicide, number one, are haunted by that experience because we then look at 

that individual, and we reflect upon what could we have done to 

have prevented it. What did we miss? What were those risk factors? 

And sometimes they are noticeable. Sometimes when they are a 

friend and they are closest to you, you might be providing counsel 

to them, you think it is a moment of just being a good friend. Then, 

when they commit a foolish act and take their own life, you are tortured for the rest of your life. 

So this is a pretty powerful issue. Especially, it cuts across the 

sections of our population, when you think of suicide being the 11th 

leading cause of death in our society. So it is just not within the 

veteran population, it is within our population as a whole. When 

we don’t have a national surveillance system, it is very difficult for 

us to even gain a better understanding. 

But we do have defined abilities to come up with the proper cohorts not only within U.S. Department of Defense (DoD), but also 

in the VA, so we can better understand, and identify those risk factors. 

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I think, Mr. Secretary, by looking at how many Members have 

come here today, it sends a signal to you that the loss of a single 

veteran is a tragedy to us. I am sure that every Member of this 

Committee, in earnest, seeks to help you to identify contributing 

factors and to do anything we possibly can to prevent servicemembers or veterans from taking their own lives. 

We recognize that many of the veterans that do take their own 

lives, in fact, are inpatients and in psychiatric care. So even though 

we can provide in a controlled environment and we do everything 

we can, half of them that are inpatients are committing suicide. 

So it is one of those things where, even in a controlled environment, we can come up with identifying factors and still can’t prevent someone from committing what we view as a very foolish act. 

So the challenge that you have is real. 

I want to thank the Chairman for continuing these hearings to 

discuss this important issue and to help those at risk. A number 

of questions were raised during our hearing last December regarding the validity of data on the number of veteran suicides. Such information is vital to understanding the scope of the problem, as 

well as identifying risk factors and providing better prevention and 

treatment protocols. 

Chairman Filner joined me in a letter I wrote to you, Mr. Secretary—and to DoD and CBS News—requesting their respective 

data on how it was formulated. For the record, CBS News failed 

to respond to Mr. Filner’s and my letter. DoD only acknowledged 

the letter, and we are still waiting on their reply. 

Mr. Secretary, you were the only one to respond to Mr. Filner’s 

and my letter. That letter included information and worksheets on 

two separate studies that the VA is conducting. So I appreciate the 

timeliness with which you responded to this Committee’s concerns. 

These studies may provide some useful information, but they are 

limited to data on suicide rates among veterans in the VA healthcare system. VA must have a better method for the systematic collection and tracking of veteran suicide data. It is also important to 

find ways to reduce the stigma associated with mental healthcare 

and encourage more servicemembers to seek treatment when it is 

needed. 

During our last hearing, I asked the VA to be proactive and to 

reach out to soldiers and their families during premobilization, and 

to start with the 76th Indiana Brigade Combat Team as it prepared to deploy. Mr. Filner and I agreed that we would proceed 

with that. 

I want to thank you, Mr. Secretary. I am very pleased that the 

VA came, as requested, and participated in such an outreach. 

I also recognize that you are operating outside the lines of your 

jurisdiction. But you didn’t say that. You didn’t say, ‘‘That is outside my jurisdiction; I am now dancing on DoD turf.’’ You said, ‘‘I 

am going to embrace the counsel of the Committee and we are 

going to see if we can follow this group. We will identify ourselves 

with the family members. They are the ones who are the closest 

to being able to identify individual risk factors or if there is a 

change in my husband, my brother, my loved one, that we could 

see.’’ 

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I stood with 3,400 Indiana soldiers, with Joe Donnelly at the 

RCA Dome on January 2, for the formal send-off ceremony. Along 

with about 20,000 friends and family members was VA staff from 

the Indianapolis VA Medical Center, the regional office, and the 

Vet Center. The VA reported about 1,700 families received information regarding VA benefits and services, including mental health 

services, Mr. Chairman, and information on post traumatic stress 

disorder and suicide prevention. 

The VA also followed up with subsequent briefings while the brigade was at Fort Stewart, Georgia, for training. As the brigade 

marched off to war, I believe they left with a clear impression that 

the VA was available to provide support and assistance to their 

families during their deployment, and that you will be there when 

they return from Iraq. 

There was very positive feedback regarding the VA’s presence at 

these events; so I want to thank you, Mr. Secretary, for working 

with the Committee to be proactive and to do something outside 

the norm. 

Mr. Secretary, you have taken decisive action to meet these increased needs. This month, for example, the VA contacted nearly 

570,000 recent combat veterans about VA medical care and benefits. These veterans were either injured in Iraq or Afghanistan or 

discharged from active duty but had yet been contacted by the VA. 

So I want to thank you for your outreach. It is something that Mr. 

Filner had also been expressing, and had expressed that to you. 

So, Mr. Chairman, I think we need to acknowledge when the Secretary acts on something that you ask for, we need to compliment 

him for it. The Secretary has also directed the creation of an independent working group to assess VA’s suicide prevention programs. 

I want to thank Secretary Peake and other witnesses for their 

participation today, and I look forward to their testimony. In the 

end, I hope this hearing will drive home the message to our Nation’s men and women who serve, and to their families, that if you 

need help, care is available and treatment works, and there is a 

road to recovery. 

I yield back. 

[The prepared statement of Congressman Buyer appears on 

p. 78.] 

The CHAIRMAN. Before the Secretary testifies, are there opening 

remarks of any Members? I will call Members in the order that we 

have. 

Mr. Hall. 

OPENING STATEMENT OF HON. JOHN J. HALL 

Mr. HALL. Thank you, Mr. Chairman. 

Just briefly, I would say that if we can prevent any single suicide 

among our veterans, it is worth going to great lengths to do that. 

I would ask you—I know you are wearing two conflicting—and, 

sometimes—hats that are at cross-purposes with the ‘‘Honorable 

Secretary’’ before your name and the initials ‘‘M.D.’’ after it, and 

most of my questions will be addressed toward the M.D. part of it. 

It strikes me that minimally adequate treatment, as described in 

our documents we have before us, of at least eight visits in 1 year 

to a counselor, psychiatrist, or psychologist; and we understand 

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from testimony before this Committee that that is not necessarily 

the same psychiatrist, psychologist or counselor. It is hard for an 

individual servicemember or veteran to strike up enough of a rapport with a doctor or counselor who is treating them, if they are 

seeing somebody different every time they go in and they have to 

kind of start from scratch. We have heard that that is a problem. 

Thirty minutes, anybody in this room who has been to therapy 

for any kind of marital counseling or depression or whatever can 

tell you that 30 minutes is just about enough to get started and 

say goodbye and book the next visit. So I would at least say that 

the definition of ‘‘minimally adequate treatment’’ is not adequate. 

I would also say that with the rates of bankruptcy and divorce 

that we are seeing, which are records, we are told are records 

among our veterans, that those two things—each of them alone, 

not to mention bankruptcy and divorce taken together—are enough 

to drive people, servicemembers or regular civilians, to suicide. 

There are many stories during the Great Depression of people 

jumping off of buildings because their material wealth was gone, 

and they saw no hope. 

So some of this is rocket science in the mental health world; 

some of it is really just nuts and bolts and simple common sense 

in taking care of our veterans. 

I think that we should be as adaptable. Just as our military 

adapts their strategy in combat, we have had to change the course. 

For instance, in the war in Iraq we have had to change our strategy several times, and the insurgents have changed their strategy 

several times in response. They make a bigger bomb, we make a 

more armored vehicle, et cetera. We need to do the same thing, I 

think, on the VA side and constantly be ready to change our strategy. 

Lastly, we had a pair of parents before, I forget whether it was 

the full Committee or Subcommittee on Disability Assistance and 

Memorial Affairs, but two parents who were courageous enough to 

come in, whose son had taken his own life. They asked us for universal screening for PTSD for all veterans so they don’t have to 

self-identify. 

I think that that is maybe one of the answers, because men or 

women who are taught to be tough and are taught to handle situations, and who also want to just get back to their families and not 

be held over for extra questioning and not have something on their 

record that might be a stigma in the future for employment or for 

being able to be in law enforcement or advance themselves in the 

Guard or Reserve or what have you. 

Their son, this couple’s son, had not shown a sign that they, the 

parents, saw that would tip them off that he was so distressed that 

he was going to take his own life. So if parents, people that are 

close to an individual, don’t see the change, and can’t see it, I think 

we need the professionals to be right on top of the case. That would 

probably call for universal screening at some point after separation. 

With that, I look forward to your testimony. Thank you very 

much. 

I yield back, Mr. Chairman. 

The CHAIRMAN. Mr. Miller. Mr. Brown. Ms. Brown-Waite. Mr. 

Turner. 

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Mr. Hare. 

OPENING STATEMENT OF HON. PHIL HARE 

Mr. HARE. Thank you, Mr. Chairman. 

Thank you, Mr. Secretary, for appearing before the Committee 

today. It is nice to see you again. 

While I appreciate the amount of time and the effort and thought 

the VA has put into veteran suicide prevention, which I honestly 

believe has saved some lives, I have to say I was shocked and very 

disturbed after reading the e-mails. 

But this isn’t about numbers or formulas or programming. This 

is about people; this is about families, wives, husbands, sons, 

daughters. This is about honoring those who serve this country. 

A few weeks ago I sat and talked with Mike and Kim Bowman 

of Illinois, whose son, Tim, committed suicide. Tim was an incredible young man who bravely served in Iraq and came home a 

changed man, suffering from PTSD. His parents did their best to 

try to help him, but they didn’t know what signs to look for and 

how to reach out to help him. They are rightly angry and frustrated that, from their perspective, the VA didn’t do more to reach 

out to help their son. 

I believe the first step in solving any problem is admitting that 

you have one. If the VA, for some reason, isn’t being honest about 

the number of veterans committing suicide, then that is stopping 

us or preventing us from giving you the resources that you need 

to prevent them. 

I have said many times at hearings, and I will continue to say 

as long as I serve on this Committee, the question isn’t, ‘‘Can we 

afford to give the necessary funds out to help our veterans?’’ The 

question should be—the statement should be, ‘‘We simply can’t afford not to give you the funds we need.’’ But we have to know how 

severe the problem is in order to be able to help you on that. 

I think, to be honest, this is more than a problem; I think it is 

an epidemic among veterans if these numbers are remotely close, 

to what is happening and I believe they are. 

But we are all here today for the same reason, to find solutions 

to stopping veteran suicides so that no family like the Bowmans 

have to go through this. The RAND report found that 300,000 military servicemembers who have returned from Iraq and Afghanistan 

report symptoms of PTSD or major depression, but only slightly 

more than half have sought treatment for their conditions. 

Let me just echo the sentiments of my friend from New York, 

Mr. Hall, when he said that screening all the veterans when they 

come back is something that we need to do. It is something that 

I think—clearly, they may not know that they have the problem, 

their families don’t know; then we need to monitor them for some 

period of time down the road to make sure that if there is a problem, we can bring them in and be able to help them. 

With mental health disorder being a significant precursor to suicidal thoughts, it is clear to me that the VA has to do more to 

proactively reach out to veterans. 

As you know, Mr. Secretary, when we met—you know I come 

from a rural district, and I am also interested—one of my questions 

to you during the question period is going to be, How do we reach 

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out to those rural veterans that come back where there may not 

be a VA hospital close to them? How do we get them in quickly and 

timely in order to prevent what happened to Mr. Bowman? 

So I thank you for coming today. 

I would yield back my time. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you. 

Mr. Rodriguez. 

OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ 

Mr. RODRIGUEZ. Thank you, Mr. Chairman. 

Let me, first of all, thank you, Mr. Secretary, for being here 

today. And let me just add that some of us have extremely high 

expectations for you—and I know that you are uniquely situated 

because you served not only in our military as a soldier, but also 

in the DoD—in terms of service there and the VA, and the difficulty that we have had as a Committee in the past to try to get 

both the DoD and the VA to work together. 

With this situation, also I think that we are talking right now 

about veterans committing suicide, but we have had a lot of activeduty soldiers also committing suicide. Nothing is worse than a soldier committing suicide in terms of how badly they and their families are treated when they come home, even by other veterans. 

They are treated as if they were cowards and those kind of things. 

Those are the numbers that we also need to seek out and get the 

right information for us to be able to do the right thing. I think 

you can be helpful there. 

Let me just add to what Chairman Bob Filner has said, we are 

coming from a perspective, when I got on this Committee some 12 

years ago, I heard about Project 112, Project SHAD, where the DoD 

was denying that it even existed. Later on, as time went on—and 

20 years have passed since the inception of those projects—we 

identified some 35 projects that were out there, that we did experimental things with our soldiers. Then we found it was not 30, it 

was 40; then it went to 50. I think the latest numbers were something like 60, where we experimented with our own soldiers. 

But it took us prying and pushing and tugging to be able to get 

that information, when we really need to work together to see how 

we can help address some of these situations—and hopefully that 

is what we will do—to move quickly to try to meet the needs of our 

soldiers and our families out there. 

I want to also lay down the groundwork for that in terms of how 

important it is, what do we do from now? We know we have a serious situation in the VA. And I know we have a serious situation 

in the DoD also, which I know you don’t oversee, but that is also 

another area that we need to deal with. 

We have situations where—I just did an interview in San Antonio regarding a VA patient that died; the accusations are basically 

that he was killed because of presumed negligence on the part of 

the doctors—and the importance of peer review in the military, I 

mean in the VA, as it deals with doctors’ recommendations and 

those kinds of things. 

So there are other areas that are very serious, and I am hoping 

that we can make some inroads in those areas. As we move forward on this testimony, I am hoping that we can come up with 

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some recommendations, and if you have recommendations for us as 

to what you need to get it done. 

And, I know that for the longest time we didn’t provide the resources that were needed, and we have a responsibility there. But 

we also ask that we be given the information and the data that is 

needed for us to be able to do that, and hopefully we can respond 

to some of those needs. 

Thank you very much. Thank you for being here, Mr. Secretary. 

[The following was subsequently received from the VA:] 

1. Update on Dallas (not requested during hearing) 

2. Noted patient died in San Antonio may be related to negligence—importance 

of peer review—provide updates. 

Response: The Office of Medical Inspector (OMI) conducted a site visit to the 

Dallas VA Medical Center (VAMC) on April 16 through April 17, 2008. Its findings 

were presented to the Dallas VAMC leadership at the conclusion of the site visit 

and to the Veterans Health Administration (VHA) leadership on the OMI’s return. 

The OMI identified a number of environmental issues that needed to be addressed. 

The Dallas VAMC reports that action to address environmental issues such as removal of metal holders for linen hampers, geriatric chairs in the showers, and replacement of unit doors that did not lock automatically were completed by April 30, 

2008. 

The OMI recommendations currently under assessment or in progress include increasing the amount of therapeutic patient activity, replacing the suicide risk assessment tool, and changing the current continuity of care model to an inpatient 

model of care. The Dallas VAMC is addressing these issues. 

On April 22, 2008, a team from VA’s Office of Mental Health Services visited the 

facility to evaluate the safety of its mental health program. It identified additional 

environmental, organizational, and programmatic issues that can improve the delivery of mental healthcare. Actions on many of these environmental issues, such as 

additional housekeeping staff, painting and repairs, installation of new doors, and 

moving cameras and monitors have been completed or will be in the near future. 

In addition to the actions noted, the Dallas VAMC is reassessing the mixing of acuities on the Mental Health unit. 

The report has not been cleared by OMI and is in the pre-decisional stage. It is 

anticipated that it will be ready by the end of May. 

San Antonio—An external Peer Review was completed in the second quarter FY 

2008. South Texas is in the process of reviewing the results and developing professional practice evaluations. 

The CHAIRMAN. Thank you. 

Mr. Mitchell. 

OPENING STATEMENT OF HON. HARRY E. MITCHELL 

Mr. MITCHELL. Thank you, Mr. Chairman. 

In November, CBS News brought some shocking and critically 

important information to light. Not just that those who served in 

the military were more than twice as likely to take their own life 

in 2005 than Americans who never served, or that veterans aged 

20 to 24 were killing themselves when they returned home at rates 

between two-and-a-half to four times higher than nonveterans the 

same age, but that the Department of Veterans Affairs wasn’t 

keeping track of veteran suicides nationwide. 

In December we had a hearing to find out why. 

Mr. Chairman, I don’t know if there is anyone here who attended 

that hearing who will ever forget it. Mr. Hare mentioned that we 

heard from Mike and Kim Bowman, whose 23-year-old son, Tim, 

survived a year of duty in Iraq, only to come home and take his 

own life. Mr. Bowman warned us that our troops were coming 

home to an underfunded, understaffed, underequipped VA mental 

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health system that imposes so many challenges that many are just 

giving up. 

So when Dr. Katz insisted at that hearing, repeatedly, that the 

VA had all the necessary resources to reach all veterans at risk for 

suicide and make special treatment available to them, I was skeptical. How could Dr. Katz be so sure that there weren’t any requests for additional resources sitting somewhere within the vast 

VA system that have gone unfulfilled? Was he absolutely certain 

that there were no pending requests for an additional mental 

health counselor, for extra gas money to enable a VA employee to 

drive somewhere to contact an outreach? 

As Chairman of the Subcommittee on Oversight and Investigations, I felt I had a responsibility to make sure, so I asked the VA 

to double-check. I asked them to take a look at their records and 

send us any documents relating to any request for additional resources that had gone unfulfilled or underfilled. My thought was, 

if we could find out what the VA needs are to address this problem, 

we could get to work and make sure they got it. 

More than four months later, however, all I have gotten are excuses, complaints, and most recently, a suggestion that I, ‘‘Go file 

a Freedom of Information Act request.’’ That is not just an insult 

to me, it is an insult to this Committee and to our veterans. 

I have tried to be reasonable. I have tried to work with Secretary 

Peake’s office. But, Mr. Chairman, my patience is at an end. 

I have given the Department until Friday to finally produce the 

documents I requested. If they do not, Mr. Chairman, I want you 

to know that I will be asking you to pursue a subpoena. 

I yield back. 

[The prepared statement of Congressman Mitchell appears on 

p. 79.] 

The CHAIRMAN. Thank you, Mr. Mitchell. 

Mr. Moran, we thank you for your interest. You have been interested in this issue and have been a leader for many years, and we 

thank you. 

OPENING STATEMENT OF HON. JIM MORAN 

Mr. MORAN OF VIRGINIA. Thank you very much, Mr. Chairman 

and Ranking Member Buyer and my friends and colleagues. 

I want to mention, incidentally, with regard to the recommendation for individual screening, in the Defense Appropriations bill, 

when we put $900 million in for PTSD and traumatic brain injury, 

we did require that everyone get an individual face-to-face screening by the Pentagon. But the problem is, that is when all they can 

think about is getting home to their families, and it is oftentimes 

only after they get home that evidence of emotional problems, 

whether it comes out in domestic abuse or inability to hold on to 

a job and so on, manifests itself. 

The fact that 20 percent of our veterans from Iraq and Afghanistan show signs and symptoms of PTSD, depression, and anxiety 

is a compelling statistic. But even more so is the fact that that 

number increases to 50 percent for soldiers with multiple tours and 

inadequate time between deployments; and in fact, that is becoming more and more the case. 

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One of the measures that I would suggest that this Committee 

might consider is to create a stand-alone, 24-hour, national, tollfree hotline to assist our veterans in times of intense crisis. The 

key is that this hotline would be staffed by veterans trained to appropriately and responsibly answer calls from other veterans. 

I understand that the Department of Veterans Affairs has developed a veterans option off of the National Suicide Hotline. While 

I applaud your effort to address this problem, I believe that there 

are about three deficiencies in this approach. First, oftentimes a 

veteran doesn’t want to talk to a doctor; he or she wants to talk 

to someone who has got a real-life perspective on what is going on 

in their mind—cultural competency, if you will. That is a term that 

has been used to express that a fellow veteran can provide a real 

difference in crisis counseling because they can better relate. 

Secondly, soldiers with mental illnesses face social stigma that is 

identified with seeking care through the VA. Research from the Air 

Force’s Suicide Prevention efforts suggests that fear of the system, 

of an unfriendly mental health establishment, and of potential jobrelated consequences do keep many active-duty soldiers and recent 

veterans from seeking the care that they need. 

Thirdly, the VHA is already overburdened by a great many 

healthcare responsibilities; and as a result, I think it is ever more 

difficult to provide a topnotch hotline effort. Stretched budgets, 

staffing shortages, they may not be able to meet the challenges of 

so many returning veterans when our Nation redeploys from Iraq 

in the future. 

A nonprofit organization dedicated to suicide prevention might be 

better able to provide focus, stability, and commitment that the VA 

is particularly challenged in being able to achieve. 

So to conclude, our vets deserve as much support when they return from combat as they receive while in battle, and I know that 

this Committee is acutely aware of that fact. But too many of our 

veterans are struggling to make the difficult adjustment back to society, and they desperately need someone that they can talk to, 

that they can relate to, someone that has walked a mile in their 

shoes. So that is why I have offered legislation that would do that. 

I very respectfully suggest that this Committee consider that legislation. I certainly applaud this Committee for your efforts on behalf of veterans. 

Mr. BUYER. Would the gentleman yield? 

Mr. MORAN OF VIRGINIA. I would be happy to. 

Mr. BUYER. Mr. Moran, I want to thank you for your leadership 

over the years. Your care and sincerity, it is real and very evident 

to me, having known you over the years. So I want to thank you 

for your leadership. 

We debated your bill; and I like the idea of having veterans, but 

not all veterans are trained in mental health. I know that is your 

aspiration. But you have a good idea, and we want to work through 

that. 

We did have a conversation, Mr. Chairman, and I want to caution my friends in the fourth branch of government who may be 

covering this hearing, please do not refer to suicide as an epidemic 

without saying that treatment is available. Because if you say or 

you put on the air that suicide is an epidemic in America, you are 

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exacerbating the problem and you could actually be moving people 

to suicide. So, please, if you write that, say that treatment and care 

are available. 

Thank you for your leadership. 

Mr. MORAN OF VIRGINIA. Thank you, Mr. Buyer. 

If I could quickly respond, what we are suggesting is that a nonprofit organization that would be available for veterans, that would 

spread the word within the network of veterans and give them 

training simply to be able to react to people on the other side of 

the line. They don’t need to be trained in mental health counseling, 

just be able to know how to listen and to talk and to calm down 

someone that is in a time of crisis. That is what we are talking 

about. 

It is just that sometimes when you have very large institutions, 

it is difficult to accomplish what a nonprofit group that is particularly committed and understanding of the problem sometimes is 

able to provide with a lot less money. That is all I am suggesting. 

I thank you for your comments, Mr. Buyer. 

And thank you very much, Mr. Chairman, for giving me this opportunity. 

[The prepared statement of Congressman Moran appears on 

p. 82.] 

The CHAIRMAN. Thank you, Mr. Moran. We will be looking again 

at that legislation. 

Mr. Salazar, any opening remarks? 

OPENING STATEMENT OF HON. JOHN T. SALAZAR 

Mr. SALAZAR. Mr. Chairman, I want to thank you for having this 

important hearing. I agree with my colleagues, but the one thing 

that I think we have to be very, very adamant about is finding out 

whether there was a cover-up by the VA to push these things 

under the carpet or was it something that they need additional 

tools for. We are here to help. That is what we are here for. 

So with that, thank you, Mr. Chairman. 

The CHAIRMAN. Ms. Berkley. 

Ms. BERKLEY. I would like to submit my opening statement for 

the record, if I may, so we can get to the witnesses. 

[The prepared statement of Ms. Berkley appears on p. 79.] 

The CHAIRMAN. So ordered. I would ask unanimous consent that 

all Members can submit their statements for the record. Hearing 

no objection, so ordered. 

The CHAIRMAN. Mr. McNerney, any quick opening? 

OPENING STATEMENT OF HON. JERRY MCNERNEY 

Mr. MCNERNEY. Thank you, Mr. Chairman. It is clear that all 

Members of the Committee are sincere in wanting to find the bottom of this. 

There is nothing that is more tragic than suicide. As Mr. Buyer 

pointed out, it is a situation that haunts the family and friends for 

years and years, especially when young men and women who have 

served our country and have looked to this country to help them 

when they have needs and, it appears, that that may not have been 

followed through. 

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So it is our solemn responsibility to get to the bottom of this and 

to find ways to move forward that will prevent this in the future. 

Thank you. 

The CHAIRMAN. Ms. Brown. 

OPENING STATEMENT OF HON. CORRINE BROWN 

Ms. BROWN OF FLORIDA. Thank you, Mr. Chairman, and I want 

to thank you for holding this hearing today. 

First of all, let me say, it is not just the veterans; it is the veterans and their families that are faced with this situation. I am 

looking forward to hearing from the Secretary and also from Dr. 

Katz on how he came up with this analysis and what can we do 

together to change this situation, because this is a serious problem. 

I have been on this Committee for 16 years, and this is a serious 

situation. We have passed the largest VA budget in the history of 

the United States, and I want to make sure that we are properly 

funding that healthcare issue, and the money is going where it 

needs to go. 

So, thank you, Mr. Chairman, for holding this hearing. 

The CHAIRMAN. Thank you. 

Mr. Secretary, I appreciate you being here. I was hoping that everybody who was associated with these e-mails would be with you 

but since they are not, I hope you can speak to those issues that 

we have raised. 

You are recognized, sir, for your statement. 

STATEMENT OF HON. JAMES B. PEAKE, M.D., SECRETARY, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 

GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY UNDER 

SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND IRA 

KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT CARE SERVICES 

OFFICER FOR MENTAL HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Secretary PEAKE. Mr. Chairman, with your permission, I would 

like to provide a written statement for the record. 

The CHAIRMAN. So ordered. 

Secretary PEAKE. Mr. Chairman, Congressman Buyer, Members 

of this Committee, thank you for the opportunity to discuss the 

issues of veteran suicides. I really do appreciate your holding this 

hearing. It is a very important subject. 

We will be talking quite a bit about the numbers in this discussion. I will tell you, quite frankly, to me personally the most important thing is that each suicide number represents a soldier, a sailor, an airman, a Marine, a veteran who has served this country in 

uniform; and each individually is a tragedy and each deserves all 

that we can do to try to prevent that tragedy. 

While it is appropriate—and frankly, it is necessary—to try to 

measure and understand variances from the norm in trending and 

statistical significance, I want to assure you and this Committee 

and, frankly, the American people that we are not waiting on these 

numbers to focus the VA on addressing this very important issue. 

The title of today’s hearing is, ‘‘The Truth about Veteran Suicides.’’ My objective is to tell you as clearly as I can what we do 

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know about veteran suicides and the sources of the information. 

Also, I will tell you what we don’t know and what I intend to do 

about that. I also will take this opportunity to tell you what we 

have been doing to address the issue of suicide directly, from a clinical perspective, and expanding our outreach even as we seek better ways to measure. 

First, to compare veterans with nonveterans, the gold standard 

and source of the database is the National Death Index. It is a 

product of the National Center for Health Statistics, a U.S. Department of Health and Human Services (HHS) function. The most current complete data set is from 2005. 2006 data should be released, 

we are told, sometime soon. 

Looking at 2005 and back to 2001, the overall rate of suicide was 

14.1 per 100,000 in the general population. That is not a percent; 

that is per 100,000. It is important to separate the rate of men and 

women. Men have a higher rate of suicide than women, and that 

is statistically significant. We must separate by age group because 

there are significant differences by age groupings. 

The National Death Index does not identify those who are veterans. To compare all veterans, not just those seen in the VA system, would require matching the full list of all 24 million veterans 

against the National Death Index to see how many of them had 

committed suicide. We do not have the identifying information for 

all veterans to do this analysis. We would love to be able to do it; 

we don’t have that information. 

The VA does have the ability to compare veteran suicide rates 

with the national average for groups of veterans who have used the 

VA health system. We have matched that group against the National Death Index by name to know the number of those veterans 

who have used the VA, who have committed a suicide. With that 

data, we can calculate a rate. 

The National Death Index data that we have broken that data 

into—first, men and women; let me just show you this is the population, 2005. Men make up about 20 percent of the population. Men 

veterans make up about 20 percent of the overall population. 

Women veterans make up only about 1 percent of the overall population, just to give you the perspective. 

What this chart is showing is for 2005. The numbers in red represent the numbers that are statistically higher than the general 

population. This is for women. This is for men. You can see that 

for 2005, in the older, but not in the younger, age groups for veterans who use the VA health system, just those veterans, the suicide rate was higher than the general population. 

Looking at this for each, from 2002, will give a more complete 

picture. But here, just to say this is the general suicide rate, this 

is the veterans’—again, those who have only been seen in our system because we don’t have all the veterans—you can see that it is 

a bit higher than the general population, and it is statistically significant. 

Now, to show you the trending, this is the summary of data from 

2002, 2003, 2004, 2005, and you can see that the red is the veteran 

population, again for age group 18 to 29, age group 30 to 64, and 

then the older age group. What you see, the national population 

figure is here in terms of rates per 100,000. 

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The rates for veterans who are users of the VA, again, just users 

of VA, have also been relatively stable over this period. You can see 

that it is, again, stable. This is women, the smaller group; and it 

is—what we are showing with these brackets here are the statistical significance. So that this is clearly statistically significant. 

Looking at the veterans who have used the VA in this period, 

male veterans commit suicide at a somewhat higher rate, but with 

varying statistical significance by age over different years. You can 

see that in the charts. 

Within the group of male veterans there are differences in age 

of suicide compared to what is seen in the general population with 

a statistically higher middle-age group. So statistically you can see 

this age group is generally higher for veterans—above the national 

average. 

Male veterans commit suicide at a higher rate than female veterans. Within the group of female veterans—and that is what this 

slide shows—by age group, there is nearly a twofold increase over 

women in the general population. That is, again, variably, statistically significant over years and by age. So in this older age group 

in 2002, it was above the national average statistically. Here, it 

was about the same, and here it has bounced up again. I don’t 

know what 2006 will show, but we need to follow that and find out. 

In 2002, to better understand the nature of violent deaths, the 

CDC Violent National Death Reporting System was established 

and gradually implemented, first in six States, then expanded to 16 

by 2005, to collect data on violent deaths, including suicides. It gets 

information from a variety of sources, including death certificates, 

police reports, medical examiners, coroners, crime laboratories; and 

unlike the National Death Index, coroner-reported veteran status 

is included in the database. VA can get, at least for these 16 

States, information on overall suicide rates among all veterans. 

This chart summarizes the 2005 data. What you see of note is 

that, at least in these 16 States, there is a significantly higher rate 

of suicide in the younger age group of veterans compared to the 

general population. This is similar in both veterans seen in the VA 

system and those who do not use the VA system. This is for veterans who are really all veterans, and these are veterans who actually use the VA system. You can see these are relatively the same, 

but they are higher than the national averages. 

We intend to trend this information over each year of the available data, going back as far as we can go to 2002. We believe that 

some of these veterans’ deaths in this data set represent servicemembers who were actually on active duty when they committed 

suicide. We will work with CDC and DoD to understand this group, 

particularly, obviously, wanting to know whether this represents 

OIF or OEF returnees. 

Clearly, OIF and OEF returning servicemen and women represent a group of particular interest to us today. We have a sense 

of urgency to understand and intervene to prevent even a single 

suicide. To better understand suicide in this particular cohort, Dr. 

Kang, of the VA, conducted a study, which matched servicemembers who had served in OIF and OEF theater and separated between 2002 and 2005 against the National Death Index. He 

found—just looking only at that group, he found that 144 out of 

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490,346 separated OIF and OEF servicemembers committed suicide 

during that time, for an overall rate of 21.9 per 100,000. 

Because there was some initial confusion around this study, I 

want to clarify that these, unlike our concerns about the last data 

that I presented, are deaths only of men and women who had separated from the military and do not include any deaths while a servicemember was on active duty. 

To compare to other national norms, we looked at this cohort 

against the national averages that I discussed earlier. For OIF/ 

OEF veterans who had deployed and separated from 2002 to 2005, 

the suicide rate was slightly higher than would be expected in an 

age-, gender-, race-matched general population, but the difference 

was not statistically significant except in the young non-VA user 

age group. So these are folks that were not seen in the VA, and 

again, it was only significant in the age group of 18 to 29. 

We have also examined this data for differences in suicide rates 

between those who use the VA and those who have not used the 

VA. We found that 17 per 100,000 OIF/OEF veterans who used the 

VA for care took their own lives, compared to 24 of 100,000 OIF/ 

OEF veterans who did not use the VA for care. Again, this apparent advantage to VA care, though encouraging, is not statistically 

significant. In this group, a slight but not improved rate is also 

true for those who visited our Vet Centers. There were only three 

women among the 144. So no conclusions can really be drawn from 

that group. 

Our medical statisticians have plumbed this data in anticipation 

of follow-on studies when the updated National Death Index information is available. Some of the insights that we have taken from 

this look include that there is little variation in suicide by branch 

of service. We also found that a diagnosis of a mental disorder predicted a nearly 1.8 times higher suicide risk than the general population. This is consistent with what has been published regarding 

people in general with mental health diagnoses, but emphasizes 

the absolute importance of our mental health efforts. 

Likewise, the use of firearms as a means of suicide in this group 

is consistent with the higher rate of this modality of suicide in all 

veterans compared to the general population. 

I would reiterate that all of this data comes from national data 

for suicide run against those who we know from our data sources 

and DoD are veterans. We must use these national numbers, because our clinical records do not capture in any reliable or complete 

way such events as suicides or suicide attempts. This national rollup of information from the coroners through the States offers the 

most complete compilation of deaths and its causes, since we may 

well not know of a death even if it occurs locally. 

The information on deaths continues to be updated as the reports 

come in over time, so our confidence in the completeness of those 

numbers comes only after several years of data collection. We are 

awaiting now, again, the release of the National Death Index compilation for the year 2006 for further analysis, and we will dig into 

that very deeply as soon as we get it. 

For this reason, and not satisfied with that data lag, Dr. Katz, 

who led in the institution of a VA-wide system of 153 suicide-prevention coordinators whose prime function was clinical in nature— 

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taking care of patients, identifying and closely following high-risk 

patients, educating staff on suicide issues—he directed them, beginning in October of 2007, to report specifically on suicide attempts. 

This entailed getting a clear definition and reporting standards 

for suicide attempts. When is a suicide attempt an attempt? Does 

a cry for help with an overdose of a non-threatening medication ingestion or a cut on the wrist so slight as to not really risk serious 

injury, is that really an attempt? Those are the kind of questions 

that we have to get standardized across 153 different reporting entities. 

On February 13, 2008, an internal e-mail from Dr. Katz discussed what was the first 3 months of this reported information. 

In his e-mail, he suggested that a thousand veterans a month 

under VA care were being reported as attempting suicide, and appropriately was concerned about releasing information that was not 

validated and was so very preliminary. 

The data was clearly not accurate. Our suicide prevention coordinators were new to their jobs. There was a great deal of uncertainty over borderline calls, and many of them were just beginning 

to make the community contacts that are essential in making an 

accurate count of the number of suicides and suicide attempts. 

A number of States had suspiciously low reporting rates. We are 

still not satisfied with the consistency of the reporting, its accuracy 

or its completeness. 

Let me show you this chart. And what this is is month by month, 

facility by facility, and what you can just see is how erratic the reporting is even now. The VA is addressing the problem through 

regular review, educating coordinators with questionable data, collaborating with our coordinators on difficult calls, and encouraging 

them to meet the right people in their communities to obtain additional data. 

To be clear, VA had not reported on suicide attempts previously, 

either to Congress or to the media. Though perhaps we should have 

been looking at it earlier, we were not. The number, 790 a year, 

was a CBS News number that they derived from a Freedom of Information data request looking at clinical records coding. I now understand, I think, the places in the spreadsheets that they got 

under the Freedom of Information and added together to get this 

number. 

But for all the reasons noted earlier, this source of data should 

not have been considered at all reliable if the purpose of the count 

was to determine the total number of suicides and attempts among 

veterans under our care. Some people who attempt suicide, but do 

not die, go elsewhere for care. Others do not admit that their injuries were due to suicide attempts, and may not, even when a counselor discusses a situation with them. CBS News’ number, while 

arithmetically correct, is in actuality misleading. 

I can appreciate that the number of a thousand suicide attempts 

a month might be shocking. But in a system as large as ours, and 

with the numbers I have shown you nationally on suicides, and 

consistent with the literature, we might well expect a larger number of attempts than that because it’s somewhere between 8 and 

25 attempts per suicide completed in the national literature. 

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But what is really important is to identify them, because people 

who attempt suicide are more likely to commit suicide and are so, 

therefore, such an important target for our interventions. 

There’s a large body of scientific literature on suicides, and the 

VA has over the years, been a prime contributor to that knowledge. 

In fact, I can submit this binder full of peer-reviewed articles for 

the record. 

It is where we have the basis for conclusions that target our efforts, conclusions such as: Among veterans receiving care from VA 

who died from suicide, almost 60 percent of those aged under 65 

have a mental health or substance abuse diagnosis, but only 24 

percent of those aged 65 and over have such a diagnosis. 

There is significant variability in suicide rates geographically. In 

general, the rates are lowest in the Northeast and highest in the 

West. I don’t know exactly why. For veterans who died from suicide, firearms are the most common means, accounting for almost 

two-thirds of the deaths. 

Among Vietnam veterans, there appears to have been an increase in suicide rates in the first few years after veterans returned home; however, after a few years, those rates became comparable to the general population. There was no increase in suicide 

rates among veterans who returned from the first Gulf War. And 

those wounded, hospitalized and multiple wounds, have had a 

higher risk of suicide. 

You know, I have focused a lot on the numbers and what we 

know and don’t know. And while I am pushing our VA team to explore these numbers in greater depth and expand our understanding of them, I want to emphasize that we are not waiting for 

perfect numbers to appreciate the importance of extending our 

intervention and outreach. Whether veterans suicides are at or 

above or below some national average, any suicide—any suicide— 

in our view, is a tragic loss. 

There is probably no system focusing on suicide and mental 

health issues in as a comprehensive and far-reaching way as your 

VA. And Dr. Katz here has been a key leader in that effort. 

Recognition of the problem by all who serve veterans is important. So we have had two national VA Suicide Prevention Awareness Days throughout our system to focus 200,000 healthcare employees on this issue. We have trained VA staff on prevention resources, including the hotline and the roll of suicide-prevention coordinators. We are incorporating special training in suicide prevention for our case managers. 

Two of our mental health education and research centers focus 

on technical assistance across the VA for suicide prevention. One 

is our Mental Health Center of Excellence in Canandaigua, New 

York, with expertise in testing clinical and public health intervention; the other in Denver with clinical and neurobiological sciences, 

emphasizing suicide risk. 

In July of 2007, a suicide hotline center was established at 

Canandaigua. In the subsequent 10 months, the hotline has fielded 

more than 37,000 calls, more than 16,000 from veterans. Nearly 

500 from active-duty servicemembers, and more than 2,000 from 

family members or friends, just as you all have pointed out. These 

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calls have led to more than 3,000 referrals to suicide-prevention coordinators and 885 rescues involving emergency services. 

Let me introduce Dr. Jan Kemp, who is with us today, who leads 

this effort on the ground up there in Canandaigua. 

Jan, stand up. Thanks. 

VA’s hotline is staffed solely by mental health professionals, 24/ 

7/365. They are trained in crisis intervention and issues such as 

traumatic brain injury and post traumatic stress disorder. In emergencies, they contact local emergency resources, police or ambulances. They can use the veteran’s electronic medical record during 

the call and link directly with the medical center if they are one 

of our patients. And they work with the local suicide-prevention coordinators directly. 

Cards, pamphlets, refrigerator magnets—I provided samples that 

I believe are at your desks—are widely distributed. And our suicide-prevention coordinators ensure at-risk veterans and their family members get them. 

[Samples of cards and pamphlets appear on pages 120 and 121. 

The refrigerator magnet will be retained in the Committee files.] 

This was pulled out by one of our veterans service organizations 

(VSOs) who said, boy, we’re using this all over the place. Posters 

and hotline information such as these are located throughout VA 

medical centers, clinics and Vet Centers. Hotline stickers are on 

phones and by the doors in our residential programs. 

Far from hiding this issue, we are more public about it than any 

organization that I know. I’ve mentioned the suicide-prevention coordinators before. Their main function is clinical, to educate staff 

and the veterans and the family members and to carefully monitor 

those at higher risk. So they maintain everyone’s higher state of 

awareness and alertness to suicide issues, as well as dealing with 

individual patients. 

It was not primarily for epidemiologic purposes that they were 

identifying suicide attempts, but rather because we know that 

those who have attempted suicide are at the highest risk. Under 

Dr. Katz’s leadership and with the help of Congress, we have 

grown our mental health program in a number of ways: more than 

3,800 new mental health employees hired in the past 3 years; incorporating mental health into primary care in our medical centers 

and in our Community-Based Outpatient Clinics (CBOCs); growing 

the number of both CBOCs and Vet Centers; expanding our hours 

of operation for mental health clinics beyond normal business 

hours; using telemental health to reach more remote veterans; providing separate access for women veterans with mental health, primary care and gynecologic care. It recognizes their increasing proportion of the force and their special needs and special desires for 

privacy. We are doing this in each of our hospitals. 

The standard for mental health access was tightened so that patients with mental health issues are screened within 24 hours, provide urgent care immediately when needed—and if we don’t have 

it in our house, we will buy it—or provided a full evaluation and 

a treatment plan within 14 days for those non-emergent patients. 

I have spoken to you before on our outreach efforts with letters 

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mobilization at both deployment health reassessment sites and on 

bases and in military hospitals. 

[A sample of an outreach letter to veterans from Hon. Michael 

Kussman, M.D., MS, MACP, Under Secretary for Health, U.S. Department of Veterans Affairs, appears on p. 122.] 

On May 2nd, we began an outreach call center program to contact nearly 570,000 combat veterans of the war on terror to ensure 

that they know about our ability to provide them care. Now we can 

do that up to 5 years after separation and to provide them information on other benefits. The first of those calls are going to veterans 

who were sick or injured while serving in Iraq or Afghanistan. And 

if any of those 17,000 or so veterans do not have a care manager, 

we will offer to appoint them one. 

All of these efforts support not only our general concerns for our 

men and women veterans but to also directly address the issue of 

suicide concern about which we are here today. 

I am impressed by the quality of my people and the dedication 

to this work, but I also appreciate the value of an outside look. I 

have directed the creation of a blue-ribbon work group of experts 

in suicide and its prevention to look at all of our data, consult with 

our team and advise me on different looks at our own data or new 

lines of inquiry that they might recommend. The members will 

come from DoD, other government agencies, and other nationally 

recognized treatment research and public health experts on suicide 

and its prevention, all from outside the VA. They will be given all 

of the data that we have and access to all of our experts. I have 

asked for a report 15 days from the completion of their meeting to 

tell me how I can better approach suicide prevention and suicide 

research. 

You know, there is nothing more tragic than the loss of even one 

of these great men and women who have served this Nation. The 

VA is committed to doing all that we can to serve the individual 

while we continue to try to understand a very complicated problem 

that is also a national problem. We owe this Committee, and the 

Nation, accurate information and carefully studied, thoughtful conclusions while we provide the best care anywhere to our veterans, 

and that’s exactly what I intend us to do. 

Again, Mr. Chairman, I do appreciate you holding this hearing, 

and I look forward to your questions. 

[The prepared statement and slide presentation of Secretary 

Peake appear on p. 83.] 

The CHAIRMAN. Thank you, Mr. Secretary. 

I don’t doubt your commitment, but I will tell you, if there is a 

book on how a bureaucratic response should be given to an emotional problem, there should be a chapter in there with your testimony. Because what you have done is make us all look at these 

charts, which are almost impossible to read, and all the things 

you’re doing and, of course, the icing on the cake, a blue-ribbon 

commission—it’s always done to avoid an issue—without us understanding what you need in terms of resources from us and what we 

are missing. It sounds to me, ‘‘Everything is fine, we have it under 

control, we are going to study our data, we dug up all this data, 

but it is under control.’’ You don’t ask for any additional resources, 

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you don’t say what you could do, you don’t say what mistakes you 

have made; everything is fine. 

[The following was subsequently received from VA:] 

The Blue Ribbon Work Group on Suicide Prevention in the Veteran Population 

provides advice and consultation to the Secretary on various matters relating to research, education and program improvements relevant to the prevention of suicide 

in the veteran population. The Blue Ribbon Work Group on Suicide Prevention in 

the Veteran Population will create a report, within 15 days of the completion of its 

meeting with recommendations for improvements in VA’s programs related to suicide prevention, research, and education. 

Recommendations will be directly related to the primary objective of reducing risk 

of suicide in the veteran population. The attached Memorandum from Hon. Michael 

J. Kussman, M.D., MS, MACP, Under Secretary for Health, U.S. Department of Veterans Affairs, to Hon. James B. Peake, Secretary, U.S. Department of Veterans Affairs, dated May 5, 2008, Regarding Blue Ribbon Work Group on Suicide Prevention 

in the Veteran Population, appears on p. 134. 

The CHAIRMAN. And that is a standard answer to everything we 

have done for years and years in this Committee. That is why we 

are upset and impatient, because you are not focusing on what we 

can do together to make sure that all the mental illness issues that 

have been associated with combat: PTSD, domestic violence, homelessness and suicides—we are not doing the job. I don’t care what 

your figures show. We have tens of thousands of young people getting out of the military or the Guard who have not been adequately 

diagnosed for either PTSD or brain injury. 

Every one of your statistics says, ‘‘those who have come to us,’’ 

which is, you know, a small fraction of who is out there. So we are 

not doing the job. And we can’t do our job if you are not honest 

with us. 

And as I said before in my opening statement, we only came into 

possession of certain e-mails—I don’t know how many there are out 

there, but we only have a few—brought to the public by discovery 

in a legal case out on the West Coast. 

So 3 days after the hearing in which we asked directly—and Mr. 

Mitchell just said this—Dr. Katz, ‘‘Do you need any help from us? 

What resources do you need?’’ And he said, ‘‘No, we have it taken 

care of, and here are our statistics, CBS News was wrong, and you 

guys shouldn’t worry about this.’’ 

Three days after that, Dr. Kussman writes to Dr. Katz and others that—I don’t know if the e-mail is from home or work, but the 

fact that you are all working Saturday, is good—18 veterans kill 

themselves every day. That is what the CBS News report said. 

‘‘Sounds awful, but let’s not worry too much if you are considering 

24 million veterans.’’ 

Even in the first e-mail that we have—and I don’t know what 

else there is—nobody is saying, ‘‘We are not doing the job here.’’ 

They are saying, ‘‘Does this sound good? Does this sound bad?’’ And 

Dr. Katz says, yes, there are 18 suicides. This is supported by the 

CBS News numbers. 

Now, Dr. Katz, this contradicts what you told us in the hearing 

3 days earlier. Why didn’t you just call us up or ask for another 

hearing and say, ‘‘You know, we are looking at things differently. 

I misspoke. I want to talk to you some more about the statistics.’’ 

This looks like a cover-up, because you didn’t tell us anything. And 

this is contradictory to what you said to our Committee in December. 

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Why shouldn’t you go to court for perjury or resign because you 

didn’t tell us the truth? 

Dr. Katz, I am asking you. You keep looking at the Secretary, 

but I am asking you. 

Dr. KATZ. Thank you for asking. 

In response to a question from Mr. Mitchell in the December 

12th hearing, I and my colleague, Dr. Fred Blow, who accompanied 

me to the hearing, did mention the 18-a-day for suicides among all 

veterans. We mentioned the four to five a day for suicides among 

those we cared for in VHA healthcare services. 

When I asked him to, Dr. Blow mentioned the fact that, overall, 

veterans had a rate of suicide about 1.5 times that of age- and sexmatched individuals from the general population. And he mentioned the fact that, among women, the ratio of suicides among veterans in our system to the general population was about two. 

That was mentioned in the hearing on December 12th. There 

was no cover-up. This was mentioned. 

The CHAIRMAN. Did you not say—and we saw the clips. Did you 

not say that the CBS News data was wrong? 

Dr. KATZ. I was not referring to the entire data, but the subset 

of data dealing with the youngest of veterans. 

The CHAIRMAN. So the ‘‘Mission accomplished’’ should have said, 

‘‘Mission accomplished only by those sailors who were aboard this 

ship on those 2 days.’’ We didn’t see the fine print. 

We asked you several times, and you said several times that the 

CBS News data was wrong. You never made any qualification of 

that as far as I can remember. Your story was that they were 

wrong, and you didn’t need any help to deal with this issue. Is that 

right? You were fine? 

Why do you keep looking at the Secretary? I am asking you, Dr. 

Katz. 

Dr. KATZ. Sir, I did speak about the suicide rates among veterans 

on December 12th, and I continue to have concerns about the CBS 

News reports about rates and standard mortality ratios or ratios 

among the youngest veterans. I wish they would present their data 

so we could review it. 

The CHAIRMAN. Yes, but you are in charge. They are just reporting. They asked for all this data, and you never gave it to them, 

so they spent 6 months trying to find stuff that, Dr. Peake said the 

VA didn’t have. Well, they went out and found it. So I assume 

somebody can go out and find it if you think it’s important enough. 

Secretary PEAKE. Mr. Chairman, if I may, I don’t disagree with 

your premise that somebody should be able to go out and find it. 

They did not provide it to us, even though we asked. And so we 

have now gone out and asked for the same information. I am very 

anxious to see what actually came back. 

As I tried to explain, we are using the data from the national 

sources, which is the gold standard that any responsible statistician would be able to use for this. 

I will tell you, I am worried that suicide in general in this Nation 

is underreported, not just in the military, not just in the VA. 

The CHAIRMAN. But don’t start that red herring. We are talking 

about veterans right now. So don’t tell me, ‘‘Well, the whole society 

is screwed up.’’ We are going to do our job for veterans. 

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So on the December 12th data, you don’t see any difference, Dr. 

Katz, between what you told us then and what you said a few days 

later. You say you are consistent. 

Dr. KATZ. Again, the issue is the 18-a-day, the 4-to-5 a day, the 

ratios of 1.5 and 2.0. And those were provided at the December 

12th hearing in response to a question from Mr. Mitchell. 

The CHAIRMAN. Now, on one, the February 13th e-mails you said, 

‘‘Shh!’’ what did you mean by that? 

Dr. KATZ. That was very unfortunate. I think the e-mail has to 

be divided into the subject line and the content. I deeply regret the 

subject line. It was an error, and I apologize for it. 

However, the content of the e-mail, the body of the e-mail reflects 

an appropriate and healthy dialogue among members of VA staff 

about when it is appropriate to disclose and make public information early in the process of developing—— 

The CHAIRMAN. No. An appropriate e-mail would say, ‘‘We are 

not sure of this data. We will study it further. Maybe we should 

inform the Committee.’’ But what you said is, ‘‘This is something 

we should carefully address ourselves before someone stumbles on 

it.’’ 

I mean, that is what you are concerned about, not the suicides, 

but somebody stumbling on this data. 

Dr. KATZ. No, sir, I am concerned about saving lives. 

The CHAIRMAN. Well, but that is not what you suggest here. 

Dr. KATZ. Sir, that e-mail was in poor tone, but the content was 

a dialogue about what we should do with new information. 

The CHAIRMAN. And did you tell Secretary Peake about all this, 

about the new data or these thousand attempts per month? 

Dr. KATZ. The purpose of that e-mail was to open extensive dialogue within VHA about this emerging data. 

The CHAIRMAN. Did you tell Secretary Peake about that, that you 

were showing a thousand suicide attempts per month? 

Dr. KATZ. I reported it to VHA’s senior leadership. 

The CHAIRMAN. That is not what we have in the e-mails. We just 

have you talking to the PR guy. 

Dr. KATZ. We were opening a dialogue about what to do with the 

new information. 

The CHAIRMAN. Yes, and the first thing you do is talk to your 

public relations guy instead of somebody who might know how to 

treat suicide. It seems to me that what you were trying to do was 

manage the data, not deal with the data. 

Dr. KATZ. Sir, there has been extensive conversation about this 

with other suicide and mental health people. 

The CHAIRMAN. I’m sorry? I didn’t—— 

Dr. KATZ. There was extensive conversation about the thousand 

a month with other people—— 

The CHAIRMAN. Yes, but not in the information we have. 

Dr. KATZ. Not in that e-mail, no. 

The CHAIRMAN. I would think that you would tell us about it 

since we have a concern about the issue and we are the ones who 

can help get you the money to deal with the issue. 

All I have is what you provided to the court by discovery motions, which I assume is as complete as you want it to be. If you 

have more complete information, then you probably didn’t give 

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enough information to the original requests. It appears to me that 

your interest is in managing the data as opposed to helping the 

veteran. 

Dr. KATZ. Sir, earlier at that same court, in a hearing, I testified 

under oath to the thousand a month and talked about how knowing 

about that number was so very important, because it pointed to a 

thousand people a month where we really could do something to 

dramatically decrease suicide risks. 

The CHAIRMAN. Why didn’t you just write us a letter, or set up 

a meeting, or brief us? I mean, instead of managing the data, why 

didn’t you just talk to us about it and say, ‘‘We are on it, we are 

serious, we care about it, we want you to know about it, and we 

need this much more money or not to do something?’’ 

Dr. KATZ. Dr. Peake spoke to the fact that this wasn’t data yet. 

These were observations and measurements very much in the state 

of development. 

The CHAIRMAN. When do you expect that to be real data? Another year, after your term is over? 

It looks like this would never have come to our attention unless 

there was the court case with discovery. You never had any intention of talking to us, dealing with the data in an open way, but you 

were trying to manage it from the inside. And who knows when we 

would have heard about it. 

Both the court case that got the data and the news media that 

has been looking at this issue have done a far better job than you 

have in keeping us informed. 

Mr. Buyer, I took too much time. I apologize. 

Mr. BUYER. I am trying to follow this. I was present at the December 12th hearing. And I know we have ongoing litigation, so I 

recognize, Mr. Secretary, you have to be careful if you have ongoing 

litigation, yet we are also asking you questions about data. 

And it appears that, when this e-mail is released in discovery in 

litigation, CBS News has created an impression now in our country 

by their report that no one knew about this 18 per day until it was 

in discovery. 

Now, when I look at the report on the December 12th hearing— 

and I want to compliment my colleague, Mr. Mitchell. You did a 

very good job here, when you look at the transcript. I mean, you 

went right in on Dr. Katz, and you asked the specific question to 

him. 

You asked this: ‘‘One last question really quick. Do you believe 

that suicide is an epidemic?’’ Dr. Katz: ‘‘There is a suicide epidemic 

in America.’’ Mr. Mitchell then says, ‘‘Among veterans?’’ Dr. Katz 

says, ‘‘The number’’—then parentheses, (inaudible) end parens— 

‘‘about 18 veterans kill themselves each day in America. That is too 

many,’’ Dr. Katz says. And Mr. Mitchell then says, ‘‘And?’’ Dr. 

Katz’s response is, ‘‘About four or five.’’ There is cross-talk, inaudible. Mr. Mitchell then: ‘‘According to CBS News, it was 120 a 

week.’’ Dr. Katz says, ‘‘About the same.’’ Mr. Mitchell then says: 

‘‘That is not higher than the general population?’’ Dr. Katz says, ‘‘It 

is somewhat higher than the general population among veterans 

because of demographics and risk factors.’’ 

Mr. Mitchell, then you asked a really good question. You said, ‘‘I 

think one way we can find out about that is if you have the data. 

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I think that is one thing that people were arguing about earlier, 

was the methodology of data that CBS had.’’ 

Now, see, when you asked that question, I homed right in on it. 

And that is the reason that I wrote the letter, and that is the reason Bob Filner joined me. And we sent this letter, with regard to 

methodology and data, not only to the Secretary but also to DoD 

and CBS News. CBS News has yet to share this with us. So if you 

can get it, Mr. Mitchell, I hope you can. 

But from what I recall from the hearing, Mr. Chairman, Dr. 

Katz, this was in response to Mr. Mitchell’s questions. 

I have other questions for you, Mr. Secretary. 

You have much in your toolbox. When you think about the access 

that you have to great intellect in your research and development 

and your abilities to study and define cohorts, I would like to know, 

is there any epidemiological resource analysis that is being done for 

the, quote, ‘‘at-risk,’’ end quote, veterans from either Vietnam or 

the first Gulf War, specifically looking at the mortality rates for intheater versus non-theater, veterans versus general population? 

Obviously, we are trying to home in on, then, those who are most 

susceptible, and so obviously you want to look at—and I just mentioned this to the Chairman—those who may already show trends 

in mental health, depression, PTSD, wounds or disabilities, whether they occur in-theater or non-theater. 

With that, I yield to you for a response. 

Secretary PEAKE. Well, sir, in this gathering of documents here 

that have been published on the Vietnam and Gulf Wars, it addresses some of those specific issues in terms of the epidemiology 

of suicide in those groups. 

It is very clear that those with mental health disorders, in some 

of our published literature just in the general veteran population, 

those with depression have a higher suicide attempt rate when you 

look at that as a group. And that gets better, that rate gets smaller 

if they are on medications. At least one of our studies has proved 

that. 

So it starts to give us the opportunity to target the individual 

groups. Those with suicide attempts clearly have a higher rate. So, 

again, we are trying to target the individual specific groups based 

on the science behind it in terms of what we are actually finding 

as you really understand what groups are at risk—those with 

wounds; we are looking at the TBI group as a potential for specific 

intervention. 

One of the reasons why I tried to emphasize in this call center 

outreach is to make sure that we are going after those who have 

returned who were injured, specifically to try to get them into care 

management, and why we are training the care managers on suicide intervention, because of just exactly that nexus. So that is exactly the direction that we are trying to go. 

Mr. BUYER. Mr. Chairman, I think what would be helpful for the 

Committee, the Secretary keeps referring to a binder that I can see 

is pretty thick, and he refers to, quote, ‘‘peer-reviewed articles.’’ 

I think it would be helpful to the Committee, Mr. Secretary, if 

you would provide the Committee with and would submit for the 

record a page of references—— 

Secretary PEAKE. Absolutely. 

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Mr. BUYER [continuing]. That would list the title, the author, the 

publisher, dates, and/or if there are Web sites, okay? 

Secretary PEAKE. Very well. We will provide that for the record. 

Mr. BUYER. Thank you very much. 

The CHAIRMAN. Mr. Michaud. 

Mr. BUYER. Mr. Chairman, and we are doing this for the record, 

it is being submitted for the record, their references would be submitted for the record. 

The CHAIRMAN. Yes, that is a fine idea, so ordered. 

[The following was subsequently received from VA:] 

In reference to the binder at the hearing, attached are research articles published 

in peer-reviewed medical journals that have relevance to the question of the rates 

and risk factors for suicide among veterans. All demonstrate VA’s investment in research and epidemiology in providing scientifically evidenced understanding in mental health conditions that impact veterans. 

Articles are separated by whether the population studied was population based 

(ie., representing the full spectrum of all veterans) or a clinical cohort (ie., representing a sample of only those veterans who sought care in VA). In cases where 

websites are available they are cited. 

Clinical cohorts cannot be used to estimate population-based rates and 

risks. 

Patients who seek and receive medical care differ from the general population. 

For instance, they may be sicker, leading to higher expected rates of death. Also, 

they may travel far from home to get medical care, in which case it may be hard 

to calculate the ‘‘denominator’’ (see below) of total patients at risk. 

Reported suicide rates in clinical cohorts are usually higher than that of the general population. Therefore, for determining the rates and risk factors for suicides 

among veterans overall, population-based studies assume a higher priority. Insights 

from clinical cohorts, however, are valuable for suggesting more effective ways to 

deliver clinical care to veterans who use the VHA healthcare system. 

References 

• Cypel Y, Kang H. Mortality patterns among women Vietnam-era veterans: Results of a retrospective cohort study. Ann Epidemiol 2008; 18:244–252. 

• Herrell, R, Goldberg J., True, WR, Ramakrislman, V., Lyons, M., Eisen, S., 

Tsuang, MT. Sexual Orientation and Suicidality. Arch General Psychiatry 1999; 

56: 867–874. 

• Bullman TA, Kang HK. Risk of suicide among wounded Vietnam veterans. Am 

J Public Health 1996;86:662–667. 

• Bullman TA, Mahan CM, Kang HK, Page WF. Mortality in U.S. Army Gulf War 

veterans exposed to 1991 Khamisiyah chemical munitions destruction. Am J 

Public Health 2005; 95:1382–1388. 

• Kang HK, Bullman TA. Mortality among U.S. veterans of the Gulf War: 7-year 

follow up. Am J Epidemiol 2001; 154: 399–405. 

• Kang HK, Bullman TA. Mortality among U.S. veterans of the Persian Gulf War. 

NEngl J Med 1996; 335:1498–1504. 

• Zivin, K., Kim, M., McCarthy, JF., Austin, KL., Hoggatt, KJ., Walters, H., 

Valenstein, M. Suicide Mortality Among Individuals Receiving Treatment for 

Depression in the Veterans Affairs Health System: Associations with Patient 

and Treatment Setting Characteristics. American Journal of Public Health 

2007; 97 (12): 2193–2198. 

• Desai, MM., Rosenbeck, RA., Desai, RA. Time Trends and Predictors of Suicide 

Among Mental Health Outpatients in the Department Veterans Affairs. Journal 

of Behavioral Health Services and Research 2007. 

• Gibbons, RD., Brown, CH., Hur, K., Marcus, SM., Bhaumik, DK., Mann, JJ. Relationship Between Antidepressants and Suicide Attempts: An Analysis of the 

Veterans Health Administration Data Sets. American Journal Psychiatry 2007; 

164:7: 1044–1049. 

• Tiet, QQ., Finney, JW., Moos, RH. Recent Sexual Abuse, Physical Abuse, and 

Suicide Attempts Among Male Veterans Seeking Psychiatric Treatment. Psychiatric Services 2006; 57(1): 107–113. 

• Desai, RA., Dausey, DJ., Rosenbeck, RA. Mental Health Service Delivery and 

Suicide Risk: The Role of Individual Patient and Facility Factors. American 

Journal of Psychiatry 2005; 162: 311–318. 

cprice-sewell on PROD1PC72 with HEARING

29 

• Kausch, O. Suicide Attempts Among Veterans Seeking Treatment for Pathological Gambling. Journal of Clinical Psychiatry 2003; 64(9): 1031–1038. 

• Desai, RA., Lui-Mares, W., Dausey, DJ., Rosenbeck, RA. Suicidal Ideation and 

Suicide Attempts in a Sample of Homeless People with Mental Illness. Journal 

of Nervous and Mental Disease 2003; 109(6): 365–371. 

• Thompson, R., Katz, I., Kane, V., Sayers, SL. Cause of Death in Veterans Receiving General Medical and Mental Health Care. Journal of Nervous and Mental Disease 2002; 190(11): 789–792. 

• Kausch, O, McCormick, RA. Suicide Prevalence in Chemical Dependency Programs: Preliminary Data from a National Sample, and an Examination of Risk 

Factors. Journal of Substance Abuse Treatment 2001; 22: 97–102. 

• Sernyak, MJ., Desai, R., Stolar, M., Rosenheck, R. Impact of Clozapine on Completed Suicide. American Journal of Psychiatry 2001; 158(6): 931–937. 

The attached table entitled, ‘‘Rates and Risk of Suicide and Other Suicidal Behaviors Among U.S. Veterans,’’ Updated April 30, 2008, Prepared by Joseph Francis, 

MD, MPH, Acting Deputy Chief Quality and Performance Officer, Office of Quality 

and Performance, U.S. Department of Veterans Affairs, appears on p. 137. 

Mr. MICHAUD. Thank you, Mr. Chairman, Mr. Ranking Member, 

for having this hearing today. 

Mr. Secretary, just looking at some information—and, actually, 

one of the panelists that is coming up, Dr. Stephen Rathbun, who 

will be testifying later on today. CBS News actually asked him to 

run a detailed analysis on the information, the raw data that he 

obtained from the States. 

In that raw data, it shows that, according to the doctor, that it 

found that veterans are more than twice as likely to commit suicide 

in 2005 than non-veterans. But it also goes on to say that, between 

the age group of 20 and 24, that veterans are two-to-four times 

higher likely to commit suicide than non-veterans. 

I don’t know if you had a chance to look at that or if Dr. Katz 

has. Is that analysis correct? 

Secretary PEAKE. Sir, we have not seen that data. 

But I would like to, if I could, and with your permission, Mr. 

Chairman, put up that slide again on the 16 State material, and 

it is on your screen now actually. This study of these States under 

the National Violent Death Registry does give coroners information 

to say if this person is or is not a veteran. We understand it may 

also include active-duty people. But you can see that the numbers 

there suggest that there is a higher rate statistically in the younger servicemember—I’m sorry, veteran or potential servicemember, 

both in those who have been seen in the VA and those who are not. 

So at least in these 16 States, which is not necessarily representative of all of our States, it does give us that kind of inference here. 

And we see that both in men and in women. 

And so we take that very seriously, and that is why we are pushing so hard and why I want this outreach. Because I believe if you 

get these people in and get them into some kind of care, if they are 

depressed and get on treatment, there is evidence that we can mitigate some of this tragic loss in terms of death. 

So I can’t speak to what was presented on data we haven’t seen, 

but this is data that is available, and we have run it against what 

data we know for VA users, so we are comfortable or confident in 

that data. 

Mr. MICHAUD. And what role has the VA found that substance 

abuse and the lack of treatment has played in a veteran’s suicide? 

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Secretary PEAKE. Sir, it is one of the clearly linked conditions for 

suicide. Depression and the co-morbid conditions do relate to an increased suicide risk. 

Mr. MICHAUD. And you had mentioned outreach. And that is one 

of the whole ideas behind the CARES process, is to get more access 

points throughout the country for our veterans. And that is probably part of the reason that we are seeing some of the problems, 

particularly in rural areas. 

You mentioned a lot of the programs that the VA is doing to help 

our veterans deal with this problem that is out there. A couple of 

years ago, when the Congress actually provided the VA with about 

$300 million to take care of mental health needs, a GAO report— 

came back and said that only about $100 million to $150 million 

was used, and, out of that amount, they really couldn’t tell what 

it was used for. It was supposed to be used specifically for mental 

health. 

So my question to you, Mr. Secretary, is, number one, how do 

you know that the money and the programs you are doing are 

going to directly benefit our veterans? 

And the second question is, have you seen a decrease in the number of suicides since these programs and outreach have been implemented? 

Secretary PEAKE. Well, sir, first, I will tell you that—and as we 

have talked about here—for 2009, we expect to increase our expenditure on mental health to $3.9 billion. We have hired 3,800 

new mental health workers—we have about 17,000 mental health 

folks working in mental health across our system. 

Going to Mr. Moran’s point, we have OEF and OIF people that 

we have hired specifically to do the peer review and reach into 

from our Vet Centers. 

And so I do know that there is a history of the inability to expend the money. And that is part of the difficulty of hiring people 

and the slowness of it. I think we are up to speed in terms of moving forward on that. And we will monitor that very carefully to 

make sure that we are putting everything that we need and that 

we have been given to use for mental health into that process. 

Mr. MICHAUD. The second question that I asked is, has there 

been a decrease? 

Secretary PEAKE. Sir, let me ask Dr. Katz. 

As I look at these numbers, you know, I can see a decrease. It 

is hard to say, well, that is the cause and effect. If you can put up 

that other slide, you can see that, at least in the one male in the 

slide that is up on the board now, in the younger age group, there 

in 2005, at least. But this is old data. And so the problem, sir, is 

being able to really get accurate data to be able to give you an honest answer on that. We are absolutely trying to plumb it and dig 

into it, but we don’t have perfect knowledge about that. 

So that is part of why we are very interested in getting our suicide coordinators out there, up to speed, in terms of giving us as 

accurate a report as we can, not because that number is exactly important, but because we want to be able to intervene for those people. 

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And so I don’t think I can actually give you an honest answer 

about if we have seen a decrease in response to those specific interventions. 

And I would ask Dr. Katz, if you have any more comments on 

that. 

Dr. KATZ. 2005 is the most recent year for which information is 

available from the National Death Index. It is just too early to 

evaluate the outcomes of the Mental Health Strategic Plan 

(MHSP), whose implementation began in the beginning of 2005. 

We are looking toward this data with incredible intensity. Just 

yesterday, I received data from the National Violent Death Reporting System about early data from 2006 veteran deaths. It is complex data; data like this always is. 

The best way to summarize it is that, at this point, the early 

data does not seem to show an increase in veteran suicide rates 

from 2005 to 2006. This is very important, but it is very early data. 

The numbers may change as late reports from State medical examiners, and county coroners come in. It has to be viewed as an evolving story. 

The CHAIRMAN. Mr. Hall, you are recognized. 

Mr. HALL. Thank you, Mr. Chairman. 

And in my short 5 minutes, I just want to ask a couple of practical questions. 

Dr. Peake, if I may call you by that title, there is a problem— 

currently, as I understand it, when a veteran gets a prescription 

or has to order a refill, there is no way for a doctor to expedite the 

delivery of the medication, which can take 10 days sometimes. For 

a veteran needing an antianxiety or antidepressant medication, it 

seems that he or she should be able to get that refill sent quicker 

by allowing the doctor to request overnight delivery. 

Is that something you can do by rule or that you think that is 

a problem that—— 

Secretary PEAKE. I would think that would be within my purview. That has not been up to me, but I would be delighted to look 

at it. 

Mr. HALL. Well, it has now, and I just am asking you, if you can, 

to make a ruling and send it down to all of the staff. Because it 

is a drop—that is one of the ways in the general population, as well 

as the veterans population, if you are on an antianxiety/ 

antidepressant drugs and you go off of them for a period of days, 

it is not a good thing; ask any doctor. 

Dr. Cross, you were going to say something? 

Dr. CROSS. There are some other options, as well. Many of our 

facilities have pharmacies, like our medical centers, and they can 

make an arrangement with the local commercial pharmacy, if necessary, or they can pick it up there. 

And I don’t think it really takes ten days for the CBOC to get 

the medicine out, but you raised an interesting issue. And I agree 

with you, that continuity of providing that medication is absolutely 

vital. And so I would like to look into that for you. 

[The information from VA was provided in response to Mr. Hall’s 

Post-Hearing Questions for the Record, which appears on p. 238.] 

Mr. HALL. Thank you. 

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And also, Dr. Peake, as far as your blue-ribbon Committee, 

would you consider, or have you already, appointed any representatives of veterans service organizations? 

Secretary PEAKE. Sir, I will tell you, what I am going after are 

people that have actually published and that are recognized experts. I am not looking—I am trying to get at our data. I mean, 

our veracity has been questioned. I think it is reasonable to be 

questioned. We are America’s VA, and we ought to be transparent. 

What I want to get is some outside look at it and see from a scientific clinical research and public health perspective. And that is 

the kind of folks I am looking at here. 

Mr. HALL. I was concerned about, on one of your slides here, the 

one showing—by the way, if you could provide the Committee 

which 16 States you were looking at in the study, that would be 

great. 

Secretary PEAKE. Sir, this is the National Violent Death Reporting, and it is on the bottom of the slide there. 

[The information from VA was subsequently received:] 

Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, Wisconsin, Kentucky, New Mexico, Utah and 4 counties in California. 

Mr. HALL. Oh, good. Okay, I’ll find that. But, anyway, it seems 

to show that the user-veteran suicide rate is higher than the allveteran suicide rate, which would indicate that the VA’s involvement may not actually be positive in these cases. Am I reading that 

correctly? 

Secretary PEAKE. Actually, what it shows is they are about the 

same, because the comparison for statistical significance is between 

the general population. So it is both the user and the non-user that 

are in that younger age group, particularly that are different from 

the general population. Between the two, there is not a statistical 

significance—it is the same whether you are in a VA or not in a 

VA. 

Mr. HALL. So a four-point difference is not considered statistically significant? 

Secretary PEAKE. In that test, in this case, it is not. 

Ira. 

Dr. KATZ. It really depends on the particular statistical test that 

one does. We are dealing with a counterbalancing of two complex 

effects—— 

Mr. HALL. Okay, thank you, Doctor. I have less than a minute 

left. If I may, I appreciate your explanation, but I wanted to ask 

two more questions. 

One is, on the following slide, the non-user, 18- to 29-year-old 

rate of 3.4, which you have illuminated in red, is of concern. And 

that would seem to indicate a need for greater outreach, and refrigerator magnets and handout cards may not be doing it. I am curious, first of all, what you would propose? 

Let me just ask a second question, and then you can answer 

them both, if you will. 

There are fewer females serving than men serving, as you point 

out. However, the rate of suicide among female veterans is approximately twice the rate of male veterans in your testimony, if I am 

reading it correctly. 

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And I am curious if you think that is related to sexual harassment or sexual abuse, which unfortunately occurs in our bases as 

well as our academies, military academies, and it is a problem that 

we are trying to deal with, I know at West Point, in particular, 

where I serve on the board of visitors. And/or is it due to a difference in the way women process their experiences in battle and 

these things they have seen and witnessed, do they have a different emotional reaction to it? 

So those are a couple of questions, if you would. 

Secretary PEAKE. Sir, first, the outreach. I agree with you, we 

are looking for whatever way of outreach that we can do. That is 

why I put this call center, outreaching call center into effect, to try 

to get at those who haven’t used us, those who may finally be at 

a point where they had the teachable moment to realize that we 

are there for them and to establish that relationship. We have 

talked about putting signs on buses and things like that, even, to 

try to do outreach. 

In relation to women, sir, I would just like to correct, if I 

misspoke before. The women’s rate is higher than the national average. Women, both veterans and non-veterans, are lower than 

males across the board. But our women veterans are higher than 

the general population. 

And I think then it is fair to try to understand why. They are 

about 14 percent of the DoD population now; they are about 14 percent of the force. And so an increasing number are becoming veterans, and why we are pushing so hard to put women’s programs 

into a system that, really, for years, was mostly an older men’s 

service organization. 

So we really are trying to address that and to try to understand 

those issues of military sexual trauma. We are seeing that. When 

I talk to our Vet Centers, they say that is an issue that is very important. And so we are targeting that group to try to make sure 

they get the counseling that they need. We train our people specifically in that. 

Mr. HALL. Thank you. 

I yield back, Mr. Chairman. 

The CHAIRMAN. Thank you, Mr. Hall. 

Mr. Hare. 

Mr. HARE. Thank you, Mr. Chairman. 

Mr. Secretary, I only have 5 minutes, so I will give you the three 

questions and then—and, again, thank you for being here today. 

Why is there not more coordination between the DoD and the VA 

with soldiers separated or discharged with either TBI or PTSD? It 

would seem to me that more effort needs to be done to reach out 

to veterans to bring them into the system rather than wait for 

them to come to us. 

The other question I have—and, again, it goes back to what I 

think we talked about last week, with the rural areas—and how do 

we, for veterans in rural areas who call the hotline—do the suicideprevention coordinator set them up with appointments at the nearest clinic, VA clinic or hospital? Because, you know, I’ve talked to 

veterans, and then asking them to ride for a few hours in a van 

ride, a lot of times they are just not going to do it. They just feel 

very uncomfortable doing that. 

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And then my last question to you—it is probably and, I understand, very broad-based—but what can we do from your perspective for this Committee to be able to—is it, you know, more money, 

which is something I think we can look at, or what is it that we 

can do to help you with whatever we need to do on our end? If you 

were to say to us, ‘‘Listen, this is what I need from you folks, to 

help me move down the road with this and to be able to bring more 

people in,’’ is it hiring more people? Is it a combination of a number 

of things? 

And so, I hate to load you with three like that, but with only 5 

minutes I thought I would try to get all three in. 

Secretary PEAKE. Sir, let me start first at the top, with DoD coordination. There is a general roster steering Committee on the 

15th of May. We have been invited to be a part of that. Dr. Katz 

works closely with DoD. I spoke to the DoD psych consultant this 

morning, who used to work for me. So I think we have good relationships going on. We have a VA deputy now for General Sutton 

who is going to be running that PTSD/TBI effort for DoD to make 

sure that we are linked. 

I think the issue of outreach is important. So we do go to the 

Post Deployment Health Reassessments (PDHRAs), we do do the 

Transition Assistance Program (TAP) debriefings, to try to get that 

message out, as Mr. Hall was talking about, to make sure people, 

wherever we can get them—part of it is trying to get them when 

they are really ready to listen finally—the hotline. 

If you have an emergency, we go to the police, we go to the fire 

station, we go to whoever can make the intervention. And we have 

had 885 rescues. We follow up a week later or 24—I guess 48 hours 

a week and then 2 weeks later to track them down. We work directly with the treating facility. If they are active-duty—and we 

have had nearly 500 active-duty people call our hotline—we have 

the relationships with DoD to get them back in the DoD system, 

if that is what they need. 

So, you know, I think we are very pleased, and we continue to 

monitor and learn from it. 

What can we do? You know, the Chairman brought up the issue 

of family members. I think we need to do a better job of being able 

to reach family members. They can be the canary in the cage, if 

you will, when you have a servicemember or a veteran who isn’t 

just quite acting right and may not even recognize it. 

I do appreciate the issue of stigma, and we need to continue to 

fight that down. I was very pleased to see what Secretary Gates 

did this last week about taking, you know, that question off the security questionnaires and so forth. I mean, it is those kinds of 

things that will help us down the road. 

But it is more than stigma, I think, that keeps people from coming to us. I think some of these folks, it is a lack of realization that 

something is wrong, that they are not quite right. They just don’t 

appreciate it until, sometimes, it is too late. And if we can get family members and employers to really understand that this is treatable, if you get them in, we can help them, it will make a difference. 

And so for helping us to find ways and the authorities to reach 

out and do that would be something that would be positive. 

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Mr. HARE. Thank you, Mr. Secretary. 

Just one last thing on the rural areas. In terms of, if somebody 

calls, a veteran who lives in a rural community, and they call the 

hotline, do you try to get them into the VA hospital? 

Secretary PEAKE. Sir, we will get them wherever the care is required and where we can get it. Unfortunately, some rural areas, 

it is a long way, whether you are a veteran or not. And that is a 

different kind of issue, but it is, again, part of that national issue 

that we were talking about before. But it is not, well, if you can’t 

get to the VA, we are not going to take care of you. 

Mr. BUYER. Will the gentleman yield? 

Mr. HARE. I certainly will be happy to. 

Mr. BUYER. You just asked a very insightful question. 

So say, for example, you have Montana or Kansas, and they are 

not close to a Vet Center or an outpatient clinic. Do you contract 

care, or how do you fill the gap, Mr. Secretary? 

I think that is what the gentleman is trying to ask. 

Secretary PEAKE. Sir, in Montana, we do contract with centers 

around Montana. I have had a chance to visit both Billings and 

Helena, because I am concerned about rural America and access to 

care for our veterans that live in those areas. 

But the fact is we do fee-based care, as you know, sir, and we 

are willing to go out and we do go out and purchase the care if it 

is not available and it is needed. 

Mr. BUYER. Mr. Secretary, I would just ask you to work with Mr. 

Hare. He’s got a rural district in Illinois, and he has a gap in coverage. Please work with him to make sure that gets covered. 

Secretary PEAKE. I absolutely will. 

Mr. HARE. Thank you, sir. 

The CHAIRMAN. Mr. Rodriguez. 

Mr. RODRIGUEZ. Thank you, Mr. Chairman. And, once again, 

thank you for holding and conducting this hearing. 

Good seeing you again, Mr. Secretary. 

You know, I indicated earlier I think you are ideally situated, because we have been working for the longest time to try to establish 

a seamless transition from DoD to the VA. And I wanted to ask 

you, and I know there has been some questions on that, if we have 

made any gains in terms of where we are at on that, of trying to 

transition that soldier to the VA. 

Because there are going to be more soldiers coming in, and there 

are going to be some that are really going to be hurting, and the 

numbers might go up you know before they go down. And I understand that. And so I wanted for you to respond to that. 

Secondly, based on the Congressional Research Service (CRS) report that we have and you have also and Dr. Katz has mentioned 

it, that we don’t have a hold on the actual suicides and attempts. 

We don’t have a good hold on that. 

[The CRS Report entitled, ‘‘Suicide Prevention Among Veterans,’’ 

May 5, 2008, appears on p. 111.] 

Mr. RODRIGUEZ. What else do we need to do besides possible recommendations later on where we can start getting and compiling 

that data in a way that makes sense where we will be able to see 

if we can make any inroads there? 

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And thirdly, what do we do now, and maybe Dr. Katz can help 

on this, what do we do now to provide the services that are needed 

that we are not doing in reaching out? 

And I know that people are hurting out there. They are probably 

not the ones that will come out. And I know Mr. Moran had some 

recommendation in terms of utilizing some of those veterans organizations to reach out for those veterans that find themselves underneath the bridges throughout our country and those individuals 

out there. 

So if you might respond to those three questions. 

Secretary PEAKE. Yes, sir. First, on the issue of transition, I’ve 

been talking lately about the notion that there is ‘‘transition’’ with 

a big T and ‘‘transition’’ with a little T, if you will; that, you know, 

for these servicemembers that are coming out of our military treatment facilities and so forth that are wounded and injured, with the 

Federal recovery coordinators that we are starting to get into place 

and expanding that program, I think that will go a long way to 

helping them for a long-term transition. 

And that really is important, because these are folks that are 

wounded and, therefore, you know, appropriate to our discussion 

today, have a higher risk for suicide. So having a care manager is 

important. 

What we are in the process right now—and on the 15th of May, 

I should get my next report on it—is going back and re-reviewing 

every soldier that we know that has been in our system to understand, okay, what is their current status on case management, who 

has been in touch with them recently, and to ensure that we have 

the follow-up that I believe we owe them. And so we are pushing 

very hard on that. 

Then there is the other issue of the transition. Sir, there has 

been a million and a half people who have deployed, a little bit 

more now. About 800,000 have separated from the service. About 

300,000, a little more now, have come in to VHA for care. When 

they come into care, they do get screened for PTSD and TBI and 

suicidal tendencies. And so, you know, we have that relationship 

with them. 

Is it perfect? No. In fact, the people that—the national preventive 

task force basically says there is no real good evidence to prove 

about screening. We believe in it, though. And so we are doing it 

every single time. 

There is that other group out there, however, that 500,000 that 

haven’t come to see us, that we will be part of this big outreach 

effort that we are doing now to try to help them if they need that 

help in transition. So we just want to make sure they have that 

relationship with the VA, that they know that we are there for 

them. 

I will tell you, I know that trying to get at the data is hard. The 

military is looking at how to really study every single suicide. We 

get an in-depth review of any suicide that we know of from one of 

our patients, because we can try to plumb it to understand what 

the factors are, so that we can learn from it. So it really becomes 

an individual case study for each one of these, as well. 

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The problem is, as I say, sometimes we don’t know if one of our 

veterans has gone out somewhere else and it has not been reported 

to us. And so we do want to stay in touch with the national data. 

Mr. RODRIGUEZ. I would hope that we would establish and start 

looking at some system that would give us information, not only 

from the 16 States, but all of them as much as possible. 

And then, finally, the last recommendation in terms of what do 

we do now, even if it is an initial phase to try to reach out there, 

and maybe even utilizing existing veterans organizations to work 

with some of our veterans. And I know they are not trained in this 

area, but they are definitely trained at reaching out and 

dialogueuing with them and maybe getting them to come back in. 

Secretary PEAKE. You know, I, kind of, made the point that when 

I was talking—I meet with the veterans service organizations regularly. And when I was talking to them, they pulled it out and said, 

‘‘Oh, look, this is a great tool.’’ This is what they are using to pass 

out; it is a VA product. 

And so we are linked with the veterans service organizations. We 

agree with you, sir, that they are an important ally and an important partner. And we share the same concerns with them about 

trying to do this kind of outreach. 

Mr. RODRIGUEZ. And before I know I ran out of time, and I don’t 

know how I can overemphasize it, let us know if we need do 

more—but when it comes to these issues in terms of working with 

a family. Because I know the VA, for a long time—you know, only 

in certain situations have they worked with the family. But I think 

when it comes to these situations, we need to really stress that and 

the importance of that and how we do that in different ways. 

Secretary PEAKE. Thank you, sir. 

The CHAIRMAN. Thank you. 

Mr. Walz. 

Mr. WALZ. Thank you, Mr. Chairman. 

And thank you, Mr. Secretary, for being here. I truly appreciate 

what you do and appreciate your service. And as the members of 

the military medical community say, you are one of them, and that 

is a very important thing. 

And you and I have talked. You know as well as I do all of us 

are here to serve our veterans, first and foremost. I have been your 

strongest supporter in whatever we can do for the VA, but because 

of that commitment I am also the biggest critic. 

And, Dr. Katz, I will have to say, your term—using ‘‘unfortunate’’ 

for that e-mail—that is very correct. And I say this, I am not a 

judge of your medical professionalism, I am not a judge on the 

things you are doing there. What I am a judge on is oversight, and 

perception of our veterans, and they are losing faith in the system 

because of instances like this. So it is very unfortunate, because 

they believe the system will fail them. And that is something we 

are fighting hard to overcome. I believe we have made great 

progress. And those types of unfortunate slip-ups or whatever or 

these beliefs are very, very damaging to what we are going to do. 

So I am deeply sorry that this incident happened. But I can tell 

you, today’s tone is much different than when you came in December. And that troubles me, in terms of restoring that faith. 

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38 

The one thing I would say, my ultimate goal—and I was just 

speaking with the Ranking Member—is how do we implement this 

plan to make sure that it is successful. I know that gathering this 

data is very difficult. But I know some of the new data we are seeing from the CDC, is actually—I think, Dr. Katz, when you get a 

chance to look at it, and we looked at it this morning, tables 5 and 

6 show a fairly significant increase in 18- to 29-year-old males. And 

I think we are going to see somewhat of a trend. 

The problem here was we didn’t start looking at this until 2005. 

We didn’t have an Inspector General (IG) report and recommendations on this until May of 2007, and here we sit in 2008. This 

should have been planned for, and prepared for, when we went into 

these conflicts. The VA knew these types of situations arose after 

Vietnam, and yet we weren’t prepared to deal with them. That is 

very troubling to me. 

So when those of us try and gather data or try and implement 

this, I can tell you, I went to the Veterans Integrated Services Network (VISN) 23, asked for data on Minnesota, they promptly replied—I was speaking with them, and they said they sent it 

through your office, and your office, Mr. Secretary, delivered it to 

me 1 hour before this hearing. 

I have nothing but the best interests of the VA at heart. I wanted to have this data so I could ask the appropriate questions as it 

deals with my constituents. And I have to believe—why was that 

held up? 

And I hear a Subcommittee Chairman say he has to use the 

Freedom of Information Act to get information from the VA? His 

concerns is for the veterans. He is on the Oversight and Investigation Committee. Why does he have to use the Freedom of Information Act? And why am I waiting until the hour before the hearing? 

Those types of things trouble me, because the issue here—and I 

think all of us understand—the key is identifying and preventing 

suicides. That is the ultimate key. The key to doing that is making 

sure these people see the proper people. 

Now, I had a proposal that I sent over, and I discussed it with 

you personally, Mr. Secretary, about this inability when a person 

transitions from the DoD to get his DD–214 into the hands of people who can help him. 

We, in Minnesota, have County Veterans Service Officers in all 

of our counties. Those County Veterans Service Officers are veterans who are professionals in navigating the system. Because of 

the support of our Governor, the Director of Veterans Affairs in 

Minnesota, all of the veterans service organizations, and our nationally recognized Beyond the Yellow Ribbon campaign, our National Guard members, 99-plus percent of them are enrolled in the 

VA system; 36 percent are regular soldiers. 

As one young veteran told me as he came back, ‘‘We come back 

in ones and twos and fall between the cracks,’’ as he sat beside his 

father who lost his leg in Vietnam. 

When we have asked, I get put off and, quite honestly, get the 

run around from the VA. ‘‘It can’t happen because we can’t trust 

the County Veterans Service Officers because they are not employees of the VA.’’ That’s what they tell me. They may lose data. I 

asked them to provide me a single case of a County Veterans Servcprice-sewell on PROD1PC72 with HEARING

39 

ice Officers breaching confidentiality, and they couldn’t do it. I need 

not remind you who lost the 26 million names. 

This issue of not wanting to cooperate on the State level, of not 

trying to get it on the front end—if we had every DD–214 assigned 

and put out, you would have a success rate like we have in Minnesota of 99 percent compliance, and you would have them identified. Maybe we wouldn’t need bus stickers as much. Maybe we 

wouldn’t need those types of things. We would have them identified, we would know who they are. 

My County Veterans Service Officers tell me this, and I tell you 

today—and I am going to find out, because I am not loose with 

facts, as you well know, Mr. Secretary. The front page of my hometown newspaper in Mankato today says, ‘‘Standoff and Tragedy 

Averted; Iraqi War Veteran Takes Hostages.’’ His complaint was he 

couldn’t access the system. 

Now, I don’t know if that is true or not. I don’t know if he is even 

an Iraqi veteran. And I don’t know if he tried to access the system, 

because wild claims have been made in the past that were not true 

about that. 

The VA does a wonderful job. They do a great job of caring for 

our veterans. We simply have improvements to be made. 

So my question is, why the resistance on allowing us to register 

the DD–214s? Why not allow us to make the necessary changes? 

I understand privacy, I understand the HIPAA regulations. But 

why, in this case, when the least we could do is at least say, you 

have a veteran living here and you need to at least make contact 

with him. 

I would like to see, and I will find out, if this young man was 

ever talked to, or why he slipped through the cracks. 

[The following was subsequently received from VA:] 

DoD controls form DD–214, Certificate of Release or Discharge from Active Duty. 

The military service mails Copy 3 of the DD–214 to VA. If a military member elects 

to do so and specifies a State, Copy 6 of the DD–2314 is sent to the State Director 

of Veterans Affairs. We have provided your staff with a point of contact at DoD (Lori 

Howes, 703–697–4491; lori.howes@osd.mil). 

State Benefits Seamless Transition Program (for seriously injured): Currently 

forty-three states, including Minnesota, participate in the State Benefits Seamless 

Transition Program. To date, 350 veterans have signed the consent form authorizing 

VA to notify their local State Department of Veterans Affairs of their return to their 

home state. 

The initiative involves VA staff located at the following Department of Defense 

medical facilities: 

• Walter Reed Army Medical Center, Washington DC 

• National Naval Medical Center, Bethesda 

• Brooke Army Medical Center, San Antonio, TX 

• Darnall Army Medical Center, Ft. Hood, TX 

• Madigan Army Medical Center, Puget Sounds, WA 

• Eisenhower Army Medical Center, Augusta, GA 

• Evans Army Community Hospital, Ft. Carson, CO 

• Naval Medical Center, San Diego, CA 

• Womack Army Medical Center, Ft. Bragg, NC 

• Naval Hospital, Camp Pendleton, CA 

• Naval Hospital, Camp Lejeune, NC 

Under the program, wounded veterans returning to their home States can elect 

to be contacted by their local State Department of Veterans Affairs about State benefits available to them and their families. VHA Liaisons for Healthcare identify injured military members who will be transferred to VA facilities, inform them about 

the program, and obtain a signed consent form from veterans electing to participate. 

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40 

The State offices, in turn, contact the veterans to inform them of available State 

benefits. 

In order to participate in the program, State Departments of Veterans Affairs 

must provide a point of contact and dedicate a fax machine in a private, locked office to receive the release of information forms. VA asked States to participate in 

the program in February 2007 when it was expanded beyond the Florida pilot program. 

Transition for non-seriously injured: In order to ensure that OIF/OEF combat veterans receive high quality healthcare and coordinated VA services and benefits as 

they transition from the DoD system to VA, VA and the National Guard developed 

a creative partnership. Late in 2005, following the signing of a MOU between the 

National Guard and VA, the National Guard (NG) hired 54 (now 60) National 

Guard Transition Assistance Advisors (TAAs) to serve as VA/NG Liaisons in the 

field at the State level to assist NG servicemembers and their families and provide 

access to VA benefits and services. In February 2006, the newly hired National 

Guard/VA TAAs were trained by VA faculty experts about VA benefits and services 

at the VBA Academy in Baltimore. The purpose of the training was to enhance the 

outreach skills of the TAAs by learning about VA benefits and services and to connect them with VA resources and staff members in the field at the VA Medical Center (VAMC) and the Regional Office (RO). This new knowledge assisted them to help 

Guard members to access VA medical and benefits and address access issues in the 

54 States and territories for returning Guard/Reserve members. Annual refresher 

training was held in January 2007 and 2008 in conjunction with the National Guard 

Family Program Conference. The TAAs have been the critical link in facilitating access to VA by National Guard/Reserves returning combat troops in each of the 50 

States and 4 territories of Puerto Rico, Virgin Islands, Guam and District of Columbia and providing VA with critical information on numbers of returning troops, location, homecoming and reintegration events. TAAs also facilitate enrollment into 

VHA care for returning troops and families. 

The TAA program continues to be a funded National Guard Program and is presently expanding this program with a goal of 2 TAAs per each State with large number of deployed troops. VHA OEF/OIF Outreach Office staff continues to be linked 

with the 60 TAAs by providing access and collaboration at monthly teleconferences, 

quarterly newsletters, and monthly identification of success stories and best practices in the States. Outreach staff work with VA experts at annual training events 

to ensure they are updated on changes in VA services/benefits. TAAs facilitate the 

development and maintenance of State coalitions utilizing the State Triad Leadership of the Adjutant General, State Director of Veterans Affairs (DVA) and VA leadership to integrate and coordinate the delivery of VA services and benefits to those 

Guard and Reservists in each State when providing needed outreach programs. 

Over 47 States have developed State Memorandum of Understandings (MOUs) 

through the Leadership Triad of the State Director VA, Adjutant General and VA 

Leadership from the VISN, VAMC and RO. These State partnerships are the foundation for State coalitions with participation by community and State organizations 

to address the coming home needs of the Guard and the Reserve members. 

Outreach: On May 2, 2008, VA began contacting nearly 570,000 combat veterans 

of the Global War on Terror to ensure they know about VA medical services and 

other benefits. The Department will reach out and touch every veteran of the war 

to let them know it is here for them. The first of those calls are going to an estimated 17,000 veterans who were sick or injured while serving in Iraq or Afghanistan. If any of these 17,000 veterans do not now have a care manager to work with 

them to ensure they get appropriate healthcare, VA will offer to appoint one for 

them. 

Mr. BUYER. Will the gentleman yield? 

Mr. WALZ. Yes. 

Mr. BUYER. Mr. Walz, when you referred to ‘‘the plan,’’ ‘‘why 

aren’t you implementing the plan,’’ were you referring to the Mental Health Strategic Plan? 

Mr. WALZ. Yes. And the Ranking Member has brought up a great 

point on this. In the IG’s report of May 2007, we have never heard 

where you are at on that or what the timeline is or where you are 

going with that. And, as I referenced earlier, I would like to have 

seen that put into place before our troops landed in Iraq. But that 

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41 

being the case, I am most concerned that it actually gets done now, 

and I am wondering where it is at. 

So I thank you. 

Secretary PEAKE. I think that it is absolutely the right thing to 

ask for both things, in terms of getting our returning servicemembers into our system is what we want to get done. And I will circle 

back and work with you. 

I would like to apologize to you and to Mr. Mitchell for what may 

seem like recalcitrance. I have seen your letter, sir. I tried to call 

you last night, actually, because I wanted to get some clarification. 

I think I have some things for you. But I am interested in increasing the transparency of the VA. And, as I said, we are America’s 

VA, and our intent is to be forthcoming. If we have something to 

hide, we shouldn’t be hiding it, we should be doing something 

about it. So I will just put that on the table. 

In terms of the Mental Health Strategic Plan, actually, when I 

looked at the IG report, it looks like we are moving ahead. I mean, 

it is a complicated and a big plan. And maybe I can come back, for 

the record, to give you the specific metrics about each one of the 

milestones. But I do know that we are moving forward on it. And, 

as I say, the complexity of it is such that I can’t give you a clear 

summary of it right now. But I have looked at it. I have had that 

same discussion with Dr. Kussman and Dr. Katz. It was one of the 

first things that I asked him to brief me on, was the strategic plan. 

It has lots of pieces. I will tell you that, like any plan, it never 

survives first contact with the enemy. So we don’t want to be just 

resting on our laurels that we have a plan and that it is moving 

along, but that it is continuing to be relevant to the needs of our 

servicemen and women that are returning as veterans. And that 

includes finding these issues, if you have a younger group that we 

need to refocus some of our efforts and our resources on. 

And I will just tell you that we will continue to be vigilant and 

look for the issues so that we become more proactive rather than 

just reactive. 

Mr. BUYER. Will the gentleman yield? 

When the Secretary answers that question—Mr. Secretary, I 

think you will be helpful to us if you will also take the plan and 

compare to it HHS, and the National Strategy for Suicide Prevention. So when you do the comparability between the two agencies, 

it will become helpful to us. 

Mr. Walz, you asked a great question. And I yield back. 

[The following was subsequently received from the VA:] 

The Comprehensive VHA Mental Health Strategic Plan, which describes initiatives 

and current status, appears on p. 142. A crosswalk between the U.S. National Strategy for Suicide Prevention, the VHA Comprehensive Mental Health Strategic Plan 

and VHA’s Suicide Prevention Actions comparing the three programs, also appears 

on p. 188. 

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42 

Mr. WALZ. Well, I thank you, Mr. Secretary. And I think today, 

again, we can’t make it any clearer that this Committee is here to 

serve our veterans. And I represent the Mayo Clinic area, and their 

mantra is: What is good for the patient is good. What is good for 

our veterans is good. And whatever we can do to deliver that, we 

are here as partners for that. 

I know it is a difficult job you have taken. I know much of this 

has happened before you were at the helm. Many of us are very, 

very optimistic that you are the man to do it. Anything unfortunate 

needs to be swept and cleaned and put out in the public eye and 

let sunshine heal it and get moving forward. 

So, thank you. 

The CHAIRMAN. Mr. Mitchell. 

Mr. MITCHELL. Thank you, Mr. Chairman. 

Thank you, Mr. Secretary, for being here. 

I mentioned in my opening statement about the testimony at the 

December hearing of Mr. and Mrs. Bowman, Mike and Kim Bowman, who lost their son to suicide. Mr. Bowman, at that hearing, 

warned us—and I want to quote this—that, ‘‘Our troops are coming 

home to an understaffed, underfunded, underequipped VA mental 

health system.’’ 

So, as a result of that, I asked the question to Dr. Katz, do we 

have the resources necessary to find these veterans and to treat 

these veterans, and the answer was yes. I said, do you have, again, 

enough resources, and the answer was yes. 

As you know, I have been trying to assess what kind of additional resources your Department may need in order to make sure 

that we can provide these resources. We need to make sure that 

we conduct an outreach to veterans who are at risk of suicide, to 

treat veterans who are at risk of suicide, to track veterans who 

commit suicide. We need that information. 

In light of what CBS News reported—in fact, it is important that 

in Arizona—and I don’t know if Arizona is one of the 16 States listcprice-sewell on PROD1PC72 with HEARING


43052a.001
43 

ed on this chart that you had, but the suicide rates among veterans 

in Arizona has increased 39 percent since 2003. They make up 

nearly a quarter of all suicides in the State. So I thought I had a 

responsibility to go and double-check to see if you do have all the 

resources necessary. 

In my last letter that was sent to your office on April 24th I 

asked, ‘‘To review documents relating to requests for additional resources within the Department that were denied, unanswered or 

responded to with less than the amount of additional resources requested.’’ 

I think it is important that we know if you are being provided 

with enough resources to make sure that the VA is not understaffed, not underfunded, not underequipped. That is what our goal 

is here. 

So I want to ask you three questions in response to this. 

First of all, do you feel that, ‘‘Go file a Freedom of Information 

Act,’’ is an appropriate response to a Member of this Committee 

seeking additional information about testimony offered by the VA 

at one of our hearings? 

The next question, do you think there is something inappropriate 

about the Chairman of the Oversight and Investigations Subcommittee to ask to review records kept by the Department about 

an issue that has been the subject of one of our hearings? 

And, finally, will you be producing the documents I requested by 

Friday? 

Secretary PEAKE. First, I am saddened to hear that somebody 

would tell you to go file a Freedom of Information Act. I don’t know 

where that came from. I will tell you that I don’t think it is appropriate. The issue is—actually, you could file that. I mean, this is 

information you would be given. 

If there is a concern about or a question about what you are asking for, I owe you a phone call, which is what I tried to do last 

night, to say I am not sure what you are really after and I want 

to make sure we have it. I think we ought to give you that information, because I agree with you that we share the same goal, in 

terms of helping veterans. 

So, as I say, I will close the loop back with you before Friday to 

give you what I think that you are asking for. 

Mr. MITCHELL. Well, and let me just repeat, Mr. Secretary. I 

asked for any documents relating to a request for additional resources within the Department that were denied, unanswered, or 

responded to with less than the amount of additional resources requested. 

What we are trying to find out is, you know, we want to make 

sure that you are funded right, you are staffed right, you have the 

equipment. We can’t do that unless—and there may be somebody, 

and I want you to be absolutely certain, that, yes, there was somebody in Montana, or wherever they may be, who asked for something and we said we didn’t have the resources or we gave them 

less than they needed. 

We just need to know what it is that we can do to make sure 

that our veterans are coming back and getting everything that they 

deserve and were promised. 

Thank you. 

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[Congressman Mitchell received the information.] 

Secretary PEAKE. Thank you, sir. 

The CHAIRMAN. Dr. Snyder. 

Dr. SNYDER. Thank you, Mr. Chairman. 

Good to see you again, General Peake. I appreciate you being 

here. 

Dr. Katz, I want to be a bit of an advocate for you, at least a 

little bit, because I want to be sure I understand. In the first—well, 

Mr. Chairman, I think Mr. Buyer brought this out, too—that one 

point of attack on you has been today that, in this exchange of emails in which Dr. Kussman sends you an e-mail back in December 

that says, the McClatchy newspaper article says these statistics, 

and you confirm those statistics. But, in fact, two or three days before, you had given those same numbers here. I mean, it is in the 

transcript. 

So, while there are a lot of reasons to be critical, I think, of those 

e-mails referring to ‘‘Shh,’’ you know, that kind of business, that 

was not what happened back in December. Is that correct? I mean, 

you gave those exact same numbers that you confirmed to Dr. 

Kussman. You did it here at the hearing, and then you did it—it 

was in response to Mr. Mitchell’s question. 

Dr. KATZ. Yes, sir. 

Dr. SNYDER. The second thing is, with regard to the facts in the 

second set of e-mails, the one that you have apologized for in terms 

of the subject line, in fact, you instigated an e-mail going to your 

communications person that says, we are now identifying 1,000 suicide attempts per month, and you’re asking the question, essentially, ‘‘Is this something we need to release after we sort it out?’’ 

But what you all are saying, I think, today, if I am hearing you 

right, is you think that 1,000 number is a pretty loosey-goosey 

number. There is a lot of variation of reporting that you are trying 

to nail down. 

Is that a fair statement, Secretary Peake. 

Secretary PEAKE. Yes, sir, I do. And we are concerned that it is 

underreporting, probably. 

Dr. SNYDER. Maybe underreporting. 

So your conversation, there, Dr. Katz, is an effort to say, we have 

some new information but it may not be accurate yet. But you are, 

in fact, instigating an inquiry about, should we be releasing this. 

And I can understand that. 

Where I would part company, I think, with you on this, Dr. Katz, 

is—and, Secretary Peake, you may want to address this, because, 

in response to somebody’s question, you talked about how you want 

to have increased transparency. I have never trusted the press operations coming out of, I guess I have to say, this administration. 

And it appears to me you got bad advice. Here you, Dr. Katz, are 

saying, ‘‘We have new information. We think it needs to get out 

there.’’ You didn’t write it very artfully. ‘‘We think it needs to get 

out there, because this is a small town and people have a way of 

stumbling on stuff.’’ And your press office comes back and says, 

‘‘Oh, no, let’s figure out how to spin it.’’ I mean, that is what that 

response is. Is this the fact—we are stopping them. Somebody is 

trying to get you to spin it. In fact, what you are trying to do is, 

‘‘We have new information; let’s get it out there.’’ 

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And my advice is you have a communications department. You 

ought to figure out what you want to communicate, and then communicate it. Tell them, ‘‘Here, get this information out there.’’ But 

don’t let people tell you how to spin information that you think is 

new. I don’t think you are well-served. 

Dr. KATZ. Sir, could I respond? 

Dr. SNYDER. Go ahead and respond. 

Dr. KATZ. The e-mail was only part of the communication. 

Dr. SNYDER. Oh, I am sure that is right. Every one of us have 

bad e-mails—— 

Dr. KATZ. The other part of the communication from VHA’s senior leadership was, make sure everything is done to address the increased risk in these thousand people a month. 

The CHAIRMAN. Was that response in writing? 

Dr. KATZ. No, it was in conversation. 

Dr. SNYDER. A specific question I wanted to ask, Secretary 

Peake, is one of the folks on the second panel suggests that, because of the way some of the CBOCs are set up, that people who 

are coming in for treatment may be getting psychotherapy and 

counseling but not an appropriate level of antidepressants and 

pharmacological therapy. 

Do you agree with that? Is that a concern that you have had? 

Secretary PEAKE. I really don’t have data to address that, but I 

would take a look at it. 

[The following was subsequently received from the VA:] 

No. To promote a consistent and portable prescription benefit, VA uses a single 

National Formulary (VANF) at all points of service, including CBOCs. The VANF 

provides access to a very broad array of medications used to treat mental health 

conditions and with few exceptions, these medications are available to CBOC mental 

health providers. If a CBOC mental health provider is not licensed to prescribe 

medications (ie., Licensed Clinical Social Worker or Psychologist), the CBOC primary care provider can prescribe them and if necessary, he or she has remote access 

to a VA Psychiatrist for mental health medication consultation. 

At present, of CBOCs serving more than 1,500 unique patients, 452 (97%) have 

a meaningful mental health presence as defined by having at least 10% of the total 

number of visits coded as mental health visits. 

For those serving less than 1500 unique veterans, mental health visits represent 

at least 10% of the total visits in 109 (58%) CBOCs.* In other facilities, mental 

health services are provided by primary care clinicians, or they are available by referral. The major difference between mental health services in medical centers or 

CBOCs is not the presence or absence of general mental healthcare, but difficulties 

in making specialty mental health services available in CBOCs, especially smaller 

and more rural ones. Historically, VA’s approach to this has been to refer patients 

when necessary to specialty mental health programs in VA or non-VA sites. However, over the past few years, there has been increasing use of telemental health 

technologies to provide these services. Currently, telemental health is available in 

196 (40%) of CBOCs serving more than 1,500 unique veterans and in 48 (21%) of 

smaller ones.** 

Vet Centers will refer veterans to the local VAMC for medical care and follow up 

of prescriptions if needed. In the mental health mental status evaluation, any indicators of need for medical psychiatric or primary care are automatically referred to 

the medical center. If veterans are on medications and have challenges in getting 

prescriptions filled, they are referred to the local VAMC or CBOC. 

*Data source is adapted from VSSC website, Past Performance Measures, Mental 

Health at CBOCs Performance Measure, FY 2008, Quarter 1. 

**Telemental health data is from the Office of Care Coordination, March 08. All 

Telemental health visits are coded as MH visits and are not separated in the data 

base summary. These data include specific fee basis visits at some sites. 

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46 

Dr. SNYDER. When you talk about the issue of trying to sort out 

veterans from active component—you may have addressed this 

with Mr. Walz—how are Reserve component members who come 

back from active duty and entitled to come to the VA for a period 

of time—are they counted as a veteran or an active component? 

Secretary PEAKE. Sir, we count them as veterans. 

Dr. SNYDER. As veterans. 

Secretary PEAKE. Yes, sir. They do have DD–214s that they have 

then demobilized. 

Dr. SNYDER. Well, I appreciate you being here. 

I think a lot of this could have been avoided, Dr. Katz, by, as you 

pointed out, some more artfully written e-mails. Because we are all 

here in the spirit of trying to solve these problems. And unfortunately, you take snippets of this, and it does not provide a very 

good picture of what was going on at the time. It appears to be a 

department under siege. 

And I don’t think that has ever been your style professionally, 

Secretary Peake. I think you are one of the ones to solve problems. 

You may want to address that with your communications department and let them work for you rather than vice versa. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Mr. Snyder. 

Mr. McNerney, any questions? 

Mr. MCNERNEY. Thank you, Mr. Chairman. 

Dr. Katz, last November you attacked a CBS News report which 

claimed that there were 6,200 suicides in 2005 among those who 

had served in the U.S. military, by saying, and I quote, ‘‘Their 

number is not, in fact, an accurate reflection of the rate.’’ But then, 

just 3 days later, you wrote an e-mail admitting there were about 

18 suicides per day among America’s 25 million veterans. That is 

about 6,570 a year. 

Did you intentionally withhold information from CBS News? 

Dr. KATZ. From CBS News? 

Mr. MCNERNEY. Well, you attacked the CBS News report, and 

then you admitted that their numbers were not only right but they 

were low. And then you didn’t—— 

Dr. KATZ. I was concerned about their findings with respect to 

very young veterans, not the entire veteran population. 

Mr. MCNERNEY. So was information withheld at that point? 

Dr. KATZ. Sir, I was not asked for information from CBS News. 

I was merely asked to react to their information. I was given a 

piece of paper, and it had ratios of veteran and non-veteran suicides, and asked if I was shocked by that. I was not shocked by the 

overall number of veteran suicides, and I think their four-to-one 

ratio for the youngest of veterans may not hold up. You saw a different ratio earlier. 

If you are interested in whether there is an epidemic related to 

the war, you would also want to see what the rates were before the 

war. CBS News never addressed that. I have concerns about the 

CBS News report. Those concerns were what I have been referring 

to. I have never had concern about their overall estimate for numbers of veteran suicides. 

Mr. MCNERNEY. After the VA provided CBS News with the 790 

number as the annual number of veteran suicide attempts, you 

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wrote an e-mail to your media advisor again, because you were concerned that there might be as high as 12,000 per year, is that correct? 

Dr. KATZ. Sir, it may be even higher than that, in terms of suicide attempts. And we could speak to that. 

As I recall, the number 790 came from information sent to CBS 

News when they asked for information about attempts or completed 

suicides from the medical records. And from that information, they 

extracted the number 790 as the count of attempted suicides or 

deaths from suicide in 2005. 

The estimate of a thousand a month came from the tabulations 

done by the suicide-prevention coordinators, which, because it was 

information and methods under development, were not yet in the 

medical records. 

Mr. MCNERNEY. Well, in the same e-mail, you question whether 

or not you should release the information before someone else 

stumbles upon it. So it seems to me that information on suicide 

statistics was either withheld or wrong numbers were released. 

My real concern here is that that would have prevented procedures that could have saved precious lives, lives of young soldiers 

who served our country and depended on us to help them when 

they needed it. 

How can you assure this Committee that that behavior doesn’t 

constitute wanton disregard of your duties and responsibilities and 

that that will change and that we will see procedures put in place 

that will prevent this? 

Secretary PEAKE. Sir, let me try to address that. 

First of all, I would tell you, as I tried to comment in my opening 

remarks, that the numbers are important for trending and all of 

those kinds of things. What is important is making sure that we 

are doing the kinds of things that we are doing to try to intervene 

in this, what we know, is a high risk group, those with suicide attempts, to intervene with that younger age group that we demonstrated have a higher level of suicide risk. And, you know, that 

is full bore out, to try to work those issues. 

Trying to get the right numbers and making sure that we give 

valid numbers is important, and I think that we owe appropriate, 

validated numbers to this Committee and to people that ask for 

that information. 

So I can’t tell you more, except to say that we are absolutely 

committed to trying to do the right thing by all of our servicemembers, our veterans, and not worry as much about whether this is 

a little above or a little below some national average, but to focus 

on doing the clinical right thing. 

Mr. MCNERNEY. Mr. Secretary, the Joshua Omvig Suicide Prevention Act requires that you submit recommendations for further 

legislation and administrative action that the Secretary considers 

appropriate to improve suicide-prevention programs within the Department of the Veterans Affairs. 

Do you have recommendations for us today, or do you have recommendations in general to meet the requirements of that act? 

Secretary PEAKE. Sir, I don’t have those to present to you today. 

But, as that may be required by the act, I will provide those. 

[The following was subsequently received from the VA:] 

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The Comprehensive Program for Suicide Prevention Among Veterans report for 

P.L. 110–110 was submitted to Congress in February 2008 and is attached for your 

review. In the report we stated that we are able to monitor risk and needs and respond to them under existing legal authority. VA did not recommend further legislative action and remains with this position. Since the report was released, VA has 

the following updated information: 

Requirement: Designation of Suicide Prevention Counselors—To support the identification of patients at high risk, the Suicide Prevention Coordinators have been integrating information from providers, other staff, and community contacts about veterans who have survived suicide attempts. In preliminary findings, we have identified approximately a thousand attempts per month. To address the increased needs 

for these vulnerable veterans, VA has implemented standardized approaches to enhancing care while, at the same time, encouraging innovation and creativity. 

Further developments in process at this time include tests of the Coordinators 

inter-rater reliability and their sensitivity in the identification of suicide attempts. 

Both will be necessary before the number of attempts (or reattempts) in a facility 

can be used as a measure for epidemiological or quality improvement purposes. 

Requirement: Hotline—From the time the veterans’ Hotline was established in 

July, 2007 until the end of April, 2008, we received 43,294 calls. From the start of 

2008 until the end of April we received 33,915 calls, with 16,414 confirmed as coming from veterans and 2,125 from family members or friends. These led to 2,725 referrals to the Suicide Prevention Coordinators at VA facilities and 746 ‘‘rescues’’ requiring emergency services. 

The ‘‘Report to Congress for Public Law 110–110, Comprehensive Program for 

Suicide Prevention Among Veterans,’’ dated February 2008, appears as an attachment to the response to Ms. Berkley’s Post-Hearing Questions for the Record, which 

appears on p. 240. 

Mr. MCNERNEY. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you. 

Ms. Brown. 

Ms. BROWN OF FLORIDA. Thank you. 

Mr. Secretary, a couple of quick questions. 

One, we have talked a lot today about the veterans. And I mentioned the families earlier. What are we doing to work with the 

families, the outreach to prevent suicide? 

Secretary PEAKE. Well, first of all, within our Vet Centers, they 

can do family counseling, and we really encourage that. When a 

servicemember is within our care, providing counseling to the family member is deemed part of that care, that we can provide that 

kind of counseling as well. 

As I was talking with Mr. Hare, one of the things I would like 

to find a way to do is to reach out and touch family members in 

a more specific way. So, as we go to the TAP briefings, you know, 

it is possible to have family members there, but, in all honesty, we 

are not seeing them available. 

I think that what the Ranking Member brought up, in terms of 

being able to participate in those kinds of events, are things that 

we need to expand on. But I think it is an area that we need to 

come up with an action plan. And I will be happy to do that and 

report back to this Committee on that action plan. 

[The following was subsequently received from VA:] 

The Secretary has asked that assistance to families be a VA priority. Since 1979, 

the Vet Center program has been authorized to provide family services as it relates 

to the readjustment of the veteran. When an individual is reactivated, they shift 

from veteran status to active military status. The servicemember and dependents 

then revert to Department of Defense protocol. Once they complete their tour and 

demobilize, they are once again veterans and they and their family members are 

eligible for Vet Center services. 

In FY 2007, Readjustment Counseling Service provided 1,055,186 visits to 164,228 

total veterans. Cumulatively since the beginning of the War, Readjustment Councprice-sewell on PROD1PC72 with HEARING

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seling Service has provided services to 288,594 OEF/OIF veterans (through 1st 

Quarter FY 2008). 216,172 were provided outreach services and 72,422 received readjustment counseling in the Vet Center. 

Cumulatively, since 2003, (bereavement counseling authorization) Readjustment 

Counseling Service has provided bereavement services to the families of 1,238 fallen 

servicemembers, 876 of which were in theater casualties in Iraq and Afghanistan. 

Ms. BROWN OF FLORIDA. The other thing is the women—I am 

very concerned that women veterans are one of the fastest-growing 

groups and one of the most underserved groups. Have you thought 

about having a task force just for women vets and trying to come 

up with how we can be more supportive and what we can do just 

targeting that group? 

Not to take anything away from veterans in general, but I think 

women are unique and they have unique needs. And in a lot of our 

VA centers, their needs have not been addressed. 

Secretary PEAKE. You know, ma’am, I have not only a Federal 

Advisory Committee Act (FACA) that looks at those kind of issues 

for women, but also an office that focuses on women’s issues, with 

Dr. Irene Trowell-Harris as my lead. 

We continue to ask this issue every time we get into it: Now, are 

we taking care of the women veterans? Because, in fact, we have 

been historically a male service organization, in a way. 

Ms. BROWN OF FLORIDA. It still is, sir. 

Secretary PEAKE. And I have been traveling a lot and, every 

time, have asked to see the women’s health unit. I have been impressed with some of the things we are doing. 

But it is very important to understand that they want to be able 

to have a single portal where they can go in and get women’s 

healthcare, primary care, and mental healthcare without being labeled. And so we are making sure that that is in there. 

But I think we must continue to monitor very closely and make 

sure that we have consistency across the whole VA when we do 

those kinds of programs. 

Ms. BROWN OF FLORIDA. What can the Committee do legislatively 

to assist, to widen your scope? 

Secretary PEAKE. As we look at being able to provide access and 

assistance to a family member, there may be ways that we need 

to work together to find a road ahead there. 

If a spouse, as an example, is depressed with their servicemember or veteran spouse who may have a physical disability or mental 

disability or TBI or something like that, it would be nice to be able 

to ensure that they have the care to include medications, if that is 

necessary, to help them through that, even if for the short term. 

And so we are looking at ways to try to get that kind of an authority. 

Ms. BROWN OF FLORIDA. You mentioned the Vet Centers, and I 

do think it is a great delivery service. But, in some cases, they have 

been cut or underfunded. Maybe we can think about how we can 

rev up those Centers. Because it is going to be comprehensive. It 

is going to be jobs, it is going to be healthcare, it is a whole list 

of things. A lot of these veterans come back, their jobs are no 

longer there. So it is comprehensive. 

Secretary PEAKE. Yes, ma’am. To my knowledge, we have not 

had—I mean, I have asked specifically, and I am told that we have 

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not cut Vet Centers, and we are funding them as they have requested. I will go back and check on that. 

I do agree with you about the jobs issue. And, frankly, you have 

young men and women who have gone overseas and have done 

something that they feel in their life is really meaningful, and they 

don’t necessarily want to go back to that old job that they had before. We do need to increase our efforts in that regard, as well. 

[The following was subsequently received from VA:] 

Vet Centers are fully funded. Their funding levels: 

• 2004 $87 million (206 Vet Centers) 

• 2005 $94 million (207 Vet Centers) 

• 2006 $100 million (209 Vet Centers) 

• 2007 $113 million (215 Vet Centers) 

• 2008 $153 million (232 Vet Centers) 

The FY 2008 budget represents a 50% increase from 2006 through 2008. 

Vet Centers provide individual and group counseling, marital and family counseling for combat service related issues, military sexual trauma counseling and referral, bereavement counseling for the families of fallen servicemembers who die 

while on active duty, demobilization outreach and direct service, substance abuse 

assessment and referral, employment services, Veterans Health Administration and 

Veterans Benefits Administration referral, and veteran community outreach and 

education. 

Twenty-two new Vet Centers have been approved. 

Ms. BROWN OF FLORIDA. Well, thank you. 

And thank you, Mr. Chairman. I yield back the rest of my time. 

The CHAIRMAN. I am trying to decide if there are additional questions. Do you want the Secretary to be back, Mr. Boozman, Mr. 

Lamborn, Mr. Kennedy? We have three votes. Do you want to talk 

to the Secretary when we return? 

Mr. LAMBORN. I don’t need to. 

The CHAIRMAN. We will get to Mr. Kennedy when we return. 

And I hope you will respond to these general questions, Secretary 

Peake. A half-dozen Members of Congress asked you very specifically, what do you want us to do, how can we help? You didn’t ask 

us for one thing, one piece of legislation, one dollar of funds. Who 

is better at outreach than we are? That is our job. Have you ever 

asked a Member of Congress to help on the outreach? Nobody has 

ever asked me. 

We know the people. We talk to the people. We are in touch with 

them every day. Otherwise, we wouldn’t be here. Use us. But you 

never mentioned one thing you wanted us to do. 

Second, although I guess Dr. Katz is a doctor and not a lawyer, 

your rhetoric still bothers me, and I am not sure you are performing your job in an effective way, given the unfortunate e-mails. 

But in answer to one question, Dr. Katz, you said, ‘‘CBS News 

asked me for medical records.’’ Why don’t you say, ‘‘Here are the 

medical records.’’ But if you really wanted to get that information, 

you should ask for the number of attempts that our coordinators 

are coming up with. 

You are not very helpful in transparency—you are not helping. 

You are supposed to be the expert. If we are not asking the right 

questions, if the press is not asking the right questions, help us ask 

the right questions. You are just sitting there with all this data, 

‘‘Well, he asked for this; I will give him this,’’ or, ‘‘I am not sure 

that is accurate, so we won’t give him that.’’ 

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The data is only important to reflect—it is a symptom of a major 

problem with our current veterans and previous veterans. The 

problem is inadequate mental health treatment. Suicide is the ultimate symptom—the tragic symptom—but PTSD is a symptom, 

homicides are a symptom, homelessness is a symptom, marital difficulties are a symptom, domestic violence is a symptom. We have 

to be focused on all the symptoms and we are not doing the job. 

I don’t care what data you have, or what programs you are starting; if you have a thousand—and you said it could be more suicide 

attempts per month, we have some real difficult issues. And you 

never asked us for anything to help you deal with it. It is as if you 

have it under control. You don’t have it under control. 

I talked to you, as I said, in our first conversation, Secretary 

Peake. I said the one thing that is the most important, that is 

missing from the mental health problem, is a mandatory evaluation by competent medical personnel. I said I had the concept of a 

Heroes Homecoming Camp that I thought we could use. It was 

never followed up on. 

We are letting tens of thousands of young men and women out 

of the service, out of the National Guard, without adequate diagnosis. You keep saying, well, everybody that comes to us, we 

screen. 

Is that screen, by the way, just a questionnaire, or is that an 

hour interview with a psychiatrist? How do you screen? You said 

it several times today. How do we screen? 

Secretary PEAKE. It is a reminder to the primary care physician 

to ask specific questions and to create the dialogue with the patient. It is not an hour-long diagnostic session with a psychiatrist. 

The CHAIRMAN. So we don’t adequately diagnosis anybody, unless 

they ask for it? Then we have to make that mandatory for every 

young man and woman who leaves combat so there is no stigma. 

I suggest that you do it in cooperation as part of their active duty 

service with the Army, Marines, et cetera, with their family there, 

and with their company of soldiers there. Let’s get everybody the 

support system they need and get that mandatory diagnosis. 

If they are coming in, psychiatrists tell me and people have testified to us, that you need competent medical personnel—and there 

is minimally adequate treatment here that the VA is not giving. 

We are not giving adequate diagnosis or treatment to these hundreds of thousands of young people who are getting out. That is the 

problem. 

Until you tell us what you need to solve the problem, all this 

data is meaningless. The data is only, as you said, a way to understand the issue. But we have to get to the issue. 

We have these kids in active duty. All I have to do is say, visit 

the psychiatrist. This is not a hard thing to do. 

Mr. Kennedy. 

Mr. KENNEDY. The evidence is so clear, and adherence to medical 

advice averts hospitalizations over and over and over again. And 

the same thing adheres to behavioral medicine and mental health. 

If we had people who called back and stayed on top of these soldiers after they got out of the military and stayed in touch with 

them with care management—not just the ones that were grievously injured, as you pointed, that are at high risk for suicide, but 

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all the soldiers. Because we want to stay in touch with the ones 

that are at modest risk, because we don’t know which ones may 

have had an exposure to trauma. Or the trauma that they were exposed to they might not have the resiliency to that that other soldiers had. 

And so if we stayed in touch with all of them, and that is not 

a huge expense, because we don’t want them to become the severe 

cases later on. So this is an investment in prevention for us. So if 

we stayed in touch with all of them, that is an investment in keeping them out of the hospital, and prevention. 

We can put this in place as a preventive measure and employ 

these new technologies in keeping in touch and preventive medicine. And I think that is one of the recommendations in prevention 

you ought to put forward. 

The CHAIRMAN. Mr. Kennedy, I thank you for your leadership 

and being a part of this. 

I will make it real simple, Secretary Peake. Get us a plan with 

the Secretary of Defense and the VA to evaluate—not screen, not 

quiz, not give self-questionnaires—to diagnosis with competent 

medical personnel for every soldier for brain injury and for PTSD. 

We will make it that simple. You will bring down every single one 

of these figures. You will not have to start with ‘‘Shh,’’ ‘‘Shh,’’ 

‘‘Shh.’’ We will come to grips with this. Come back with a plan, 

which I already gave to you, in a week or two. I will bet you that 

every single issue we talked about today comes under control. 

Mr. Secretary, you have been generous with your time. 

We have three votes. We are going to come back in about 20 minutes. The first panel is excused, and we will go to the second and 

third. 

[Recess.] 

The CHAIRMAN. Dr. Maris, thank you for joining us. The other 

Members of the Committee will be following. 

I know you have to catch a plane. I would like to introduce you 

as a Distinguished Professor Emeritus at the University of South 

Carolina, past director of the Suicide Center at the University of 

South Carolina, and you have an extensive background in research 

on suicidal behaviors. 

I believe you will testify as to the problem of suicide among veterans, whether or not it is an epidemic, and what you think the 

VA is doing about it. 

Let me thank you for taking the time to be here with us. 

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STATEMENTS OF RONALD WILLIAM MARIS, PH.D., DISTINGUISHED PROFESSOR EMERITUS, PAST DIRECTOR OF SUICIDE CENTER, ADJUNCT PROFESSOR OF PSYCHIATRY, AND 

ADJUNCT PROFESSOR OF FAMILY MEDICINE, UNIVERSITY 

OF SOUTH CAROLINA, SCHOOL OF MEDICINE, COLUMBIA, 

SC; STEPHEN L. RATHBUN, PH.D., INTERIM HEAD AND ASSOCIATE PROFESSOR OF BIOSTATISTICS, DEPARTMENT OF EPIDEMIOLOGY AND BIOSTATISTICS, UNIVERSITY OF GEORGIA, ATHENS, GA; AND M. DAVID RUDD, PH.D., ABPP, PROFESSOR AND CHAIR, DEPARTMENT OF PSYCHOLOGY, TEXAS 

TECH UNIVERSITY, LUBBOCK, TX 

STATEMENT OF RONALD WILLIAM MARIS, PH.D. 

Dr. MARIS. Thank you, Mr. Chairman, Committee Members, ladies and gentlemen. 

Just for the record, I was a plaintiff expert in the Vets v. Peake 

trial in San Francisco. So I am coming at this partly with a plaintiff perspective. 

In my written report, I want to highlight that suicide is more 

than one outcome; it is a multidimensional outcome. And for the 

Committee’s sake, I would hope they would look not just at completed suicides, but suicide attempts and other kinds of collateral 

damage, partially self-destructive behaviors, depression, alcohol, 

domestic violence, PTSD. 

Secondly, I have also identified some risk factors, and I list those 

in my written report, starting off, of course, with depression and 

affective disorders, alcohol and substance abuse. My point is that 

I think all these 15 risk factors that have been shown to be related 

to suicide outcomes ought to be asked of all vets. And I will come 

back to that in just a minute. What the VA does is they ask two 

simple questions; they don’t ask all the risk factors for everybody. 

I was asked whether or not we could talk about what causes veteran suicide. And I want to say that part of the problem is the Department of Veterans Affairs has not provided me or the courts 

with crucial data that are needed. Every time there is a military 

death, suicide attempt or serious incident, the VA produces something called an incident brief, which summarily decides the suicide 

or suicide attempt. Then, about 45 days later, each incident goes 

through what is called a root-cause analysis, and a three-page report is generated. 

When I was an expert in San Francisco in the Vets v. Peake 

trial, I was given only 170 of the somewhat estimated 15,000 incident briefs and none of the root-cause analyses. My point being 

that such crucial documents would help clarify how many vet suicides there are and what the VA itself thinks causes them. 

One of the documents in that trial was a document by William 

Feeley, a Deputy Under Secretary for Health Care. And he said in 

his deposition, I quote, ‘‘Suicide occurs like cancer.’’ That is wrong. 

We all have to die, some by cancer, some by heart disease, but no 

one needs to suicide. It seemed to me that that comment suggested 

that the VA seems to think there are a certain number of vet suicide deaths that are inevitable and there is not a lot we can do 

about them. 

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The VA has a number of suicide coordinators. Interestingly, I 

think the Committee should remember none of these suicide coordinators are in what they call their CBOCs, their 875 outpatient clinics. They are all at the VA medical centers. So the vast majority 

of treatment is at these outpatient clinics, which I understand do 

not have suicide coordinators and do not have people who can write 

prescriptions for antidepressant medications. 

When they measure suicide risk in the VA, they have something 

called the suicide template, and that just has two simple questions. 

Those questions have to do with whether or not the patient felt 

hopeless, whether or not they felt depressed, and whether or not 

they were thinking about suicide. If you answer ‘‘no’’ to either of 

those two questions on the so-called suicide template, you are not 

asked any more questions, even though there are a number of 

other risk factors that I have outlined in the first part of my written report and that the VA itself actually states in their suicide 

template the vets do not get asked those important questions. 

So they are simply asking about self-reports of suicide ideation 

and hopelessness or depression. They don’t even measure depression and hopelessness using standardized clinical scales like the 

Beck or the Hamilton scales. So I have some problems with how 

they measure these important variables and the kinds of questions 

that they ask. 

There is surprisingly little in the VA healthcare policies about 

treating depressive disorders psychopharmacologically. One of the 

backbones of the standard of care for suicidal depression is to get 

somebody diagnosed appropriately and, if they need it, to put them 

on some sort of psychopharmacological treatment. I am not sure 

why this is not a major part of the documents that I have read. 

There are serious questions about these suicide coordinators: 

Who are they? What do they do? Are they really trained as well 

as they claim they are trained? 

And then, finally, there are some questions about delays in treatment. To even get mental health treatment for 2 years, a vet has 

to fill out a 23-page application, which can be hard to do if you 

have PTSD, and then receive a disability rating from zero to 100 

percent from a compensation and pension examination. If the disability is denied or too low, found not to be related to military service, then the appeal process can be long and drawn out and sometimes—— 

The CHAIRMAN. Dr. Maris, I hate to interrupt you, and I apologize. There is another procedural vote that was just called and I 

have to run over and vote. I apologize again. 

We will recess for a few minutes and hopefully return right 

away. 

[Recess.] 

Mr. HALL [presiding]. The hearing will resume and come to 

order. We do have a couple of Members here, so there is a quorum. 

And I will, at the request of Counsel, sit in as Chairman until 

Chairman Filner returns. 

And, Dr. Maris, you were testifying. If you would be so kind as 

to—— 

Dr. MARIS. Yes, I have one sentence left. 

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Mr. HALL. Is that all? Well, feel free to add one or two more if 

you would like. 

Dr. MARIS. Defense expert Alan Berman in the Peake v. Vets 

trial testified that it could take up to 10 years for the 2007 MHSP 

plan to be implemented. One wonders how many vets are going to 

die in the interim due to lack of assessment and intervention. 

[The prepared statement of Dr. Maris appears on p. 96.] 

Mr. HALL. Thank you, Dr. Maris. 

Dr. Rathbun, your statement has been entered in full into the 

record, and you are recognized for 5 minutes. 

STATEMENT OF STEPHEN L. RATHBUN, PH.D. 

Dr. RATHBUN. Thank you, Mr. Substitute Chairman, I guess. The 

Chairman is out. I have never done this before, so you will have 

to excuse me if I am not quite on protocol. 

I got involved in this when Pia Malbran from CBS News contacted me last fall. I believe it was some time in August. 

The CHAIRMAN [presiding]. I apologize again for—— 

Dr. RATHBUN. Sure. 

The CHAIRMAN. I wonder, Dr. Maris, for the people who weren’t 

here, if you could repeat the two points you made on the 15 risk 

factors versus two questions and CBOCs without suicide coordinators. 

Dr. MARIS. Sure. The VA suicide risk assessment has something 

called a suicide template. They ask two questions to vets at any 

particular time, either at deployment or clinic visits. Those questions are: In the last 2 weeks, have you felt hopeless or depressed? 

Number two, in the last 2 weeks, have you thought about harming 

yourself? 

If the vet answers no, actually, to the second question, they are 

asked no more risk factors. And my point is that is way below the 

standard, to leave it at that. There are many reasons why somebody would not answer yes to those questions, many of which have 

been discussed earlier today: fear of career advancement, you 

know, kind of, being a tough guy. So that you need to ask all of 

those risk factors on their template or my 15 risk factors on my 

written report of all vets. 

The CBOC question is that there is 154 VA medical centers; that 

is where the suicide coordinators are located. They also have most 

of their service delivered by the CBOCs, community-based outpatient clinics. None of the suicide coordinators are in those 875 

outpatient clinics. 

As I understand it, most of those outpatient clinics do not have 

licensed physicians who are capable of prescribing antidepressants. 

So it concerns me that the vast majority structurally of the treatment is being given at the outpatient clinics and that the suicide 

coordinators actually aren’t even there. 

The CHAIRMAN. Thank you. I think those are two very important 

points for us to keep in mind. 

Dr. Stephen Rathbun is the Interim Head and Associate Professor of Biostatistics at the Department of Epidemiology and Biostatistics at the University of Georgia. Dr. Rathbun has performed 

statistical analysis of veteran suicide data for the CBS News and 

will talk about that analysis. 

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56 

I, again, apologize for breaking in on you. 

Dr. RATHBUN. Okay. No problem. I will just start all over. 

It wasn’t really made clear exactly what I should be talking 

about today, but I think I can go over a little bit of the history of 

how I came to do the data analysis and some of the results that 

I found. 

I was approached originally back in August by Pia Malbran from 

CBS News to assist them with the analysis of veteran suicide data. 

After being approached, I agreed to do so, essentially as a statistical consultant. I am a biostatistician and not an expert on veteran 

suicides. I consulted with her on the format that the data needed 

to come in, and she eventually did provide the data in that format. 

One of the important things when analyzing data of an observational nature, as these data are—these are not the results of experimental manipulations of study subjects—the statistical protocol 

should be specified in advance. So, prior to actually receiving the 

data, I determined what type of analysis should be carried out on 

the data. And in the interest of keeping things simple, which is 

usually a good idea, I tried to keep it the most straightforward 

analysis, standard data analysis as possible. 

What Pia actually asked me to do was estimate rates of veteran 

and non-veteran suicides over the general population and broken 

down by gender and age, among other things. And when making 

these estimates, it is important to adjust for the fact that veterans 

are not representative of the general population. Veterans tend to 

be more male, and their representation in different age groups are 

different according to, I suppose, how many, you know—what the 

current state of the world affairs are. Certainly, in World War II, 

there were a lot higher percentage of veterans than there are currently. 

So I carried out the analysis using standard statistical methods, 

and those analyses were reported on CBS News on November 13. 

And the general findings were that veteran suicides were about 

roughly double of the non-veteran suicides. 

The comparisons I am making here are veterans versus non-veterans. The results that you saw earlier were veterans versus the 

general population. Since the general population includes veterans, 

that can have an impact of reducing the magnitude of the effects 

somewhat. So that can explain some of the differences between my 

results and the results that the Veterans Administration might be 

presenting. 

But, in general, the veterans had about double, roughly double, 

the suicide rates as the non-veterans. If you break it down by gender, you find a similar pattern of higher rates among males than 

females. And within both genders, you also have higher rates of 

suicides among veterans than non-veterans, roughly about double 

the rates of non-veterans in both genders. 

One of the things I was asked to look at was the breakdown by 

age. And in our story, we broke it down by 5-year age classes: 20 

to 24, 25 to 29, and so on. And when looking at those ages, in this 

case gender-adjusted rates for each of the ages, the thing that stood 

out to me the most was the higher relative rate of veteran suicides 

among the 20- to 24-year-olds. Here those rates were estimated becprice-sewell on PROD1PC72 with HEARING

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tween about 24 to 36 per 100,000 veterans compared to about eight 

per 100,000 nonveterans. 

Higher rates also can be found among the 40-year-olds, but the 

non-veterans in that group also have higher rates, so it is not quite 

as striking there. 

In the interest of brevity, I guess I can leave it up for questions 

right now. 

[The prepared statement of Dr. Rathbun appears on p. 102.] 

The CHAIRMAN. Let me just make sure I understand what you 

said. The charts that we saw earlier included the veterans back 

into the general population? 

Dr. RATHBUN. Yeah, the figures were general population numbers. 

The CHAIRMAN. So that is a real distorting aspect? 

Dr. RATHBUN. I don’t know how much a distortion it is. I would 

have to have the actual numbers on the numbers of veterans in 

each of the age groups to get some idea of exactly how big an effect. 

The CHAIRMAN. But it could be? 

Dr. RATHBUN. Some. I think it is only just the relative magnitude 

that would be affected. The general story, I think, will be the same. 

You might not get—if you had different ages—if you have in different age groups of our population differential veteran representation, then that can cause some pattern in the relative rates when 

comparing veterans to non-veterans, if you were to do that direct 

comparison instead. 

To defend what they did, however, I think the records, the national death records were very readily obtained from the CDC, I 

think it is where they come from. And it is the viable thing to do, 

but you really have to understand what is going on with those 

numbers. And it can be a little bit misleading if you don’t understand the numbers. 

The CHAIRMAN. You know, I see Dr. Katz is still here, but I don’t 

see the expertise in the VA that you are showing here to analyze 

the data. So maybe we could talk about that again of who should 

be questioning whom. 

Dr. David Rudd is the Professor and Chairman of the Department of Psychology at Texas Tech University. He is a former Army 

psychologist with a background as a practicing psychologist in clinical research whose work focuses on the assessment, management 

and treatment of suicide. He will highlight the scope of the problem 

of suicide and some steps that might be taken by the VA. 

Thank you again for taking the time to be here with us. 

STATEMENT OF M. DAVID RUDD, PH.D. 

Dr. RUDD. Thank you, Mr. Chairman. You have my testimony, 

and it has been entered into the record. Rather than repeat much 

of what has been shared this morning and some of what Dr. Maris 

shared, I would like to highlight a couple of points that I think are 

important to consider when you look at the context for this problem. 

If you look at the issue of veterans being treated for depression, 

estimates are that the suicide rate is seven to eight times greater 

than the general adult population. In order to understand the context for that, it is important to look at comparable civilian data. 

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And I have offered some of that in the written testimony, but I will 

highlight a few things for you along those lines. 

The suicide prevalence rate for major depression and affective 

disorders in general is actually lower than is oftentimes quoted, but 

seems to depend on the apparent severity of the illness, with the 

outpatient suicide prevalence rate being 2 percent in contrast to 6 

percent for those previously hospitalized for suicidal symptoms and 

4 percent for those hospitalized for other reasons. Basically, that is 

a function of severity. The more likely someone is to be hospitalized, the more severe the illness, and the higher the risk over the 

course of a lifetime. 

If you are looking at estimates in terms of suicide attempt rates, 

it is estimated that 24 percent of those suffering major depression 

make a suicide attempt during the course of the illness. It is estimated that up to 50 percent of individuals with bipolar disorder 

will make a suicide attempt, and up to 80 percent will manifest suicidal symptoms of some sort during the course of the illness. 

Standardized mortality ratios for major depression and bipolar 

disorder paint a very stark picture. Those with major depression 

evidence a 20-fold increase for risk of death by suicide relative to 

the general population; and those with bipolar disorder, a 15-fold 

increase. There are data available for other disorders, but the takehome message is a simple one: that suicide risk is considerable for 

a number of mental illnesses, and ultimately the mental illness, 

untreated, unrecognized or undertreated, can be fatal. 

It is also important to consider the expected rates of adverse 

events during treatment. And this actually is something that gets 

very little attention in terms of the literature, particularly looking 

at suicide attempt rates. Data are now available from a number of 

randomized clinical trials. We actually have 53 randomized clinical 

trials that can be considered and reviewed. Estimates indicate that 

as many as 40 to 47 percent of those in treatment, meaning psychotherapy and/or medication, make a suicide attempt during the 

first year of treatment. Once they have made one suicide attempt, 

it is estimated that they will make an average of approximately 2.5 

during the course of treatment. I think it is important to consider 

that in terms of providing the context. 

Standardized mortality ratios for men and women recently discharged from the hospital for suicidal behavior range from 100 to 

350 across several studies. These are tragically high numbers. And 

what those numbers indicate is that the death rate is remarkably 

high for people that are discharged from a hospital. And the rate 

varies within the first week of discharge relative to the first month 

of discharge as well. 

I think you take those couple of points, in addition to what Dr. 

Maris shared, as well as what was shared this morning, and there 

are a number of possible conclusions. 

First, as was outlined nicely in the RAND study, there are high 

rates of psychiatric illness following combat exposure, and that includes both direct and vicarious exposure. Multiple deployments for 

Operation Iraqi Freedom and Operation Enduring Freedom likely 

compound the situation because of repeated combat exposure, 

sometimes after the initial emergence of symptoms. The VA is 

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faced with assessing and treating very large numbers of seriously 

ill veterans. 

Second, the overall rates of both suicide and suicide attempts are 

tragic but consistent with the general trends for the types and observed rates of psychiatric illness that present. 

Third, an effective response requires effective resources. 

And, finally, there is an element of this problem that is likely to 

be enduring and potentially chronic in nature. And, actually, that 

is one of the things that I would emphasize, is my concern that this 

is going to be a chronic issue, much like we saw with some of the 

Vietnam veterans over time. 

If you look at the treatment literature in general, I would encourage you that, ultimately, the treatment literature says some very 

basic things about treating and addressing suicidality, that very 

simple things work. Making sure people have access to emergency 

services when they need them—that works; that will save lives. 

Making sure that somebody gets into the system quickly after the 

emergence of significant symptomatology works and can save lives. 

Very simple things like managing crises effectively, in terms of the 

removal of method or access to method, works and can save lives. 

So I think, ultimately, if you take the data that is available elsewhere, it provides considerable information that helps inform a response to this problem in terms of the veteran-specific population. 

Thank you, Mr. Chairman. I am happy to respond to any questions. 

[The prepared statement of Dr. Rudd appears on p. 105.] 

The CHAIRMAN. Thank you so much. 

Mr. Hall, do you have any questions for the panel? 

Mr. HALL. If the Ranking Member has none. 

The CHAIRMAN. No, I am just going to call them, and then we 

can conclude. 

Mr. HALL. Oh, okay. 

I would like to ask Dr. Rudd, in your written testimony, you 

state that, ‘‘Delays in evaluating the escalating numbers of serviceconnected disability claims can be one of the barriers to effective 

care being provided.’’ 

And just to make a point that we voted out of this Committee 

a bill last week, which would help to remove some of those barriers 

and allow earlier decisions for service-connected disability claims. 

And also to ask you—and I guess this would be to both you and 

Dr. Rathbun—about the standard for care of a minimum of 8 atleast-30-minute sessions per year with either a psychiatrist or psychologist or a counselor, which does not have to be the same psychiatrist, psychologist or counselor. 

As a professional mental health expert, what is your opinion of 

that standard? 

Dr. RUDD. Well, I would think that it could be potentially problematic for a number of reasons. I think one of the things that we 

know from the treatment outcome literature is that there is a portion of this problem that will be enduring and chronic in nature. 

And that amount of care may not be adequate to address the problem. There will be some chronicity. It will take more visits and 

probably for a longer period of time than many people expect. 

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Mr. HALL. And how much weight or how much credibility or belief should we put in treatment by medication versus treatment by 

psychotherapy? 

Dr. RUDD. Well, I think both have been proven very effective. It 

really depends on the nature of the disorder. But both have been 

proven very effective. And, for many disorders, doing both simultaneously has actually been evidenced to be the most effective intervention and the most effective treatment. 

Mr. HALL. I wanted to ask Dr. Rathbun about, under your statistical page here, you show what we saw earlier in the charts from 

the VA, that the younger veteran seems to be having a much harder time coping, and the suicide rates are higher among the 20–24- 

year old rate. 

Obviously, we know, as was testified to earlier, that there are 

more males than females serving, and young men are notoriously 

slower to mature than young women. I am a father of a daughter, 

so I have witnessed, you know, the other side of it. 

But I am wondering if maybe we shouldn’t be trying to provide 

a slightly different type of treatment or screening for younger veterans who, for whatever reasons, are not either processing their experience in combat as well or are not reaching out for help as well. 

Dr. RATHBUN. Well, I can only address the numbers themselves. 

I am not an expert on suicide and/or its treatment. I am a biostatistician, mainly trained in analysis of numerical data, numerical 

information. And I do have some background in other disciplines, 

but it is primarily ecology, the environment and environmental 

health, rather than the suicide issue. This is my first real exposure 

to suicide. 

Mr. HALL. Well, maybe we should ask Dr. Rudd then. 

Dr. RATHBUN. I think his comments would have a little more 

knowledge than mine would. 

Dr. RUDD. Well, I would tell you that we do know scientifically 

that there are some treatments that work. We actually did a largescale study with Army individuals on active duty a number of 

years ago, more than a decade ago, and had some efficacy in terms 

of response with those individuals that were all suicidal. That was 

one of the criteria to get into the study. 

I think that there are issues in terms of barriers that are critical. 

And this is just anecdotal; I can’t give you scientific evidence for 

it. But having served as an Army psychologist, I can tell you there 

is great concern among young people about issues of confidentiality, about the impact of receiving mental health, psychiatric, 

psychological care on their future prospects for their employment 

either inside the military or outside the military. Much of that is 

myth. I think targeting that very specifically becomes critical, helping people understand the importance of care early in the cycle of 

the problem. 

Part of my personal concern about this is that you have young 

people who return from combat who have the emergence of symptoms and then are hesitant to get care because they worry about 

the impact on their status, the potential for promotion and success 

in the military, don’t get care, symptoms become much more complicated, they develop comorbid disorders, in terms of substance 

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abuse and other problems, which makes it much more difficult to 

treat later on. 

And so I think there is a piece of this that very much is a misunderstanding about the importance of getting care and that it is 

not going to impact your future, it is not going to impact your promotion and status in the military. There seems to be a considerable 

misunderstanding about that. 

Mr. HALL. Thank you. 

And I would just point out before I yield back, Mr. Chairman, 

that the parents of one of the veterans who took his own life who 

testified before us suggested that the name or the initials be 

changed from ‘‘PTSD’’ to ‘‘post traumatic stress injury’’ or ‘‘syndrome’’ or something else, because ‘‘disorder’’ suggested a malady, 

like there is something wrong with you as a person, whereas what 

you are really having is a reaction to an experience that is not normal. 

Dr. RUDD. Absolutely. 

Mr. HALL. And that the stigma should be removed somehow. 

Whether a name change can do that alone, I doubt. But I appreciate your comments on removing the stigma and trying to reach 

our veterans as early as possible. 

Thank you, Mr. Chairman. I yield back. 

The CHAIRMAN. Thank you. 

Mr. Rodriguez, any questions? 

Mr. RODRIGUEZ. Let me just follow up on the same comments. 

Because I know we have struggled with trying to pick them up as 

quickly as possible and talked about maybe providing services to 

them automatically and maybe not to label them at that point in 

time. And I don’t know if you might have some comments as it relates to that, because it would be just in terms of maybe for 6 

months or a year to provide services automatically. That way, 

every soldier that has gone into a combat would automatically go 

through that without the stigma of being labeled having one thing 

or another and getting some degree of access to some services beforehand. 

I was wondering if you want to make some comments on that. 

Dr. RUDD. Sure. I think it would be interesting to look at that 

as an option. 

I think you can look at other areas of the literature, and specifically you can look at suicide-prevention programs that have been 

in school systems, you can look at stress debriefings that have been 

done for firefighters and other individuals. And what that literature seems to suggest is that universal kinds of intervention 

usually don’t work very well, that they don’t tend to reach the people that are at highest risk. And I think that what they suggest 

is that we need to be more creative about what we do and how we 

reach individuals. 

When I think about that, I will tell you very simple things make 

a difference. Simply reminding people of the availability of a service actually has an impact on suicidality. There was a wonderful 

study done decades ago where they simply sent a reminder letter 

to people who were at suicide risk from the Los Angeles Suicide 

Prevention Resource Center. They sent them periodic reminders on 

an annual basis. And the people who got the letters actually comcprice-sewell on PROD1PC72 with HEARING

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mitted suicide at markedly lower rates than those who did not get 

the letters. So just an expression of care and expression of concern 

to let someone know that you are available can go a long way. 

But I am not sure that universal intervention programs would be 

received well and work well, I think, just from an anecdotal experience when I was in the service. 

Mr. RODRIGUEZ. Doctor, you also talked about the ones who were 

hospitalized and their health. I guess it jumped from 2 to 4 to 6 

percent in terms of actual suicide. 

Are there certain programs that could be triggered automatically 

because there are those stressors? Any thoughts on that? 

Dr. RUDD. I think speculation suggests that when somebody is 

hospitalized for an episode of suicidality and they are discharged, 

that one of the things that happens is they are returned to the environment that was stressful for them to begin with, and so risk 

is elevated. 

I think that data suggests very simple things need to be done. 

When somebody is discharged from the hospital, they need to follow up very quickly with an outpatient provider. That doesn’t always happen. Sometimes that takes weeks for someone to follow 

up. 

Those sorts of interventions, I would hypothesize, would save 

lives. Making sure that somebody follows up within a day to 2 days 

after discharge from a hospital with an outpatient provider and 

make that something that is routine as a part of care. That is 

something that might well save lives. 

Mr. RODRIGUEZ. And, Dr. Rathbun, your data basically, if I can 

summarize, let me know if I am—you indicated that veterans are 

twice as likely to commit suicide than the general public? Is that 

what it is? 

Dr. RATHBUN. Yes, it is roughly about that. I can give you a little 

bit more precise ratios. 

Mr. RODRIGUEZ. Okay. And on the data on the young soldier, 

that was a little higher? 

Dr. RATHBUN. For the young veterans, the range that I gave in 

my report is on the order of about three to four times the non-veteran. 

Mr. RODRIGUEZ. Okay. Thank you very much. 

Thank you. 

The CHAIRMAN. Mr. Buyer. 

Mr. BUYER. Mr. Rathbun, I want to focus on your—I want to become clear. Your testimony is that, based upon your statistical 

analysis of the data, that there is approximately a 2-to-1 ratio of 

more veterans committing suicide than those in the general population? 

Dr. RATHBUN. That is right. 

Mr. BUYER. Okay. Of the non-veterans, okay. So what that CBS 

News story, then, is attempting to do is challenge the credibility of 

the VA, right? 

Dr. RATHBUN. No, that is not the intent here. 

Mr. BUYER. Pardon? 

Dr. RATHBUN. My role in this was as a statistical consultant, just 

to provide the estimates that are given here. 

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Mr. BUYER. All right. I understand. You are not a health clinician. You are a statistician. 

Dr. RATHBUN. Yes, I am a statistician. 

Mr. BUYER. And what CBS News did with your analysis was 

their own business and how they used it and created a story with 

it, that is CBS News’ business, correct? 

Dr. RATHBUN. Well, I do care how they use the information. 

Mr. BUYER. Well, I not only care how it is used, I care about how 

you came to your conclusions. 

Dr. RATHBUN. I didn’t—— 

Mr. BUYER. Wait a second. 

Dr. RATHBUN. Okay, sure. 

Mr. BUYER. I care because the credibility of the VA, then, has 

been placed at stake with the American people. 

Now, I have a series of questions for you, okay? 

Dr. RATHBUN. Okay. 

Mr. BUYER. One, I would like to know—first of all, I would ask 

unanimous consent that the letter that Chairman Filner and I sent 

to Rick Kaplan, the Executive Producer of CBS Evening News With 

Katie Couric, dated December 21, 2007, be entered into the record. 

The CHAIRMAN. Without objection. 

[The letter to Rick Kaplan, Executive Director, CBS Evening 

News With Katie Couric, dated December 21, 2007, and the response from Linda Mason, Senior Vice President, Standards and 

Special Projects, CBS News, dated May 16, 2008, appears on p. 

123.] 

Mr. BUYER. I would also ask that the letters that you and I, Mr. 

Chairman, had sent to Secretary Peake, along with his responses, 

be entered into the record. 

The CHAIRMAN. Without objection. 

[The letter to Hon. James B. Peake, M.D., Secretary, U.S. Department of Veterans Affairs, letter dated December 21, 2007, and 

response letter dated February 5, 2008, requesting additional data 

on suicide rates among veterans, appears on p. 122.] 

Mr. BUYER. I also ask that the responses from the Department 

of Defense regarding not only our letter to DoD and their response 

be entered into the record. 

The CHAIRMAN. Without objection. 

[Chairman Filner and Congressman Buyer wrote to Hon. Robert 

M. Gates, Secretary, U.S. Department of Defense, on December 21, 

2007, requesting the number of active-duty suicides for each year 

from 1995 to 2006. On January 17, 2008, Secretary Gates responded designating David Chu, Under Secretary of Defense for 

Personnel and Readiness to provide information to the Committee. 

Chairman Filner again wrote to Secretary Gates on May 6 and 

May 21, 2008, requesting the information. On June 3, 2008, Secretary Gates again responded that he was designating David Chu, 

Under Secretary of Defense for Personnel and Readiness to provide 

information to the Committee. On June 5, 2008, Chairman Filner 

again wrote Secretary Gates requesting the information. As of September 25, 2008, the U.S. Department of Defense has refused to respond to the Committee’s request for information regarding the 

number of active-duty suicides for each year from 1995 to 2006. 

The referenced letters appear on p. 123.] 

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Mr. BUYER. With letter that the Chairman and I had sent to 

CBS News, we had asked CBS News to share with us the data on 

suicide among veterans with the Committee. 

Given your written statement, obviously CBS News is unable to 

do that because you destroyed the data. Is that not correct? 

Dr. RATHBUN. CBS News retains a copy of the data, I thought. 

I am not certain if they do or not. But they had asked me to not 

keep a copy. They were concerned about the confidentiality of some 

of the veterans, mainly in the smaller States. 

Mr. BUYER. So, is your belief that CBS News still has the data? 

Dr. RATHBUN. I don’t know one way or the other, actually. 

Mr. BUYER. But they had asked for you to destroy the data? 

Dr. RATHBUN. Yes. 

Mr. BUYER. Okay. Did you conduct a blind analysis to improve 

the integrity of your tests? 

Dr. RATHBUN. A blind analysis? You mean—I am not knowing 

what you are referring to. I am not an epidemiologist, so it is—— 

Mr. BUYER. A blind analysis, meaning anybody else have an opportunity to look at the data? Is it peer-reviewed? 

Dr. RATHBUN. No, this is not peer-reviewed. 

Mr. BUYER. It was not peer-reviewed and you destroyed the 

data? 

Dr. RATHBUN. Yeah. That makes me feel—— 

Mr. BUYER. Then thereby we are to embrace with great trust 

that what you did in your work was correct? 

Dr. RATHBUN. I have to say that, for the record, I have been very 

uneasy about this aspect of it, given that this is going beyond the 

story. 

Mr. BUYER. I would think so. You are a professor? 

Dr. RATHBUN. Yes, I am. 

Mr. BUYER. Would you advocate that of your students? 

Dr. RATHBUN. Not at all. 

Mr. BUYER. As a methodology in normal business practice? 

Dr. RATHBUN. That is why I have been very uneasy. 

Mr. BUYER. Sir, would you advocate that to your students? 

Dr. RATHBUN. No, I would not. 

Mr. BUYER. No, you would not. Now, you said that you were not 

paid by CBS News; you got a baseball cap. 

Dr. RATHBUN. I did get a baseball cap. 

Mr. BUYER. Do you know whether or not the parent company of 

CBS News made any forms of contribution to the University of 

Georgia? 

Dr. RATHBUN. I have no information on that. 

Mr. BUYER. Viacom, is that who owns CBS News? You have no 

knowledge whether or not they made any contributions on research 

or anything? 

Dr. RATHBUN. I am not aware of what the University receives in 

terms of those contributions. 

Mr. BUYER. Then let me ask this. If you are uncomfortable and 

you would never advise your students to destroy data and not permit a peer-review process with regard to the results, why? 

Dr. RATHBUN. This was not intended as a scientific investigation. 

I was asked as a consultant to do a data analysis. 

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What I am really uncomfortable with is having it gone beyond 

the story and being asked to testify in court about it and, actually, 

quite frankly, in this group, given that I no longer had the data to 

back up the numbers. 

Mr. BUYER. Yes, I think CBS News put you, as a professional, 

in a very, very uncomfortable position. I think the best thing, Professor, coming out of this that you can always do now is use this 

as an example for your students here and ever after as to why you 

should never do something like this. Because it is being used and 

manipulated and it brings things into question, and it makes it 

challenging for us. 

Dr. RATHBUN. I am comfortable with the results that I found, but 

I am uncomfortable in presenting them beyond their original intent, which was just that story. 

Mr. BUYER. But, professionally, you would even be more comfortable if it were peer-reviewed and one of your peers objectively 

confirms your findings, would you not? 

Dr. RATHBUN. Of course. Sure. I had never—since I do not do my 

work in suicide, my work is really far outside that discipline, I 

would have been unlikely to publish this kind of results anyway. 

It is just not my priority, at the moment. 

Mr. BUYER. Well, I want to thank you for coming. I want to 

thank you for being very honest and forward with us. Because we 

have a new Secretary in the VA, who is a doctor himself, who spent 

40 years in the Army, and he cares a lot about the men and women 

who wear the uniform, and I think he embraces this issue with 

great sincerity. 

And I know the Chairman has challenged the Secretary here 

today and members of his staff. But when I am faced with a story 

that CBS News put out there, when, in fact, we can’t gain access 

to the data, the data was destroyed, and a process that was not 

peer-reviewed, and the last thing, Mr. Chairman, I would like to 

conclude with is, when we look at the CRS Report for Congress, 

‘‘Suicide Prevention Among Veterans,’’ the CRS report on page five 

said, quote, ‘‘It is tempting to make comparisons between studies 

and with information about suicide in the general population. Such 

comparisons are often made, but they are not necessarily valid. 

Among other things, data about suicides in the general population 

includes suicides among veterans, information about suicides in 

groups that exclude veterans, is scant, and is information about the 

extent for which data for veterans may skew the data for the general population, if at all.’’ 

CRS, Mr. Chairman, did a pretty good report, they are pretty 

concerned, and they laid out that there is much work for us to do 

to build a database nationally for us to be able to track this kind 

of thing. 

But I do appreciate you coming here today. 

And I would note to the Secretary, your time is very valuable, 

sir, and I, with deep respect, appreciate you being here to listen to 

this. But I think we are going to have to place great trust and confidence in your analysis and what you are going to have to do, Mr. 

Secretary, if this is what has been done out in the population generally. 

I yield back. 

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The CHAIRMAN. Thank you, Mr. Buyer. 

What we heard today is that the VA data basically confirms the 

CBS News data. 

Dr. Rathbun, when Dr. Katz was with us a few months ago, he 

said something about VA controlled for gender but in a strange 

way. 

Do you know what he is talking about? Or how did you control 

for gender? 

Dr. RATHBUN. I have no idea about what that would mean. 

The CHAIRMAN. You don’t know? 

Dr. RATHBUN. I used, I think, very standard methodology adjusting for gender and age. 

The CHAIRMAN. Dr. Katz, you said something about your objection to the data for younger veterans. You clarified that today. 

What was your problem with the way the data dealt with younger 

veterans? Can you just repeat that for us? 

Dr. KATZ. I was much less concerned with what Dr. Rathbun did 

to the data than the data that was given to Dr. Rathbun. 

Mr. STEARNS. Point of order, Mr. Chairman. 

Dr. KATZ. When the coroner—— 

The CHAIRMAN. Can you just come to the microphone? 

Mr. STEARNS. Point of order, Mr. Chairman. I think what you 

should do is bring this person up and identify who he is for the 

record, so we know. 

The CHAIRMAN. Dr. Katz, can you come forward, please? 

Dr. Katz testified earlier today. 

Mr. STEARNS. Okay. 

The CHAIRMAN. I was trying to clarify what I took as your general condemnation of the CBS News data. Today, you clarified that 

you were concerned with younger veterans. If you want to make 

that more clear, you have the opportunity. 

Dr. KATZ. Well, in the spirit of attribution and review, I want to 

acknowledge that it was Dr. Cross who pointed out this issue to 

me. 

When coroners and medical examiners check or don’t check the 

veteran status box on a standardized death certificate, they don’t 

distinguish between active duty and veterans. Someone may have 

died while in active duty in the community and be evaluated for 

cause of death by a coroner or medical examiner, and that coroner 

or medical examiner would check off ‘‘yes’’ for a veteran, because 

that person was, in the past, a service man or woman. 

So that the States’ death certificates tabulation of veteran status 

will include veterans as evaluated by the coroner or funeral director. It will also perhaps include some people who are active-duty 

personnel who took their lives while on active duty. 

The CHAIRMAN. But—— 

Dr. KATZ. So that the number of suicides tabulated will include 

both active duty and veterans. 

The denominator, the evaluation of the number of people at risk, 

given your data source, includes only veterans. An extended numerator with a focused denominator will lead to an inflated rate. 

That will be a greater problem in the younger veterans, for which 

the mathematical contribution from active-duty personnel would be 

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greater. And that is why I have concerns about the younger veterans. 

The CHAIRMAN. I understand your concern. 

Dr. KATZ. Thank you. 

The CHAIRMAN. Thank you for coming back. 

Dr. Rathbun, do you have any response to that? 

Dr. RATHBUN. Yes, I do have some response. 

CBS News, after the original taping and before they actually 

broadcast the story on November 13th, approached me with additional numbers which were active-duty suicide numbers, and asked 

me to subtract those from the data on the veteran suicides. And 

that is, actually, why the data on the veterans is given as a range 

rather than as a single number. It is really one—the lower number 

reflects the subtraction of those observations that were of some 

question. Pia Malbran expressed concern that some of the active 

duty may have been counted as veterans. 

The CHAIRMAN. So, I mean, this was figured out before any actual—— 

Dr. RATHBUN. I am not really certain where she came up with 

those numbers. I really can’t talk to the quality of those particular 

numbers. We didn’t discuss them at any great length. 

The CHAIRMAN. But the concept was understood? 

Dr. RATHBUN. Yes. 

The CHAIRMAN. Dr. Rudd, I missed what you were saying. When 

a question was asked by Mr. Hall, you said universal prevention 

was problematical. Did I understand you correctly? 

You heard what I said earlier about universal diagnosis of everybody who is discharged or even after combat. That is a universal 

process that I believe can be done. 

Did you say that was not a good thing to do or wasn’t effective? 

Dr. RUDD. No, no, that is not what I was saying. Actually, let me 

be a little more specific around that. 

Universal prevention programs where there is a targeted intervention for everyone, where everyone gets an intervention regardless of whether or not—and those are usually psychoeducational 

programs that have been done in the school system. 

The CHAIRMAN. But you wouldn’t object to universal diagnosis? 

Dr. RUDD. No, not coming out of a combat zone. 

The CHAIRMAN. All right. Counsel wanted me to ask, again, it 

was along the same lines as Mr. Hall; the RAND report defined 

minimally adequate treatment, eight visits in the past 12 months, 

averaging at least 30 minutes. 

I forget what Mr. Hall asked about that, but is that an adequate 

standard? 

Dr. RUDD. It won’t be an adequate standard for a portion of those 

that are diagnosed and identified as ill. 

The CHAIRMAN. I remember now. Thank you. You clarified that. 

In looking back at this over the years, it seems to me that, a big 

problem is the vast number of both National Guard and active-duty 

troops who do not get adequately diagnosed. 

Everybody knows what they have to check on a form to get home 

quickly. We have had reports of commanding officers telling their 

troops, ‘‘Don’t check that box, because that will keep you here,’’ or 

lead to further security problems, which has been clarified recently, 

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or possible denial of law enforcement jobs. There is a self-denial. 

There is an ethos that says don’t admit mental illness. And there 

may be a true lack of symptoms, which might not be seen right 

away. 

When that soldier returns to civilian society they don’t always 

have the support mechanisms they had while on active duty. They 

are often without the understanding of their family, the community 

and their employer. By the way, I want to invite the VA—and I appreciate you staying here. 

Tomorrow at four o’clock, the Sesame Street people are going to 

roll out the DVD they just finished for young children under the 

age of five. There are more than a million children of those currently deployed in Iraq, those who have returned, or those who will 

be deployed. Sesame Street has done a DVD on how to deal with 

situations when Dad or Mom come back injured, or perhaps, with 

an amputation or PTSD. They rotate their puppets of Elmo and 

Rosita with real-life situations. For instance, they have a young 

child, four or five, bringing a prosthetic leg to Dad and making it 

look natural and that it is something not to fear. 

They are doing outreach, which I think is incredible. They are 

going to distribute this DVD free of charge to all the families who 

request it. That is the kind of knowledge everybody needs to have. 

If you let people out of the military without diagnosis or having 

that knowledge, it is going to be pretty hard to deal with, which 

is why we have the problem we have now. 

So, my plan is for soldiers to be given treatment while on active 

duty within a company-size of fellow soldiers to keep that camaraderie there, along with their families who help in both diagnosis 

and treatment. I call it a Heroes Homecoming Camp. It is like a 

‘‘de-boot camp’’ or a boot camp just before discharge where you can 

decompress and get an understanding of what went on and then 

get an adequate diagnosis and early treatment. 

It seems to me that it would do a lot to remedying all the symptoms that we have seen in our society. You can’t catch everybody, 

and you can’t prevent every suicide. You would have to do followup 

at 3 months, 6 months or a year later. It seems to me we can help 

a lot of soliders before they are allowed out of active duty. 

And I don’t know if you want to comment on that as a concept. 

Dr. RUDD. I think the one comment that I would offer is that the 

Air Force actually has had a model suicide-prevention program for 

a number of years and were able to significantly reduce suicide 

rates across several years. 

And a part of that program is very much similar to what you are 

talking about, which is a universal change in how we think about 

mental illness, how we think about suicide prevention, an acceptance of the risk of mental illness from the very top and changing 

the community psyche about how we think about issues of illness 

and getting treatment when it is needed. 

And that program could serve as a model and a very effective 

one. 

The CHAIRMAN. I hope that Secretary Peake heard that. 

Secretary Peake, you were the surgeon general of the Army. I 

just met with the current surgeon general and he was saying something about doing some education. I asked why he didn’t promote 

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or bring out in public the generals or colonels who have had PTSD 

and have dealt with it to show in a public way, that they can be 

promoted to general. Show that they have been successful in the 

military, even having dealt with PTSD. That would be the way to 

take away the stigma and to give soldiers the confidence that it is 

okay. I mean, I would call it combat stress injury and get the whole 

‘‘disorder’’ out of the name. 

But that would be a real good example for soldiers, which would 

be faster than anything the Army or Marines are doing now to say, 

hey, it is okay because General X or General Petraeus says, ‘‘I have 

had PTSD, and it is okay.’’ 

I assume that would be a good thing for soldiers to see? 

Dr. RUDD. Well, I think, actually, that is one of the things that 

the Air Force program did. They talked about these issues from the 

very top, about the importance and significance. It was emphasized 

from the top all the way through the system. And the focus shifted, 

and there is greater acceptability. 

And when you have that, you have people willing to talk about 

their own personal issues, I think, with greater frequency. And 

that, sort of, demystifies and, to some degree, helps destigmatize 

the problem. 

The CHAIRMAN. Thank you. 

I appreciate you all spending the time, Dr. Rathbun and Dr. 

Rudd. You have helped us understand this, and we appreciate it 

very much. Thank you so much. 

Our last panel is Dr. Michael Shepherd from the Office of Inspector General at the Department of Veterans Affairs. Dr. Shepherd 

is a physician with the Office of Health Care Inspections that will 

discuss the need for VA to continue moving forward with full implementation of the suicide-prevention initiatives from the Mental 

Health Strategic Plan. 

Thank you, again, for taking the time. 

STATEMENT OF MICHAEL SHEPHERD, M.D., SENIOR PHYSICIAN, OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF 

INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Dr. SHEPHERD. Mr. Chairman and Members of the Committee, 

thank you for the opportunity to testify on suicide prevention and 

the Office of the Inspector General report, ‘‘Implementing VHA’s 

Mental Health Strategic Plan Initiatives for Suicide Prevention.’’ 

My statement today is based on that report, as well as individual 

cases that the IG has reviewed and reported on involving veteran 

suicides and accompanying mental health issues. 

In the process of these inspections, clinicians in our office have 

had the opportunity to meet with and listen to the concerns of surviving family members and to witness the devastating impact that 

veteran mental health issues and suicide have had on their lives. 

In prior testimony, we have stressed the importance of the need 

for VA to continue moving forward toward full implementation of 

suicide-prevention initiatives from the strategic plan. In terms of 

some additional changes VA could make, we would offer the following observations. 

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Number one, community-based outreach. In our report, we noted 

that, while several facilities had implemented innovative, community-based suicide-prevention outreach programs, the majority of 

facilities did not report community linkages aimed at suicide prevention. Although facilities would need to tailor strategies to consider local demographics and resources, a system-wide effort at 

community outreach appears prudent. 

Number two, timeliness from referral to mental health evaluation. In our report, we noted that, while most facilities reported at 

least three-fourths of those patients with moderate depression referred by primary care providers are seen within 2 weeks of referral, approximately 5 percent reported a 4- to 8-week wait. Because 

these patients are at risk of progression of symptom severity and 

development of suicidal ideation, VISN leadership should work 

with facility directors to ensure that, once referred, patients with 

moderate depression and those recently discharged from the hospital are seen in a timely manner at all VA medical centers. 

Number three, co-occurring combat stress-related illness and 

substance use. Substance use may contribute to the severity of a 

concurrent mental health condition, such as major depression. The 

presence of alcohol may exacerbate impulsivity, and acute alcohol 

use is associated with suicide. Quality of life becomes duly impacted by anxiety and depressive symptoms and comorbid substance use issues. Augmenting services to equally address combat 

stress and comorbid substance use should, therefore, be given due 

consideration for inclusion in a comprehensive program aimed at 

suicide prevention. 

Number four, enhanced access to mental healthcare. Treatments 

for mental health problems may necessitate multiple visits over 

time and may entail multiple modalities, including individual and 

group therapy, medication management and/or readjustment counseling. Therefore, efforts of enhanced patient access to appropriate 

treatment may help facilitate both patient engagement and the potential for treatment benefit. 

For example, improved availability of mental health services at 

CBOCs may help mitigate vocational and logistical challenges facing some veterans residing in rural areas who otherwise may have 

to travel longer distances to appointments. In certain locations, 

availability of care during off-tour hours may increase the ability 

for some transitioning veterans to access mental health treatment 

while minimizing interference with occupational and educational 

obligations, and would be consistent with the recovery model for 

mental health treatment, which emphasizes not only symptom reduction, but also restoration of function. 

Number five, facilitating early family involvement. Mental health 

symptoms can have a significant and disruptive impact on family 

and domestic relationships. Relational discord has been cited as 

one factor associated with suicide in active-duty military and returning veterans. The VA should consider efforts to bolster early 

family participation in patient treatment. 

Lastly, coordination between VHA and non-VA providers. When 

patients receive mental health treatment from both VA and nonVHA providers, communication becomes an increasingly complex 

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challenge. Fragmentation of care is particularly worrisome in periods of patient destabilization or following hospital discharge. 

The Office of Mental Health Services should consider development of innovative methods to facilitate flow of information for patients receiving simultaneous treatment from VA and non-VA providers within the constraints of relevant privacy statutes. 

In addition, the Readjustment Counseling Service and Office of 

Patient Care Services should pursue further efforts to foster communication for patients receiving treatment services at Vet Centers 

and VAMCs or CBOCs. 

Mr. Chairman, thank you again for the opportunity to testify. I 

would be pleased to answer any questions that you or other Members of the Committee may have. 

[The prepared statement of Dr. Shepherd appears on p. 107.] 

The CHAIRMAN. Thank you, Dr. Shepherd. 

Mr. Rodriguez, do you have any questions? 

Mr. RODRIGUEZ. On those five recommendations that you have 

made, do you know how the VA ranks in those areas? 

Dr. SHEPHERD. Well, in terms of number one and number 

two—— 

Mr. RODRIGUEZ. Excuse me, six recommendations. 

Dr. SHEPHERD. You mean from this statement? 

Mr. RODRIGUEZ. Yes, from the statement. You mentioned community-based outreach, also timely referrals, between referrals. You 

mentioned enhancing mental healthcare. You mentioned family involvement in the last one, in terms of coordination with others. 

Do you know how the VA might rank? 

Dr. SHEPHERD. Sure. In terms of community-based outreach in 

the Mental Health Strategic Plan implementation report, we found 

that a minority of facilities were engaged in community linkages or 

use of the chaplaincy for community-based outreach. 

In terms of timeliness from referral to mental health evaluation, 

rather than considering all waiting times, we focused on patients 

with moderate depression. Those with severe depression you would 

expect to be referred quickly. Those with minor, it would be debatable. And those with moderate depression or those who recently 

have been hospitalized and discharged, you would think of as a 

group that is an at-risk subpopulation that you would really want 

to hone in on. So we looked at their reporting on that, which 

showed that most did do a timely job in referring. But, in our view, 

even a small percent means there is more work to be done on that. 

In terms of the other items, those reflect our observations from 

a series of cases involving individual patients that we have looked 

at. 

Mr. RODRIGUEZ. Okay. Thank you. 

The CHAIRMAN. Thank you. 

Mr. Stearns, any questions? 

Mr. STEARNS. Thank you, Mr. Chairman. 

Dr. Shepherd, as mentioned, there are six recommendations 

here. So you say if these six recommendations were implemented, 

the problem would be totally solved, partially solved, would move 

to a better conclusion? What is your feeling? 

Dr. SHEPHERD. I am not saying the problem would be solved. I 

am saying that it is our feeling that these recommendations would 

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help move the ball forward, in terms of additional considerations 

that may help with suicide prevention. 

Mr. STEARNS. Additional considerations that would help with suicide prevention. 

Dr. SHEPHERD. Right. 

Mr. STEARNS. Who asked you to do the survey? I wasn’t clear. 

Dr. SHEPHERD. Originally, we were asked by this Committee. 

Specifically, we were asked by Congressman Michaud. 

Mr. STEARNS. Okay. How long ago? 

Dr. SHEPHERD. The report came out in May 2007. The request 

was in the late fall of 2006. 

Mr. STEARNS. 2006, okay. So it took you, what, 2 years to do 

this? 

Dr. SHEPHERD. No, about 6 months. 

Mr. STEARNS. 6 months, okay. And were you the prime person, 

or were there other people? 

Dr. SHEPHERD. I was the prime person, and then there were a 

couple other people. 

Mr. STEARNS. Did it ever occur to you while you were doing this 

that DoD has a component of this? That is, at the point the DoD 

has the soldier, if they don’t do anything, and then the soldier 

comes to the VA, perhaps it might be too late, because the soldier 

will not be as obligatory as he was still in the Department of Defense and still in regular duty. Had that ever occurred to you during this study? 

Dr. SHEPHERD. Yes. And I would agree with that sentiment, we 

don’t, obviously, provide oversight to the DoD, but maximizing 

intervention in both DoD and VA would be ideal. 

Mr. STEARNS. I know you didn’t look and you weren’t requested 

to look at DoD. But if you did the study, you are saying when you 

came up with your six recommendations, it occurred to you that 

there is responsibility for the Department of Defense here? 

Dr. SHEPHERD. Yes. Again, I think that it is a joint effort. 

Mr. STEARNS. It is a joint effort. And would you say that is 50/ 

50 or maybe the predominance of this initial, shall we say, solution 

to the problem would be at the Department of Defense? 

Dr. SHEPHERD. I honestly don’t know how I would partition that. 

Mr. STEARNS. Dr. Shepherd, would you describe in detail the actions that the VA has taken to address the recommendations made 

by the May 10, 2007, IG report and perhaps what challenge exists? 

Dr. SHEPHERD. Sure. 

One of our recommendations in the original report was basically 

making arrangements for 24-hour crisis mental healthcare availability. And one of the responses to the report, VA did establish a 

suicide-prevention hotline based out of Canandaigua, New York. 

And I have visited that hotline in person and seen the folks working there in action, and have to applaud the work they are doing 

up there. 

We suggested that they needed to develop education for non-clinical first-exposure personnel, such as clerks, on suicide prevention. 

VA subsequently developed a CD and training module, which they 

began, I believe, in December to disseminate. 

We asked them to develop a similar module for clinicians. My understanding is that module and development has not occurred yet. 

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We had recommended that sustained sobriety should not be a 

barrier to treatment in specialized mental health programs for returning combat veterans. And subsequent to our report, the Deputy 

Under Secretary for Health Operations and Management did put 

out a directive basically stating—I am going to put this in my 

words—that substance use issues should not keep people from getting appropriate mental healthcare. Because, in the past, there 

were instances where people would say, well, someone needs to be 

completely sober before we can treat them. And so that directive 

did occur to address that. 

Mr. STEARNS. So would you say four of the six have been implemented, it sounds like? 

Dr. SHEPHERD. Yes, four of the six have been implemented. 

Mr. STEARNS. Okay. And have you seen any appreciable difference since that, or has there been any feedback to say, okay, 

these six recommendations, we have done four of them, which is 

four out of six, is two-thirds, 67 percent have been done, and we 

have noticed a dramatic difference? Have you heard anything? 

Dr. SHEPHERD. I haven’t, but it is also too early a time horizon 

to tell. I think when you are—— 

Mr. STEARNS. Well, it has been a year. 

Dr. SHEPHERD. It has been a year. And we have heard, again, 

very good feedback about the number of veterans calling the suicide hotline. 

Mr. STEARNS. So when you are making these recommendations, 

you put in place so that you get feedback and know how it is working on your recommendations? 

Dr. SHEPHERD. Yes. We have gotten feedback that a lot of the 

veterans are obviously calling the hotline and utilizing that as an 

outreach tool. 

In terms of ultimate impact, because of numbers in terms of suicide, really would take a longer time horizon to fully appreciate. 

Mr. STEARNS. Well, I can just tell you, in the private sector, if 

recommendations came that we all agreed upon, they would be put 

in place about a year, and everybody would move on and have a 

measurement, a metric to determine how well they had been implemented. 

So the fact—you are saying that two of them have not been implemented, right? 

Dr. SHEPHERD. Right, and that is concerning to us. And as I have 

stated earlier, we continue and have continued to ask them to 

move forward. 

Mr. STEARNS. Okay. My time has expired. 

Do you think it is because of lack of money, or why haven’t these 

two been implemented? 

Dr. SHEPHERD. I am not sure why they haven’t been implemented. 

Mr. STEARNS. Do you want to venture a guess? 

Dr. SHEPHERD. It would be a pure guess. 

Mr. STEARNS. No one has come back to you and said, this is a 

problem why haven’t we done these? 

Dr. SHEPHERD. No. 

The CHAIRMAN. I am sorry, which two? 

Mr. STEARNS. The last two. 

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All right. Well, I think my time has expired, Mr. Chairman. But 

I think the point is, it has been a year since the recommendations. 

Two of them have not been implemented. We can’t even find out 

whether it is because of money or because of personnel. Dr. Shepherd can’t even give us an idea—— 

The CHAIRMAN. What are you trying to get at? What is your conclusion? 

Mr. STEARNS. Well, I am not a witness here today, Mr. Chairman, but I sure am here to try to find out. And I am just a little 

concerned, after a year, why these two haven’t been implemented. 

And I would think that the IG could tell us that the feedback they 

get—they don’t have the money, the personnel, or is it just a low 

priority? 

The CHAIRMAN. Let me ask you the procedure on these reports. 

Do you have to get another request to report on the follow-up? 

Dr. SHEPHERD. No. We—— 

The CHAIRMAN. Or do you follow it up automatically? Is the VA 

given a certain amount of time to respond? 

Dr. SHEPHERD. The VA is given a certain amount of time to respond to the initial report. And then, subsequent to the response, 

I believe it is quarterly, we have an office within the IG that requests further follow-up. The next one is due mid-June. And then 

I look at the responses that are sent to that office, in terms of 

whether I think they are legitimate responses or not. 

In addition, since the issuance of this report, I have had subsequent conversations with various people, for instance, I met with 

someone from Ann Arbor about 2 months ago, wanting to know 

where things are at in terms of one of the initiatives they were 

working on. And I have visited Canandaigua. 

So, as a process, quarterly, we have an office that does do followup. And that is passed through me to make sure that if they say, 

we are going to do it and we are going to do it by blank, then I 

think that is reasonable, or I may say I don’t think that is reasonable. 

[The following was subsequently received from VHA:] 

The Office of Inspector General re-opened the following recommendations: 

Recommendation 2: The Acting Under Secretary for Health should ensure that 

VISN directors ensure that facility directors ensure that all non-clinical staff who 

interact with veterans receive mandatory training about responding to crisis situations involving at-risk veterans; this should include suicide protocols for first contact 

personnel. 

VHA Update 8/2007: Planning for facility based training in suicide prevention for 

clinical and non-clinical staff is proceeding with full rollout anticipated for no later 

than October 31, 2007. Suicide Prevention Coordinators have been identified at each 

VA Medical Center to support the implementation of these educational efforts locally. In addition to monthly conference calls, these providers attended a special 

training conference August 21–23, 2007. This Conference included a protocol for 

Guide Training to assist nonclinical personnel in appropriate identification and 

management of veterans who present with suicidal ideation or behavior. VA will 

hold a national Suicide Prevention Awareness Week (September 9–15, 2007) that 

will feature educational presentations for clinical and non-clinical staff from VACO 

and the Canandaigua Center of Excellence in Suicide Prevention. 

Update 3/6/2008: The National Suicide Prevention Center of Excellence in 

Canandaigua has developed and distributed a standard suicide awareness training 

package to the field through the facility Suicide Prevention Coordinators. A memo 

from the Under Secretary for Health has been drafted, and is concurrent for release 

through the office of the Deputy Under Secretary for Health for Operations and 

Management, that will task each facility with developing their own ongoing traincprice-sewell on PROD1PC72 with HEARING

75 

ing, awareness and communication plan that includes appropriate procedures/suicide protocols, and community resources for all first contact personnel in both clinical and non-clinical personnel. It is expected that all frontline staff complete the 

training by September 1, 2008. Facility Suicide Prevention Coordinators are required to report compliance with this training monthly to the National Suicide Prevention Coordinator. 

Update 5/9/2008: Mandatory training for non-clinical staff is in place. Monitoring 

of the training and documentation of compliance is currently through forwarding of 

sign-in sheets to the National Suicide Prevention Coordinator. Processes for use of 

the Learning Management System for documentation are being developed. 

Recommendation 3: The Acting Under Secretary for Health should ensure that 

VISN directors ensure that facility directors ensure that all healthcare providers receive mandatory education about suicide risks and ways to address these risks. 

VHA Update 8/2007: Educational protocols for clinicians as well as non-clinicians 

are under development for implementation no later than October 30, 2007, and full 

compliance by April 30, 2008. The facility Suicide Prevention Coordinators will be 

critical in ensuring implementation and compliance across the system. 

Update 3/6/2008: A ‘‘State of the Art’’ conference on Suicide Awareness and Intervention Training was held in Canandaigua on March 5 and 6, 2008 to finalize the 

content used in development of a mandatory ‘‘Suicide Risk and Treatment’’ training 

program for VHA clinicians. Final program content will be forwarded to the Employee Education System (EES) by April 1, 2008, who expect to complete development of the on-line standardized training program by September 30, 2008. Once the 

program has been fully implemented, clinicians will be given 120 days to complete. 

Full compliance with the training requirement is expected to be completed by January 31, 2009. 

Update 5/9/08: Training activities are in place. The remaining issue is to ensure 

accountability of participation of all healthcare providers. A Directive to this effect 

is in the concurrence process; monitoring of completion will be accomplished through 

VA’s Learning Management System (LMS). 

The CHAIRMAN. Thank you. 

The first thing you did mention was the National Call Center 

and the Secretary provided us with the pamphlet advertising this. 

It sounds like a lot of people are calling. I don’t know if Mr. 

Stearns was here when Mr. Moran from Virginia was talking about 

the concern of many veterans dealing with the Federal Government. 

I know, Mr. Stearns, that you always say, ‘‘Well, the Federal 

Government can’t do this, and besides, people aren’t worried about 

it.’’ Mr. Moran made the point that many veterans may not want 

to interact with the Federal Government, as represented by the 

VA, and that this kind of advertisement may work with a certain 

percentage but it is probably also turning off a certain percentage. 

He was arguing—and I think we need to look at his bill—for a 

hotline to be run by peers especially, but probably working with a 

nonprofit, for both privacy and the understanding that they don’t 

want to deal with the Federal Government anymore. They don’t 

trust them. I think there is a point there. 

I don’t know if there is a way to even look at that. Have you been 

trying to make any study about people who would call the hotline 

center? Of course, you can’t ask anybody who committed suicide, 

but maybe the veterans who have attempted suicide. 

Dr. SHEPHERD. No, I haven’t looked at or studied who the callers 

are. I do think that Congressman Moran’s suggestion and the existing hotline are not necessarily mutually exclusive, and maybe there 

could be a way to combine ideas. 

The CHAIRMAN. Exactly. I think you are right. Mr. Moran stimulated me to read this, and I know Mr. Stearns would use this in 

another context sometime, but, ‘‘Pick up the phone if you are expecprice-sewell on PROD1PC72 with HEARING

76 

riencing an emotional crisis and need to talk to a trained VA professional.’’ 

I mean, there are a lot of folks where that would be the last 

thing they would do. You are dealing with, again, a bureaucracy or 

the Government, and I don’t think that kind of appeal would work. 

Dr. SHEPHERD. And, again, talking about combining ideas, I believe Morris Armstrong is a veteran who started the Vet-to-Vet 

model in New Haven, which I believe is a program that follows a 

Vet-to-Vet model. But he does work with VAMCs and VA facilities. 

And so, following that model of a joint non-VA and VA venture, 

perhaps is a way to think about it. 

The CHAIRMAN. I think you are right; they are not mutually exclusive. I was hearing from the VA that this is their outreach; however, we need to look at it from the point of view of someone who, 

by their very problem, is suspicious of an organized bureaucracy. 

Dr. SHEPHERD. Sure. And that is why also as I said in my statement, we would encourage all forms of aggressive outreach, including, for instance, one center invites local clergy in and gives them 

information about the facility and what the services are, so that if 

a parishioner or relative comes up to the reverend and says, ‘‘My 

son is having trouble,’’ they know where to refer them or how to 

get them help. And I think innovative outreach ideas like that 

should continue to be pursued. 

The CHAIRMAN. Well, again, thank you very much. 

Remind me, on the quarterly reports, are they automatically sent 

to Congress? 

Dr. SHEPHERD. No, I don’t believe they are. But that is a statement out of ignorance, so I will have to check on that. 

The CHAIRMAN. I hope they are. I think we have talked about 

this with the IG before, that the reports should come to us, we 

should not have to ask about what is going on. 

We thank you for your contribution, and we look forward to your 

continuing oversight. 

[The Chairman and the Ranking Member are provided quarterly 

updates on the status of open recommendations. The Committee receives copies of Office of Inspector General reports as they are released.] 

Dr. SHEPHERD. Thank you, Mr. Chairman. 

The CHAIRMAN. And unless there are further questions, this 

hearing is adjourned. 

[Whereupon, at 2:58 p.m., the Committee was adjourned.] 

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A P P E N D I X 

Prepared Statement of Honorable Bob Filner, 

Chairman, Full Committee on Veterans’ Affairs 

Good morning and welcome to the Committee on Veterans’ Affairs’ hearing on 

‘‘The Truth about Veterans’ Suicides.’’ 

On December 12, 2007, this Committee held a hearing entitled ‘‘Stopping Suicides: Mental Health Challenges within the Department of Veterans Affairs.’’ Nearly 

five months later, we are again holding a hearing on the tragic issue of suicide 

among our veterans and what the VA is doing to address what is clearly an epidemic. In November of last year, CBS News aired a story entitled ‘‘Suicide Epidemic 

Among Veterans.’’ On April 21, 2008, CBS News aired a story ‘‘VA Hid Suicide Risk, 

Internal E-Mails Show.’’ 

The first step in addressing a problem is to understand the scope and extent of 

the problem. In the case of the VA and the epidemic of veteran suicides, either the 

VA has not adequately attempted to determine the scope of the problem, which is 

an indictment of the VA’s basic competence, or the VA knows the extent of the problem, but has attempted to obfuscate and minimize the problem to veterans, Congress, and the American people, which is an indictment of the leadership of the entire Department. 

In December, Dr. Katz, in testimony before this Committee, stressed a low-rate 

of veteran suicide, stating that ‘‘from the beginning of the war through the end of 

2005 there were 144 known suicides among these new veterans.’’ In responding to 

the figures used by CBS, Dr. Katz stated that ‘‘their number for veteran suicides 

is not, in fact, an accurate reflection of the rates of suicide.’’ 

Either Dr. Katz knew that the CBS figures were indeed an accurate reflection of 

the rates of suicide at that hearing or had a sudden epiphany only days later. 

In an internal email, Dr. Kussman, on December 15, 2007, referring to a newspaper article, writes that ‘‘18 veterans kill themselves every day and this is confirmed by the VA’s own statistics. Is that true? Sounds awful but if one is considering 24 million veterans.’’ That same day, Dr. Katz responds: ‘‘There are about 18 

suicides per day among America’s 25 million veterans. This follows from CDC findings that 20% of suicides are among veterans it is supported by CBS numbers.’’ 

In February of this year Dr. Katz sends an email stating ‘‘Shh!—Our suicide prevention coordinators are identifying about 1000 suicide attempts per month among 

the veterans we see in our medical facilities. Is this something we should (carefully) 

address ourselves in some sort of release before someone stumbles on it?’’ 

There was silence from the VA. 

Armen Keteyian, Chief Investigative Reporter for CBS News, characterized the 

VA’s internal emails as ‘‘a paper trail of denial and deceit—a disservice to all veterans and their families—[that] has rightfully been exposed.’’ 

In an April 24, 2008, newspaper article, a VA spokeswoman stated that ‘‘there are 

an estimated 1,000 suicide attempts per month among the 7.8 million veterans 

treated by Veterans Affairs, she said.’’ 

The VA spokeswoman may have misspoke, or this could be yet another example 

of the VA’s attempt to hide the true magnitude of the problem. In the VA’s most 

recent budget submission, the VA claims it will treat 5.2 million veterans this year, 

and 5.3 million next year—2.5 million fewer veterans than the 7.8 million quoted 

in the newspaper article. 

In April, a Dallas Morning News editorial, describing a ‘‘recent spike in suicides 

among psychiatric patients treated at the Dallas VA hospital’’ stated that ‘‘descriptions of how four veterans committed suicide in four months—prompting the psychiatric ward to close—suggest that patients went to conspicuous and time-consuming lengths to end their own lives. There seemed to be ample time for staffers 

to stop them had they been doing their jobs better.’’ 

The RAND Corporation, in a recently published study entitled the ‘‘Invisible 

Wounds of War,’’ found that since October 2001, approximately 1.6 million U.S. 

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troops have deployed, and that ‘‘upward of 26 percent of returning troops may have 

mental health conditions.’’ The study estimated that approximately 300,000 of those 

deployed suffer from PTSD or major depression. Among those with PTSD or major 

depression, only half had seen a mental health provider or physician to seek help 

in the past 12 months, and among those who had sought help, ‘‘just over half received minimally adequate treatment.’’ 

The study defined minimally adequate exposure to psychotherapy as consisting of 

at least eight visits with a mental health professional such as a psychiatrist, psychologist or counselor in the past 12 months, with visits averaging at least 30 minutes. How does VA mental health care treatment stack up against this definition 

of minimally adequate care? 

The RAND study also found that ‘‘the VA too faces challenges in providing access 

to OEF/OIF veterans, many of whom have difficulty securing appointments, particularly in facilities that have been resourced primarily to meet the demands of older 

veterans. 

‘‘Better projections of the amount and type of demand among newer veterans are 

needed to ensure that the VA has the appropriate resources to meet the potential 

demand. New approaches of outreach could make facilities more acceptable to OEF/ 

OIF veterans.’’ 

I think many of us believe that the VA health care system has been pushed to 

the edge in dealing with the mental health care needs of our veterans. And, I believe that we are witnessing either an inability to address this problem, or a purposeful attempt to minimize the problems faced by veterans and the VA and sweep 

the epidemic of veteran suicides, and the mental health care needs of our returning 

servicemembers, under the rug. 

So this morning we are going to attempt to get a better idea of the scope of this 

epidemic, and what the VA is doing to respond to it. What specific steps has the 

VA taken since December, steps not previously planned before December, to get a 

better idea of the scope of the problem, and what has it done to begin to address 

the problem? 

Finally, I believe we must also seek real accountability from the VA, and, Mr. Secretary, we look to you to provide that accountability. 

f 

Prepared Statement of Honorable Steve Buyer, 

Ranking Repubican Member, Full Committee on Veteran’s Affairs 

Thank you Mr. Chairman. 

The loss of a single veteran to suicide is a tragedy. 

I am sure that like me, every member of this committee seeks to identify and 

eliminate contributing factors, and to prevent one more service-member or veteran 

from taking his or her own life. I want to thank Chairman Filner for continuing 

hearings to discuss this issue and to help those at risk. 

A number of questions were raised during our hearing last December regarding 

the validity of data on the number of veteran suicides. Such information is vital to 

understanding the scope of the problem, as well as identifying risk factors and providing better prevention and treatment protocols. 

Chairman Filner joined with me in a letter I wrote to VA, DoD, and CBS requesting their respective data and how it was formulated. CBS failed to respond. 

DoD acknowledged the letter, yet I am still awaiting a further reply. 

Secretary Peake was the only one to provide a thorough response, which was 

about two separate studies VA is conducting. 

These studies may provide some useful information, but they are limited to data 

on suicide rates among veterans in the VA health care system. VA must have a better method for the systematic collection and tracking of veteran suicide data. It is 

also important to find ways to reduce the stigma associated with mental health care 

and encourage more servicemembers to seek treatment when it is needed. 

During our last hearing, I asked VA to be proactive and reach out to soldiers and 

their families during pre-mobilization—and to start with the 76th Indiana Brigade 

Combat Team as it prepared to deploy to Iraq. I was very pleased that VA came 

as requested and participated in the outreach event. 

I stood with 3,400 Indiana soldiers at the RCA dome on January 2 for the formal 

send-off ceremony. Along with about 20,000 friends and family members was VA 

staff from the Indianapolis VA Medical Center, Regional Office, and Vet Center. 

VA reported that about 1,700 families received information regarding VA benefits 

and services, including mental health services and Information on Post Traumatic 

Stress Disorder (PTSD) and Suicide Prevention. 

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VA also followed-up with subsequent briefings while the Brigade was at Ft. Stewart, Georgia for training. 

As the Brigade marched to war, I believe they left with a clear impression that 

VA will be available to provide support and assistance to their family during their 

deployment and will be there when they return from Iraq. There was very positive 

feedback regarding the VA presence at these events. 

Secretary Peake has taken decisive actions to meet the increased needs for mental 

health services. For example, on May 1st, VA began contacting nearly 570,000 recent combat veterans about VA medical care and benefits. 

These veterans were either injured in Iraq or Afghanistan or discharged from active duty, but have not yet contacted VA. 

The Secretary has also directed the creation of an independent workgroup to assess VA’s suicide prevention programs. 

I want to thank Secretary Peake and the other witnesses for their participation 

today and I look forward to their testimony. 

In the end, I hope that this hearing will drive home the message to our Nation’s 

men and women who serve, and to their families, that if you are in need of help, 

care is available, treatment works and there is a road to recovery. 

f 

Prepared Statement of Honorable Harry E. Mitchell 

Thank you Mr. Chairman. 

In November, CBS News brought some shocking, and critically important information to light. Not just that those who served in the military were more than twice 

as likely to take their own life in 2005 than Americans who never served . . . or 

that Veterans aged 20–24 were killing themselves when they returned home at 

rates between two-and-a-half to four times higher than non-vets the same age, but 

that the Department of Veterans Affairs wasn’t keeping track of veteran suicides 

nationwide. 

In December, we held a hearing to find out why. 

And, Mr. Chairman, I don’t think there is anyone who attended that hearing who 

will ever forget it. 

We heard from Mike and Kim Bowman, whose 23-year-old son, Tim, survived a 

year of duty in Iraq, only to come home and take his own life. 

Mr. Bowman warned us that our troops are coming home to an, ‘‘understaffed, 

under-funded, under-equipped VA mental health system’’ that imposes so many 

challenges, many are just giving up. 

And so, when Dr. Katz insisted at that hearing, repeatedly, that the VA had all 

the necessary resources to reach all veterans at risk for suicide and make treatment 

available to them, I was skeptical. 

How could Dr. Katz be so sure that there weren’t any requests for additional resources sitting somewhere, within the vast VA system, that had gone unfulfilled? 

Was he absolutely certain that there were no pending request for an additional 

mental health counselor? Or for extra gas money to enable a VA employee to drive 

somewhere to conduct outreach? 

As Chairman of the Subcommittee on Oversight and Investigations, I felt I had 

a responsibility to make sure. 

So I asked the VA to double-check. 

I asked them take a look at their records, and send us any documents relating 

to any requests for additional resources that had gone unfulfilled or under-fulfilled. 

My thought was, if we could find out what the VA needs to address this problem, 

we could get to work make sure they get it. 

More than 4 months later, however, all I’ve gotten are excuses, complaints, and, 

most recently, a suggestion that I, ‘‘go file a Freedom of Information Act request.’’ 

That’s not just an insult to me, it is an insult to this Committee, and to our veterans. 

I’ve tried to be reasonable. I’ve tried to work with Secretary Peake’s office. But, 

Mr. Chairman, my patience is at an end. 

I’ve given the Department until Friday to finally produce the documents I requested. If they do not, Mr. Chairman, I want you to know that I will be asking 

you to pursue a subpoena. 

I yield back. 

f 

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Prepared Statement of Honorable Stephanie Herseth Sandlin 

Thank you to everyone for being here. I congratulate Chairman Filner and Ranking Member Buyer for holding today’s hearing to examine and identify mental 

health challenges within the Department of Veterans Affairs healthcare system and 

the problem of suicides among veterans. 

As the wars in Iraq and Afghanistan continue to produce a new generation of veterans, it is important that Congress evaluate the impact of these conflicts on the 

mental well-being of returning servicemembers. We must closely evaluate the ability 

of the VA to meet the mental healthcare demands placed upon it. 

While the VA offers a wide array of mental health programs, there continues to 

be room for improvement. In particular, I believe we must do more to meet the mental healthcare needs of our rural veterans—who often must travel long distances to 

reach VA healthcare services. 

I am pleased that we have the opportunity to hear from today’s panelists and am 

grateful to have the opportunity to hear their suggestions and answers to the critical issues involved. I look forward to hearing their testimonies. 

Again, I want to thank everyone for taking the time to be here and discuss these 

important matters. 

f 

Prepared Statement of Hon. Shelley Berkley 

Mr. Chairman, 

I am extremely discouraged that we are here today holding a hearing on the VA’s 

cover-up of veterans’ suicide attempts. I find it absolutely appalling that anyone 

would try to conceal these numbers—preventing us from addressing the root of the 

issue of suicide among veterans. We must provide sufficient mental health services 

to our veterans in order to address the needs facing our servicemembers returning 

from Iraq and Afghanistan. 

Nationally, one in five veterans returning from Iraq and Afghanistan suffers from 

PTSD. Twenty-three percent of members of the Armed Forces on active duty acknowledge a significant problem with alcohol use. It is vital that our veterans receive the help they need to deal with these conditions. 

The effects of substance abuse are wide ranging, including significantly increased 

risk of suicide, exacerbation of mental and physical health disorders, breakdown of 

family support, and increased risk of unemployment and homelessness. Veterans 

suffering from a mental health issue are at an increased risk for developing a substance abuse disorder. 

As servicemembers return from combat, it becomes increasingly important to provide them with the mental health services they need to readjust to society and deal 

with the invisible wounds of war. 

A constituent of mine, Army Pfc. Travis Virgadamo returned home from Iraq on 

leave. During this trip, he told his family he had been so frightened, he had sought 

and received psychiatric counseling from the military in Iraq. He also received additional counseling during that trip home in late July. The Army’s response was to 

treat him with Prozac. After returning to Iraq, Virgadamo was placed on suicide 

watch and the bolt from his rifle was taken away, making the weapon useless. He 

was also given a desk job. After Virgadamo was cleared for combat again, they gave 

him back the bolt to his rifle. Hours later, he killed himself. 

Even though he was still on active duty (placing him under DoD jurisdiction), this 

incident only reinforces the fact that we need to place more emphasis on mental 

health of servicemembers in or returning from combat. 

f 

Prepared Statement of Honorable Jeff Miller 

Thank you, Mr. Chairman. 

There is no doubt that suicide under any condition is a tragedy. Suicide that could 

have been prevented is even more so, and we here on this Committee have a duty 

to provide the best services for a targeted group: our Nation’s veterans. These brave 

men and women spend countless hours, days, and years defending liberty for us 

here at home, and it is imperative that we provide them the best services upon their 

return from combat. 

As we learn more each day about mental health, it is imperative that we apply 

these findings toward helping those who suffer, especially when it comes to preventing suicide. To be sure, veterans have a unique set of factors that may lead to 

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an increased suicide rate. None of us here doubt the extreme rigors of combat and 

the toll it can take on a person. However, with no single factor causing suicide, it 

is a difficult and ongoing process to identify those most at risk and those most likely 

to attempt suicide. 

While this Committee cannot identify and eliminate every factor that may contribute to suicide risk, especially those arising from the civilian world, we certainly 

can work toward addressing those arising from service, including PTSD and substance abuse. I look forward to hearing what steps have been implemented by VA, 

what progress has been made, and what steps they will take in the future. Our soldiers gave too much to not receive the best treatment across all fronts upon their 

return home. A smooth transition to civilian life and easy access to care must be 

ensured for them, and this can be aided with a proactive approach by the VA to 

see that they have everything they need before it is too late. 

I yield back. 

f 

Prepared Statement of Honorable Ginny Brown-Waite 

Thank you Mr. Chairman. 

It is no secret that the Department of Veterans Affairs is seeing an increase in 

cases of Traumatic Brain Injury and Post Traumatic Stress Disorder among OEF/ 

OIF veterans. While these conditions may not be as visible as an amputated leg or 

gun shot wound, they can be just as debilitating. Left untreated, these conditions 

may lead to the veteran committing suicide. 

To address these growing concerns, this Committee approved and the President 

signed into law the Joshua Omvig Veterans Suicide Prevention Act. The act requires 

the VA to establish a comprehensive program for suicide prevention among veterans. Signed into law in November 2007, this act will dramatically affect the way 

the VA handles veterans with suicidal tendencies. 

Unfortunately, a majority of veterans with conditions that lead to suicide do not 

seek help for these conditions. That is why the outreach section of the Joshua 

Omvig Veterans Suicide Prevention Act is so important. The VA must reach out to 

veterans, their families and the organizations that help veterans to ensure this nation’s veterans receive the care they deserve. 

I look forward to hearing from all of the witnesses here today about what is being 

done and what still needs to be done to minimize the number of veteran suicides. 

Specifically, I look forward to hearing from Secretary Peake as to the implementation of the programs contained in the Joshua Omvig Veterans Suicide Prevention 

Act and the impact they have made thus far. 

Thank you, Mr. Chairman. 

f 

Prepared Statement of Honorable Timothy J. Walz 

Mr. Chairman, Ranking Member Buyer, Members of the Committee, thank you 

for the opportunity to speak. And thank you to the witnesses who are here today. 

I have been troubled by recent, credible allegations that the U.S. Department of 

Veterans Affairs has been withholding important information about the rates of suicides and suicide attempts among America’s veterans. I wrote to Chairman Filner 

requesting a hearing, and I am very pleased that we are having one. We must reach 

out to our veterans—young and old—to make sure they know where they should go 

for help if they are feeling suicidal. The VA should get all of the resources and tools 

it needs to care for our veterans. The reason I called for an investigation is so that 

we can get our facts straight, and from there, we’ll have a better sense of whether 

new legislation is needed to address this problem . . . or just new leadership on 

these issues. The VA must be forthcoming about what it knows about suicide attempts among veterans in the VA system and overall, as well as about suicides. 

Only if we have accurate information can we act decisively to address this troubling 

trend among veterans. 

I have been very pleased to work with the fine people at the VA in Minnesota 

to ensure that our veterans continue to receive world-class healthcare at VA facilities. When the latest information about the VA was disclosed, I wrote to the head 

of VISN 23 requesting information on mental healthcare for Minnesota’s veterans 

and statistics on suicide and suicide attempts among them. He and his staff have 

worked diligently to gather the facts that I had requested, and I appreciate that. 

I have not yet seen the information, as it came back from VA in Washington only 

this morning, right before this hearing began, but I look forward to reviewing it 

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carefully so the people of the First District and all of Minnesota can be sure that 

we are doing all we can to help Minnesota’s veterans. 

I commend CBS NEWS for bringing important facts to light, fulfilling the press’ 

duty to the public and its right to know. Internal VA e-mails obtained by CBS show 

a concerted effort by Dr. Katz and others at the VA to minimize the extent to which 

the public would learn facts unflattering to the VA and its ability to serve veterans 

in need of mental health assistance. In February of this year, Dr. Katz sent an email to Ev Chasen, VA’s Chief Communications Officer, with the subject: ‘‘Not for 

the CBS News Interview Request.’’ In the e-mail exchange, Dr. Katz and Ev Chasen 

discussed how to deal with the VA’s own data showing alarming rates of suicide attempts—1000 per month—among veterans in the VA medical system itself. They 

were clearly trying to minimize the publicity the information might receive. The 

spirit of Dr. Katz’s e-mail was characterized by its first line, stating, ‘‘Shhh!’’ 

In December of 2007, the House Veterans’ Affairs Committee held a hearing on 

the topic at which Dr. Katz testified. At that hearing, he at times sought to cast 

doubt on a recent CBS report about the numbers of suicides among veterans. At 

other times in the hearing, he appeared to confirm the numbers CBS was reporting, 

but did so in a way that was not clear, parsing words and numbers. In an e-mail 

just three days after that hearing, also published by CBS, Dr. Katz wrote an e-mail 

to a colleague at the VA which made clear that VA’s own numbers on the rate of 

suicide among veterans were in line with the CBS report. Reviewing that transcript 

is a disturbing experience, because Dr. Katz and others seemed more interested in 

distracting from the issue at hand by bashing the news media, than in informing 

the Committee, the press and the public about this very important matter so that 

we can address it in as effective a way as possible. 

I am pleased that we are having this follow up hearing today, so that we may 

gain all the facts and thereby work to prevent suicide among our veterans. 

f 

Prepared Statement of Honorable James P. Moran, 

a Representative in Congress from the State of Virginia 

• Mr. Chairman, Members of the Committee, I thank you for holding this important hearing and I commend your work that you’ve already undertaken on behalf of our Nation’s veterans. • Most of us understand from the media reports and anecdotal accounts from our 

constituents that suicide among our veterans is one of the most pressing issues 

that we should address. • We know that the new generation of returning soldiers is more vulnerable to 

the immediate psychological wounds of war that lead to suicide. 20 percent of 

our veterans from Iraq and Afghanistan show signs and symptoms of PTSD, depression and anxiety. This number increases to 50 percent for soldiers with 

multiple tours or inadequate time between deployments. • One of the measures that we can take to prevent suicide is to provide a voice 

of understanding in their time of need. The ‘‘Veterans Suicide Prevention Hotline Act’’ would create a stand-alone 24-hour National toll-free hotline to assist 

our Nation’s veterans in crisis. • The key is that this hotline would be staffed by veterans, trained to appropriately and responsibly answer calls from other veterans. These volunteers 

would be trained in active listening and crisis de-escalation respond to a variety 

of crisis calls. • I understand that the Department of Veterans’ Affairs has developed a veterans’ option off of the National Suicide Hotline. While I applaud their effort 

to finally address this problem, I believe that there are key differences in the 

approach. 

• Sometimes a veteran doesn’t want to talk to a doctor—he or she wants to talk 

to someone who’s got a real-life perspective of what’s happening. This ‘‘cultural 

competency’’ that a fellow veteran provides can make a real difference in crisis 

counseling. 

• Moreover, soldiers with mental illnesses face societal stigma associated with 

seeking care through the VA. Research from the Air Force’s suicide prevention 

efforts suggest that fear of ‘‘the system’’, of an unfriendly mental health establishment, and of potential job-related consequences keep many active duty soldiers and recent veterans from seeking the care they need. 

• I am also concerned that the VHA is already overburdened by their many 

healthcare responsibilities to provide a top-notch hotline effort. Stretched budgets and staffing shortages may not be able to meet the challenges of many recprice-sewell on PROD1PC72 with HEARING

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turning veterans as our Nation redeploys from Iraq in the future. A non-profit 

organization dedicated to suicide prevention would be able to provide focus, stability and commitment that the VA may not. • To conclude, our vets deserve as much support when they return from combat 

as they receive while in battle. Too many of our veterans are struggling to make 

the difficult adjustment back to society and need someone they can talk to, 

someone who’s walked a mile in their shoes. This legislation will offer that caring voice at the end of the line. • I applaud the Committee for their work on this effort. 

f 

Prepared Statement of Honorable James B. Peake, M.D., 

Secretary, U.S. Department of Veterans Affairs 

1. ISSUES RELATED TO COLLECTING SUICIDE DATA 

The purpose of this testimony is to provide information on the issues related to 

veterans suicide: what VA knows, including the sources of information we use; what 

we do not know, and what we intend to do about that problem; and what we have 

been doing to directly address the issues of suicide from a clinical perspective, and 

how we are expanding our outreach, even as we seek better ways to measure the 

problem. 

The language used to talk about suicide is complex. Suicidal behavior exists along 

a continuum; from thinking about ending one’s life, to developing a plan to do so, 

to non-fatal suicidal behavior, to actually ending one’s own life. The Centers for Disease Control (CDC) has come up with some definitions of suicidal behavior which 

the Department of Veterans Affairs (VA) has adopted. 

CDC has defined suicidal ideation as having thoughts of harming or killing oneself; a suicide attempt is a non-fatal, self-inflicted destructive act in which a person 

has either an explicit or an inferred intent to die; self-inflicted injuries are suicidal 

and non-suicidal behaviors such as self mutilation; and suicide itself refers to a fatal 

self-inflicted destructive act in which there is an explicit or an inferred intent to die. 

Suicide is a relatively infrequent act. Although suicide is the 11th leading cause 

of death among Americans of all ages, when studying any group over short periods 

of time the number of actual suicides will be low. Only very large studies conducted 

over long periods of time allow the accumulation of enough observations to make 

meaningful comparisons. 

Suicide risks vary by age, gender and other factors. For Americans in general, the 

highest rates of suicide are among older men, but middle-aged veterans appear to 

take their own lives in greater proportions than their elders. 

Suicides often occur in close proximity, especially after media attention. This kind 

of behavior is called ‘‘copycat behavior,’’ or the ‘‘Werther effect,’’ after a wave of suicides in 18th century Europe following the publication of a book by Goethe. It can 

be difficult to tell when a cluster represents a temporary trend, or a sustained 

trend. 

Official suicide rates based on death certificate data can be incomplete. There are 

regional differences in how suicides are defined; how ambiguous cases are classified; 

and how thoroughly coroners or medical examiners investigate causes of death. In 

some areas religious traditions, life insurance policies, or legal sanctions may lead 

to underreporting. The increased awareness of the relationship between mental illness and suicide may cause an apparent increase in the reported number of suicides—without the rates actually differing. 

And finally, reconstructing the events leading up to a death is difficult. Death certificates provide only a limited amount of information about actual causes of death, 

so researchers need to contact those closest to the victim to understand the true circumstances of death, and the factors that contributed to a death. Family members 

and others can often provide inaccurate or incomplete information. 

The way researchers determine incidences for suicide is to express the number of 

suicides in a population per hundred thousand people per year. Because suicide 

rates vary by age, with both older and younger people at higher risk, any rates that 

attempt to make comparisons across different populations by year must be adjusted 

to allow for accurate comparisons. One way to do so is to look at age specific rates 

of suicides and compare them to the U.S. population as distributed by age. CDC 

uses the U.S. population census figures for 2000 to do this. 

Another method of adjustment is called the standardized mortality ratio. This 

ratio compares the number of observed deaths in a defined group with the number 

of deaths that would be expected if that group had the same age-specific rates as 

a standard population. 

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Finally, there are sophisticated statistical techniques which can be used to derive 

a relative risk that take into account multiple characteristics of individuals, such 

as gender, race and ethnicity, medical conditions and other factors. 

Each of these methods of adjustment has their strengths and their weaknesses. 

Each is potentially misleading when comparing populations with very different age 

or gender distributions. A careful analysis of suicide rates that is age and gender 

specific is both necessary and appropriate. 

Because of this, VA has long subjected its own data, that of the Department of 

Defense, and data from nationally accepted statistical sources to careful and painstaking analysis to obtain the truth about veterans’ suicide. 

A suicide rate is normally calculated by describing the number of cases occurring 

in a defined group over a specific period of time. These are called incidences of suicide, and to avoid expressing incidences as very small fractions, suicide rate is typically expressed in terms of the number of suicides per 100,000 persons per year. 

To make accurate comparisons of suicide rates, such as trends over time or comparisons among veterans and non-veterans, three important elements are needed. 

First is an accurate count of events for both groups, called the numerator. Second 

is an accurate estimate of the total population at risk, called the denominator. And 

third, as already mentioned, there needs to be an adjustment for age and gender 

differences between populations. 

2. HOW VA COLLECTS SUICIDE DATA 

VA relies on multiple sources of information to identify deaths that are potentially 

due to suicide. This includes VA’s own Beneficiary Identification and Records Locator Subsystem, called BIRLS; records from the Social Security Administration; and 

data compiled by the National Center for Health Statistics in its National Death 

Index. 

This is a painstaking and difficult process for VA and for others, best illustrated 

by the fact that suicide data from the Centers for Disease Control and Prevention 

are available only through 2005. Calculating suicide rates specifically for veterans 

is made even more difficult by the fact that the National Death Index does not include information about whether a deceased individual is a veteran or not. 

The National Death Index is simply a central computerized index of death record 

information on file in the vital statistics offices of every state. The Index is compiled 

from computer files submitted by State vital statistics offices. Death records are 

added to the file annually, about twelve months after the end of a calendar year. 

CDC uses this data to compile its statistics on American death rates. 

Given that the NDI does not indicate veteran status, VA regularly submits requests for information to NDI. Because the system contains a list of all Americans 

who have died, and because of the capabilities of its Electronic Health Record system, VA is able to send NDI a list of all patients who have not been treated at any 

VA medical centers in the past twelve months and before, to see if they are still 

among the living. 

NDI checks this list against their records, and tells VA which veterans have died, 

and the cause of their death as listed on the veterans’ death certificates. From this 

information, VA is able to learn the approximate number of veterans under its care 

who have died of suicide, and to use that information to make comparisons on rates 

of suicide among those veterans and all other Americans. 

This information tells VA about the suicide rates among veterans under its care, 

but says nothing about the rates of suicide among veterans who are not currently 

in the system. For those veterans, an even more complicated process has to be followed in order to estimate rates. VA obtains regular updates from the Department 

of Defense’s Defense Manpower Data Center on soldiers separating from the military. Those new veterans immediately become part of total population and suicide 

calculations. 

In 2002, the CDC established the National Violent Death Reporting System, or 

NVDRS. NVDRS today is fully implemented in 16 states, and collects data on violent deaths, including suicides. NVDRS collects data on violent deaths from a variety of sources, including death certificates, police reports, medical examiner and coroner reports, and crime laboratories. Veteran status is included in the database. 

Together, these sources offer a comprehensive picture of the circumstances surrounding homicides and suicides. This, too, is a time-consuming and difficult task, 

and standard reports from NVDRS are available only through 2005. 

Because NVDRS is a comprehensive source of data, and because it indicates 

whether or not a coroner has indicated that the deceased is a veteran, VA is able 

to obtain counts of the number of suicides among all veterans in the sixteen stats 

that have fully implemented this system, broken down by sex, age, race and state. 

To summarize, determining suicide rates among veterans is a challenging puzzle. 

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Multiple data sources must be used, and data must be carefully checked and rechecked. Each system helps obtain a piece of the complicated puzzle that constitutes 

the process of accurately estimating rates of veteran suicides. 

These are time-consuming processes—but they are the best ways VA knows to obtain aggregate data on suicide. The weaknesses inherent in this method are clear. 

First, the CDC’s manual for completion of death certificates states that the determination of whether or not someone is a veteran should usually be done by funeral 

directors. The information available to directors is limited, and their willingness to 

investigate the question of veteran status varies. Generally, these directors allow 

families to self-certify their response to the question of whether their loved one was 

a veteran; an approach fraught with pitfalls. In addition, funeral directors may not 

be clear on whether a young person died on active duty, or shortly after leaving the 

service. 

Second, the classification of a death as suicide is dependent on the work of coroner’s offices throughout America. This paper has already discussed issues related to 

coroner determinations: regional differences in definitions; the manner in which ambiguous cases are classified; the level of investigative determination; religious traditions, and legal sanctions all create difficulties in data reliability. 

And third, data takes a very long time to assemble. Neither NDI nor NVDRS has 

released reports of data newer than 2005—and it is midway through 2008 at 

present. 

There are actions VA can take, and is taking, to improve the reliability and the 

speed of the data the Department is obtaining and providing to Congress. First, VA 

has begun negotiations with NVDRS staff that will provide information from all of 

NVDRS’ sources (death certificates, police reports, medical examiner and coroner reports, and crime laboratories) on a monthly and quarterly basis, as they are received 

by NVDRS. 

VA will not be able to determine when there is sufficient information to provide 

full and publishable data—only NVDRS can do that—but will be able to examine 

and analyze these reports in a way that will allow the Department to spot suicide 

trends by age, sex and even region more quickly and to take action in those areas. 

The Department will also systematically assess its efforts to inform funeral directors about the importance of determining whether or not a person who has died of 

suicide is or is not a veteran, and what sorts of information to consider in making 

that determination. 

VA will also investigate working directly with state vital records offices, as the 

NDI does, to obtain information on veteran suicides directly from them. 

And finally, VA has a new way of obtaining information on both suicides and suicide attempts: the Department’s suicide prevention coordinators. 

Until VA committed itself last year to providing full time suicide prevention coordinators at each of its 153 hospitals, it could provide no useful number of attempted 

suicides among patients. Last October, a standardized definition of suicide attempts 

was developed and coordinators were asked to begin to count the number of such 

attempts of which they were aware. 

VA’s definition of a suicide attempt included any behaviors that might have potentially allowed veterans to injure themselves, when there was evidence that the veteran had the intent to kill himself or herself—whether or not he or she was actually 

injured. The definition also included events in which a veteran was rescued, an attempt thwarted, or a veteran changed his or her mind after taking an initial action. 

On February 13, 2008, an internal email from VA’s Deputy Chief of Patient Care 

Services for Mental Health discussed the existence of this information. In this email, 

he suggested 1,000 veterans a month under VA care were being reported as attempting suicide, and was concerned about disclosing the information. 

The data was not sent to CBS because of his concerns. 

The number of attempts referenced was based on only three months worth of 

data, too short a time period to determine if it was reliable. 

The data was demonstrably not accurate. Even now, six months after collecting 

data began, the reports indicate that a number of states have suspiciously low reporting rates—and there is remarkable variability among individual VA facilities 

throughout the United States, due either to regional variability in suicide rates, differences in the manner in which individual suicide coordinators reported data, or 

both. 

VA’s suicide prevention coordinators were new to their jobs, and new to their 

tasks. There was a great deal of uncertainty over ‘‘borderline calls,’’ and many of 

them were just beginning to make the community and in-hospital contacts that are 

essential in making an accurate count of the number of suicide attempts among patients. 

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VA is addressing the problem of the accuracy of suicide coordinators’ data in a 

number of important ways; by regularly reviewing the data the Department receives, and educating coordinators on the proper way to collect and report this information; 

And VA is regularly reviewing difficult ‘‘calls’’ with its suicide coordinators—and 

encouraging them to meet the right people in their communities to obtain additional 

data. 

In the near future, the Department intends to ask suicide prevention coordinators 

for the names of all those in their facility who have attempted suicide. This will 

allow further refinement of this data by checking the electronic medical records of 

individual veterans whose names have been reported as having attempted suicide. 

VA will learn how this information has been entered into the health record, and 

how practitioners have incorporated this information into the treatment plan for the 

individual whose record is being reviewed—with important implications for preventing suicide throughout VA’s system. 

VA’s suicide coordinators are providing another important service; they are providing an additional source of data on the number of completed suicides at their facilities. This data, too, has significant problems: while VA can tell with considerable 

accuracy how many veterans commit suicide within its facilities, suicide coordinators have both limited time and contacts among coroners and funeral directors to 

provide accurate counts of the numbers who have died of suicide in the community. 

While coordinators will be encouraged to continue to make those contacts, and to 

attempt to refine the accuracy of the numbers of dead they submit, VA believes that 

the focus of suicide prevention coordinators must be on preventing suicide among 

the living. Epidemiologists and researchers, using the data sources described above, 

will be the ones to learn more from those who have been lost. 

Before turning to the actual data, here is a brief explanation of some data which 

has been widely attributed to VA, but which, in fact, is not the Department’s. On 

March 20, 2008, CBS aired a story on veterans’ suicide which included a statement 

in which the network said it had ‘‘obtained from VA’’ the information that there had 

been 790 attempted suicides among veterans under the Department’s care in all of 

2007. 

VA has since reviewed its records to try to understand where CBS might have 

gotten their information, and believes the number stemmed from a response to a 

Freedom of Information Act Request CBS made to the Veterans Health Administration’s Freedom of Information Act Officer on December 20, 2007; a request that was 

subsequently modified on January 29, 2008. VA provided CBS with the information 

they asked for—information in the Department’s National Patient Care Data base 

for the years 2000 through 2007, broken down by year, state, age group, gender and 

race. 

This data provides a breakdown of why veterans were seen in VA’s hospitals and 

clinics by International Classification of Diseases code. Once such code is ‘‘Suicide 

and other Self-Inflicted Injuries.’’ CBS apparently counted the total number of veterans for whom that code was entered—and came up with 790 attempts for 2007. 

That number, unfortunately, is not at all useful if the purpose of the count is to 

determine the total number of suicides and attempts among veterans under VA’s 

care. Some people who attempt suicide, but do not die, do not then present directly 

to VA for care. Others do not admit that their injuries were due to suicide attempts 

until a counselor discusses their situation with them. And still others treat their 

own wounds without seeing a clinician; the attempt is only revealed later, during 

counseling. CBS’s number, while arithmetically correct, is actually misleading. 

3. VA’S DATA ON SUICIDES AND ATTEMPTS 

To review what we do know specifically, let us compare veterans’ rates of suicide 

to non-veterans rates. The source of the base data is the National Death Index, a 

product of the National Center for Health Statistics of the Department of Health 

and Human Services. The most current complete data in this area is from 2005; 

2006 data should be released soon. The overall rates of suicide for men and women 

from 2001 through 2005 are shown in Tables 1 and 2. It is important to separate 

the rates for men and women. By doing so, we see that men have a higher rate of 

suicide than women; a rate that is statistically significant. It is also important to 

separate these figures by age groupings, because there are significant differences in 

that area as well. These tables provide that information as well. 

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Table 1: Suicide Rates Per 100,000 Male U.S. Citizens by Fiscal Year and 

Age 

2001 2002 2003 2004 2005 

All men 23.18 23.63 23.20 23.20 23.19 

18–29 20.14 20.08 19.38 20.21 19.35 

30–64 22.45 23.10 23.13 23.00 23.19 

65+ 31.42 31.81 29.76 29.01 29.53 

Table 2: Suicide Rates Per 100,000 Female U.S. Citizens by Fiscal Year and 

Age 

2001 2002 2003 2004 2005 

All women 5.22 5.44 5.42 5.81 5.65 

18–29 3.40 3.67 3.56 3.91 3.90 

30–64 6.28 6.47 6.57 7.09 6.78 

65+ 3.88 4.09 3.79 3.79 3.99 

Source: CDC’s WISQARS Injury Reporting System and CDC’s National Center for Health Statistics’ National Death Index 

Tables 3 and 4 provide overall rates of suicide for male and female Veteran VA 

users, broken down into three age groups: 18 to 29; 30 to 64; and 65 and older. 

Table 3: Suicide Rates Per 100,000 Male Veteran VA Users by Fiscal Year 

and Age 

2001 2002 2003 2004 2005 

All Male VA users 36.49 41.58 32.92 35.40 37.19 

18–29 27.75 36.54 35.64 42.54 26.94 

30–64 41.37 46.32 39.57 38.44 40.66 

65+ 32.03 37.03 26.77 32.09 34.27 

Table 4: Suicide Rates Per 100,000 Female Veteran VA Users by Fiscal 

Year and Age 

2001 2002 2003 2004 2005 

All Female VA users 9.87 12.49 9.00 12.28 13.59 

18–29 2.12 15.75 5.93 7.41 7.81 

30–64 11.99 11.17 10.76 14.88 13.96 

65+ 6.58 15.66 3.95 4.31 17.60 

Source: CDC’s National Center For Health Statistics’ National Death Index 

These tables show that men, whether or not they are veterans, have a higher rate 

of suicide than women, in numbers that can be considered statistically significant. 

In addition, there are significant differences by age groupings. VA is able to make 

these comparisons, because it is able to match the names of veterans under our care 

whom we have not recently seen against the National Death Index. The Death 

Index then provides information on which of these men and women have died, and 

the cause of their death, including suicide. 

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What cannot be learned from this table is how the rates of suicide compare among 

all veterans, not only those in the VA system, to the general population. Doing so 

would require matching the full list of 24.5 million veterans against the National 

Death Index to see how many of them have committed suicide. That currently is 

not possible. However, VA has matched up general population rates of suicide in the 

sixteen states reporting to NVDRS in 2005 against the rate of veteran suicide in 

those states. 

Table 5: Suicide Rates per 100,000 in 16 States Among General Population 

vs. Veteran Population (Males) in 2005 

18–29 30–64 65+ 

All male VA users 53.18 36.85 36.00 

All male veterans 44.99 25.60 31.52 

All men 20.36 23.28 30.51 

Table 6: Suicide Rates per 100,000 in 16 States Among General Population 

vs. Veteran Population (Women) in 2005 

18–29 30–64 65+ 

All female VA users 25.02 15.81 --- 

All female veterans 15.35 11.41 3.66 

All women 4.35 7.04 3.63 

Sources: 

General Population: CDC’s Web-based Injury Statistics Query and Reporting System 

OEF/OIF: DoD’s Defense Manpower Data Center 

Suicide Data: CDC’s National Center for Health Statistics National Death Index and CDC’s National Violent 

Death Reporting System 

At this time, there is no firm explanation of the reason for the disparity in rates 

between VA’s patients and other Americans. However, the veterans VA serves—as 

opposed to the overall population of American veterans—are older, sicker, and poorer than the general population of the United States. VA researchers believe this 

may account for at least some of the apparent differences. 

VA’s summary of this data from 2001 through 2005 yields the following 

hypotheses: 

• Male veterans commit suicide at a somewhat higher rate than other men, but 

with varying statistical significance by age and over different years. • Within the group of male veterans there are differences in the age at which veterans die of suicide compared to what is seen in the general population—especially in the ages between 30 and 64, at which ages veterans have a statistically 

significant higher rate. This finding is reproducible over time. • Male veterans commit suicide at a higher rate than female veterans. • Within the group of female veterans, there is nearly a twofold increase over the 

rate of suicide for women in the general population, which is also variably statistically significant over the years and by age. 

Clearly, returning service men and women represent a group of particular interest 

to the Nation. VA has a particular sense of urgency to understand why these men 

and women might be taking their own lives—and to intervene to prevent even a single suicide. To better understand suicide in this particular cohort, Dr. Han Kang 

of VA’s Environmental Epidemiological Service conducted a study that matched 

those servicemembers who had served in the theater of operations, and who separated from service between 2002 and 2005 against the National Death Index. 

Using this method, Dr. Kang found that 144 out of 490,346 separated OEF/OIF 

servicemembers committed suicide during that time, for an overall rate of 21.9 per 

100,000. These are deaths only of men and women who separated from the military, 

and the data does not include any suicides while a servicemember was on active 

duty. 

To compare this to other national norms, Dr. Kang looked at this cohort against 

the national averages discussed above. For OIF/OEF veterans who had deployed and 

separated from 2002–2005, the rate was slightly higher than would be expected in 

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an age, gender and race matched general population, but not by a statistically significant amount. (Standardized mortality Ratio of 1.15 (p >.05.) 

Dr. Kang also examined this data for differences in suicide rates between those 

who have used VA for care and those who have not. He found that 17.0 of every 

100,000 OEF/OIF veterans who use VA for care take their own lives, compared to 

24.0 of every 100,000 OEF/OIF veterans who do not use VA for care. This apparent 

advantage of VA care, though encouraging, is not statistically significant. In this 

group, the same is true for vet center users. 

Male veterans 18–29 who used VA care took their own lives at a rate of 21.0 per 

100,000, compared to veterans of that age who did not use VA for care, a group 

which died of suicide at a rate of 30.4 per 100,000—a statistically significant difference. Male veterans aged 30–64 who used VA for care died of suicide at a rate 

of 17.5 per 100,000, compared to a rate of 22.8 per 100,000 for their fellow veterans 

who did not use VA for care—not a statistically significant difference. Since only 3 

women OEF/OIF veterans died of suicide through 2005, accurate rates within age 

groups cannot be calculated. 

VA statisticians have worked with this now-older data in anticipation of followon data when the updated National Death Index information is available. Some of 

the insights they have found include the knowledge that there appears to be little 

variation in suicide risk by branch of service. Statisticians also found that a diagnosis of a mental disorder predicted a nearly 1.8 times higher suicide risk than the 

general population. This is consistent with what has been published in research 

journals regarding the non-veteran population, and emphasizes the importance of 

the Department’s mental health efforts. 

All of this data comes from national data for suicide against those who are known, 

from VA’s data sources or from Department of Defense records, to be veterans. 

These national numbers must be used because VA’s clinical records do not capture, 

in any reliable or complete way, such events as suicides or suicide attempts. 

The National Death Index, a national roll-up of information from coroners 

through the states, offers the most complete compilation of deaths among veterans 

and their causes—since VA may not know of a death even if it occurs in an area 

in which the Department has a facility. Because information on deaths continues 

to be updated as reports come in over time, confidence in the completeness of those 

numbers only comes after several years of data collection. VA is awaiting at this 

time the release of National Death Index compilations for 2006 for further analysis. 

Regarding inpatient deaths: from 2000 through 2007, exactly 50 VA inpatients 

took their own lives while under the Department’s care, based on root cause analyses of the deaths received by VA’s Office of Patient Safety. That number varies 

from a high of 14 such suicides in 2002, to a low of 2 in 2007, when Veterans Health 

Administration officials demanded that all facilities pay special attention to improving their environment of care to reduce opportunities for suicide. 

4. VA’S SUICIDE PREVENTION EFFORTS 

The steps VA is taking to prevent suicide among veterans are important and significant. All VA employees have been given the message that even strong and resilient people can develop mental health conditions; care for those conditions is readily 

available and should be immediately provided; and treatment works. 

VA has held two National VA Suicide Prevention Awareness Days throughout its 

system to focus all 200,000 health care employees on this issue. The first event focused on enhancing overall awareness of the issue. The second coincided with National Suicide Prevention Awareness Week. During that week, VA staff was trained 

on how to work with available prevention resources, including the hotline and the 

suicide prevention coordinators. VA will continue participating in Suicide Prevention 

Awareness Week activities every year, with a special focus on veterans and ways 

VA can continually improve its suicide prevention efforts. 

The Department is in the process of adding 23 new vet centers throughout the 

Nation to provide more individual, group and family counseling to veterans of all 

wars who have served in combat zones, bringing the total number of vet centers to 

232. 

VA’s suicide prevention program includes two centers that conduct research and 

provide technical assistance in this area to all locations of care. One is the Mental 

Health Center of Excellence in Canandaigua, New York, which focuses in developing 

and testing clinical and public health intervention related to suicide risk and prevention. The other is the VISN 19 Mental Illness Research Education and Clinical 

Center in Denver, which focuses on research in the clinical and neurobiological 

sciences with special emphasis on issues related to suicide risk. 

VA’s system of care also includes a suicide prevention call center, also located in 

Canandaigua, and the suicide prevention coordinators previously discussed, who are 

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located at each of VA’s 153 hospitals. Altogether, VA has more than 200 mental 

health providers whose jobs are specifically devoted to preventing suicide among 

veterans. 

To develop the suicide prevention call center, the Department has partnered with 

the Lifeline Program of the Substance Abuse and Mental Health Services Administration. Those who call 1–800–273–TALK are asked to press ‘‘1’’ if they are a veteran, or are calling about a veteran. 

Unlike other such hotlines, VA’s hotline is staffed solely by mental health professionals—24 hours a day, seven days a week. Hotline staff is trained in both crisis 

intervention strategies, and in issues relating specifically to veterans, such as traumatic brain injury and post traumatic stress disorder. In emergencies, the hotline 

contacts local emergency resources such as police or ambulance services to ensure 

an immediate response. 

Cards, pamphlets and posters—even refrigerator magnets—bearing the number 

are distributed by suicide prevention coordinators to at-risk veterans and their family members. 

In addition, posters with hotline information are located throughout VA medical 

centers and clinics, and in all residential rehabilitation programs there are stickers 

on phones and by doors with the hotline number. Vet Centers also make this information available. 

If the caller is a veteran enrolled with VA for care, the hotline staff is able to 

use the veteran’s electronic medical record during the call, if the veteran is a VA 

patient and willing to identify himself or herself. These records provide information 

that is invaluable during a crisis, including information on medications; the patient’s treatment plan; and who to contact during this emergency. 

Staff can talk directly to the facility that is treating the veteran. They can place 

consults in the patient’s medical record, and are able to make arrangements to directly refer veterans to a Medical Center or Community-based outpatient clinic to 

be seen if that’s appropriate. 

And hotline staff follows up on these referrals. They check patient’s records to see 

if consultations were completed; actions are taken; and followups are ongoing. If the 

record does not show this information, the suicide prevention coordinator is called, 

ensuring that no referral is lost in the process. 

From its beginnings in July, 2007 through the end of April, 16, 414 calls have 

come to the hotline from veterans and 2125 family members or friends have called. 

These calls have led to 3464 referrals to suicide prevention coordinators and 885 

rescues involving emergency services. 493 active duty servicemembers have also 

called. 

Besides keeping track of veterans who have tried to take their own lives, suicide 

prevention coordinators receive referrals of those at risk for suicide from both the 

hotline and from providers in their facilities. They also ensure that care for these 

veterans is appropriate for their situations. 

Coordinators educate their colleagues, veterans and families about risks for suicide. They provide enhanced treatment monitoring for veterans at risk and ensure 

that any missed appointments are followed up on. The coordinators work with the 

entire staff of their medical centers to maintain awareness of those who have previously attempted suicide, and ensure their care is enhanced to reduce the risk of 

renewed attempts. 

They also work with patient safety officers to conduct quarterly safety inspections 

of inpatient psychiatry units, and coordinate staff education programs about suicide 

prevention. These coordinators are in the process of organizing a system of flags in 

the electronic medical record system to alert providers about those at high risk. 

They are also conducting training for community members who have frequent contact with veterans to help them recognize those at risk and encourage them to seek 

treatment. 

There is a large body of scientific literature on suicide. Over the years, VA has 

been a prime contributor to the knowledge that has been developed in the scientific 

community on this issue. Our research has helped us target our efforts to reduce 

suicide. Some of the information our researchers have developed includes: 

• Among veterans receiving care from VA who died from suicide, almost 60% of 

those under age 65 had a mental health or substance abuse diagnosis on their 

medical records—but only 24% of those 65 or over had such a diagnosis. 

• There is significant variability in suicide rates among veterans by geography. 

In general, rates are lowest in the Northeast and highest in the West. 

• Firearms are the most common means used by veterans who died of suicide, accounting for nearly two-thirds of all deaths. 

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• There appears to have been an increase in suicide rates among Vietnam veterans during the first two years after these veterans returned home. After a few 

years, however, Vietnam veterans’ rates of suicide were comparable to those of 

the general population. 

• There was no increase in suicide rates among veterans who returned from the 

first Gulf War. 

• Those veterans who are wounded in combat are at higher risk of suicide. 

5. FUTURE ACTIVITIES 

In the near future, the Department will continue to educate its employees; 

through additional Suicide Prevention Days; through posters identifying the warning signs of suicide; and through its continuing Employee Education process to identify those at possible risk of suicide to ensure they get proper care. As new data 

on suicide rates, risk factors for suicide and regional variations become available, 

VA will use that data to refine its programs, and to better evaluate their level of 

success. 

VA will increasingly reach out to the newest generation of veterans, by using communications outlets familiar to them. VA now has a virtual office on ‘‘Second Life;’’ 

and recently collaborated with MTV on a video on readjustment issues for returning 

veterans that can be found on their Web site. 

VA will continue its efforts to meet the mandate of the President’s New Freedom 

Commission to reduce the stigma that surrounds mental illness. 

VA will also continue the expansion of its mental health program that has enabled the Department to hire more than 3800 new mental health employees in the 

past three years, and expand hours of operation for mental health clinics beyond 

normal business hours. These efforts to better identify and treat mental illness will 

help prevent contemplation of suicide and suicide attempts—and will help ensure 

that veterans in crisis are already involved in VA’s system and have somewhere to 

turn when they need help. 

The Department will aggressively follow up on patients in mental health and substance abuse programs who miss appointments to ensure they are not lost to follow 

up care. VA will also monitor the standards the Veterans Health Administration has 

set for itself: to provide initial evaluations of all patients with mental health issues 

within 24 hours, provide urgent care immediately when that evaluation indicates it 

is needed, and to complete a full evaluation and initiate a treatment plan within 

14 days for those not needing immediate crisis care. 

On May 2, VA began contacting nearly 570,000 combat veterans of the Global 

War on Terror to ensure they know about VA medical services and other benefits. 

The Department will reach out and touch every veteran of the war to let them know 

it is here for them. The first of those calls are going to an estimated 17,000 veterans 

who were sick or injured while serving in Iraq or Afghanistan. If any of these 17,000 

veterans do not now have a care manager to work with them to ensure they get 

appropriate healthcare, VA will offer to appoint one for them. 

All case managers for OEF/OIF veterans will be trained in suicide risk recognition 

and management for their patients, and encouraged to establish a personal relationship with those veterans to support their healthcare needs. 

I have also directed the creation of a work group on suicide prevention in the veteran population. This work group will look at all matters relating to VA’s ability 

to prevent suicide among veterans. They will be given all the data VA has, and access to the best experts VA knows. 

The work group will be asked to provide a report within fifteen days of the completion of their meeting on how VA can better approach suicide prevention, suicide 

research, and suicide education. 

All work group members will come from outside the Department of Veterans Affairs. Some will be DoD specialists; others will be from other government agencies. 

Nationally recognized clinical treatment, research and public health experts on suicide and suicide prevention will augment them. The work group will provide an additional level of advice and oversight to all the issues described above. 

There is nothing more tragic than the loss of even one of those great men or 

women who have served this nation. The VA is committed to doing all that we can 

to serve the individual while we continue to try to understand a very complicated 

problem that is also a national problem. We owe this committee and the nation accurate information and carefully studied, thoughtful conclusions while we provide 

the ‘‘best care anywhere’’ to our Veterans. 

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Statement of Ronald William Maris, Ph.D., 

Distinguished Professor Emeritus, Past Director of Suicide Center, 

Adjunct Professor of Psychiatry, 

and Adjunct Professor of Family Medicine, 

University of South Carolina, School of Medicine, Columbia, SC 

What Causes Suicide? Suicide is not one thing, but is a multidimensional outcome (including a continuum of self-destruction from unintentional self-harm, partially self-destructive behaviors, ideas about suicide, plans to suicide, lethal and 

non-fatal suicide attempts, and finally, to suicide completions; which themselves can 

be escape, revenge, altruistic, and/or risk-taking) resulting from several risk factors 

interacting over time (what I call a ‘‘suicidal career,’’ Maris, 1981). Risk factors for 

suicide include relatively chronic vulnerabilities (like being an aging male, owning 

a gun, having a history of depressive disorder, being an alcoholic, etc.) and more 

acute stressors (like post-traumatic stress disorder, recent losses, pharmacological 

crises [such as serotonergic dysfunctions], inability to get effective healthcare, etc.). 

From my case-control surveys I have derived about 15 evidence-based risk factors 

for suicide outcomes (the following list includes statistically significant risk factors 

compared to controls of nonfatal suicide attempts and natural death in a random 

sample of 2,153 suicides (Maris, 1969 and 2002). There could be more than just fifteen risk factors for suicide (See Maris, 2000, Chapter 17) and the list below is not 

necessarily ranked (although factors 1 and 2 tend to be the most prevalent in suicides). The factors that cause most suicides are (See Maris et al., 2000:80; Maris, 

2002; Maris, 2007): 

• Depressive and affective disorders, schizophrenia 

• Alcohol and substance abuse 

• Suicide ideas, plans, preparations 

• Prior suicide attempts (caveat: many white males die after one attempt) 

• Available lethal methods (especially, firearms) 

• Social isolation, loss of social support 

• Hopelessness (Beck claims hopelessness is more predictive of a suicide outcome 

than depression is; See Maris et al., 1992) 

• Being an older white male (generally the older, the more likely suicide is) 

• History of suicide or mental disorder in one’s first degree relatives 

• Work problems, unemployment, lower SES, homelessness 

• Marital problems & discord, separation, divorce, widowhood 

• Stress, PTSD, negative life events, traumas 

• Feelings of anger, aggression, impulsivity, serotonergic dysfunction 

• Physical illnesses; like spinal cord, brain injury, epilepsy, arthritis, ulcers 

• Repetition and co-morbidity of above risk factors; ‘‘suicidal careers’’ 

Obviously, what causes veteran suicides has both common and unique factors 

compared to the general population in the United States. Murphy and Robins (1970, 

1981) found in St. Louis county that about 47% of all suicides had an affective disorder and 25% had alcohol problems. Rates of depression, alcohol abuse, having a 

firearm, isolation, marital disruption, and trained aggression are all more prevalent 

in veteran populations. Zivin (12/7/07 @ 2193) estimated that veteran depression 

symptoms are 2 to 5 times higher than those in the general population. 

Kang (12/11/07) states that as of 9/2007 among vets in healthcare at the VA, 40% 

had major depression diagnoses and 20% had diagnoses of PTSD (DSM IV code 

309.81). 

Post-traumatic stress disorder is extremely important among combat veterans 

(about 33% of female veterans experience sexual trauma, which can also cause 

PTSD) because it is common (15 to 50% of vets have PTSD; See Vets for Common 

Sense et al. v. Peake et al. Complaint, 7/23/07 @ 18–69) and it is interactively related 

to other suicide risk factors. CBS (11/13/07) reports that 28.3 percent of Iraq vets 

had mental health problems. Kang (12/11/07 @ 445) claims that of the approximately 1.6 million troops deployed in Afghanistan and Iraq 3,444 (now over 4,000) 

have been killed and 90% have been ‘‘traumatized.’’ 

PTSD was first stated as a psychiatric anxiety diagnosis in 1980 in the DSM–III 

(code 309.81). It involved the following symptoms or criteria: 

• Being exposed to a traumatic event where death or serious injury occurs accompanied by feeling of intense fear and helplessness. 

• The event is persistently re-experienced. 

• The victim avoids trauma-associated stimuli. 

• The victim experiences symptoms of increased arousal. 

• The symptoms last one month or more (acute v. chronic) and are characterized 

by social and occupation dysfunction 

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PTSD is one of the unique suicidogenic factors among veterans and interactively 

raises other suicide risk factors. Note, too that the percentage of all USA general 

population deaths that are suicides is 2.1% (AAS, 1/24/08). But among 15 to 24 yearolds 12.3% of all death are by suicide. Kang reminds us that the median vet suicide 

age is 20 to 29 (12/11/07 @ 441) and 18–24 year-old soldier suicides make up 26.3 

% of all suicide [about twice that of the non-soldier population]. Thus, obviously, the 

prompt and accurate diagnosis and treatment of vet PTSD (and related depressive 

and substance abuse disorders) is a major condition for veteran suicide prevention. 

One reason I cannot answer definitely about what causes veteran suicides is that 

the Office of Veteran Affairs has not provided me or the courts crucial data that 

are needed. For example, each time there is a military death, suicide attempt, or 

other serious incident, the VA produces a short ‘‘incident brief’’ which summarily describes the suicide or suicide attempt (Feeley, 4/9/08 @ 158). Then about 45 days 

later each incident undergoes what is called a ‘‘root cause analysis’’ and a 3-page 

report is generated (Feeley @ 160). On April 22, 2008, when I was an expert for 

the Plaintiff in the Veterans . . . v. Peake trial in San Francisco, I was given only 

170 of the estimated 15,000 incident briefs and none of the root cause analyses. 

Clearly these VA documents could go a long way in establishing what causes veteran suicides and whether or not there is an ‘‘epidemic’’ (Dr. Katz denies that there 

is an epidemic, 11/13/07). It seems that these personal, clinical documents could be 

redacted, with patients’ names and other identifying information removed, and then 

supplied to independent scientific investigators, like myself. Clearly such crucial 

documents would help clarify how many vet suicides there are and what the VA 

thinks causes them (i.e., what are the root causes). 

How High is the Veteran Suicide Rate and Is It An ‘‘Epidemic’’? Virtually 

everyone agrees that the Iraq & Afghan vet suicide rates are higher than those of 

the general USA population. One problem in getting a consistent answer to our 

question is that there are shifting veteran populations (all vets, WWII, Korea, Viet 

Nam, Gulf War, Afghanistan, and Iraq), shifting times frames (e.g., yearly, 01–05, 

06–08, etc.) and various samples based on different data sets (e.g., incident briefs, 

death certificates from the U.S. Department of Vital Statistics, Department of Defense data, etc. Consequently there is a very wide range of estimates of vet suicides. 

Nevertheless, there is consensus that the vet suicide rates (especially in OEF/OIF 

veterans; viz., Afghan and Iraq vets) are higher than those of the general population; 

high enough to constitute a serious national problem that demands resolution (Katz, 

11/13/07). 

Some of the estimates of veteran suicides rates and how much higher they are 

than those of the general population are: 

• Katz (VA Deputy Chief of Patient Care Services) (2/21/08) says 3.2 times high- er (suicide rate of 34.6 /11, N = 8,218, VHA patients from 2001–2005). • OIG Mental Health Strategic Plan for Suicide Prevention (5/10/07) says 7.5 

times higher (viz., 83/100,000/11), page 8. 

• Rathbun/CBS (2/28/08) says 1.8 to 2.3 times higher (6,256 vets of any war surveyed in 45 states = about 120 vet suicides per week). 

• Zivin (12/7/07 @ page 2194) says 1683 of 807,694 vets suicided = 208/100,000 

or about 19 times higher than the general population. 

• Katz (2/13/08 in an e-mail to Ev. Chasen) says that ‘‘VA suicide prevention coordinators are identifying about 1,000 suicide attempts per month among vets 

seen in VA medical facilities (note: usually suicide attempts exceed completed 

suicides about ten to twenty-five times [AAS, 1/24/08]). 

• Katz (e-mail to Kussman [Under Secretary for Health] on 12/15/07) reports 18 

suicides per day out of 25,000,000 total vets. 

• Kang (12/11/07) simply says ‘‘the risk of death for vets from suicide and motor 

vehicle accidents is higher that for the general population’’ (page 444, N 

= 144, 01–05, OIF/OEF vets only). 

How high is a high enough vet suicide rate to merit national concern? From one 

perspective even one suicide is too many, since suicide is one of the leading causes 

of unnecessary death (See Maris et al. 2000). William Feeley, Deputy Under Secretary for Health Care Operations at the VA, said in a deposition (4/9/08, p. 38): 

‘‘Suicide occurs like cancer occurs.’’ Wrong! We all have to die (some by cancer, some 

by heart disease, etc.), but no one needs to suicide. The VA seems to think that a 

certain number of vet suicide deaths are inevitable and that there is not much we 

can do about them. 

When I consulted with Columbia University and the FDA to determine if 9 

antidepressant medications caused child and adolescent suicide, the FDA decided 

that a relative risk of 2.1 or higher was sufficient to require a Black Box warning 

be put in the drug’s package insert and in the Physician’s Desk Reference. While 

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there is no arbitrary bright line for danger, note that almost all of the relative risks 

for vet suicide are above 2.0. 

Webster says an ‘‘epidemic’’ means prevalent and spreading rapidly among many 

people in a community (like the U.S. military) at the same time.’’ Although we often 

reserve the concept of epidemic for extreme cases like the plague, smallpox, influenza, polio, etc. It does seem that veteran suicides are the product of a disease process and are increasing. For example, Kang (12/11/07 @ 441) claims the following 

percentages for vet suicides (OIF/OEF) from 2002 to 2006: 

2002 = 7% 

2003 = 21% 

2004 = 48% 

2005 = 68% 

This looks a little like an epidemic to me (although one would need to control for 

the numbers of vets and calculate rates). 

The Office of the Inspector General’s Mental Health Strategic Plan for 

Suicide Prevention (by John Daigh, Jr., M.D., Assistant Inspector General. 5/10/ 

07). The purpose of this ambitious document is to assess implementation of action 

pertaining to suicide prevention in the VHA’s mental health strategic plan (p. 1). 

Overall I found this plan to be a systematic, well-organized survey, but in fact it 

points out many of the VA’s shortcomings in suicide assessment and prevention. For 

the record in the VA there are (1) 21 regions (‘‘VISNs’’), (2) 154 hospitals or medical 

centers, (3) 875 outpatient clinics or ‘‘CBOCs’’, and (4) 136 nursing homes (Feeley, 

4/9/08 @ 45). 

In the plan overview (@ iv) it indicates that ‘‘at present the MHSP initiatives for 

suicide prevention are only partially implemented.’’ For example, on page 21 there 

is a chart summarizing the findings for six major objectives: 

Areas: Findings:

A. Crisis intervention 24 hour mental health services in 94.5% of facilities 

B. Screening 98% screen for depression, major suicide risk factor 

C. Assessment 70% do not have tracking system 

D. Interventions 61.8% do not target special groups 

E. Databases See SMITREC (data not available) 

F. Education 61.4% of facilities did not make information on suicide 

risks mandatory 

The document (Cf., ‘‘Suicide Risk Assessment Guide, Reference Manual,’’ VA 

001510 in Vets . . . v. Peake, 5/21/08, p. 1, no date) argues that suicide attempts 

are a major risk factor for suicide in vets (p. 1). The problem with this finding is 

that about 90% of older white males only make one suicide attempt (usually because 

they shoot themselves in the head; See Maris, 1981). Thus, for most vet suicides, 

a prior suicide attempt cannot be used to prevent their suicides. It is too late already. 

Later (p. 16) the MHSP document argues that the ‘‘VA strategy for suicide prevention should include universal screening designed to activate the system for suicide prevention.’’ In fact (See ‘‘Suicide Template,’’ below) universal screening for vet 

suicide prevention includes asking only two questions (viz., ‘‘Have you felt depressed 

or hopeless in the last two weeks?’’, and ‘‘Have you thought about hurting/harming 

yourself in the last two weeks?’’ If the vet answers ‘‘No’’ to question # two, no further 

suicide screening is done (Cf., Marcus Nemuth deposition, 3/25/08, VA staff psychiatrist in Seattle area). Asking one or two suicide questions, which could easily be denied, misunderstood, misrepresented, etc., is not a suicide screen up to the standard 

of care. Probably self-destruction is under-counted by the VA with such perfunctory 

screens. Importantly, when the VA measures the crucial suicide risk factors of depression 

and hopelessness, as far as I could determine, they just use self-reporting; not short, 

reliable and valid scales, like: 

• The Hamilton Rating Scale for Depression (1960) • The Beck Depression Inventory (1967; Cf., Maris et al., 2000: 84) • Beck Hopelessness Scale (1974; Maris et al., 2000, Figure 3.5, p. 85) • Beck Suicide Intent Scale (1990) 

All of these scales are relatively short (17–20 questions), have the advantage of 

indirection (i.e., the vet is not sure what they measure), have known validity and 

reliability, and could be done in 15 to 30 minutes. Since hopelessness and depression are key suicide risk factors, they should be measured systematically, not by 

subjective self-reporting. Finally, some vets may not even know if they are depressed, hopeless, or suicidal. 

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On page 36 of the MHSP we are told ‘‘90.9% of the VA facilities do not have suicide case managers.’’ Why identify vets with suicide risk, if no one follows them? 

Recently, I have been told that in fact there are ‘‘suicide coordinators’’ in all 21 VA 

VISNs in the 154 medical centers (but none at the 875 CBOCs). However, it is unclear (to me) who these people are, what their suicide prevention training is, what 

their exact job descriptions are, and how effective they are. There is also a question 

about the quality of staffing of CBOCs, most of which have LPNs, RNs, MSWs, and 

MA psychologists, and not psychiatrists. 

We know that two psychiatric drugs have proven very effective in reducing 

suicidality in patient populations. One of these medications is lithium (See 

Baldessarini in Simon and Hales, 2006) for depressed and bipolar I patients even 

get lithium (@ p. 41). Likewise with suicidal schizophrenic patients, the drug 

Clozaril has been shown to be effective in clinical trials in reducing the suicide rate 

(See MHSP @ 42). In the vast majority of VA clinics (90.7%) fewer than 10% of their 

schizophrenic patients are on Clozaril. 

Thus, most of the MHSP initiatives are only partially implemented after several 

years (about four years) and some of the operational definitions of key risk factors 

are below the standard of care. 

Measuring Suicide Risk Factors and the Suicide Template. There is no reason why all veterans could not have all significant suicide risk factors measured at 

least at deployment, discharge, or at other crucial clinic visits (see my list of 15 suicide risk factors on page 1, above). The VA’s ‘‘Suicide Risk Screening and Comprehensive Suicide Risk Assessment’’ form (aka ‘‘Suicide Template’’ or ‘‘Suicide Risk 

Assessment Pocket Card’’) is woefully inadequate to detect suicidality. As I said 

above, just asking if the vet felt (1) hopeless or depressed in the last two weeks or 

(2) thought about harming themselves in any way does not measure suicidality. 

The vet could easily deny depression or suicide ideation (especially if they thought 

it might affect their promotions or military career, or were ashamed of their mental 

health issues). When I worked for the U.S. Army in Berlin, Germany, doing suicide 

prevention training, the staff psychiatrist there told me he had little to do, because 

especially male soldiers would not admit to any mental health problems for various 

career reasons. Many males do not seek mental health treatment. Other soldiers 

may not even realize they are depressed or self-destructive. 

In short, all the questions on the suicide template need to be asked and answered 

and put in objective formats that do not make it obvious what is being measured. 

The suicide pocket assessment card has questions about (1) a suicide plan, (2) 

whether the plan includes firearms, (3) what psychiatric symptoms the vet is having, if any, (4) lack of social support, (5) the age, sex, race and family history of 

suicide of the vet, (6) whether or not there have been any prior suicide attempts, 

(7) levels of impulsivity, (8) past psychiatric diagnoses or treatment, (9) chronic 

pain, (10) protective factors like religion, (11) additional risk factors, (12) quantification of suicide risk level, and (13) immediate actions and treatment needed. Every 

vet should have every risk factor assessed, not just one or two of them, and asked 

in a manner that is effective. 

Systematic Healthcare Deficiencies as Reflected in the VA Incident Briefs. 

Although I was provided only 170 of the estimated 15,000 incident briefs in which 

VA patients’ suicides and suicide attempts were described, nonetheless they provide 

a sample of suggested systematic healthcare and treatment deficiencies identified by 

the VA itself. Below are some of the highlighted treatment failures of the VA in assessing and managing suicidal veterans (all documents were provided in the Vets 

v. Peake trial in San Francisco, California and were Bates-stamped for that trial; 

obviously, they have been redacted to protect individual patients; in each bullet item 

one could add ‘‘and the vet suicided or attempted suicide,’’ etc. Since these documents are ‘‘protected,’’ I have removed the VA Bates-stamped numbers): 

• Treatment was delayed. • Patient with suicide ideation not evaluated for suicide risk (violates template, 

criterion # 2). • No coordination of patient’s care (even though there are s. coordinators). • Vet should have been admitted but was not. • Inadequate response to vet’s expressed wish-to-die. • VA needs a suicide hotline (Note: VA now has a hotline, but research shows 

that a very small percentage of suicides [perhaps < 1%] even call the hotline; 

Feeley @ 51; I am not persuaded that male soldiers are likely to call a hotline). 

• No referral for severe antisocial behavior of vet. 

• No psychiatric evaluation of vet was done in the ER. 

• Suicide assessment policies and procedures were not followed. 

• Hopeless vet not identified as such. 

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• Vet not rescheduled for appointment within one week per policy. 

• Suicide risk assessment was negative, but patient suicided anyway. 

• Patient denied access to VA hospital and then suicided. 

• Doctor at VA fired for inadequate treatment of soldier found dead. 

• Inadequate healthcare for homeless vet with suicide ideation and threat. 

• VA not meeting the needs of suicidal vet. 

• Feeley says of this vet’s suicide: ‘‘VHA not meeting standard that we are after.’’ 

• Vet actually shoots self on the grounds of the VA outpatient clinic. 

These bulleted items reflect the VA’s own admissions of healthcare problems or 

failures in treating suicidal vets. One can only imagine how much more investigators could have learned about assessment and treatment failures of suicidal vets, 

had they been given all of the redacted incident briefs and root cause analyses. 

Since this hearing is entitled ‘‘The Truth About Veterans’ Suicides,’’ it only makes 

sense that all incidents be made public, after removing references to individual vets. 

William Feeley, VA Deputy Under Secretary for Health Operations and 

Management (He reports to Dr. Kussman and Kussman reports to Secretary 

Peake; the following facts are reported in Mr. Feeley’s deposition of April 9, 2008 

in the Vets v. Peake legal suit). Feeley said that although he was 3rd in the chain 

of command, and when it came to vet healthcare, ‘‘the buck stops here’’ (although 

later on Feeley tried to pass the buck to Dr. Katz and others at the VA). 

• Feeley said (@ 19) that the 21 VISN directors all report to him at least once 

a week, but when asked about vet suicide rates, he said he did not talk to directors about their suicide rates (why not, if this is a ‘‘major problem’’?). As Feeley 

put it (@ 35): ‘‘Suicide rates are not a metric we are measuring.’’ 

• When asked about implementing the MHS Plan of 7/2004, his reply was (@ 64): 

‘‘I did not read the plan from cover to cover.’’ 

• When asked between 2004 and 2008 if there were a national systematic program for suicide prevention, Feeley answered ‘‘No.’’ 

• One of the policies that have been supposedly fully implemented in the MHSP 

of 2007 was 24-hour VA healthcare. @ 97 Feeley was asked to name that policy. 

His answer: ‘‘I don’t know that policy.’’ 

• @ 100 Feeley was asked, (well) ‘‘where are these policies?’’ Answer: ‘‘I don’t 

know where they are.’’ 

• Question @ 104: ‘‘Has the idea of screening every service person coming back 

from Iraq or Afghanistan for PTSD been a subject of discussion?’’ Answer: ‘‘I 

really could not give you an answer on that.’’ 

• Question @ 105: ‘‘Is there a national screening program for every returning 

serviceman or woman to meet with a mental health professional?’’ Answer: ‘‘I 

don’t know the answer to that.’’ 

• The MHSP (7/20/04) @ A–14 says that every military person . . . will meet individually with a mental health professional as part of post-deployment and separation. Question: ‘‘Has that happened?’’ Answer: ‘‘I don’t believe it has.’’ 

• Question @ 141–142: ‘‘Have you read the national strategy for suicide prevention and the Institute of Medicine’s report Reducing Suicide (2002)?’’ Answer: 

‘‘No.’’ 

• Question @ 147: ‘‘What methods are there for tracking at-risk (for suicide) veterans?’’ Answer: ‘‘ I’m not sure, sorry.’’ What are suicide coordinators for? 

• Question @ 171: ‘‘Is there any relationship between the number of times a vet 

is deployed and suicide?’’ Answer: ‘‘Don’t know.’’ 

One could easily conclude that if the ‘‘suicidal buck’’ stops with Mr. Feeley, then 

the VA is in serious trouble when it comes to assessing and preventing veteran suicides. Mr. Feeley is singularly and dramatically uninformed about suicide. But 

maybe that is when Feeley passes the buck to Dr. Katz? 

Leftovers and Loose Ends. There are a few other important issues that at least 

deserve mention. 

First, it is possible that soldiers become suicidal in part due to conditions predating their military recruitment. If so, their baseline vulnerabilities (See the concept of ‘‘stress-diathesis’’ in Maris et al., 1992, Chapter 27) may interact with the 

stressors of combat to exacerbate their suicidality. One example on this might be 

the DSM diagnosis of antisocial personality disorder among young males (@ least 

18 years old; DSM code 301.7). There is some evidence (See Vets v. Peake Complaint, 

7/23/07 @ 8–24) that some soldiers may have been induced to accept a discharge diagnosis of antisocial personality disorder, rather than (say) PTSD. Importantly, a 

diagnosis of personality disorder precludes the veteran from receiving disability benefits, since the psychopathology was presumed to be present prior to the recruitment. Nevertheless, even if true, the Department of Defense needs to improve its 

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recruitment screening procedures to keep such recruits out of the military in the 

first place. 

Second, there is surprisingly little mention in the VA mental healthcare policies 

and procedures documents about treating the depressive disorders psycho-pharmacologically. It is axiomatic in suicide prevention that much of the treatment of 

suicidality requires prompt and precise diagnosis of depressive disorders, followed 

by appropriate specific pharmacological treatment of the patient with one or more 

of the SSRI antidepressants (e.g., Lexapro, Prozac, Zoloft, Paxil, Louvox, Celexa, 

etc.), SNRIs (e.g., Cymbalta or Effexor, etc.), anxiolytics (such as the benzodiazepines like Xanax, Klonopin, Traxene, Ativan or non BZs, like Buspar, etc.), perhaps a major tranquilizer (like Risperdal or Zyprexa, etc.), and even electroconvulsive therapy in some cases. Note that many of the VA’s 875 outpatient clinics or 

‘‘CBOCs’’ often do not even have a physician on staff, who can write critical prescriptions that suicidal vets may need. Since there are 875 CBOCs but only 154 VA 

hospitals or medical centers, structurally (given the VA healthcare system) a depressed vet is likely to get only psychotherapy, rather than both pharmacotherapy 

and psychotherapy. 

Third, the VA takes pride that they now have ‘‘suicide coordinators’’ in their medical centers (See Feeley, 4/9/08 @ 88). However, serious questions remain about 

these suicide coordinators. Only the 154 medical center hospitals even have suicide 

coordinators; none of the 875 CBOCs do. Thus, the vast majority of VA facilities in 

fact do not have suicide coordinators. Several questions remain: (a) What do these 

coordinators do, exactly (job descriptions)? (b) How are they trained to do suicide 

assessment and prevention (Berman addressed this issue in Vets v. Peake)? (c) What 

are their professional credentials and licensing (LPN, RN, SW, MA psychologist, MH 

techs, etc)? (d) Who supervises these suicide coordinators? (e) Do suicide coordinators interact directly with suicidal vets in clinical care of the VA patients? (f) What 

exactly are they ‘‘coordinating’’ (data, people, policies and procedures, etc.)? 

Finally, there is a whole set of issues concerning diagnosis, treatment, and benefit delays in VA mental healthcare, which I have not yet commented on (See Vets 

v. Peake, 4/21/08, Federal trial in San Francisco). To even get mental health treatment for up to two years the veteran must fill out a 23-page application form (which 

can be very hard to do, if you in fact do have PTSD) and then receive a disability 

rate from 0 to 100% from a ‘‘Compensation and Pension’’ examination (Complaint, 

25–98). If the disability is denied or too low, found not to be related to military service; then the appeal process can be long and drawn-out (some vets die during the 

appeal process), which can encourage a suicidal resolution of the vet’s problems. 

Note, too, that most of the VA suicide prevention initiatives (See OIG, MHSP, 5/ 

10/07) have only been partially implemented after four years. Defense expert Alan 

Berman in the Vets v. Peake trial, testified that it could take up to 10 years for the 

MHSP to be implemented. One wonders how many vets are going to die in the interim due to lack of assessment and treatment? 

References 

American Association of Suicidology. 1/17/08. USA Suicide. 2005 Official Final 

Data. 

American Psychiatric Association. 2000. DSM–IV–TR. Washington, DC: American 

Psychiatric Press. 

CBS/Stephen Rathbun. 1/19/08 & 2/22/08 Declaration. 

Beck, A.T. 1967. Depression. New York: Harper. 

Beck et al. 1974. The measurement of pessimism: the hopelessness scale. J. Consulting & Clinical Psychology 42: 861–865. 

Beck, A.T. 1990. Suicide intent scale in Blumenthal, S. & Kupfer, D. (eds.). Suicide over the Life-Cycle. Washington, DC: American Psychiatric Press. 

Beck, A.T. et al. 1999. Suicide ideation at its worst point. . . . Suicide and Lifethreatening Behavior 29: 1–9. 

Feeley, William. 4/9/08 deposition in Vets. v. Peake trial in Federal court in San 

Francisco, 4/21/08. 

Goldsmith, S.K. et al. (eds) 2002. Reducing Suicide: a National Imperative. 

Washington, DC: National Academies Press. 

Hamilton, M. 1960. A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry 23:56–61. 

Hoge, C. W. et al. 2004. Combat duty in Iraq and Afghanistan, mental health 

problems, and barriers to care. The New England Journal of Medicine 351: 13– 

22. 

Kang, H.K. & Bullman, T.A. 12/11/07. The risk of suicide . . . among vets of OIF 

and OEF (unpublished). 

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Katz, Ira. 2/21/08. Suicide study (unpublished). 

Maris, R.W. 1969. Social Forces in Urban Suicide. Homewood, IL: Dorsey 

Press. 

Maris, R.W. 1981. Pathways to Suicide. Baltimore: Johns Hopkins University 

Press. 

Maris, R.W. et al. 1992. Assessment and Prediction of Suicide. NY: Guilford 

Press. 

Maris, R.W. et al. 2000. Comprehensive Textbook of Suicidology. NY: Guilford Press. 

Maris, R.W. 2002. Suicide. The Lancet. Vol 360: 219–226. 

Maris, R.W. 2007. Foreword to Cutliffe & Stevenson. Care of the Suicidal Per- son. Edinburgh, Elsevier. 

Office of the Inspector General. 5/10/07. Mental Health Strategic Plan for Suicide Prevention. John Daigh, Jr. VA Office of the Inspector General. Pages 1071. 

Robins, E. (with Murphy, G.). 1981. The Final Months. NY: Oxford Press. 

Nemuth, M. 3/25/08. Deposition in Vets v. Peake. Simon, R.I & Hales, R.E. 2006. Textbook of Suicide Assessment and Management. Washington, DC: American Psychiatric Press. 

Veterans for Common Sense et al. v. Peake et al. Trial commencing 4/21/08 in Federal Court, San Francisco, CA. Judge Samuel Conti. 

Zivin, K. et al. 2007. Suicide mortality among individuals receiving treatment for 

depression in the VA health system. American Journal of Public Health, 2193– 

2197. 

f 

Prepared Statement of Stephen L. Rathbun, Ph.D., 

Interim Head and Associate Professor of Biostatistics, 

Department of Epidemiology and Biostatistics, University of Georgia, 

Athens, GA 

Summary 

In the fall of 2007, I was asked to perform a statistical analysis of veterans’ suicide data collected by CBS News for a story that was broadcast on November 13, 

2007. I agreed to do so, and was not compensated for my contributions. For 2004 

and 2005, CBS provided data on numbers of veteran and non-veteran suicides and 

veteran and non-veteran population sizes, cross-tabulated by state, gender and age 

class. Suicide data were obtained from state death records and population sizes from 

the U.S. Census. These data are the property of CBS News and were erased from 

my computer following the broadcast on November 13, 2007. To avoid investigator 

biases, methods of statistical analyses were specified prior to receiving the data. 

Standard statistical procedures were used to analyze the data; estimated suicide 

rates adjusted for age and gender. Veteran suicide rates were estimated to be approximately double those of non-veterans. This pattern of higher estimated veteran 

suicide risk was observed for both genders and all age classes. The most striking 

pattern was an especially high risk ratio for 20–24 year old veterans; in this age 

class, veteran suicide rates were estimated to be about 3 times those of non-veterans. 

Introduction 

This statement concerns the analyses of veterans’ suicide data conducted at the 

request of CBS News during the fall of 2007, the results of which were broadcast 

during CBS Evening News on November 13, 2007. The following will describe my 

relationship with CBS News, the data that were analyzed, the method of statistical 

data analyses, and the results of those analyses. 

Before proceeding, please note the following: 

1. I am an expert in biostatistics, but not an expert on veterans’ suicides. Although 

I have a 18-year record of teaching and research in biostatistics, I have not had 

any prior experience with suicide data. While I can comment on the methods 

of data analyses, estimated suicide rates and limits of statistical inference regarding the data analysis, I cannot make expert comments regarding what 

causes the observed patterns of suicide rates. 

2. The suicide data are a property of CBS News and at the request of CBS News, 

my copy was erased following the November 13, 2007 broadcast. This was done 

to comply with agreements made between CBS News and States to ensure the 

confidentiality of sensitive human-subjects data. 

3. On March 4, 2008 I testified on behalf of the plaintiffs in the case of Veterans 

for Common Sense and Veterans United for Truth, Inc. vs. Gordon H. Manscprice-sewell on PROD1PC72 with HEARING

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field, Acting Secretary of Veterans Affairs (U.S. District Court, Northern District of California, San Francisco Division, Case No. C–07–3758–SC). No compensation was received from the plaintiffs for this testimony. I had no prior 

relation with either party in this action. 

Relationship with CBS News 

I had no prior relationship with CBS News before Pia Malbran, producer of the 

veterans’ suicide news story, contacted me in August 2007 asking me to analyze veterans’ suicide data. Aside from the gift of a CBS News baseball cap (valued at less 

than 20), I was not paid by CBS News for the work that I have done. I understand 

from Pia Malbran, producer of the veterans’ suicide news story, that I was contacted 

because I had no relationship with the Veterans Administration, veterans groups, 

or involvement with advocacy related to veterans’ issues. 

Data Collection 

During my initial consultations, Pia Malbran discussed the sources of the data, 

and I advised her regarding the format in which the data should be provided for 

data analysis. Ms. Malbran requested that suicide rates be adjusted for age, gender, 

and race. She obtained population totals from the U.S. Census, and population totals for veterans from the Veterans Administration. The states provided her information on the number of veteran suicides and total number of suicides. Veteran status was to be ascertained from state death records indicating that suicide was the 

cause of death, and including a check box indicating whether or not the subject was 

a veteran. In a few cases, veteran status was not available in the death records. 

Data were to be provided for 2004 and 2005. Death records after 2005 were not 

available at the time that the news story was prepared. 

In response to Pia Malbran’s description of the available data, I indicated that an 

excel spreadsheet should be prepared including columns for state, age class, gender, 

race, number of veteran suicides, number of suicides with unknown veteran status, 

total number of suicides, number of veterans, and population total. Suicides with 

unknown veteran status were allocated to veterans and non-veterans in numbers 

proportional to the respective sizes of veteran and non-veteran populations. For example, if 10% of all 25–29 year old males in a given state were veterans, then 10% 

of the suicides of unknown veteran status in that group would be allocated to veterans, while the remaining 90% of suicides in that group would be allocated to nonveterans. This proportional allocation results in conservative estimates, under-estimating the differences between veteran and non-veteran suicide rates. 

Preliminary data analysis indicated that states and the Veterans Administration 

had different definitions of race with respect to the classification of black HispanicAmericans. So, race was dropped from the data collection efforts. Thus, the data can 

be cross-classified by state, age class, gender, veteran status, and population size 

for data analysis. A total of 45 states provided data for 2004 and 2005. 

For states with small populations of veterans, the cross classification of veterans 

by age, gender and suicide status may suffice to identify individual subjects. For 

that reason, CBS News had to agree that data be kept confidential before data were 

released to CBS News. To ensure this confidentiality, I was asked to erase the data 

immediately following the November 13, 2007 broadcast of the veterans’ suicides 

news story. This was done as requested. 

Data Analysis 

To avoid investigator bias, the methods of statistical data analyses were specified 

before data were received from CBS News. The specific choice of methods was based 

on the type of data collected, and the specific estimates that Pia Malbran requested 

in her memo of October 1, 2007: 

1. What is the overall rate of suicide (per 100,000—age and gender adjusted) for 

veterans verses non-veterans nationwide? 

2. What is rate (per 100,000—age and gender adjusted) of suicide for veterans 

verses non-veterans state by state ranked highest to lowest? 

3. What is the overall rate of suicide (per 100,000) for veteran males (all ages) 

verses non-veteran males nationwide? 

4. What is the rate of suicide (per 100,000) among male veterans, 65 or older? 

And, how does that compare with male non-veterans, 65 or older? 

5 What is the rate of suicide (per 100,000) among veterans (both genders) 

aged 20 to 34? 

A logistic regression model was fit to the data from each year (2004 and 2005), 

including main effects for age-class, gender, and veteran status, as well as two-way 

interactions among pairs of these explanatory variables. Logistic regression is the 

standard statistical method for modeling binary responses such as suicide status; a 

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person has either committed suicide or not committed suicide. The inclusion of 

interactions allows the effect of veteran status on suicide risk to depend on gender 

and age. As per the pre-specified protocol for data analysis, the three-way interaction among age, gender and veteran status was dropped from the model since it 

was not statistically significant. 

All estimated suicide rates were adjusted for the impact of age and gender. This 

was done because suicide rates depend on age and gender. For example, suicide 

rates are higher among males and than among females. Moreover, males are overrepresented among veterans since males are more likely to serve in the military 

than females. Given the higher suicide rates among males, and the over-representation of males in veteran populations, failure to adjust for gender will result in overestimates of veteran suicide rates. Similar arguments can be made for the impact 

of age. 

Initial data analysis was completed before my portion of the story was taped by 

CBS News on October 3, 2007. On October 16, Pia Malbran contacted me with data 

on the numbers of active-duty soldiers committing suicide in 2004 and 2005, crossclassified by age and gender. She expressed concern that some of these soldiers may 

have been mistakenly classified as veterans in the state death records, and asked 

me to re-analyze the data subtracting these cases from the veteran suicide counts. 

Thus, two estimates of veteran suicide rates will be presented. The higher estimate 

is based on the original analysis, while the lower estimate was obtained after these 

active-duty suicides were subtracted. 

All analyses were carried out using SAS. Analyses using this statistical software 

involve written code documenting exactly how the analyses are carried out. This is 

as opposed to other statistical software packages that rely on point-and-click menudriving procedures for data analysis that leave no record documenting the method 

of analysis. SAS code used for my data analysis was provided to Ira Katz following 

the November 13 CBS News broadcast. 

Results 

The estimated suicide risk is higher among veterans than non-veterans. Table 1 

presents the age- and gender-adjusted estimates of suicide rates by veteran status 

for each of the two years. The suicide risk among veterans was estimated to be 

1.86–2.32 times the risk among non-veterans in 2004, and 2.10–2.34 times the risk 

among non-veterans in 2005. These risk ratios were computed by dividing the suicide rates among veterans by the suicide rates among non-veterans. 

Table 1. Estimates of overall suicide rates adjusted for age and gender. All 

rates are expressed as numbers of suicides per 100,000 people. 

Veteran Status 2004 2005 

Veterans 17.5–21.8 18.7–20.8.

Non-Veterans 9.4 8.9.

Table 2 presents the age-adjusted estimates of suicide rates for males and females 

by veteran status for each of the two years. For both veterans and non-veterans, 

suicide rates were higher among males than among females. Among males, the suicide risk for veterans was estimated to be 1.67–2.09 times the risk among non-veterans in 2004, and 1.79–2.01 times the risk among non-veterans in 2005. Among 

females, the suicide risk for veterans was estimated to be 2.08–2.60 times the risk 

among non-veterans, and 2.47–2.73 times the risk among non-veterans in 2005. 

Table 2. Estimates of suicide rates by gender adjusted for age. All rates are 

expressed as numbers of suicides per 100,000 people. 

Gender Veteran Status 2004 2005 

Males Veterans 30.6–38.3 31.5–35.3 

Non-Veterans 18.3 17.6 

Females Veterans 10.0–12.5 11.1–12.3 

Non-Veterans 14.8 4.5 

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Table 3 presents the gender-adjusted estimates of suicide rates for the various 

age-classes by veteran status. The most striking result is the high relative risk of 

suicide among 20–24 year old veterans when compared to non-veterans. For this 

group of young veterans, the suicide risk is estimated to be 2.81–4.31 times the risk 

among non-veterans in 2004, and 2.75–3.84 times the risk among non-veterans in 

2005. Veterans in their forties also had high estimated suicide rates, but the risk 

of suicide among non-veterans in their forties was also estimated to be high. Consequently, the risk ratio did not exceed 1.73 in this age group. 

Table 3. Estimates of suicide rates by age adjusted for gender. All rates 

are expressed as numbers of suicides per 100,000 people. 

Age Class Veteran Status 2004 2005 

20–24 Veteran 23.3–35.8 22.9–31.9 

Non-Veteran 8.3 8.3.

25–29 Veteran 12.8–15.5 13.1–16.1 

Non-Veteran 9.0 8.3 

30–34 Veteran 14.1–14.7 16.1–17.7 

Non-Veteran 10.2 9.9 

35–39 Veteran 16.4–17.8 16.1–16.5 

Non-Veteran 11.4 10.5 

40–44 Veteran 20.4–20.6 19.4–19.7 

Non-Veteran 13.4 12.6 

45–49 Veteran 22.4–22.5 23.4 

Non-Veteran 14.4 13.5 

50–54 Veteran 20.3 21.0 

Non-Veteran 13.4 12.9 

55–59 Veteran 15.3–15.4 16.0–16.1 

Non-Veteran 11.4 11.0 

60–64 Veteran 14.3–14.4 13.6 

Non-Veteran 10.3 10.5 

65+ Veteran 11.8 14.9–15.0 

Non-Veteran 9.6 

f 

9.7 

Prepared Statement of M. David Rudd, Ph.D., ABPP, 

Professor and Chair, Department of Psychology, 

Texas Tech University, Lubbock, TX 

Mr. Chairman and Members of the Committee, thank you for the invitation and 

opportunity to join you here today and discuss the tragic, but important problem 

of suicide among our Nation’s veterans. I am honored to be here. My scientific and 

clinical opinions are influenced by a diverse background as a practicing psychologist, 

clinical researcher whose work focuses on the assessment, management and treatment of suicidality, along with the fact that I’m a veteran. Having served previously 

as an Army psychologist, I’m keenly aware of the complexity and challenge of clinical decisionmaking during wartime, the competing demands juggled by military 

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mental health providers, and the arduous task of managing soldiers at risk for suicide both during active duty and after discharge. As a researcher, I understand suicide is most often the end outcome of a complex web of variables, several easily 

identified but not so easily treated. As a veteran, I have some understanding of 

what it means to serve our country, the personal and professional sacrifices that are 

made, and the potential consequences, but only a fraction compared to those that 

return from war struggling with injuries both visible and invisible. 

The tragic increase in both active duty and veteran suicide rates since the beginning of Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) underscore a seldom recognized but very real fact about mental illness; that it can be 

fatal. Data are now available from multiple sources, including the Department of 

Veterans Affairs (VA), the recently released RAND Corporation study, along with 

the existing literature indicating that anywhere from a quarter to a third of previously deployed veterans present with a mental health problem following discharge. 

Most prominent among the problems are major depression, post-traumatic stress 

disorder (PTSD), traumatic brain injury (TBI), and substance abuse. Data available 

prior to the most recent military conflicts (OIF/OEF) indicated heightened suicide 

risk among the general veteran population, with estimates indicating that veterans 

are twice as likely to die by suicide, regardless of whether or not they were affiliated 

with the VA. More recent data indicate a marked increase in suicide risk among 

veterans being treated for depression, with the risk being 7–8 times greater than 

that for the general adult population in the United States. Similarly, recent revelations about suicide and suicide attempt rates among veterans have been alarming, 

with estimates as high as 18 suicides a day. Recent data on TBI are also of concern, 

indicating suicide rates in the range of 3–4 times the general population and lifetime suicide attempt rates of 8%, along with significant rates of suicidal ideation 

(23%). At this point, the relationship between brain injury and suicidality is not well 

understood. 

An accurate and meaningful interpretation of these data requires a look at and 

consideration of comparable civilian data. Although it is certainly difficult to accurately estimate suicide rates for those in and out of treatment, there is some data 

for comparison. The suicide prevalence rate for major depression and affective disorders in general (i.e. major depression, bipolar disorder I and II and affective psychosis) is actually lower than often quoted. Rates differ depending on the apparent 

severity of the illness, with the outpatient suicide prevalence rate being 2%, in contrast to 6% for those previously hospitalized for suicidal symptoms and 4% for those 

hospitalized for other reasons. Rates of suicide attempts are much higher. It is estimated that as many 24% of those suffering major depression make a suicide attempt during the course of the illness. It is estimated that up to 50% of individuals 

with bipolar disorder will make a suicide attempt and up to 80% will manifest suicidal symptoms of some sort. Standardized mortality ratios (ratio of observed deaths 

to expected deaths) for major depression and bipolar disorder paint a stark picture; 

those with major depression evidence a twentyfold increased risk for death by suicide relative to the general population and those with bipolar disorder a fifteenfold 

increase in risk. There are data available regarding other disorders, but the take 

home message is that the risk for suicide is considerable for a number of mental 

illnesses. Mental illness can be fatal, particularly if unrecognized, untreated or 

under-treated. 

It is also important to consider the expected rates of adverse events during treatment, in particular, suicide attempt rates. Data are available from randomized clinical trials targeting suicidal behavior (irrespective of diagnosis). Estimates indicate 

that as many as 40–47% of those receiving treatment (psychotherapy and medications) make suicide attempts during the first year of treatment. If an attempt is 

made during the first year, the average is approximately 2.5 attempts. This is what 

routinely happens during treatment. We also know that an individual making multiple suicide attempts will likely struggle with suicidality for many years, if not a 

lifetime. These data, coupled with data about recent discharge from the hospital, indicate that risk for suicide (in the context of mental illness) is not only potent but 

enduring. Standardized mortality ratios (ratio of observed deaths to expected 

deaths) for men and women recently discharged from the hospital range from 100 

to 350 across several studies. These are tragically high numbers. The VA experience 

is not markedly different than its civilian counterpart when it comes to the presentation of high-risk suicidal patients. 

There are several possible conclusions. First, as outlined nicely in the RAND 

study, there are high rates of psychiatric illness following combat exposure, including both direct and vicarious exposure. Multiple deployments for OIF/OEF likely 

compound the situation because of repeated combat exposure, sometimes after the 

initial emergence of symptoms. The VA is faced with assessing and treating large 

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numbers of seriously ill veterans. Second, the overall rates of both suicide and suicide attempts are tragic but consistent with general trends for the types and observed rates of psychiatric illness. Third, an effective response requires effective resources. Finally, there is an element of this problem that is likely to be enduring 

and potentially chronic in nature. 

The VA has already moved toward increasing recognition and treatment of suicidal veterans, implementing a telephone hotline and making available training on 

recognizing and responding to suicide warning signs. Treatment outcome studies 

targeting suicidality have confirmed that simple things work and can save lives. 

Limiting and removing access to the suspected method can save lives. Removing 

barriers to emergency care can save lives. Patient tracking and effective followup 

for treatment non-compliance can save lives. Evidence-based treatments for depression, bipolar disorder, PTSD are effective and can save lives. Despite the fact that 

treatment is effective, it’s estimated that only about half of those at risk pursue 

care. 

The military and VA system face unique barriers to providing effective care, including issues of confidentiality, delays in evaluating the escalating numbers of 

service-connected disability claims, and misconceptions about the nature and effectiveness of mental healthcare. The FDA warning label for antidepressants is but one 

example of how misunderstanding of the scientific data can lead to fewer people expressing a willingness to seek care, with potentially tragic results. Science, clinical 

experience, and common sense converge when it comes to suicidality. Improving our 

ability to both recognize and respond quickly to those at risk can save lives. Removing barriers to care, particularly emergency care, can and will save lives. Those that 

have served our Nation deserve no less. It is tragic and heartbreaking when a soldier that has survived the trauma of war returns home to die by his or her own 

hand, especially when treatment is an option. 

Thank you, I appreciate the opportunity to speak with you today and welcome the 

chance to respond to questions. 

f 

Prepared Statement of Michael Shepherd, M.D., 

Senior Physician, Office of Healthcare Inspections, 

Office of Inspector General, U.S. Department of Veterans Affairs 

Mr. Chairman and Members of the Committee, thank you for the opportunity to 

testify today on suicide prevention and the Office of Inspector General (OIG) report, 

Implementing the VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention. My statement today is based on that report as well as individual cases that 

the OIG has reviewed and reported on involving veteran suicides and accompanying 

mental health issues. In the process of these inspections, clinicians in our office 

have had the opportunity to meet with and listen to the concerns of surviving family 

members, and to witness the devastating impact that veteran mental health issues 

and suicide have had on their lives. 

The May 2007 OIG report reviewed initiatives from the Veterans Health Administration’s (VHA) mental health strategic plan pertaining to suicide prevention and 

assessed the extent to which these initiatives had been implemented. In prior testimony, we have stressed the importance of the need for VA to continue moving forward toward full implementation of suicide prevention initiatives from the mental 

health strategic plan. In terms of other changes VA could make, we would offer the 

following observations: 

Community Based Outreach—In our report, we noted that while several facilities 

had implemented innovative community based suicide prevention outreach programs, (e.g., facility presentations to New York City Police Department officers who 

are Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans, participation by mental health staff in local Spanish radio and television shows) the 

majority of facilities did not report community based linkages and outreach aimed 

at suicide prevention. In addition, less than 20 percent of facilities reported utilizing 

the Chaplain service for liaison and outreach to faith-based organizations in the 

community (e.g., inviting faith-based organizations in the area to a community 

meeting at a VA Medical Center (VAMC) to explain VHA services available, having 

a VA Chaplain accompany the OIF/OEF coordinator to post-deployment events in 

the community). Although facilities would need to tailor strategies to consider local 

demographics and resources, a system-wide effort at community based outreach appears prudent. 

Timeliness from Referral to Mental Health Evaluation—In our report we noted 

that while most facilities self-reported that three-fourths or more of those patients 

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with a moderate level of depression referred by primary care providers are seen 

within 2 weeks of referral, approximately 5 percent reported a significant 4–8 week 

wait. Because these patients are at risk for progression of symptom severity and 

possible development of suicidal ideation, Veterans Integrated Service Network 

leadership should work with facility directors to ensure that once referred, patients 

with a moderate level of depression and those recently discharged following hospitalization are seen in a timely manner at all VAMCs and Community Based Outpatient Clinics (CBOCs). 

Co-Occurring Combat Stress Related Illness and Substance Use—Substance use 

may contribute to the severity of a concurrent or underlying mental health condition 

such as major depression. The presence of alcohol may cause or exacerbate 

impulsivity and acute alcohol use is associated with completed suicide. In a recent 

study published in the Journal of the American Medical Association (JAMA), Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning from the Iraq War, Milliken et al., found that soldiers frequently reported alcohol concerns on the Post Deployment Health Assessment and 

Reassessments ‘‘yet very few were referred to alcohol treatment.’’ 

Regardless of why a patient begins to abuse alcohol, with frequent and/or excessive use, physiologic and psychologic drives develop until alcohol misuse ultimately 

takes on a life of its own that is independent of patient history and circumstance. 

Functional ability and quality of life become dually impacted by both underlying 

anxiety and depressive symptoms and co-morbid substance use issues. For patients 

with concurrent conditions, an effective treatment paradigm may require addressing 

the primacy of not only anxiety/depressive conditions but also of co-morbid substance use disorders. VA should consider augmenting services that address substance use disorders co-morbid with combat stress related illness for inclusion in a 

comprehensive program aimed at suicide prevention. 

Enhanced Access to Mental Health Care—Treatments for mental health problems 

may take time to show effect. For example, antidepressant medication, when indicated, may take several weeks to several months to effect symptom reduction or remission. For some patients, treatment may necessitate multiple visits that occur 

consistently over time and may entail multiple modalities including individual and/ 

or group evidence based psychotherapy, medication management, and/or readjustment counseling. Therefore, efforts that enhance patient access to appropriate treatment may help facilitate both patient engagement and the potential for treatment 

benefit. 

For example, ongoing enhancements in the availability of mental health services 

at CBOCs may help mitigate vocational and logistical challenges facing some veterans residing in more rural areas who otherwise may have to travel longer distances to appointments at the parent VAMC. 

In certain locations, the VA may want to consider expanding care during off-tour 

hours to increase the ability for some transitioning OIF/OEF veterans to access 

mental health treatment while minimizing interference with occupational, and/or 

educational obligations. This would be consistent with the recovery model for mental 

health treatment which emphasizes not only symptom reduction but also promotion 

and return to functional status. 

Facilitating Early Family Involvement—Mental health symptoms can have a significant and disruptive impact on family and domestic relationships. Relational discord has been cited as one factor associated with suicide in active duty military and 

returning veterans. In addition, some studies indicate that family involvement in a 

patient’s treatment may enhance the ability for some patients to maintain treatment adherence. VA should consider efforts to bolster early family participation in 

patient treatment. 

Coordination between VHA and Non-VHA Providers—When patients receive mental health treatment from both VHA and non-VHA providers, seamless communication becomes an increasingly complex challenge. This fragmentation of care is particularly worrisome in periods of patient destabilization or following discharge from 

a hospital or residential mental health program. VA’s Office of Mental Health Services should consider development of innovative methods or procedures to facilitate 

flow of information for patients receiving simultaneous treatment from VA and nonVA providers while adhering to relevant privacy statutes. In addition, VA’s Readjustment Counseling Service and VA’s Office of Patient Care Services should pursue 

further efforts to heighten communication and record sharing for patients receiving 

both counseling at Vet Centers and treatment at VAMCs and/or affiliated CBOCs. 

Mr. Chairman, thank you again for this opportunity to testify. I would be pleased 

to answer any questions that you or other Members of the Committee may have. 

f 

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CBS News 

Suicide Epidemic Among Veterans 

NEW YORK, Nov. 13, 2007 

(CBS) They are the casualties of wars you don’t often hear about—soldiers who 

die of self-inflicted wounds. Little is known about the true scope of suicides among 

those who have served in the military. 

But a 5-month CBS News investigation discovered data that shows a startling 

rate of suicide, what some call a hidden epidemic, Chief Investigative Reporter 

Armen Keteyian reports exclusively. 

‘‘I just felt like this silent scream inside of me,’’ said Jessica Harrell, the sister 

of a soldier who took his own life. 

‘‘I opened up the door and there he was,’’ recalled Mike Bowman, the father of 

an Army reservist. 

‘‘I saw the hose double looped around his neck,’’ said Kevin Lucey, another military father. 

‘‘He was gone,’’ said Mia Sagahon, whose soldier boyfriend committed suicide. 

Keteyian spoke with the families of five former soldiers who each served in Iraq— 

only to die battling an enemy they could not conquer. Their loved ones are now 

speaking out in their names. 

They survived the hell that’s Iraq and then they come home only to lose their life. 

Twenty-three-year-old Marine Reservist Jeff Lucey hanged himself with a garden 

hose in the cellar of this parents’ home—where his father, Kevin, found him. 

‘‘There’s a crisis going on and people are just turning the other way,’’ Kevin Lucey 

said. 

Kim and Mike Bowman’s son Tim was an Army reservist who patrolled one of 

the most dangerous places in Baghdad, known as Airport Road. 

‘‘His eyes when he came back were just dead. The light wasn’t there anymore,’’ 

Kim Bowman said. 

Eight months later, on Thanksgiving Day, Tim shot himself. He was 23. 

Diana Henderson’s son, Derek, served three tours of duty in Iraq. He died jumping off a bridge at 27. 

‘‘Going to that morgue and seeing my baby . . . my life will never be the same,’’ 

she said. 

Beyond the individual loss, it turns out little information exists about how widespread suicides are among these who have served in the military. There have been 

some studies, but no one has ever counted the numbers nationwide. 

‘‘Nobody wants to tally it up in the form of a government total,’’ Bowman said. 

Why do the families think that is? 

‘‘Because they don’t want the true numbers of casualties to really be known,’’ 

Lucey said. 

Sen. Patty Murray, D-Wash., is a Member of the Veterans’ Affairs Committee. 

‘‘If you’re just looking at the overall number of veterans themselves who’ve committed suicide, we have not been able to get the numbers,’’ Murray said. 

CBS News’ investigative unit wanted the numbers, so it submitted a Freedom of 

Information Act request to the Department of Defense asking for the numbers of 

suicides among all servicemembers for the past 12 years. 

Four months later, they sent CBS News a document, showing that between 1995 

and 2007, there were almost 2,200 suicides. That’s 188 last year alone. But these 

numbers included only ‘‘active duty’’ soldiers. 

CBS News went to the Department of Veterans Affairs, where Dr. Ira Katz is 

head of mental health. 

‘‘There is no epidemic in suicide in the VA, but suicide is a major problem,’’ he 

said. 

Why hasn’t the VA done a national study seeking national data on how many veterans have committed suicide in this country? 

‘‘That research is ongoing,’’ he said. 

So CBS News did an investigation—asking all 50 states for their suicide data, 

based on death records, for veterans and non-veterans, dating back to 1995. Fortyfive states sent what turned out to be a mountain of information. 

And what it revealed was stunning. 

In 2005, for example, in just those 45 states, there were at least 6,256 suicides 

among those who served in the armed forces. That’s 120 each and every week, in 

just one year. 

Dr. Steve Rathbun is the acting head of the Epidemiology and Biostatistics Department at the University of Georgia. CBS News asked him to run a detailed analysis of the raw numbers that we obtained from state authorities for 2004 and 2005. 

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It found that veterans were more than twice as likely to commit suicide in 2005 

than non-vets. (Veterans committed suicide at the rate of between 18.7 to 20.8 per 

100,000, compared to other Americans, who did so at the rate of 8.9 per 100,000.) 

One age group stood out. Veterans aged 20 through 24, those who have served 

during the war on terror. They had the highest suicide rate among all veterans, estimated between two and four times higher than civilians the same age. (The suicide 

rate for non-veterans is 8.3 per 100,000, while the rate for veterans was found to 

be between 22.9 and 31.9 per 100,000.) 

‘‘Wow! Those are devastating,’’ said Paul Sullivan, a former VA analyst who is 

now an advocate for veterans rights from the group Veterans For Common Sense. 

‘‘Those numbers clearly show an epidemic of mental health problems,’’ he said. 

‘‘We are determined to decrease veteran suicides,’’ Dr. Katz said. 

‘‘One hundred and twenty a week. Is that a problem?’’ Keteyian asked. 

‘‘You bet it’s a problem,’’ he said. 

Is it an epidemic? 

‘‘Suicide in America is an epidemic, and that includes veterans,’’ Katz said. 

Sen. Murray said the numbers CBS News uncovered are significant: ‘‘These statistics tell me we’ve really failed people that served our country.’’ 

Do these numbers serve as a wake-up call for this country? 

‘‘If these numbers don’t wake up this country, nothing will,’’ she said. ‘‘We each 

have a responsibility to the men and women who serve us aren’t lost when they 

come home.’’ 

f 

CBS News 

VA Hid Suicide Risk, Internal E-Mails Show 

April 21, 2008 

(CBS) The Department of Veterans Affairs came under fire again Monday, this 

time in California Federal court where it’s facing a national lawsuit by veterans 

rights groups accusing the agency of not doing enough to stem a looming mental 

health crisis among veterans. As part of the lawsuit, internal e-mails raise questions 

as to whether top officials deliberately deceived the American public about the number of veterans attempting and committing suicide. CBS News chief investigative 

correspondent Armen Keteyian reports. 

In San Francisco Federal court Monday, attorneys for veterans’ rights groups accused the U.S. Department of Veteran’s Affairs of nothing less than a cover-up— 

deliberately concealing the real risk of suicide among veterans. 

‘‘The system is in crisis and unfortunately the VA is in denial,’’ said veterans 

rights attorney Gordon Erspamer. 

The charges were backed by internal e-mails written by Dr. Ira Katz, the VA’s 

head of Mental Health. 

In the past, Katz has repeatedly insisted while the risk of suicide among veterans 

is serious, it’s not outside the norm. 

‘‘There is no epidemic in suicide in VA,’’ Katz told Keteyian in November. 

But in this e-mail to his top media adviser, written two months ago, Katz appears 

to be saying something very different, stating: ‘‘Our suicide prevention coordinators 

are identifying about 1,000 suicide attempts per month among veterans we see in 

our medical facilities.’’ 

Katz’s e-mail was written shortly after the VA provided CBS News data showing 

there were only 790 attempted suicides in all 2007—a fraction of Katz’s estimate. 

‘‘This 12,000 attempted suicides per year shows clearly, without a doubt, that 

there is an epidemic of suicide among veterans,’’ said Paul Sullivan of Veterans for 

Common Sense. 

And it appears that Katz went out of his way to conceal these numbers. 

First, he titled his e-mail: ‘‘Not for the CBS News Interview Request.’’ 

He opened it with ‘‘Shh!’’—as in keep it quiet—before ending with ‘‘Is this something we should (carefully) address—before someone stumbles on it?’’ 

On Monday, CBS News showed the e-mail to Rep. Bob Filner, D-Calif., who chairs 

the House Committee on Veterans Affairs. 

‘‘This is disgraceful. This is a crime against our Nation, our Nation’s veterans,’’ 

Filner told CBS News. ‘‘They do not want to come to grips with the reality, with 

the truth.’’ 

And that’s not all. 

Last November when CBS News exposed an epidemic of more than 6,200 suicides 

in 2005 among those who had served in the military, Katz attacked our report. 

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‘‘Their number is not, in fact, an accurate reflection of the rate,’’ he said last November. 

But it turns out they were, as Katz admitted in this e-mail, just three days later. 

He wrote: there ‘‘are about 18 suicides per day among America’s 25 million veterans.’’ 

That works out to about 6,570 per year, which Katz admits in the same e-mail, 

‘‘is supported by the CBS numbers.’’ 

In an e-mail late Monday to CBS News, Katz wrote that the reason the numbers 

were not released was due to questions about the consistency and reliability of the 

findings—and that there was no public cover up involved. 

f 

CRS REPORT TO CONGRESS 

Suicide Prevention Among Veterans 

May 5, 2008 

Order Code RL34471 

By Ramya Sundararaman, Sidath Viranga Panangala, and Sarah A. Lister 

Domestic Social Policy Division, Congressional Research Service 

CONTENTS 

• Summary 

• Introduction 

• Data and Data Systems for Tracking Suicide 

• Suicide in the U.S. General Population 

• Incidence of Suicide 

• Risk and Protective Factors 

• Suicide Among Veterans 

• Incidence of Suicide 

• Risk and Protective Factors 

• The Effects of PTSD, TBI, and Depression on Suicide Risk 

• Congressional Action 

• VA’s Suicide Prevention Efforts 

• Mental Health Strategic Plan 

• Mental Health Research 

• Suicide Awareness 

• Screening 

• Suicide Prevention Hotline 

• Funding for Suicide Prevention 

• Conclusion 

List of Tables 

• Table 1. U.S. Death Rates for Suicide, by Age, 2004 

Summary 

Numerous news stories in the popular print and electronic media have documented suicides among servicemembers and veterans returning from Operation 

Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). In the United States, 

there are more than 30,000 suicides annually. Suicides among veterans are included 

in this number, but it is not known in what proportion. There is no nationwide system for surveillance of suicide specifically among veterans. Recent data show that 

about 20% of suicide deaths nationwide could be among veterans. It is not known 

what proportion of these deaths are among OIF/OEF veterans. 

Veterans have a number of risk factors that increase their chance of attempting 

suicide. These risk factors include combat exposure, post-traumatic stress disorder 

(PTSD) and other mental health problems, traumatic brain injury (TBI), poor social 

support structures, and access to lethal means. 

Several bills addressing suicide in veterans have been introduced in the 110th 

Congress. On November 5, 2007, the Joshua Omvig Veterans Suicide Prevention Act 

(P.L. 110–110) was signed into law, requiring the Department of Veterans Affairs 

(VA) to establish a comprehensive program for suicide prevention among veterans. 

More recently, the Veterans Suicide Study Act (S. 2899) was introduced. This bill 

would require the VA to conduct a study, and report to Congress, regarding suicides 

among veterans since 1997. 

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1Ken Fuson and Jennifer Jacobs, ‘‘Iowans Lauded for Anti-suicide Efforts,’’ The Des Moines 

Register, January 26, 2008; Dana Priest, ‘‘Soldier Suicides at Record Level,’’ Washington Post, January 31, 2008, Page A01; ‘‘Soldier, After Bipolar Treatment and Suicide Attempts, Sent Back 

to War Zone,’’ Editor & Publisher, February 11, 2008; ‘‘Suicide Epidemic Among Veterans—A 

CBS News Investigation Uncovers a Suicide Rate for Veterans Twice That of Other Americans,’’ 

aired November 13, 2007. OEF, which began in October 2001, conducts combat operations in 

Afghanistan and other locations. OIF, which began in March 2003, conducts combat operations 

in Iraq and other locations. 2 Veterans for Common Sense and Veterans United for Truth, Inc., v. James B. Peake, Secretary of Veterans Affairs, et al., Plaintiffs Trial Brief, Case No. C–07–3758–SC, filed April 17, 

2008. 3Within the context of the VA, a veteran is defined as a ‘‘person who served in the active 

military, naval, or air service, and who was discharged or released there from under conditions 

other than dishonorable.’’ [38 USC § 101(2); 38 CFR § 3.1(d)]. The VA largely bases its determination of veteran status upon military department service records. 4 In reference to fatal suicides, the public health community prefers to use the term ‘‘completed,’’ rather than ‘‘committed’’ or ‘‘successful,’’ to recognize the frequent association of suicide 

with mental illness, and reduce the accompanying stigma. 5For more information, see Centers for Disease Control and Prevention (CDC), Mortality Data 

from the National Vital Statistics System, at http://www.cdc.gov/nchs/deaths.htm, visited May 

2, 2008. 

The VA has carried out a number of suicide prevention initiatives, including establishing a national suicide prevention hotline for veterans, conducting awareness 

events at VA medical centers, and screening and assessing veterans for suicide risk. 

This report discusses data sources and systems that can provide information 

about suicides in the general population and among veterans, and known risk and 

protective factors associated with suicide in each group. It also discusses suicide prevention efforts by the VA. It does not discuss Department of Defense (DoD) activities, or VA’s treatment of risk factors for suicide, such as depression, PTSD, and 

substance abuse. 

This report will be updated when legislative activity warrants. 

————— 

Introduction 

Considerable public attention has been drawn toward the mental healthcare 

needs of veterans, especially those returning from combat in Iraq and Afghanistan. 

Numerous news stories in the popular print and electronic media have documented 

suicides among servicemembers and veterans returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).1 Some veterans advocacy 

groups have filed a class-action lawsuit claiming that the Department of Veterans 

Affairs (VA) is not providing adequate and timely access to mental healthcare, and 

that this has led to an ‘‘epidemic of suicides.’’ 2

However, most often the data cited in these press reports do not differentiate between suicides among veterans and active duty servicemembers.3 It is important to 

make this distinction, because two separate healthcare systems—at the VA and the 

Department of Defense (DoD), respectively—are responsible for providing mental 

healthcare to these two distinct populations. This report explains the difficulties in 

determining the incidence of suicide among veterans, summarizes what is known 

about suicides in the general population and among veterans, and discusses known 

risk and protective factors associated with suicide in each group. It also discusses 

recent congressional action to address suicide among veterans, and suicide prevention efforts by the VA. The report does not discuss DoD activities, or VA’s treatment 

of risk factors for suicide, such as depression, post-traumatic stress disorder (PTSD), 

and substance abuse. 

Data and Data Systems for Tracking Suicide 

Suicide is the act of intentionally ending one’s life, attempted suicide is an effort 

that does not have a fatal outcome, and suicidal ideation is thinking about or wanting to end one’s life. Because completed (versus attempted) suicide results in death, 

national statistics on suicide come from death certificate data.4 These data are collected by state and territorial health officials, under their authority, and are voluntarily reported to the Centers for Disease Control and Prevention’s (CDC’s) National 

Vital Statistics System. The CDC analyzes the data and publishes information on 

numbers and rates of death, and important trends, in the United States.5 The CDC 

also publishes a U.S. standard death certificate, which states and territories can 

modify. Most U.S. deaths are not investigated by government officials. Possible suicprice-sewell on PROD1PC72 with HEARING

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6See CDC, National Violent Death Reporting System, at http://www.cdc.gov/ncipc/profiles/ 

nvdrs/default.htm. 7This definition captures current and former U.S. military servicemembers. 

8See CDC, National Death Index, at http://www.cdc.gov/nchs/ndi.htm. 

9Zivin et al., ‘‘Suicide Mortality among Individuals Receiving Treatment for Depression in the 

Veterans Affairs Health System: Associations with Patient and Treatment Setting Characteristics,’’ American Journal of Public Health, Vol. 97, No. 12, pp. 2193–8, December 2007, hereafter 

referred to as Zivin et al., study of depression and suicide in veterans. 

cides may be investigated, however, pursuant to state and territorial authorities. To 

the extent that a death is recognized as a suicide, the standard death certificate provides the means to report suicide as the manner of death, but it has limited options 

for noting other information that may be relevant to the suicide. 

In 2003, CDC launched the National Violent Death Reporting System (NVDRS), 

an active surveillance system that provides detailed information about the circumstances of violent deaths, including suicide.6 The NVDRS augments death certificate data by linking it to death investigation reports filed by coroners, medical 

examiners, and law enforcement officials. These added layers of information allow 

the NVDRS to identify suicide risk factors, such as depression; to gather additional 

information, such as toxicology results; and to more reliably capture information 

that could have been, but was not, completed on the standard death certificate. At 

this time, the NVDRS is not in operation nationwide, but only in 17 states, and 

NVDRS data might not be generalizable to the entire U.S. population. Also, because 

protocols for death investigation vary from one state to the next, NVDRS data might 

not be comparable between those states in which it is in operation. CDC’s goal is 

to expand the system to all 50 states, all U.S. territories, and the District of Columbia, and to continue efforts to standardize data collection and analysis across states. 

At this time, there is no nationwide system for surveillance (i.e., tracking) of suicide among all veterans. As with all suicides in civilian jurisdiction, suicides among 

veterans may be investigated, and the death certificates completed, by state and territorial authorities. Unless a veteran’s suicide occurs in a VA facility, opportunities 

for the VA to become aware of the incident may be limited. Three approaches are 

being used to track the incidence of suicide among veterans, though each of them 

has serious shortcomings. 

First, CDC’s standard death certificate allows officials to note if a decedent has 

ever served 7 in the U.S. Armed Forces. However, the fact that a decedent is a veteran is not always known when the certificate is completed. Although suicides 

among veterans are a part of total national suicide statistics, it is not known what 

proportion of that total is made up of veterans. 

Second, VA data may be linked to CDC’s vital statistics data through the National 

Death Index (NDI). This CDC data system allows authorized researchers to link national death data to other data systems, identifying the fact that an individual had 

died of suicide, and that a death certificate has been filed.8 This would allow the 

VA to identify suicide deaths among its enrollees. (Subsequent research steps are 

cumbersome. For example, researchers typically must contact state officials to access the actual death certificates.) The NDI is not an ongoing data linkage that 

would constitute surveillance for suicide. It can be used, however, to support special 

studies by linking specific data sets. For example, researchers from the VA and the 

University of Michigan conducted a study in which they linked data from VA’s National Registry for Depression (NARDEP) to the NDI, allowing VA to match its patient registry to certified suicide deaths even when the decedent’s veteran status 

had not been noted on the death certificate.9 However, because only about one-third 

of veterans receive their healthcare from the VA, using VA health systems data for 

linkage would not capture the complete experience of suicide among veterans. 

Third, the NVDRS resolves many of the problems discussed above. Through ongoing active surveillance, NVDRS substantially improves the likelihood that a suicide 

victim’s veteran status will be captured, and it provides additional useful information about suicide incidents. But NVDRS is in operation in only 17 states. Though 

CDC intends it to become a nationwide system, expansion would depend on appropriations. Congress first provided funding for NVDRS in FY 2002 and has expressed 

support for the program in annual appropriations report language. The program has 

not received a specified appropriation in recent years, but rather is funded through 

CDC’s budget for intentional injury prevention and control. 

Suicide in the U.S. General Population 

There are risk factors that increase the likelihood that someone will attempt suicide, and protective factors that decrease that likelihood. This section provides some 

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10 Unless otherwise noted, information in this section is drawn from CDC: ‘‘Suicide, Facts at 

a Glance,’’ Summer 2007, and ‘‘Understanding Suicide, Fact Sheet,’’ 2006, at http://www.cdc.gov/ 

ncipc/dvp/suicide/; and ‘‘Surveillance for Violent Deaths—National Violent Death Reporting System, 16 States, 2005,’’ MMWR, vol. 57(SS03), April 11, 2008, hereafter referred to as NVDRS 

2005 report, at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5703a1.htm. 11Testimony of Michael Shepherd, M.D., Office of Healthcare Inspections, Office of Inspector 

General, Department of Veterans Affairs, in U.S. Congress, House Committee on Veterans’ Affairs, hearing on Stopping Suicides: Mental Health Challenges Within the Department of Veterans Affairs, December 12, 2007. 12Suicide Prevention Resource Center, ‘‘Risk and Protective Factors for Suicide,’’ at http:// 

www.sprc.org/library/srisk.pdf, visited April 30, 2008. 

context for suicide among veterans by discussing the incidence, and risk and protective factors, for suicide in the U.S. general population.10

Incidence of Suicide 

Suicide is a serious public health problem in the United States. According to CDC, 

there were more than 32,000 suicide deaths in the United States in 2004, making 

it the 11th leading cause of death that year. On average, there are four suicides 

among males for each one among females. Use of firearms is the most common 

method of suicide among males, while poisoning is the most common method among 

females. Suicide is the second leading cause of death among 25–34 year olds, and 

the third leading cause of death among 15–24 year olds. Although suicide is a leading cause of death in younger adults, the rate of suicide (number of suicides within 

the age group per 100,000 resident population in the age group) is actually highest 

in individuals aged 45 or older. Table 1 presents suicide rates across age groups 

in the United States for 2004, as published by CDC. It is important to note that 

except in the youngest age group, these rates may, and probably do, include suicides 

among veterans, though in proportions that are not known. 

Table 1. U.S. Death Rates for Suicide, by Age, 2004 

Age Group 5–14 

years 

15–24 

years 

25–44 

years 

45–64 

years 

65 years 

and over 

All age 

groupsa

Suicide rate 0.7 10.3 13.9 15.4 14.3 10.9 

ASource: CDC, death rates for suicide, according to sex, race, Hispanic origin, and age: selected years, 

1950–2004, ‘‘Health, United States, 2007,’’ Table 46, at http://www.cdc.gov/nchs/data/hus/hus07.pdf. ANotes: CDC does not calculate rates based on small numbers of suicides among those younger than five 

years of age, as such rates are not statistically reliable. In the source above, CDC also published rates for subintervals of the age intervals presented here (e.g., for those aged 25–34 years and 35–44 years). 

Aa. This rate is age-adjusted, calculated using the year 2000 standard population. 

There are no official national statistics on attempted suicide (i.e., attempts that 

were not fatal), but it is generally estimated that there are 25 attempts for each 

death by suicide. Also, it is reported that there are three suicide attempts among 

females for every one among males. 

Risk and Protective Factors 

No single cause or factor leads to suicide. It is a ‘‘final common outcome with multiple potential antecedents, precipitants, and underlying causes.’’ 11 A number of factors are known to increase or decrease the likelihood that an individual will attempt 

suicide. Factors that increase this likelihood are called risk factors. Risk factors 

exist at multiple levels, involving individual, family, community, and societal factors. Conversely, factors that decrease a person’s inclination to attempt suicide are 

called protective factors, which also exist at multiple levels. It is important to note 

that none of these factors in isolation is known to cause or prevent suicide. 

The single best predictor of an increased risk of suicide is a history of a prior suicide attempt. Other risk factors for suicide in the general population include certain 

mental illnesses such as depression, alcohol and substance abuse, history of trauma 

or abuse, family history of suicide, job or financial stress, the stigma associated with 

seeking mental healthcare, barriers to healthcare access, and easy access to lethal 

means. Protective factors include strong family or community connections; accessible 

and effective clinical care; skills in problem solving, conflict resolution, and nonviolent handling of disputes; and cultural and religious beliefs that discourage suicide.12

Suicide Among Veterans 

In the absence of national surveillance for suicide among veterans, information is 

limited to the findings of special epidemiological studies and surveys. These vary 

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13 NVDRS 2005 report. The definition ‘‘current and former military personnel’’ is likely to include both current military personnel and veterans, but the publication does not provide information about each group separately, or about whether such separate information is available. 14The remaining small number of decedents were ‘‘married but separated,’’ ‘‘single, not otherwise specified,’’ or their marital status was not known. These findings were not cross-tabulated 

by age. 15Zivin et al., study of depression and suicide in veterans. The authors used CDC’s National 

Death Index to link NARDEP registrants with death certificate data, in order to identify registrants who had died, and determine that they died of suicide, during the study period. 16The authors cited only one study on which to base this comparison, though, which likely 

reflects the limited availability of studies in groups that are meaningful for comparison. It is 

not clear whether the comparison group included or excluded veterans. 17Testimony of Ira Katz, M.D., Ph.D., Deputy Chief Patient Care Services Officer, Office of 

Mental Health, Veterans Health Administration, Department of Veterans Affairs in U.S. Congress, House Committee on Veterans’ Affairs, Stopping Suicides: Mental Health Challenges 

Within the U.S. Department of Veterans Affairs, hearings, 110th Cong., 1st sess., December 12, 

2007. 

considerably in their design and in the sub-population of veterans studied, and they 

often yield conflicting results. 

It is tempting to make comparisons between these studies, and with information 

about suicide in the general population. Such comparisons are often made, but they 

are not necessarily valid. Among other things, data about suicides in the general 

population includes suicides among veterans. Information about suicide in groups 

that exclude veterans is scant, as is information about the extent to which data for 

veterans may skew the data for the general population, if at all. An additional problem in interpreting the findings of these special studies is that they are often conducted on populations of veterans who are receiving treatment for suicide risk factors. On the one hand, this makes it difficult to determine whether study findings 

reflect the effects of risk factors, or the effects of interventions. On the other hand, 

it indicates that efforts to develop systematic surveillance of suicide among veterans 

may, with careful attention to design, also provide the means to evaluate the effectiveness of prevention and treatment programs. This section discusses the findings 

of some key studies of suicide among veterans. 

Incidence of Suicide 

The true incidence of suicide among veterans is not known. This section discusses 

information from two recent published studies that yield a partial picture of the burden of suicide in this group. 

In 2005, the NVDRS identified 1,821 suicides among former or current military 

personnel, comprising 20% of all suicides, in the 16 states in which the system was 

operational that year.13 CDC’s published findings about these 1,821 decedents include the following: 

• 1,765 (96.9%) were male. • 1,415 (77.7%) were 45 years of age or older. • The most common method used was firearms (67.9%), followed by poisoning 

(12.7%), and hanging/strangulation/suffocation (11.5%). • 47.2% were married, 25.0% were divorced, 13.0% were widowed, and 14.0% 

were never married.14

Researchers from the VA and the University of Michigan conducted a cohort study 

of 807,694 veterans who were diagnosed with depression in the VA health system, 

and registered in the VA’s National Registry for Depression (NARDEP), between 

1999 and 2004.15 During the study period, 1,683 (0.21%) of the veterans in this 

high-risk group committed suicide. The researchers calculated a rate of 88.25 suicides per 100,000 person-years in this group, seven to eight times higher than the 

rate in the general population for the same time period. They noted that this rate 

was similar, though, to a more relevant comparison, namely, to suicides among 

those in the general population who were depressed.16 They also found the rate 

among the group of veterans studied to be highest among those who were younger 

than 45 years of age, in contrast with the age trend in the general population. 

In December 2007, VA testified that it had identified 144 known suicides among 

OIF/OEF veterans from the time the conflicts began through the end of 2005, and 

that this number translated into a rate that is not statistically different from the 

rate for age, sex, and race matched individuals from the general population. These 

data have not been published.17

Risk and Protective Factors 

While there have been a number of studies to identify risk and protective factors 

for suicide in the general population, few studies have looked at factors specific to 

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18Lambert et al., ‘‘Suicide Risk Factors among Veterans: Risk Management in the Changing 

Culture of the Department of Veterans Affairs,’’ Journal of Mental Health Administration, Vol. 

24, No. 3, pp. 350–8, Summer 1997. 19Lish et al., ‘‘Suicide Screening in a Primary Care Setting at a Veterans Affairs Medical Center,’’ Psychosomatics, Vol. 37, No. 5, pp. 413–24, 1996. 20 NVDRS 2005 report. This group is a subset of the 1,821 former or current military personnel whose suicides were recorded in NVDRS in 2005, for whom these additional types of information were collected. 21Zivin et al., study of depression and suicide in veterans. 22Tanelian and Jaycox, ‘‘Invisible Wounds of War,’’ RAND, 2008, at http://RAND.org/pubs/ 

monographs/2008/RAND_MG720.1.pdf, visited April 28, 2008. 

veterans. In the general population, suicide risk factors include male gender; older 

age; diminished psycho-social support (e.g., homelessness or unmarried status); 

availability and knowledge of firearms; and the co-existence of medical and psychiatric conditions. This profile describes a large portion of the veteran patient population, making suicide risk management particularly challenging in the VA healthcare system.18 A study that screened 703 patients from a general medical outpatient 

clinic at a VA hospital found that 7.3% of the patients had suicidal ideation.19

Younger and white patients were found to be at increased risk. The risk was higher 

in patients with self-described fair or poor mental health, a history of mental health 

treatment, and fair or poor perceived physical health. When major depression was 

controlled for, anxiety and substance abuse disorders continued to show an association with suicidal ideation. 

CDC’s NVDRS data identified the following associated circumstances among a 

group of 1,622 former or current military personnel who died by suicide in 2005: 20

• Although almost half of them (47.2%) were depressed at the time of death, only 

about a fourth (26.7%) were receiving mental health treatment. • 17.2% had an alcohol problem, and 7.7% had a problem with other substances. • 24.5% had a problem with an intimate partner. • 38.4% had a physical health problem. • 28.0% had experienced an acute crisis during the prior two weeks. • 33.9% had left a suicide note, 13.3% had made a previous suicide attempt, and 

29.0% had disclosed their intent to commit suicide with enough time for someone to have intervened. 

The VA/University of Michigan study of suicide among veterans with depression 

found that having a service-connected disability was associated with a lower risk of 

suicide in this group.21 The authors suggest that greater access to VA health facilities and regular compensation payments may explain the protective effect. 

The Effects of PTSD, TBI, and Depression on Suicide Risk 

This section describes three suicide risk factors that are common among veterans: 

Post-traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), and depression. PTSD and TBI are common consequences of war, with distinct symptoms, 

treatment modalities, and long-term effects. PTSD has been recognized in various 

forms throughout military history. It is an anxiety disorder, with symptoms of varying severity, that can occur following experiences, such as military combat, in which 

grave physical injury occurred or was threatened. People who suffer from PTSD 

often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged. TBI occurs when a sudden physical trauma 

causes damage to the brain. Improvised explosive devices (IEDs), which have been 

used extensively in the current conflict in Iraq, can cause TBI, sometimes in the 

absence of obvious external signs of injury. Symptoms of TBI can be mild, moderate, 

or severe, depending on the extent of the brain injury. When symptoms of TBI or 

PTSD are mild, they may go undiagnosed, or be confused with conditions with similar symptoms, such as other mental illnesses, including depression, or substance use 

disorders. Either PTSD or TBI may co-occur with depression or substance abuse. Finally, some veterans have both a TBI and PTSD. 

In April 2008, the RAND Corporation published a study of mental health problems in servicemembers and veterans.22 From their review of the literature, the authors found that in the general population, depression, PTSD, and TBI are each 

independent risk factors for suicide. More limited information from studies of servicemembers or veterans generally shows the same effect of these three risk factors 

in specific groups that were studied. This information also typically shows trends 

comparable to those in the general population with respect to other risk factors for 

suicide, though the demonstrated effects of interactions of these factors with depression, PTSD and TBI may differ. For example, studies have found that while males 

are at greater risk of death from suicide than are females, the effects that deprescprice-sewell on PROD1PC72 with HEARING

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23Zivin et al., study of depression and suicide in veterans. 24The Joshua Omvig Veterans Suicide Prevention Act is named for a veteran who completed 

suicide on December 22, 2005. 25 Codified at 38 USC § 1720F. For a detailed legislative history of PL 110–110, see H.Rept. 

110–55 and S.Rept. 110–132. 26See CRS Report RL34371, ‘‘Wounded Warrior’’ and Veterans Provisions in the FY 2008 National Defense Authorization Act, by Sarah A. Lister, Sidath Viranga Panangala, and Christine 

Scott. 27Drawn from the Department of Veterans Affairs, Report to Congress, P.L. 110–110, Comprehensive Program for Suicide Prevention Among Veterans, February 2008. 

sion, PTSD and TBI have on increasing this risk is greater in females. Among the 

general population, substance abuse, prior nonfatal suicide attempts, severity of 

PTSD symptoms, and certain types of TBI are more predictive for suicide, and may 

signal areas of greater suicide risk among military and veterans populations as well. 

Researchers also found that combat exposure increases the risk of suicide, as well 

as the likelihood of PTSD, which itself also increases the risk of suicide. 

The VA/University of Michigan study of suicide among veterans with depression 

found that PTSD was associated with a lower risk of suicide in this group.23 The 

authors suggest that this unexpected finding may reflect the effect of treatment for 

PTSD, rather than a protective effect of PTSD itself. 

Congressional Action 

In the 109th Congress, two measures (H.R. 5771 and S. 3808) were introduced 

regarding the prevention of suicide among veterans. However, these bills did not see 

further legislative action. 

In the 110th Congress, the Joshua Omvig Veterans Suicide Prevention Act (H.R. 

327) was introduced in the House, and a companion version (S. 479) was introduced 

in the Senate.24 The House passed H.R. 327 on March 21, 2007, and the Senate 

passed the House measure with an amendment on September 27. The bill was 

signed into law (P.L. 110–110) on November 5, 2007.25 The act, among other things, 

requires the VA to establish a comprehensive program for suicide prevention among 

veterans. In carrying out this comprehensive program, the VA must designate a suicide prevention counselor at each VA medical facility. Each counselor is required to 

work with local emergency rooms, police departments, mental health organizations, 

and veterans service organizations to engage in outreach to veterans. The act also 

requires the VA to provide for research on best practices for suicide prevention 

among veterans, and requires the VA Secretary to provide for outreach and education for veterans and their families, with special emphasis on providing information to veterans of OIF and OEF. The act requires VA to provide for the availability 

of 24-hour mental healthcare for veterans and to establish a 24-hour hotline for veterans to call if needed. 

Also in the 110th Congress, the National Defense Authorization Act for Fiscal 

Year 2008 (P.L. 110–181) requires the Secretaries of DoD and VA to develop a comprehensive care and transition policy for servicemembers who are recovering from 

serious injuries or illnesses related to their military service, and to specifically address the risk of suicide among these individuals in developing the required policy.26

More recently, the Veterans Suicide Study Act (S. 2899) was introduced. This 

measure would require the VA to study and report to Congress regarding suicides 

that have occurred among veterans since 1997. In carrying out this study, the VA 

Secretary would have to coordinate with the Secretary of Defense, Veterans Service 

Organizations, the CDC, and state public health offices and veterans agencies. 

VA’s Suicide Prevention Efforts 27

In response to legislation and congressional oversight, the VA has initiated several suicide prevention activities. Following is a summary of major activities. 

Mental Health Strategic Plan 

In 2004, the VA developed the Mental Health Strategic Plan (MHSP), which 

aimed to present a new approach to mental healthcare, to focus on recovery rather 

than pathology, and to integrate mental healthcare into overall healthcare for veteran patients. This 5-year action plan, with more than 200 initiatives, includes 

timetables and responsible offices identified for each action item. A number of these 

action items are specifically aimed at the prevention of suicide. In 2006, following 

a request by the House Committee on Veterans Affairs, the VA’s Inspector General 

(IG) undertook an assessment of VA’s progress in implementing the MHSP initiacprice-sewell on PROD1PC72 with HEARING

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28Department of Veterans Affairs, Office of Inspector General, ‘‘Implementing VHA’s Mental 

Health Strategic Plan Initiatives for Suicide Prevention,’’ Report No. 06–03706–126, 2007. 29For more information on screening tools and their effectiveness, see CRS Report RS22647, 

Screening for Youth Suicide Prevention, by Ramya Sundararaman. 30The PDHRA (DD Form 2900) includes questions about feeling down, depressed, or hopeless, 

the occurrence of nightmares, relationship issues with family and friends, and increased alcohol 

use. 

tives for suicide prevention, and provided recommendations.28 The IG’s findings revealed that MHSP initiatives pertaining to 24-hour crisis availability, outreach, referral, and development of methods for tracking veterans at risk have been implemented in multiple facilities, but not yet systemwide. Initiatives focused on the development of methods for screening, assessment of veterans at risk, emerging best 

practice treatment interventions, education of VA health providers, and an electronic suicide prevention database have been piloted or are in the process of being 

piloted at selected facilities. 

Mental Health Research 

VA’s Mental Illness Research, Education and Clinical Center (MIRECC) at Denver, Colorado, and the Center of Excellence in Mental Health and PTSD at 

Canandaigua, New York, have been specifically focusing on research related to suicide prevention. According to the VA, ongoing studies at these centers are studying 

suicide risk factors, validation of suicide ideation screening instruments, quality of 

mental healthcare and its relationship to suicide prevention, and risk factors for suicide as it relates to depression. 

Suicide Awareness 

In April 2007, VA held its first Suicide Prevention Awareness Day at all VA medical centers (VAMCs). The program included recognizing risk factors for suicide, and 

proper protocols for responding to crisis situations. VA held its second Suicide Prevention Awareness Day in September 2007. The program consisted of required 

training for all staff on general principles of suicide prevention, and the use of the 

national VA Suicide Prevention Hotline (see below). 

VA has also appointed Suicide Prevention Coordinators who are located at each 

VA medical center. They were appointed in response to P.L. 110–110, which required VA to appoint suicide prevention counselors in each VA medical facility. The 

primary function of these coordinators is to support the identification of patients at 

high risk for suicide, and to ensure that their monitoring and care are intensified. 

Furthermore, they are involved in training and education, both within the VA and 

in the community. All the coordinators are licensed mental health professionals. 

Screening 

A screening program aims to identify individuals who have mental or emotional 

problems that increase their risk for suicide.29 VA has implemented a policy to 

screen all OEF/OIF veterans for depression, PTSD, and alcohol abuse upon their initial visit to VA medical centers or clinics. Furthermore, screening for depression and 

alcohol abuse is required on an annual basis for all veterans, and screening for 

PTSD is required annually for the first five years after enrollment, and every five 

years thereafter. Veterans who screen positive for one of these conditions are required to receive a follow-up clinical evaluation that considers both the condition(s) 

related to the positive screen, and the risk of suicide. When this process confirms 

the presence of a mental disorder or suicide risk, veterans are offered mental health 

treatment. When there is a referral or request for mental health services, veterans 

must receive an initial evaluation within 24 hours. If this evaluation identifies an 

urgent need, treatment is to be provided immediately. Otherwise, veterans must receive a full diagnostic and treatment planning evaluation and the initiation of care 

within two weeks. 

In addition, the DoD administers a post-deployment health reassessment 

(PDHRA) 90–180 days after a servicemember’s return from deployment, to identify 

health concerns, with an emphasis placed on screening for mental health conditions 

that may have emerged since returning home. Information gathered during this assessment helps DoD identify servicemembers who require referrals for further evaluation.30 The Government Accountability Office (GAO) has stated that DoD shares 

information gathered through the PDHRA with the VA. According to GAO, ‘‘VA officials obtain PDHRA information about servicemembers referred to VA and individual servicemembers’ [PDHRA] when they access VA healthcare. Each month, VA 

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31 U.S. Government Accountability Office (GAO), DoD’s Post-Deployment Health Reassessment, 

GAO–08–181R, January 25, 2008, p.7. 32 VA is using the national suicide prevention hotline to provide this service to veterans. 33Testimony of Ira Katz, M.D., Ph.D., Deputy Chief Patient Care Services Officer, Office of 

Mental Health, Veterans Health Administration, Department of Veterans Affairs in U.S. Congress, House Committee on Veterans’ Affairs, Stopping Suicides: Mental Health Challenges 

Within the U.S. Department of Veterans Affairs, hearings, 110th Cong., 1st sess., December 12, 

2007. 34Department of Veterans Affairs, Report to Congress, P.L. 110–110, Comprehensive Program 

for Suicide Prevention Among Veterans, p. 7, February 2008. 

ferred, including servicemembers referred to VA facilities.’’ 31 However, it is unclear 

at this time if VA uses this information to specifically screen those who may be potentially at risk of suicide. 

Suicide Prevention Hotline 

The VA has also partnered with the Lifeline Program, a grantee of the Substance 

Abuse and Mental Health Services Administration (SAMHSA), of the Department 

of Health and Human Services (HHS), to develop a VA suicide prevention hotline. 

Those who call 1–800–273–TALK are asked to press ‘‘1’’ if they are a veteran, or 

are calling about a veteran.32 When they do so, they are connected directly to VA’s 

hotline call center, where they speak to a VA mental health professional with realtime access to the veteran’s medical records. The responders at the VA suicide prevention hotline have received American Association of Suicidology (AAS) 

credentialing and certification. 

In emergencies, the hotline contacts local emergency resources such as police or 

ambulance services to ensure an immediate response. In other cases, after providing 

support and counseling, the hotline transfers care to the suicide prevention coordinator at the nearest VAMC for follow-up care. 

From October 7 to November 10, 2007, 1,636 veterans and 311 family members 

or friends called the VA suicide prevention hotline. These calls led to 363 referrals 

to suicide prevention coordinators and 93 rescues involving emergency services.33

Funding for Suicide Prevention 

According to VA estimates, in FY 2008, spending for the suicide prevention program will include $970,000 to establish the suicide prevention hotline; $1.97 million 

for the Center of Excellence in Canandaigua, New York; $2.20 million for the Mental Illness Research, Education and Clinical Center in Denver, Colorado; $90,000 for 

the Serious Mental Illness Research, Education and Clinical Center for monitoring 

of suicide rates and risk factors; and $14.32 million for Suicide Prevention Coordinators.34

Conclusion 

There has been considerable recent interest in the burden of suicide among veterans, in particular those who have recently returned from military service in Operation Iraqi Freedom and Operation Enduring Freedom. This interest has thrown a 

spotlight on the fact that there is not, at this time, a system of surveillance for suicide among veterans. 

Despite recent interest in comparing suicide rates between veterans and the general population, this may not be the most useful comparison. In numerous ways that 

affect their suicide risk, veterans are not like the general population. Also, the VA 

has an interest in decreasing the burden of suicide among veterans, whether this 

burden exceeds that of the general population or not. What may be more meaningful, and more important to achieve, is the establishment of data systems that support a more robust and reliable understanding of suicide among veterans. The ideal 

systems would describe a clear baseline, and provide a means to track changes 

going forward—with respect to such things as risk and protective factors, and the 

effects of treatment—in order to know which interventions work, and where to target them. 

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Department of Veterans Affairs 

Under Secretary for HealthAddress 

Washington, DC. 

In Reply Refer To: 

Dear Veteran, 

If you’re experiencing an emotional crisis and need to talk with a trained VA professional, the National Suicide Prevention toll-free hotline number, 1–800– 

273–TALK (8255), is now available 24 hours a day, seven days a week. You will 

be immediately connected with a qualified and caring provider who can help. 

Here are some suicide warning signs: 

1. Threatening to hurt or kill yourself 

2. Looking for ways to kill yourself 

3. Seeking access to pills, weapons or other self destructive behavior 

4 Talking about death, dying or suicide 

The presence of these signs requires immediate attention. If you or a veteran you 

care about has been showing any of these signs, do not hesitate to call and ask for 

help! 

Additional warning signs may include: 

1. Hopelessness 

2. Rage, anger, seeking revenge 

3. Acting reckless or engaging in risky activities, seemingly without thinking 

4. Increasing alcohol or drug abuse 

5. Feeling trapped—like there’s no way out 

6. Withdrawing from friends and family 

7. Anxiety, agitation, inability to sleep—or, excessive sleepiness 

8. Dramatic mood swings 

9. Feeling there is no reason for living, no sense of purpose in life 

Please call the toll-free hotline number, 1–800–273–TALK (8255) if you experience any of these warning signs. We’ll get you the help and assistance you need 

right away! 

Sincerely yours, 

Michael J. Kussman, MD, MS, MACP 

————— 

VA Suicide Crisis Hotline (1–800–273 TALK) 

Who Should Call? 

• Anyone, but especially those who feel sad, hopeless, or suicidal 

• Family and friends who are concerned about a loved one who may be having 

these feelings. 

• Anyone interested in suicide prevention, treatment and service 

1–800–273 TALK 

• The service is free and confidential 

• The hotline is staffed by trained counselors 

• We are available 24 hours a day, 7 days a week 

• We have information about support services that can help you. 

Crisis Response Plan 

When thinking about suicide, I agree to do the following: 

Step 1: Try to identify my thoughts and specifically what’s upsetting me 

Step 2: Write out and review more reasonable responses to my suicidal thoughts 

Step 3: Do things that help me feel better for about 30 min (e.g., taking a bath, 

listening to music, going for a walk) 

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Step 4: If your suicidal thoughts persist, call 1–800–273–TALK 

Step 5: If the thoughts continue, get specific, and I find myself preparing to do 

something, call 911 

Step 6: If I’m still feeling suicidal and don’t feel like I can control my behavior, 

I go to the emergency room 

REMEMBER: The VA Suicide Hot Line is 1–800–273–TALK 

Get Mental Health Follow-Up 1–202–745–8267 for an APPOINTMENT 

f 

Committee on Veterans’ Affairs 

Washington, DC. 

December 21, 2007 

Mr. Rick Kaplan 

Executive Producer 

CBS Evening News With Katie Couric 

524 West 57th Street 

New York, NY 10019 

Dear Mr. Kaplan: 

On December 12, 2007, the House Committee on Veterans’ Affairs held a hearing 

to assess the programs that the Department of Veterans Affairs (VA) provides for 

veterans who are at risk for suicide. This hearing raised concerns regarding the discrepancy between the numbers of veteran suicides reported by VA as compared to 

those reported by CBS News on November 13, 2007. 

Accurate data is crucial in identifying risk factors and providing better treatment 

and suicide prevention programs. For this reason, we respectfully request that CBS 

News share their data on suicide among veterans with the Committee. 

Specifically, we request data on the number of veteran and non-veteran suicides 

for each year from 1995 through 2005 reported by State with year of death, age, 

race, gender and manner of suicide. Additionally, request the data that CBS News 

used to define the at-risk populations (e.g., veterans/non-veterans, men/women) by 

age group. 

Undoubtedly, you and the entire CBS Evening News staff, share our desire to ensure that every possible measure is taken to prevent those who have worn the uniform from succumbing to the tragedy of suicide. As such, we would greatly appreciate your willingness to share the information you have accumulated with the Committee. 

Thank you for your prompt consideration and attention to this request. Should 

you have any questions, please feel free to contact either Committee Staff Director, 

Malcom Shorter, at 202–225–9756 or Republican Staff Director, Jim Lariviere, at 

202–225–3527. 

Sincerely, 

Bob Filner 

Chairman 

Steve Buyer 

Ranking Member 

CW/mh 

————— 

CBS News 

New York, NY. 

May 16, 2008 

Honorable Bob Filner, Chairman 

Committee on Veterans’ Affairs 

United States House of Representatives 

One Hundred Tenth Congress 

335 Cannon House Office Building 

Washington, DC 20515 

Dear Congressmen Filner: 

This is in reply to your letter of last December to Rick Kaplan, Executive Producer of the CBS Evening News. It appears that your letter was originally lost withcprice-sewell on PROD1PC72 with HEARING

124 

in CBS and only came to light when a copy of it was given to Armen Keteyian, CBS 

News’ Chief Investigative Correspondent, at last week’s hearing of the House Committee on Veterans’ Affairs. I apologize for the delay. 

In your letter you request that CBS News provide ‘‘data on numbers the veteran 

and non-veteran suicides for each year from 1995 through 2005 reported by. . . . 

[and] data that CBS News used to define the at-risk populations (e.g., veterans/nonveterans, men/women) by age group.’’ 

You are quite right, Congressmen, in stating that we at CBS News share your 

desire to ensure that every possible measure is taken to prevent veteran suicide. 

We believe, however, that the respect in which we are best able to serve the interests of veterans and of all other segments of the American public is to preserve our 

ability to do effective news reporting; and that to be effective reporters, we must 

maintain our journalistic independence. For that reason we must respectfully decline to provide the data you request. 

Insofar as the Committee’s request derives from its need for the raw data on 

which CBS News based its reporting, that data is readily available to the Committee from State agencies, which are public. If the Committee’s goal is to review 

the editorial process by which we arrived at our reports’ content, we respectfully 

urge that it would be quite wrong of CBS News to submit voluntarily to such governmental oversight. Indeed, doing so would fundamentally compromise the editorial independence on which we and all news organizations depend. 

I should also point out that obtaining suicide data from the various States involved more than just a basic public records request. Initially, several States refused 

to provide their data to CBS News out of a concern for the privacy of the veterans 

involved and their families. These States believed that the suicide numbers in some 

categories are small enough so that individuals could be identified and their privacy 

compromised. In order to obtain the data, CBS News had to give these States our 

assurance that we would keep the raw data confidential. Some States insisted upon 

written agreements to this effect. Accordingly, we are constrained not only by principle, but by these specific undertakings, from providing the Committee with the 

data you have requested. 

I hope you will appreciate Congressmen, that we take the work of the House Committee on Veterans’ Affairs very seriously and that we withhold our cooperation only 

out of deference to our own responsibilities as journalists. 

Respectfully, 

Linda Mason 

Senior Vice President 

Standards and Special Projects 

cc Rick Kaplan 

Armen Keteyian 

f 

Committee on Veterans’ Affairs 

Washington, DC. 

December 21, 2007 

The Honorable James B. Peake, M.D. 

Secretary 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Secretary Peake: 

On December 12, 2007, the House Committee on Veterans’ Affairs held a hearing 

to assess the programs that the Department of Veterans Affairs (VA) provides for 

veterans who are at risk for suicide. This hearing raised concerns regarding the discrepancy between the numbers of veteran suicides reported by VA as compared to 

those reported by CBS News on November 13, 2007. 

Accurate data is crucial in identifying risk factors and providing better treatment 

and suicide prevention programs. For this reason, we respectfully request that the 

Department of Veterans Affairs share their data on suicide among veterans with the 

Committee. 

Specifically, we request to have the number of veteran suicides for each year from 

1995 through 2006, reported by year of death, age, race, gender and manner of suicide. Additionally, we ask for the methodology the Department uses to collect data 

on veteran suicides. 

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125 

Undoubtedly, you share our desire to ensure that every measure is taken to prevent our Nation’s veterans from committing suicide. We would greatly appreciate 

your willingness to share any information you may have regarding this issue with 

the Committee. 

Thank you for your prompt consideration and attention to this request. Should 

you have any questions, please feel free to contact either Committee Staff Director, 

Malcom Shorter, at 202–225–9756 or Republican Staff Director, Jim Lariviere, at 

202–225–3527. 

Sincerely, 

Bob Filner 

Chairman 

Steve Buyer 

Ranking Member 

————— 

The Secretary of Veterans Affairs 

Washington, DC. 

February 5, 2008 

The Honorable Bob Filner 

Chairman 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Washington, DC 20515 

Dear Mr. Chairman: 

This is in response to your letter requesting data on suicide rates among veterans 

and the methodologies used by the Department of Veterans Affairs (VA) to collect 

data on veteran suicides. 

The enclosed information and worksheet contains data on veteran suicides from 

two separate projects. One is an ongoing study of mortality in Operation Enduring 

Freedom and Operation Iraqi Freedom (OEF/OIF) veterans being conducted by VA’s 

Office of Environmental Epidemiology. Identification of veterans is based on information from the Department of Defense and includes all OEF/OIF servicemembers 

who were separated from active duty including National Guard and Reserve personnel. The second project is an ongoing study of suicide in veterans who have used 

Veterans Health Administration services from 2000 onward and who were alive at 

the start of 2001. The study includes veterans of all eras. 

For both projects, information about the time and causes of death was derived 

from the National Death Index. Information contained in data files on causes of 

death from the National Death Index is only available through the end of 2005. I 

have also enclosed the methodology used for both projects. 

Your interest in our Nation’s veterans is appreciated. A similar letter is being 

sent to Congressman Steve Buyer. 

Sincerely yours, 

James B. Peake, M.D. 

Enclosures 

————— 

Study of Operation Enduring Freedom/Operation Iraqi Freedom Veterans 

Methodology 

Population: As part of our mortality study of veterans who served in Operation 

Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF), the Department of Veterans Affairs (VA) obtained the identities of 490,346 OEF/OIF veterans who served 

as part of either OEF or OIF and were separated or deactivated from military service between October 2001 and December 2005. This study will assess both overall 

mortality risk as well as cause-specific mortality risk. Among the cause specific mortality of particular interest are deaths due to motor vehicle accidents and suicides. 

Data Sources: The identities of the 490,346 OEF/OIF veterans, military service 

characteristics, and various demographic data were provided to VA by the Department of Defense Manpower Data Center. Vital statistics data pertaining to OEF/OIF 

veterans was determined by using VA’s database, Beneficiary Identification and 

Records Locator Subsystem, and deaths reported to the Social Security Administration Death Master File. The Beneficiary Identification and Records Locator Subsystem file has the identities of all veterans who have applied for VA benefits (incprice-sewell on PROD1PC72 with HEARING

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cluding death benefits), and the Social Security Administration Death Master File 

includes all deaths reported to that agency. All veterans were matched against the 

Beneficiary Identification and Records Locator Subsystem and Social Security Administration files using Social Security numbers. Cause of death data was obtained 

from the National Death Index. Since 1979, the Office of Vital Statistics in each 

State has reported deaths, including cause of death data to the National Center for 

Health Statistics, where the National Death Index is compiled. Causes of death 

were recorded using International Classification of Diseases codes 10th Revision 

(ICD–10). For traumatic deaths, including suicide, part of the ICD–10 codes records 

the method of injury. For suicides, the ICD–10 codes report the method of suicide. 

At the time this study began, the National Death Index had cause of death data 

through December 31, 2005. Using the aforementioned databases, VA identified a 

total of 818 deaths to include 144 suicides. 

The attached table has demographic and military service characteristics as well 

as death certificate data and method of suicide for the 144 suicides identified in this 

study. 

CHARACTERISTICS OF 144 SUICIDES AMONG OEF/OIF* VETERANS 

THROUGH 2005 

Characteristic Frequency Percentage 

Age at death 

20–29 78 54.1 

30–39 39 27.1 

40–49 14 9.7 

50–59 13 9.1 

Year of death 

2002 7 4.9 

2003 21 14.6 

2004 48 33.3 

2005 68 47.2 

Method of suicide 

Poisoning 7 4.9 

Hanging 30 20.8 

Firearm 105 72.9 

Jumping 1 .7 

Sharp Object 1 .7 

Sex 

Male 141 97.9 

Female 3 2.1 

Race 

White 118 81.9 

Non-White 26 18.1 

Ever seen at VAMC 

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CHARACTERISTICS OF 144 SUICIDES AMONG OEF/OIF* VETERANS 

THROUGH 2005—Continued 

Characteristic Frequency Percentage 

Yes 33 22.9 

Branch of service 

Army 73 50.7 

Marines 15 10.4 

Air Force 33 22.9 

Navy 23 16.0 

Rank 

Officer 8 5.6 

Warrant Officer 1 0.7 

Enlisted 135 93.7 

Unit component 

Active 68 47.2 

Reserve 35 24.3 

National Guard 41 28.5 

* These suicides were identified among a cohort of 490,346 OEF/OIF veterans selected for mortality followup through 2005. 

Study of Veterans Using Veterans Health Administration 

Methodology 

Population: The Veterans Health Administration defined the population of VA patients at risk for suicide in each fiscal year as those who were alive at the start 

of the year, and who had received VA services during either that year or the prior 

one. This approach to identifying VA’s patient population was developed in consultation with VA mental health leadership and assumes that patients seen in VA settings in the prior year would still be considered to be in active VA care and part 

of the at-risk patient population in the following year. 

Data Sources: This study used data from VA’s National Patient Care Database to 

identify all veterans with inpatient or outpatient services utilization in any VA facility during the relevant years. Measures of vital status and cause of death were 

based on information from the National Death Index. The National Death Index is 

considered the ‘‘gold standard’’ for mortality assessment information and includes 

national data regarding dates and causes of death for all U.S. residents. This information is derived from death certificates filed in the Office of Vital Statistics for 

each State. National Death Index searches were performed for cohorts of VA patients who received any VA services during the relevant years, and who had no subsequent VA services through June 2006. This cost-efficient method for conducting 

National Death Index searches enables comprehensive assessment of vital statistics 

and cause of death among all veterans in the VA patient population. The National 

Death Index data request included Social Security number, last name, first name, 

middle initial, date of birth, race and ethnicity, sex, and State of residence. National 

Death Index search results often include multiple records that are potential 

matches. ‘‘True matches’’ were identified based on established procedures. 

Veterans’ age and gender were identified from VA administrative files included 

in the National Patient Care Database. Age at the start of Fiscal Year 2001 was 

categorized as being either less than 30, 30 to 39, 40 to 49, 50 to 59, 60 to 69, 70 

to 79, or greater than or equal to 80 years. Information regarding race and ethnicity 

was not consistently available in the National Patient Care Database for all VA patients. VA identified dates and causes of death using National Death Index data. 

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Suicide deaths were identified using International Classification of Diseases codes 

X60 through X84, and Y87.0 (World Health Organization 2004). 

VA is conducting a comprehensive program for preventing veteran suicides, and 

is conducting ongoing research to guide its prevention strategies. The VA Office of 

Mental Health staff is available to provide additional briefings to the Committee on 

rates, risks factors and strategies. 

Number of Suicides Among VHA Veterans for Fiscal Years 2001–2005 

Characteristic 

FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 

N % N % N % N % N % 

Total* 1403 100 1737 100.0 1600 100.0 1702 100.0 1784 100.0 

Total, age 20 and over 1401 100 1734 100.0 1598 100.0 1701 100.0 1781 100.0 

Sex 

Male 1360 97.1 1682 97.0 1559 97.6 1647 96.8 1720 96.6 

Female 41 2.9 52 3.0 39 2.4 54 3.2 61 3.4 

Age Group 

20–29 yrs 26 1.9 44 2.5 38 2.4 50 2.9 38 2.1 

30–39 yrs 108 7.7 119 6.9 111 6.9 105 6.2 105 5.9 

40–49 yrs 240 17.1 283 16.3 272 17.0 256 15.0 254 14.3 

50–59 yrs 359 25.6 437 25.2 407 25.5 424 24.9 470 26.4 

60–69 yrs 202 14.4 261 15.1 264 16.5 272 16.0 291 16.3 

70–79 yrs 320 22.8 393 22.7 345 21.6 381 22.4 380 21.3 

80+ yrs 146 10.4 197 11.4 161 10.1 213 12.5 243 13.6 

Race 

White Hispanic 30 2.1 25 1.4 32 2.0 24 1.4 29 1.6 

Black Hispanic 2 0.1 1 0.1 1 0.1 2 0.1 2 0.1 

Native American 2 0.1 6 0.3 3 0.2 2 0.1 7 0.4 

African American 55 3.9 80 4.6 47 2.9 62 3.6 78 4.4 

Asian/Pacific Islander 0 0.0 4 0.2 2 0.1 3 0.2 16 0.9 

Caucasian 895 63.9 1078 62.2 894 55.9 814 47.9 1142 64.1 

Unknown 417 29.8 540 31.1 619 38.7 794 46.7 507 28.5 

*Includes age <20 years old 

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Number of Suicides Among VHA Veterans for Fiscal Years 2001–2005 

Characteristic 

FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 

N % N % N % N % N % 

Total* 1403 100.0 1737 100.0 1600 100.0 1702 100.0 1784 100.0 

Total, age 20 and over 1401 100.0 1734 100.0 1598 100.0 1701 100.0 1781 100.0 

Mechanism of Suicide 

X60 Intentional self-poisoning (suicide) by 

and exposure to nonopioid analgesics, 

anti-pyretics, and 

anti-rheumatics 5 0.4 4 0.2 8 0.5 5 0.3 12 0.7 

X61 Intentional self-poisoning (suicide) by 

and exposure to 

antiepileptic, sedative-hypnotic antiparkinsonism, and 

psychotropic drugs, 

not elsewhere classified 39 2.8 49 2.8 38 2.4 43 2.5 53 3.0 

X62 Intentional self-poisoning (suicide) by 

and exposure to narcotics and 

psychodysleptics 

(hallucinogens), not 

elsewhere classified 26 1.9 42 2.4 30 1.9 27 1.6 48 2.7 

X63 Intentional self-poisoning (suicide) by 

and exposure to 

other drugs acting 

on the autonomic 

nervous system 1 0.1 3 0.2 1 0.1 0 0.0 2 0.1 

X64 Intentional self-poisoning (suicide) by 

and exposure to 

other and unspecified drugs, medicaments, and biological 

substances 100 7.1 97 5.6 103 6.4 112 6.6 102 5.7 

X65 Intentional self-poisoning (suicide) by 

and exposure to alcohol 2 0.1 2 0.1 5 0.3 0 0.0 1 0.1 

X66 Intentional self-poisoning (suicide) by 

and exposure to organic solvents and 

halogenated hydrocarbons and their 

vapors 2 0.1 3 0.2 1 0.1 6 0.4 3 0.2 

X67 Intentional self-poisoning (suicide) by 

and exposure to 

other gases and vapors 34 2.4 62 3.6 35 2.2 59 3.5 50 2.8 

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Number of Suicides Among VHA Veterans for Fiscal Years 2001–2005— 

Continued 

Characteristic 

FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 

N % N % N % N % N % 

X68 Intentional self-poisoning (suicide) by 

and exposure to pesticides 1 0.1 1 0.1 1 0.1 0 0.0 0 0.0 

X69 Intentional self-poisoning (suicide) by 

and exposure to 

other and unspecified chemicals and 

noxious substances 3 0.2 6 0.3 4 0.3 3 0.2 4 0.2 

X70 Intentional self harm 

(suicide) by hanging, 

strangulation, and 

suffocation 163 11.6 214 12.3 189 11.8 207 12.2 189 10.6 

X71 Intentional self harm 

(suicide) by drowning and submersion 17 1.2 19 1.1 12 0.8 10 0.6 15 0.8 

X72 Intentional self harm 

(suicide) by handgun 

discharge 192 13.7 248 14.3 255 16.0 227 13.3 277 15.6 

X73 Intentional self harm 

(suicide) by rifle, 

shotgun, and larger 

firearm discharge 145 10.3 174 10.0 150 9.4 171 10.1 170 9.5 

X74 Intentional self harm 

(suicide) by other 

and unspecified firearm discharge 566 40.4 726 41.9 675 42.2 728 42.8 758 42.6 

X75 Intentional self harm 

(suicide) by explosive 

material 0 0.0 0 0.0 0 0.0 0 0.0 2 0.1 

X76 Intentional self harm 

(suicide) by smoke, 

fire, and flames 6 0.4 4 0.2 6 0.4 14 0.8 12 0.7 

X77 Intentional self harm 

(suicide) by steam, 

hot vapors, and hot 

objects 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 

X78 Intentional self harm 

(suicide) by sharp 

object 34 2.4 33 1.9 33 2.1 35 2.1 28 1.6 

X79 Intentional self harm 

(suicide) by blunt object 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 

X80 Intentional self harm 

(suicide) by jumping 

from a high place 31 2.2 18 1.0 30 1.9 27 1.6 22 1.2 

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Number of Suicides Among VHA Veterans for Fiscal Years 2001–2005— 

Continued 

Characteristic 

FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 

N % N % N % N % N % 

X81 Intentional self harm 

(suicide) by jumping 

or lying before moving object 14 1.0 10 0.6 7 0.4 12 0.7 8 0.4 

X82 Intentional self harm 

(suicide) by crashing 

of motor vehicle 1 0.1 4 0.2 5 0.3 4 0.2 7 0.4 

X83 Intentional self harm 

(suicide) by other 

specified means 7 0.5 6 0.3 3 0.2 4 0.2 2 0.1 

X84 Intentional self harm 

(suicide) by unspecified means 5 0.4 6 0.3 4 0.3 4 0.2 11 0.6 

V87 Sequelae of intentional 

self harm 7 0.5 3 0.2 3 0.2 3 0.2 5 0.3 

*Includes age <20 years old 

f 

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Committee on Veterans’ Affairs 

Washington, DC. 

December 21, 2007 

Honorable Robert M. Gates 

Secretary 

U.S. Department of Defense 

1000 Defense Pentagon 

Washington, DC 20301 

Dear Secretary Gates: 

On December 12, 2007, the House Committee on Veterans’ Affairs held a hearing 

to assess the programs that the Department of Veterans Affairs (VA) provides for 

veterans who are at risk for suicide. This hearing raised concerns regarding the discrepancy between the numbers of veteran suicides reported by VA as compared to 

those reported by CBS News on November 13, 2007. 

Accurate data is crucial in identifying risk factors and providing better treatment 

and suicide prevention programs. For this reason, we respectfully request that the 

Department of Defense share their data on suicide among the active military population with the Committee. 

Specifically, we request the number of active duty suicides for each year from 

1995 through 2006. We ask that this information be listed by military branch, year 

of death, age, race, gender and manner of suicide. Additionally, we ask for the methodology the Department uses to collect data on active duty suicides. 

Undoubtedly, you share our desire to ensure that every measure is taken to prevent those in the military from committing suicide. We would greatly appreciate 

your willingness to share any information you may have regarding this issue with 

the Committee. 

Thank you for your prompt consideration and attention to this request. Should 

you have any questions, please feel free to contact either Committee Staff Director, 

Malcom Shorter, at 202–225–9756 or Republican Staff Director, Jim Lariviere, at 

202–225–3527. 

Sincerely, 

Bob Filner 

Chairman 

Steve Buyer 

Ranking Member 

CW/mh 

***** 

The Secretary of Defense 

Washington, DC 

January 17, 2008 

The Honorable Bob Filner 

Chairman 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Washington, DC 20515 

Dear Mr. Chairman: 

Thank you for the letter you signed with Representative Buyer requesting data 

on the number of active duty suicides from 1995 through 2006. I have asked Dr. 

David Chu, Under Secretary of Defense for Personnel and Readiness, to address this 

matter. We will get back to you as soon as possible. 

With best wishes, 

Sincerely, 

Robert M. Gates 

————— 

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Committee on Veterans’ Affairs 

Washington, DC. 

May 6, 2008 

Honorable Robert M. Gates 

Secretary 

U.S. Department of Defense 

1000 Defense Pentagon 

Washington, DC 20301–1000 

Dear Secretary Gates: 

I would appreciate it if you could respond to the enclosed request regarding assessing the programs that the Department of Veterans Affairs (VA) provides for veterans who are at risk for suicide. Previous letters were sent to you on December 

21, 2007, and the Committee received notices on January 17, 2008, indicating that 

your office was looking into the matter. 

Because your response will be entered into the record for today’s Full Committee 

hearing on ‘‘The Truth About Veterans’ Suicides,’’ the Committee would appreciate 

a reply back from your office by no later than May 20, 2008. If you have any questions in this regard, please contact Mark Heyman, Professional Staff Member, at 

(202) 225–9756. 

Sincerely, 

Bob Filner 

Chairman 

Enclosure 

MS/jz 

————— 

Committee on Veterans’ Affairs 

Washington, DC. 

May 21, 2008 

Honorable Robert M. Gates 

Secretary 

U.S. Department of Defense 

1000 Defense Pentagon 

Washington, DC 20301–1000 

Dear Secretary Gates: 

I would appreciate it if you could respond to the enclosed request regarding assessing the programs that the Department of Veterans Affairs (VA) provides for veterans who are at risk for suicide. Previous letters were sent to you on December 

21, 2007, and May 6, 2008, and the Committee received notices on January 17, 

2008, indicating that your office was looking into the matter. 

Because your response will be entered into the record for today’s Full Committee 

hearing on ‘‘The Truth About Veterans’ Suicides,’’ the Committee would appreciate 

a reply back from your office by no later than June 4, 2008. 

If you have any questions in this regard, please contact Mark Heyman, Professional 

Staff Member, at (202) 225–9756. 

Sincerely, 

Bob Filner 

Chairman 

Enclosure 

MS/jz 

————— 

The Secretary of Defense 

Washington, DC 

June 3, 2008 

The Honorable Bob Filner 

Chairman 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Washington, DC 20515 

Dear Mr. Chairman: 

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Thank you for your letter regarding a Department of Defense assessment of the 

Department of Veterans Affairs’ programs for veterans at risk for suicide. I have 

asked Dr. David Chu, Under Secretary of Defense for Personnel and Readiness, to 

address the matter. He will get back to you as soon as possible. 

With best wishes, 

Sincerely, 

Robert M. Gates 

————— 

Committee on Veterans’ Affairs 

Washington, DC. 

June 5, 2008 

Honorable Robert M. Gates 

Secretary 

U.S. Department of Defense 

1000 Defense Pentagon 

Washington, DC 20301–1000 

Dear Secretary Gates: 

I would appreciate it if you could respond to the enclosed request regarding assessing the programs that the Department of Veterans Affairs (VA) provides for veterans who are at risk for suicide. Previous letters were sent to you on December 

21, 2007; May 6, 2008; and May 21, 2008, and the Committee received notices on 

January 17, 2008, and June 4, 2008, indicating that your office was looking into the 

matter. 

Because your response will be entered into the record for today’s Full Committee 

hearing on ‘‘The Truth About Veterans’ Suicides,’’ the Committee would appreciate 

a completed response to the enclosed request by no later than June 19, 2008. If you 

have any questions in this regard, please contact Mark Heyman, Professional Staff 

Member, at (202) 225–9756. 

Sincerely, 

Bob Filner 

Chairman 

Enclosure 

MS/jz 

f 

Department of Veterans Affairs 

MEMORANDUM 

Date: May 5, 2008 

From: Under Secretary for Health (10) 

Subj: Blue Ribbon Work Group on Suicide Prevention in the Veteran Population 

To: Secretary (00) 

1. At your request, VHA has developed a draft charter and draft membership list 

for your consideration for the Blue Ribbon Work Group on Suicide Prevention 

in the Veteran Population (see attachments). We have also contacted prospective members to determine their willingness to do so and to do so without compensation. 

2. With your approval, we will proceed with formally contacting the members that 

you have approved and setting up the one-time meeting. 

Michael J. Kussman, MD, MS, MACP 

APPROVE/DISAPPROVE Date 5/5/08 

James B. Peake, M.D. 

Attachments: 

• Draft Charter 

• Draft Membership and Staff Support List (with approval/disapproval lines for 

each) 

• CVs for Potential Members of The Work Group 

• CVs for Potential Member of The Expert Panel 

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————— 

DEPARTMENT OF VETERANS AFFAIRS 

CHARTER OF THE 

BLUE RIBBON WORK GROUP ON SUICIDE PREVENTION IN THE 

VETERAN POPULATION 

A. OFFICIAL DESIGNATION: Blue Ribbon Work Group on Suicide Prevention in 

the Veteran Population (‘‘Work Group’’). 

B. OBJECTIVES AND SCOPE OF ACTIVITY: The Blue Ribbon Work Group on 

Suicide Prevention in the Veteran Population advises the Secretary on research and 

programs relevant to the prevention of suicide in the veteran population. 

C. PERIOD OF TIME NECESSARY FOR THE COMMITTEE TO CARRY OUT 

ITS PURPOSES: Established as an Executive Branch Task Force that will meet one 

time for approximately 3 days with a final report to the Secretary within 15 days. 

D. OFFICIAL TO WHOM THE COMMITTEE REPORTS: The Blue Ribbon Work 

Group on Suicide Prevention in the Veteran Population reports to the Secretary of 

Veterans Affairs. 

E. OFFICE RESPONSIBLE FOR PROVIDING THE NECESSARY SUPPORT 

FOR THE COMMITTEE: The Veterans Health Administration, Department of Veterans Affairs, is responsible for providing administrative and logistical support to 

the Blue Ribbon Work Group on Suicide Prevention in the Veteran Population. 

F. DUTIES OF THE COMMITTEE: The Blue Ribbon Work Group on Suicide Prevention in the Veteran Population provides advice and consultation to the Secretary 

on various matters relating to research, education and program improvements relevant to the prevention of suicide in the veteran population. The Blue Ribbon Work 

Group on Suicide Prevention in the Veteran Population will create a report within 

15 days of the completion of its meeting with recommendations for improvements 

in VA’s programs related to suicide prevention, research, and education. Recommendations will be directly related to the primary objective of reducing risk of 

suicide in the veteran population. 

G. MEMBERSHIP: Blue Ribbon Work Group on Suicide Prevention in the Veteran Population membership shall include only Executive Branch employees who 

are experts in public health suicide programs (including suicide prevention and education programs), suicide research (especially epidemiology and suicidiology), and 

clinical treatment programs for patients at risk for suicide. The Work Group will 

be comprised of five (5) members. The Work Group process will be informed by the 

testimony and counsel of a panel (The Expert Panel) with nationally recognized expertise in public health suicide programs, suicide research, and clinical treatment 

programs for patients, and other relevant areas. Members of The Expert Panel will 

have no significant direct relationship with the Department of Veterans Affairs. The 

role of each member of the panel is to individually provide: expert opinion, interpretation, and conclusions on information and data presented to the Work Group; expert information and data from other (non-VA) sources; and recommendations to the 

Work Group on opportunities for improvement in VA’s programs. The Expert Panel 

will be comprised of nine (9) members. Employees of the Department of Veterans 

Affairs and other Federal Government employees may be called upon the Work 

Group to provide background briefings on any relevant information to better inform 

the Work Group decision process and The Expert Panel. 

H. EXPENSES: All Work Group and Expert Panel members will receive travel 

expenses and a per diem allowance in accordance with the Federal Travel Regulations for any travel made in connection with their duties as members of the Work 

Group or Expert Panel. No member of the Work Group or the Expert Panel will receive honorarium. 

I. ESTIMATED NUMBER AND FREQUENCY OF MEETING: The Group is expected to meet once for approximately three (3) days. Administrative support to the 

Work Group will be provided by the Veterans Health Administration. The Veterans 

Health Administration, Office of Mental Health Services, will support the Chair in 

the development of the schedule, operation of the meeting, general logistical requirements, and production of the final report. A representative of the Secretary will be 

present at the meeting, and the meeting will be conducted in accordance with an 

agenda provided by the Secretary. 

J. COMMITTEE TERMINATION DATE: The Work Group and The Expert Panel 

will be terminated upon completion and transmittal of the final report to the Secretary. 

K. DATE CHARTER IS FILES: 

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136 

Approved: James B. Peake, M.D. 

Secretary of Veterans Affairs 

Date 5/5/08 

————— 

Membership 

Work Group 

• CDR (USPHS) Alex E. Crosby, MD, MPH, Medical Epidemiologists, Surveillance Team/ESB/DVP/NCIPC Centers for Disease Control and Prevent (CDC), 

Atlanta, GA 

APPROVE/DISAPPROVE Date 5/5/08 

• COL (USA) Charles W. Hoge, MD, Director, Division of Psychiatry And Behavior Services, Walter Reed Army Institute Of Research, Silver Spring, MD 

APPROVE/DISAPPROVE Date 5/5/08 

• COL (USAF) Robert Roy Ireland, MC, Chairman, Program Director for Mental 

Health Policy, Clinical and Program Policy, Office of the Assistant Secretary of 

Defense (Health Affairs, Falls Church, VA 

APPROVE/DISAPPROVE Date 5/5/08 

• Richard McKeon, PhD, MPH, Special Advisory Suicide Prevention, CMHS, Substance Abuse and Mental Health Services Administration (SAMHSA) 

APPROVE/DISAPPROVE Date 5/5/08 

• Jane Pearson, MA, PhD, Associate Director for Preventive Interventions, Division of Services and Intervention Research, National Institute of Mental Health 

APPROVE/DISAPPROVE Date 5/5/08 

Expert Panel: 

• Dan Blazer II, MD, MPH, PhD, Professor of Psychology, Co-Director of Clinical 

Training, Catholic University of America 

APPROVE/DISAPPROVE Date 5/5/08 

• Greg Brown, PhD, University of Pennsylvania 

APPROVE/DISAPPROVE Date 5/5/08 

• Martha Livingston Bruce, PhD, MPH, Professor, Program in Clinical Epidemiology and Health Services Research, Graduate School of Medical Sciences, and 

Associate Vice-Chair for Research, Weill Medical College of Cornell University 

APPROVE/DISAPPROVE Date 5/5/08 

• Eric D. Caine, MD, Chair of Psychiatry, John Romano Professor Psychiatry and 

Chair, Department of Psychiatry, University of Rochester 

APPROVE/DISAPPROVE Date 5/5/08 

• Jan Fawcett, MD Professor of Psychiatry, School of Medicine, Department of 

Psychiatry, University of New Mexico 

APPROVE/DISAPPROVE Date 5/5/08 

• Robert D. Gibbons, Director, Center for Health Statistics, University of Illinois 

at Chicago 

APPROVE/DISAPPROVE Date 5/5/08 

• David Alan Jobes, PhD, ABBPP, Professor of Psychology, Department of Psychology, The Catholic University of America 

APPROVE/DISAPPROVE Date 5/5/08 

• Mark S. Kaplan, PhD, Portland State University, Member, Suicide Prevention 

Action Network-USA National Scientific Advisory Council 

APPROVE/DISAPPROVE Date 5/5/08 

• Thomas R. Ten Have, Director of the Biostatistics Analysis Center of the Center 

for Clinical Epidemiology and Biostatistics and Senior Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicprice-sewell on PROD1PC72 with HEARING

137 

cine; Member, Biomedical Graduate Studies, University of Pennsylvania School 

of Medicine 

APPROVE/DISAPPROVE Date 5/5/08 

Administrative Support/Planning: 

• Secretary’s Representative Jaewon Ryupao, JD (Secretary to specify) 

• Seth Eisen, MD, Director, Health Services Research and Development (12) 

• Ira Katz, MD, Deputy Chief Patient Care Services Officer for Mental Health 

(116) 

• Antoinette Zeiss, Ph.D., Deputy Chief Mental Health Services (116) 

• John O’Hara, Executive Assistant, Office of Policy and Planning (008) 

• Technical Writer TBD 

f 

Rates and Risk of Suicide and other Suicidal Behaviors among U.S. 

Veterans 

Population-based Studies of Vietnam-era Veterans 

Author 

Publication 

Year 

Institution, 

Sponsor 

Study and 

Comparison 

Groups 

Key Findings Limitations and 

Concerns 

Cypel, 2008 WRIISC, EES, 

VHA 

Women veterans 

who served in 

Vietnam (n=4586) 

or elsewhere during the Vietnam 

era (n=5325), 

compared with 

the U.S. population. Mortality 

followed through 

2004 using BIRLS 

and SSA death 

files 

Women Vietnam 

era veterans had 

lower all-cause 

mortality 

(SMR=0.87). SMR 

for suicide was 1.22 for women 

veterans who 

served in Vietnam, but this was 

not statistically 

significant 

Only 12 suicide 

deaths reported in 

women Vietnam 

veterans 

Herrell, 1999 VET registry, 

HSR&D, VHA 

103 male twin 

pairs were identified in which one 

member of the 

pair reported 

male sexual partners but the other 

did not. Suicidal 

ideation and suicide attempts 

were assessed by 

a structured psychiatric interview. 

Homosexual orientation was significantly associated with suicidal 

ideation and suicide attempts (approximately 2.5- 

fold increased risk 

after adjusting for 

substance abuse 

and depression 

Analysis of discordant twin pairs 

is a strong scientific design because it adjusts 

for confounding 

based on genetic 

predisposition. 

Data were gathered via interview 

at a single point 

in time and do 

not address risk 

for suicide. 

Bullman, 1996 EES, VHA Vietnam veterans 

with nonlethal 

wounds 

(n=34,534) were 

assessed for risk 

of suicide through 

1991 

In comparison 

with the U.S. 

male population, 

veterans hospitalized because of a 

combat wound or 

wounded more 

than once had increased suicide 

risk (SMR=1.22 

for hospitalized 

veterans; 

SMR=1.58 for 

multiple wounded 

veterans) 

Death certificate 

data might be inaccurate; no data 

on psychological 

and behavioral 

characteristics 

that might have 

predisposed individuals to both injury as well as 

suicide. 

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Rates and Risks of Suicide and other Suicidal Behaviors among U.S. 

Veterans—Continued 

Population-based Studies of Post-Vietnam Veterans 

Author 

Publication 

Year 

Institution, 

Sponsor 

Study and 

Comparison 

Groups 

Key Findings Limitations and 

Concerns 

Bullman, 

2005 

EES, VHA Gulf War Veterans potentially 

exposed to chemical warfare 

agents 

(n=100,487) with 

those not likely to 

have been exposed 

(n=224,980). 

Relative risk for 

suicide not increased (RR=1.05) 

Death certificates 

might not be accurate; exposure 

data might not be 

accurate 

Kang, 2001 EES, VHA Gulf War Veterans (n=695,516) 

compared with 

other military on 

active duty from 

8/90 thru 4/91 

(n=746,291). 

Deaths through 

1997 obtained 

from BIRLS and 

SSA. 

Relative risk for 

suicide not increased (RR=0.92 

for males) 

Death certificates 

might not be accurate; ‘‘health 

soldier effect’’ 

Kang, 1996 EES, VHA Gulf War Veterans (n=695,516) 

compared with 

other military on 

active duty (n= 

746,291). Deaths 

through 9/93 obtained from 

BIRLS and SSA 

Small increase in 

death rate from 

accidents 

(SMR=1.25) but 

no increase in suicide rates. There 

were 261 suicides 

among the Gulf 

War veterans 

Death certificates 

might not be accurate; ‘‘health 

soldier effect’’ 

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Rates and Risk of Suicide and other Suicidal Behaviors among U.S. 

Veterans—Continued 

Clinical Cohort Studies 

Author 

Publication 

Year 

Institution, 

Sponsor 

Study and 

Comparison 

Groups 

Key Findings Limitations and 

Concerns 

Zivin, 2007 SMITREC, 

VHA 

Veterans receiving treatment in 

VA for depression 

between 1999 and 

2004 (n=807,694). 

Cause of death 

determined from 

state death certificates obtained 

from NDI 

Among depressed 

veterans, 1683 

(0.21%) committed suicide 

during followup. 

Rate of suicide 

was 90/100,000/yr 

among males, 29/ 

100,000/yr among 

females. Risk was 

higher among 

whites, younger 

veterans, those 

without serviceconnected disabilities, those with 

prior inpatient 

hospitalizations, 

veterans with comorbid substance 

abuse, and those 

living in the 

southern or western United States. 

PTSD with comorbid depression 

was associated 

with a lower suicide rate. 

Lower rate of suicide among veterans with PTSD 

and depression is 

surprising and 

counter-intuitive, 

though it may be 

explained by the 

more intensive 

treatment received by such 

veterans. Important contributors 

to suicide risk, 

such as family 

structure, stress, 

and prior suicide 

attempts, were 

not assessed 

Desai, 2007 NEPEC, VHA VA mental health 

outpatient users 

in three cohorts: 

1995 (76,105), 

1997 (81,512) and 

2001 (102,184) 

followed for 

trends in suicide 

rates during the 

year after their 

mental health 

visit. Study occurred during a 

period of systemwide reorganization including bed 

closures 

Overall, a decreasing trend in 

suicide rates over 

time among outpatient users 

(13.2/10,000/yr in 

1995 versus 10.3/ 

10,000/yr in 2001) 

which was not 

statistically significant. Greater 

per capita mental 

health expenditure was associated with lower 

suicide risk. Outpatients at larger 

programs were at 

greater suicide 

risk. 

Short follow-up 

period (1 year). 

Did not control for 

potential confounders such as 

prior suicide attempts or suicidal 

ideation. Sicker 

patients may attend larger programs, accounting 

for some of the results. Sample 

likely under-represented the more 

chronically ill patients. 

Gibbons, 2007 VA CSP, 

NIMH 

All veterans 

newly diagnosed 

with depression in 

2003 or 2004 

(n=226,866), followed up for at 

least 6 months in 

VA. Inpatient and 

outpatient records 

assessed for administrative codes 

indicating suicide 

attempt. 

Overall rate of 

suicide attempts 

was 364/100,000 

among those receiving treatment 

with an SSRI, 

versus 1057/ 

100,000 among 

the untreated. 

Risk of suicide 

was higher during 

the period prior to 

initiating an SSRI 

Data apply only 

to suicide attempts—suicides 

would not necessarily show up 

in VA medical 

records. Administrative codes may 

not accurately reflect clinical status of veteran. 

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Rates and Risk of Suicide and other Suicidal Behaviors among U.S. 

Veterans—Continued 

Clinical Cohort Studies—Continued 

Author 

Publication 

Year 

Institution, 

Sponsor 

Study and 

Comparison 

Groups 

Key Findings Limitations and 

Concerns 

Tiet, 2006 HSR&D, VHA Veterans aged 19 

and older seeking 

treatment for substance use disorder or other 

psychiatric disorders between 

July and September, 1997 

(n=34,245). 

Veterans who had 

recently experienced physical or 

sexual abuse had 

a 3- to 5-fold increased risk of a 

suicide attempt. 

Study examined 

veterans only at 

one point in time, 

so author’s belief 

that abuse events 

precipitate suicide 

attempts is still 

speculative. 

Desai, 2005 NEPEC, VHA All VA mental 

health inpatients 

discharged between 1994 and 

1998 (n=121,933). 

Death within one 

year of discharge 

was ascertained 

through VA 

records and the 

National Death 

Index. 481 suicides were identified in the study 

sample 

Suicide was higher among whites, 

older veterans, 

and those with 

depression, as 

well as veterans 

with lengths of inpatient stay 

under 14 days 

and those with 

higher risk for 

suicide. Readmission with 6 

months was associated with decreased suicide 

risk. No facilitylevel characteristics were associated with suicide 

risk. 

Facilities could 

not be accurately 

ranked for quality 

based on suicide 

rates due to the 

instability of suicide estimates 

once adjusted for 

case mix. 

Kausch, 2003 VHA Reviewed charts 

of consecutive admissions (n=114) 

to a Gambling 

Treatment Program at the St. 

Louis VA. 

40% of patients 

reported a prior 

suicide attempt. 

59% of those with 

history of drug 

dependence had a 

history of suicide 

attempts 

Retrospective 

chart review; no 

denominator to 

allow calculation 

of rates; did not 

study completed 

suicides 

Desai, 2003 NEPEC, VHA Homeless veterans (n=7224) 

participating in a 

national demonstration project 

of intensive case 

management. 

Two-thirds of participants reported 

suicidal ideation 

sometime in their 

life, and over half 

had attempted 

suicide. Younger 

age, substance 

abuse, and psychiatric symptoms 

were associated 

with risk for suicide attempts. 

This sample was 

self-selected based 

on willingness to 

enter into intensive case management. Whether 

homelessness 

causes suicidal 

ideation or suicidal ideation 

causes homelessness cannot be determined since 

the study examined veterans at 

only one point in 

time 

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Rates and Risk of Suicide and other Suicidal Behaviors among U.S. 

Veterans—Continued 

Clinical Cohort Studies—Continued 

Author 

Publication 

Year 

Institution, 

Sponsor 

Study and 

Comparison 

Groups 

Key Findings Limitations and 

Concerns 

Thompson, 

2002 

Philadelphia 

MIRECC, VHA 

Compared cause 

of death among 

veterans receiving 

medical and mental healthcare at 

the Philadelphia 

VA (4123 deaths). 

Confirmed and 

suspected suicide 

accounted for 

1.1% of deaths. 

Suicide was much 

higher among 

mental health 

than general medical patients. 

Total number of 

suicides as small 

(36). Lack of denominator (‘‘at 

risk’’ group) 

makes calculation 

and comparison of 

rates impossible. 

Kausch, 2001 Case Western, 

VHA 

Survey of all VA 

medical centers in 

1992 identifying 

suicide attempts 

and suicides in 

fiscal year 1991. 

Of 248 completed 

suicides, most 

(63%) were committed by males 

with alcohol addiction; 38% had 

a mood disorder, 

and 38% a personality disorder. 

There were 7 suicide attempts on 

inpatient units 

and 37 suicide attempts in outpatient substance 

use disorder 

treatment. 

Retrospective 

study with no 

control group. 

Sernyak, 2001 NEPEC, VHA All veterans who 

had clozapine initiated during a 

VA hospital stay 

between 1992 and 

1995 (n=1415) 

were compared 

with a match 

group of veterans 

with schizophrenia not receiving clozapine. 

VA databases and 

the National 

Death Index were 

used to identify 

all deaths over a 

3 year follow-up 

time. 

Veterans receiving clozapine had 

lower overall 

death rates, primarily due to reduced risk of 

death from respiratory disease. 

Suicides and accidental deaths did 

not differ between 

the groups. Suicide rate among 

clozapine users 

was 150/100,000/ 

yr 

Only 10 deaths 

due to suicide 

among clozapinetreated veterans 

makes statistical 

comparisons difficult. Clozapine 

users are not likely to be representative of all veterans with serious 

mental illness. 

Definitions: 

Suicidal ideation: Thoughts of harming or killing oneself. The severity of suicidal 

ideation can be determined by assessing the frequency, intensity, and duration of 

these thoughts. 

Suicide attempt: A non-fatal, self-inflicted destructive act with explicit or inferred 

intent to die. 

Suicide: Fatal self-inflicted destructive act with explicit or inferred intent to die. 

Self-inflicted injuries: Refers to suicidal and non-suicidal behaviors such as selfmutilation. 

Abbreviations: 

BIRLS: Beneficiary Identification and Records Locator Subsystem, maintained by 

VBA 

CDC: Center for Disease Control and Prevention 

DoD: Department of Defense 

EES: VA Environmental Epidemiology Service 

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HSR&D: VA Health Services Research and Development Service 

MIRECC: Mental Illness Research, Education, and Clinical Center 

NEPEC: Department of Veterans Affairs Northeast Program Evaluation Center located in West Haven, CT 

NDI: National Death Index, maintained by the National Center for Health Statistics 

NIMH: National Institute of Mental Health 

RR: Relative risk 

SSA: Social Security Administration 

SMITREC: Serious Mental Illness Treatment Research and Evaluation Center located in Ann Arbor, MI 

SMR: Standardized Mortality Ratio 

SSRI: Selective serotonin reuptake inhibitor (e.g. Prozac, Zoloft, Paxel) 

VA CSP: VA Cooperative Studies Program 

VET Registry: Vietnam Era Twin Registry, a population-based database of malemale twin pairs housed at Hines, IL 

WRAMC: Walter Reed Army Medical Center 

WRIISC: War-Related Illness and Injury Study Center located in Washington, DC 

Summary prepared by: 

Joseph Francis, MD, MPH 

Acting Deputy Chief Quality and Performance Officer 

Office of Quality and Performance (10Q) 

202–266–4513 

Joe.francis@va.qov 

Updated April 30, 2008 

f 

The Comprehensive VHA Mental Health Strategic Plan 

Aligned with the Recommendations of the Action Agenda (AA) 

Key 

1. Completed or incorporated into ongoing operations. 

2. Goal achieved by alternate mechanisms. 

3. In planning. 

4. Requires reevaluation or further guidance. 

President’s New Freedom Commission Goal 1. Americans understand that 

mental health is essential to overall health. 

Commission Recommendation 1.1. Advance and implement a national 

campaign to reduce the stigma of seeking care and a national strategy for 

suicide prevention. 

Create a VA National Mental Health Campaign to increase awareness in veteran 

community that mental health is essential to overall health and that very effective 

modern treatments can promote recovery in mental illness. Request that Secretary 

Principi serve as the champion for this campaign and declare 2004 Veterans Mental 

Health Year. A. Initiate a campaign targeted at Iraqi Freedom and Enduring Freedom veterans and their families. B. Develop monthly messages on VA’s Intranet 

home page focused on the theme that mental health is essential to overall health. 

The message would change monthly. C. Develop destigmatizing messages on VA’s 

Internet home page for veterans, their families and the general public focused on 

the themes that mental health is essential to overall health and on the availability 

of effective new treatments. The monthly message would be developed with the help 

of VA Mental Health Consumer/Advocate Councils to be culturally competent and 

acceptable to veterans and their families D. Secretary Principi and other senior officials would include this theme in public addresses, speeches, and VSO convention 

addresses. 

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AA Rec. # Mental Health 

Strategies Initiatives 

1.1.1 A, B, 

C, D 

Initiatives 

1–4 

Promote mental 

health awareness 

in collaboration 

with VA Office of 

Communications, 

EES, NAMI, SMI 

Committee Consumer Liaison 

Council, etc. 

Identify a spokesperson to represent 

VA in this effort. This will be a 

cross-cutting campaign with emphasis on special groups, e.g., PTSD, 

women, older groups, returning service personnel. This will be accomplished by outreach to veterans & 

families; use of public service announcements, train VA staff in these 

approaches to new vets/ families. 

Mental Health Strategic Healthcare 

Group (MHSHG) will coordinate 

Mental Health Awareness Day, with 

educational activities mandated at 

each VAMC and kickoff of Veterans 

Mental Health Year in 2005. 

Ongoing 1 

MHSHG will create a Mental Health 

Workgroup to identify existing resources and develop a communications plan, based on the Action 

Agenda recommendation 1.1.1 A, B, 

C, D, to inform the veteran community, including families, Veterans 

Support Organizations, VHA staff, 

Veterans Benefits Administration 

staff, and veterans themselves as 

well as the public of the importance 

of mental health care. 

An enhanced 

communication 

plan is under 

development 

3 

Promote effective 

outreach and reintegration of 

soon to be or recently deactivated military 

personnel. 

1. Provide ‘‘State of the Art’’ outreach, screening and referral to military personnel transitioning from active or reserve status to civilian status. 2. Readjustment Counseling 

Service (RCS)/MHSHG to extend 

seamless care model to mental 

health service for combat veterans. 

3. RCS/MHSHG to develop and coordinate VHA outreach to National 

Guard, Reserve, and soon to be or 

recently discharged military personnel and to the families of these 

groups. 4. RCS/MHSHG to develop 

models of care to address mental 

health needs of recently discharged 

combat veterans. 

Ongoing 1 

Promote 

destigmatization 

through 

partnering with 

VBA, Department 

of Labor, state 

and local programs to provide 

career development services. 

Design and establish Career Development Centers in VHA Medical 

Centers and Community-based Outpatient Clinics (CBOCs), for recently 

deactivated military personnel based 

on partnerships between Psychology 

Services in Mental Health, VBA, 

and DoL. 

To be reevaluated 4 

Promote a Mental Health Awareness Day, for instance in May, which is Mental 

Health Month. 

AA Rec. # Mental Health 

Strategies Initiatives 

1.1.2 Institute an annual Mental 

Health Awareness Day. 

Mental Health Awareness Day annually and partner with other national organizations to reach broader 

audience. 

Ongoing 1 

Identify Mental Health an Employee Education Services (EES) focus area in 2005. 

All health care workers should understand that mental health is essential to overall 

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health; reduce stigma by their interactions with veterans and their families; and understand the major suicide risk factors and the principles of suicide prevention. A. 

Use the Mental Illness Research, Educational and Clinical Centers (MIRECC) and 

National Center for PTSD (NCPTSD) Education Groups for VA staff education for 

Best Practices. B. A satellite broadcast program similar to the ‘‘Face Behind the 

File’’ series can be launched in which veterans; perhaps some with national stature 

address their mental health and physical problems and their interconnection. The 

profiles will illustrate veterans overcoming disability and demonstrating recovery 

and individual success. C. Develop a Mental Health Speakers Bureau for Continuing 

Medical Education (CME) credits and patient education. 

AA Rec. # Mental Health 

Strategies Initiatives 

1.1.3 A, B, 

C Initiatives 1–2 

Educate all VHA 

health care providers that mental health is essential to overall 

health and that 

integrating mental health care 

with medical 

health care promotes recovery in 

both aspects of 

health. 

MHSHG will assign a staff person to 

work with EES in the development 

of education programs which will include issues related to all special 

emphasis groups, i.e., PTSD, women 

veterans, older adults, etc. These 

programs will emphasize the interrelationships between mental health 

and physical health and the recovery 

model of care. 

Ongoing 1 

Task MIRECCs and NCPTSD with 

development of a joint education 

plan by 12/31/2005. This plan will 

include the three tenets of recovery; 

consumer self determination, empowering relationships and veteran 

consumer participation in the development and delivery of mental 

health care services. 

Ongoing. Reassigned to OMHS 

PSR section 

2 

Endorse the National Strategy for Suicide Prevention (2001) and the Institute of 

Medicine’s report, ‘‘Reducing Suicide: A National Imperative’’ (2003). Implement 

their recommendations. A. Develop a Suicide Prevention Program for VA patients, 

families, staff and the community. B. Develop electronic suicide prevention database 

using institutional surveillance mechanisms that support population-based screening. 

AA Rec. # Mental Health 

Strategies Initiatives 

1.1.4 A, B Reduce suicide 

among veterans. 

Promote evidence based strategies 

for suicide assessment and prevention, including emphasis on special 

emphasis groups. MHSHG will work 

with HSR&D, NEPEC, and 

SMITREC to develop and test an 

electronic suicide prevention database. Develop a national systematic 

program for suicide prevention. 

MHSHG develops a plan to educate 

all staff that interact with veterans, 

including clerks and telephone operators, about responding to crisis situations involving at-risk veterans. 

This would include suicide protocols 

for intake, telephone operators, and 

other first contact personnel. 

Ongoing 1 

Develop and promote support programs that: A. reinforce help seeking from marital and family counselors, etc B. establish crisis-support, and C. support programs 

for development of more adaptive coping skills and resilience. 

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AA Rec. # Mental Health 

Strategies Initiatives 

1.1.5 A, B, 

C 

Initiatives 

1–11.

Promote coping 

skills, resiliency 

and community 

support. 

1. Educate and train DoD mental 

health care providers about VHA 

and VBA programs and eligibility 

requirements equivalent to a TAP 

for staff; 2. Develop and disseminate 

educational material on VHA and 

VBA programs and eligibility requirements for mental health patients and families; 3. Outreach to 

active duty, especially those with life 

altering injuries, and recently deactivated military personnel and 

their families to make them aware 

of VHA and VBA programs and eligibility requirements for persons 

with mental health problems. 

Ongoing through 

activities of multiple office 

2 

In its National Mental Health Campaign, MHSHG will promote veterans’ seeking help from multiple 

sources and points of entry (e.g., 

marital and family counselors, legal 

counselors, financial counselors, 

mental health specialists, clergy and 

other appropriate community leaders), and promote to all VHA and 

VBA staff a biopsychosocial/spiritual 

orientation to health care that includes cultural competency with relation to unique veterans, racial, 

ethnic, sexual orientation, and gender sensitivities. 

To be reevaluated 4 

Medical Centers establish contacts 

through the Chaplain Service with 

faith-based organizations and community resources to assist with culturally competent suicide prevention 

and other mental health issues at 

local and national levels. 

Requires additional guidance 4 

MHSHG develops a plan for 24 hour 

mental health care availability 

throughout VHA. 

In planning and 

concurrence 

3 

MHSHG directs the VISNs to develop plans, including peer support 

programs, to assist veterans in coping with common problems. 

Ongoing 1 

Peer Support: FY–05: Issue national 

Information Letter to promote paid 

Peer-led services programming, (directly or through contract with community providers) as an adjunct to 

traditional mental health services at 

all facilities serving veterans with 

serious mental illness. FY–06: Issue 

national directive with detailed procedural guidance. Peer Support: FY– 

06: Explore expansion of Vet Centers to include veterans with SMI. 

A strategy for 

broad implementation of peer 

support is included in the 

Uniform MH 

Services package 

3 

Ease Transition 

of victims of Military Sexual Trauma (MST) from 

active duty into 

the VA health 

care system. 

Initiate universal MST screening at 

MTFs and all components of national guard and reserves for separating servicemembers (self-administered with counselors available). 

Universal MST 

screening is ongoing at all VA 

facilities. 

2 

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AA Rec. # Mental Health 

Strategies Initiatives 

TAP literature will include material 

on MST. 

OMHS has established a resource center for 

training and for 

monitoring MST 

programs 

2 

Establish EPRP MST screening supporting indicator: 90% of all veterans will be screened for MST; 80% 

of all veterans screening positive 

will be referred for counseling within 30 days of screening. 

Required MST 

screening is in 

place 

1 

VISN 4/5 MIRECC to expand work 

to focus on female veteran transition 

issues including MST. 

Ongoing, Reassigned to MST 

Resource Center 

2 

Provide seamless 

transition of 

women veterans 

from outpatient 

care to more 

acute levels of 

mental health 

care and vice 

versa. 

The outpatient and Inpatient Mental 

health providers will serve as team 

members for both treatment modalities for female veterans. 

Strategies for 

ensuring transitional care are 

included in the 

Uniform MH 

Services Package 

3 

Commission Recommendation 1.2. Address mental health with the same 

urgency as physical health 

Develop a modular VA-adapted mental health collaborative care model dissemination package as the basis for national rollout, in collaboration with the mental 

health Quality Enhancement Research Initiative (QUERI) Mental Health, VA Central Office and Veterans Integrated Service Networks (VISN) leaders. 

AA Rec. # Mental Health 

Strategies Initiatives 

1.2.6 Initiatives 1–5 Develop a collaborative care 

model for mental 

health disorders 

that elevates 

mental health 

care to the same 

level of urgency/ 

intervention as 

medical health 

care. 

MHSHG will collaborate with Mental Health QUERI to develop infrastructure needed for national rollout, 

including an organizational structure in which the Mental Health 

QUERI Depression Working group 

connects to MHSHG, Primary and 

Ambulatory Care SHG, OQP, National Clinical Practice Guidelines 

Council and the Performance Measures Workgroup, as well as to the 

TIDES Leadership Group. The development will include a VA integrated care model. 

Ongoing. Implementation has 

been based on 

TIDES and 

other models 

2 

Align performance measures to promote evidence-based collaborative 

care for depression. 

Ongoing 1 

Work with OQP to rapidly update 

depression guidelines to include evidence-based collaborative care for 

depression. 

Ongoing 1 

Develop a VA integrated care model 

similar to the Four Quadrant Clinical Integration Model for dissemination to VA medical centers. This will 

be done in collaboration with the 

Quality Enhancement Research Initiative (QUERI) program and VISN 

leadership. 

Completed 1 

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AA Rec. # Mental Health 

Strategies Initiatives 

Assure that medical comorbidities are 

identified and addressed in the 

mental health 

care population 

at the same rate 

as medical issues 

in the primary 

care population. 

Develop a tool and process for assessing physical co-morbidities in 

mental health patients. Collect and 

monitor data at a national level on 

medical co-morbidities in the mental 

health population using existing 

electronic databases; Promote and 

support epidemiological research in 

the area of medical co-morbidities in 

the mental health population; Collect and monitor data at a national 

level regarding access to medical 

care for the mental health population using existing electronic databases. 

Ongoing 1 

Identify good working models of Mental Health/ Primary Care/ Geriatric integration (including a module on differentiating normal and abnormal aspects of aging) 

in terms of service delivery and workload/supervision arrangements. Promote research activities on mental health/primary care integration best practices. 

AA Rec. # Mental Health 

Strategies Initiatives 

1.2.7 Initiatives 1–13 Develop an accurate mental 

health projection 

model for the full 

continuum of 

mental health 

care. 

Continue the MH CARES Advisory 

Work Group to further develop the 

projection model with special emphasis on domiciliaries and 

geropsychiatry. 

DOMs have 

been 

transitioned to 

OMHS. Projection models are 

run by OPP 

2 

A projection model has been developed by a combined subgroup (SMI 

Committee and GEC). Validation of 

this model as an accurate projection 

tool will occur from now through the 

end of FY07. This will be monitored 

by the continuing subgroup which 

will become a subgroup of the AASC. 

This projection model will be further 

evaluated in relation to its utility in 

conjunction with the algorithm to 

guide clinical decisions for long term 

psychiatric and nursing home care 

described in 1.2.8. Expand to cover 

all MH. 

Responsibility 

transferred to 

OMHS, who 

work with OPP 

on this projection model 

2 

Develop innovative programs of 

integrated care 

involving some 

combination of 

primary care, 

geriatrics, and 

mental health. 

The MHSHG will continue to work 

closely with geriatrics and primary 

care to develop clinical models of 

care and guidelines that better integrate mental and physical health. 

Ongoing 2 

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AA Rec. # Mental Health 

Strategies Initiatives 

Educate VHA 

providers on the 

normal and abnormal aspects of 

aging. 

Develop a module on differentiating 

normal and abnormal aspects of 

aging. Address principles of information processing and memory processes for older adults, based on normal age-related changes. Provide information on sensory needs (e.g., use 

of large font). Differentiate normal 

cognitive changes with aging from 

changes indicating dementia or 

other cognitive functional problems. 

Cover evidence on demographics of 

aging and mental health, challenging common distortions (e.g., 

that depression is normative for 

older adults). Discuss evidence that 

older adults benefit at least as much 

from psychotherapy and psychotropic medication as do younger 

adults. Discuss adaptations of psychotherapy that enhance its effectiveness with older adults. In accord 

with recovery principles, articulate 

respect for the older veteran’s 

choices for mental health resources. 

Training for 

some target 

groups completed. Further 

training is being 

planning; was 

deferred to focus 

on returning 

veterans 

3 

Integrate primary 

medical care with 

homeless services. 

Expand two existing pilots (VA Conn 

HCS & West LA) to other facilities. 

Incorporate primary care into the 

women’s homeless demonstration 

program. 

In planning and 

development 

3 

Identify outreach 

to homeless recently discharged 

military servicepersons. 

Add an indicator to the intake form 

to assess outreach. A draft document 

has already been sent to the field for 

evaluation of feasibility and other 

comments. 

Ongoing. Indicator completed 

and continues to 

be utilized. 

1 

Ensure that mental health examinations are a 

part of all physical examinations 

in VHA. 

Every returning service man/woman 

will meet with a mental health professional as part of the post-deployment and separation medical examinations and be provided with a brief 

pamphlet that reviews the information provided during the session. He/ 

she will be encouraged to share this 

pamphlet with his/her family. Those 

found to have significant readjustment problems in the course of the 

examination would be triaged to 

care as appropriate. Those who decline intervention at time of screening, or who are not presently symptomatic, but deemed at risk for future readjustment problems based 

on the exam, will have their medical 

record flagged for repeat screening 

at future medical appointments. 

Ongoing— 

PDHRA process 

2 

Eliminate gender 

disparities and 

provide accessible 

mental health 

services to 

women veterans. 

Charge a women’s mental health 

committee to identify and design evidence based optimal women’s mental 

health practice models. 

Ongoing 1 

Expand women’s HSR&D research 

agenda to evaluate women’s mental 

health programs effectiveness and 

patient outcomes. 

Assigned to 

Women’s Mental 

Health Committee 

2 

Appoint a women’s health representative to the SMI Committee. Completed. 1 

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AA Rec. # Mental Health 

Strategies Initiatives 

Women veterans 

will have access 

to mental health 

services in a milieu that promotes comfort 

and security. 

Women Veterans Program Manager 

will participate in the MH EOC 

planning process for both inpatient 

and residential programs. 

Participation in 

planning is part 

of the WVPM 

duties and responsibilities as 

identified in the 

VHA Handbook. 

2 

Expand dental 

services for homeless veterans. 

NEPEC and Dental Service will 

jointly develop a means of monitoring services delivered. 

Mental Health 

Enhancement 

funding has 

been used to expand dental 

services for SMI 

and homeless 

veterans 

2 

Realign Domiciliary Program. The domiciliary programs that primarily treat substance abuse and 

PTSD patients should be placed 

under MH in VACO and the field. A 

subgroup of the AASC will be 

formed to explore details of how this 

can be accomplished while maintaining domiciliary-type services for frail 

elderly veterans and for enhancing 

services for special populations such 

as women veterans. Subgroup to include representatives of MH, GEC 

and the Women’s Strategic Planning 

Task Force, as well as others selected by the Exec Comm of the 

AASC. Subgroup to be formed and 

begin to explore implementation 

plans by 10/1/04. 

Completed. 1 

Eliminate variability in access to mental health, substance abuse, long term psychiatric care and homeless services by 2008. A. Complete expansion of specialty 

mental health services in all Community Based Outpatient Clinics (CBOCs). B. Use 

tele-mental health approaches for smaller sites including access to specialized services such as PTSD and substance abuse counseling. C. Implement the Veterans’ Millennium Health Care Act requirements for long-term psychiatric care. D. Produce 

VHA mental health strategic plan and VISN-level tactical plans to ensure uniform 

implementation. 

AA Rec. # Mental Health 

Strategies Initiatives 

1.2.8 A, B, 

C, D Initiatives 1–40 

Provide a full 

continuum of 

compassionate 

care to veterans 

with mental illness. 

Implement Performance Measure for 

FY05: 85% of CBOCs serving more 

than 1,500 veterans will provide onsite, contract, or tele-mental health 

services at or above 10% of all clinic 

visits by FY05. Increase to 15% of 

all clinic visits by FY07. 

MH in CBOCs 

have been expanded, and initial performance 

measures have 

been met. Further enhancement will occur 

through Uniform MH Services package 

3 

All Networks that are below the 85% 

standard at COB 3rd Qtr FY04 must 

submit an Action Plan to the Action 

Agenda Steering Committee Task 

Force for review and recommended 

approval, and the Task Force will 

monitor progress. Appendix B of the 

Secretary’s Mental Health Task 

Force contains a list of over 200 

CBOCs that are below the standards 

as of 6/30/04. 

Ongoing 1 

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AA Rec. # Mental Health 

Strategies Initiatives 

Establish a Point of Contact for 

Mental Health in CBOCs and notify 

VACO MHSHG who that individual 

is. 

Directors of MH 

in parent 

VAMCs have responsibility for 

MH in CBOCs 

2 

All CBOCs should provide access to 

mental health services, either on 

site or by contract with offsite being 

the option of last resort. In remote 

locations telemental health may be 

used. The level care of care and the 

competencies of the staff available at 

the CBOCs must be equivalent to 

the care at the parent medical center and not at the expense of the 

parent facility (VHA Directive 2001– 

060). This workgroup recommends 

an integrated model of 1.0 FTE behavioral health clinician per 1,500 

primary care patients. Clinicians 

who operate at a distance from 

VAMCs in CBOCs manage a broader 

and more complex range of mental 

health disorders and require an adjusted case load size. Develop a national performance measure that addresses the mental health staff/patient ratios in CBOCs. All VISNs 

should develop a plan of how to deliver mental health services in 

CBOCs to patients with primary 

substance use disorder diagnoses. 

Ongoing 1 

Develop national performance measure that addresses MH staff/patient 

ratios in CBOCs. 

Requires additional guidance; 

decisions will be 

related to mental health productivity work 

group recommendations. 

4 

Update CBOC application directive 

and form to include requirement to 

specifically detail MH services and 

staffing to be provided at all new 

CBOCs. Ask for a focused evaluation 

from the Mental Health representative on each CBOC application currently under review and secure additional information as needed. 

Ongoing 1 

All medical centers and CBOCs will 

develop service agreements between 

primary care and mental health on 

bipolar disorder, schizophrenia, 

PTSD, SA defining treatment and 

referral guidelines. 

Included in Uniform MH Services Package 3 

Reduce geographic variation 

and include access to specialized MH and SA 

service delivery 

to homeless veterans. 

Expand homeless programs to bring 

all VISNs up to the current national 

average for provision of mental 

health services to homeless veterans. 

Ongoing 1 

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AA Rec. # Mental Health 

Strategies Initiatives 

Consistent with the recommendation 

that variation in service availability 

will be reduced, the homelessness 

subgroup of MHSPWG developed a 

model for meeting the needs of 

homeless vets which suggests that 

$11.6 M of new annual funding over 

the next 5 years will bring all VISNs 

up to the current national average of 

38.4 veterans served by homeless 

staff in homeless programs per 1000 

veterans at risk for homelessness. 

$33 M could bring all VISNs up to 

the current 85th percentile or 49.7 

for 1000 at risk. It could cost $86 M 

to bring all VISNs up to the level of 

the top VISNs (73.4/1000) in FY03. 

NEPEC, in collaboration with Performance Measures Work Group, 

will develop a performance measure. 

Projecting need 

is the responsibility of OPP. 

Services have 

been enhanced 

in recent years. 

2 

Provide a full 

continuum of care 

to homeless veterans with mental illness. 

Implement Performance Measure for 

FY05: 75% of homeless veterans will 

receive at least one mental health or 

substance abuse visit and one primary care visit within six months of 

initial outreach (The denominator 

against which the 75% measure is 

calculated will be all veterans for 

whom a Form X is completed). 

Ongoing 1 

75% of veterans with SMI who meet 

clinical criteria for MHICM program 

will be enrolled and provided services. The denominator for this measurement is the population based 

need estimate developed by the SMI 

Subcommittee of the MHSPWG. All 

VISNs will submit a plan (by 9/30/ 

04) for providing care to meet this 

measure. 

MHICM programs have been 

expanded. In 

general, these 

programs do not 

target homeless 

veterans 

2 

VHA Directive 2000–034 specifies 

the evidence based operational performance criteria for MHICM in 

VHA and defines the target population. This directive to be renewed 

and facilities held accountable for 

adhering to all performance criteria. 

Ongoing 1 

Require that all homeless veterans 

who meet clinical eligibility criteria 

for MHICM programs be offered assignment to a MHICM team and enrollment in the MHICM program. 

All MHICM teams will adhere to established clinical standards and 

caseloads. 

Homeless veterans may be 

entered into 

MHICM programs when 

they complete 

transitional 

housing programs 

2 

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AA Rec. # Mental Health 

Strategies Initiatives 

Restore VHA’s 

ability to consistently deliver 

state of the art 

care for veterans 

with SA disorders. 

Mandate that VAMCs restore specialized SA treatment programs. All 

networks will be ranked on their 

percentage of substance abuse treatment capacity, which is defined as 

follows: The numerator is the number of substance abuse patients 

treated in FY03 as defined in the capacity report, and the denominator 

is the number of enrolled veterans 

in the network. The lowest quartile 

of networks (i.e., the bottom 5) on 

this measure will be required to 

bring their networks up to the national average on this measure on 

the rapid schedule laid out by the 

Secretary. 

Ongoing planning. There is a 

need to restore 

specialized SA 

treatment, AND 

to account for 

SA treatment in 

general MH care 

settings and primary care 

3 

Develop a National Plan to meet SA 

capacity requirements. Capacity distributed by VISNs to meet all dimensions of access: geographic distribution, affordability, availability, 

acceptability, and accommodation. 

The plan uses VHA’s clinical practice guidelines for substance abuse 

treatment as primary guide in reestablishing services and show how 

VISNs resources will be reallocated 

to accomplish the plan objectives. 

SA capacity is 

being expanded 

through the 

Mental Health 

Enhancement 

Initiative 

1 

Ensure that primary care at all VA 

facilities has physicians trained, accredited and privileged in primary 

care provision of buprenorphine and 

Naltrexone or technology to connect 

to services at a larger medical center. Recommend that Pharmacy and 

Therapeutics Committees approve 

these agents for the facility’s formulary. Ensure that all VA facilities 

have the resources to provide 5 days 

of inpatient/residential detoxification 

services either on-site, at a nearby 

VA facility, or at a contracted facility. All facilities will have a specialized substance abuse provider to ensure linkage between the inpatient 

and outpatient follow-up treatment 

programs. 

Further planning is needed. 

Many sites remain without 

OAT in spite of 

ongoing support 

for 

buprenorphine 

staffing and 

training. 

3 

Implement HEDIS for benchmarked 

performance measures for substance 

abuse in FY06. 

Ongoing 1 

Establish case 

management programs for homeless veterans 

with mental illness and/or substance abuse. 

Implement a special needs grant 

program for homeless chronically ill 

veterans coupled with Critical Time 

Intervention (CTI) services at 

partnering VAMCs. Current available funding in the Homeless Provider Grant and Per Diem Program 

can support five collaborative 

projects. Based on the outcome of 

the pilots, a plan for national implementation will be developed. Homeless veterans with complex medical 

problems, serious mental illnesses 

and/or substance use disorders will 

be assigned to a targeted case management program. 

Ongoing 1 

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AA Rec. # Mental Health 

Strategies Initiatives 

Eligible veterans who receive services in grant and per diem programs 

will have the number of visits (529 

stop codes) consistent with their 

need, but no less than one HCHV 

visit per month, to assure facilitated 

access to VA mental health and 

medical services. Telemental health 

can be used to provide these services 

in remote locations. NEPEC to track 

data and report to MHSHG. 

Ongoing 1 

Establish a performance measure requiring that homeless veterans suffering from SMI and/or SA who receive residential services receive at 

least one MH or SA treatment visit 

during residential care and one follow-up visit during discharge from 

residential care. 

Ongoing—Four 

performance 

measures have 

been implemented focusing 

on timely access 

for homeless 

veterans to VA 

MH/SUD and 

Primary Care 

Services. 

2 

Develop a full 

range of supportive services 

for veterans in 

collaboration with 

community partners. 

Provide incentives to improve homeless veterans access to VA treatment 

services and enhance collaboration 

between VA medical centers and 

Grant and Per Diem funded transitional housing programs. 

Ongoing. 1 

Establish financial incentives for 

providing necessary VHA mental 

health services to homeless veteran 

in Grant and Per Diem programs. A 

report of options will be sent to the 

Secretary from the VHA National 

Leadership Board Finance Committee. 

Ongoing. 1 

Enhance supported CWT and employment activities within VA by: 1. 

Establish a performance measure/ 

monitor for assessment of occupational dysfunction, and referral to 

transitional and supported employment models authorized by 38 USC 

1718. Such a measure/monitor will 

establish reasonable expectations for 

access to transitional and supported 

employment separately for veterans 

with homelessness and for those 

with psychosis. 2. Provide approx 

$6,000,000 in FY’04 for staffing resources to implement supported employments at 107 existing vocational 

programs authorized by 38 USC 

1718. Provide approx $4,000,000 in 

FY’05 for staffing resources to operate and sustain work restoration 

services authorized under 38 USC 

1718 for the provision of both transitional and supported employment 

models at facilities without existing 

CWT programs. These resources 

should be provided through recurring Specific Purpose funding with 

new permanent positions established. 

CWT programs 

have been expanded through 

the Mental 

Health Enhancement Initiative 

2 

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AA Rec. # Mental Health 

Strategies Initiatives 

Finalize a policy directive that 

places a priority on making underutilized space on VAMC campuses 

available to nonprofit communitybased organizations that wish to develop residential programs for homeless veterans. Enhance partnerships 

with community partners to provide 

transitional housing. 

To be reevaluated 4 

Mandate that all VISNs address the 

transition needs of incarcerated veterans and develop a plan that will 

be implemented in FY 2005. 

Ongoing for veterans being discharged from 

state and Federal prisons 

1 

Each VISN will submit a specific 

plan for pre-release assessments of 

veterans in Federal and state correctional facilities to determine degree 

and type of need and methods of 

providing services. The assessments 

to include mental health, medical 

and social service needs. 

Ongoing 1 

Meet the needs of 

SMI veterans for 

Community Residential Care. 

1. Meet levels as projected by the 

MHSPWG for FY07. Market level 

plans developed for any market with 

a gap that exceeds 1,000 CRC stops 

in FY07. For meeting these gaps, a 

plan must be submitted by 10/1/04 

to the AASC. 2. Increase staffing to 

meet the required minimum one 

case management visit per month. 3. 

Emphasize individualized, recoveryoriented placements versus placements that have an institutionalized 

atmosphere and very little rehabilitation services. 

Requires guidance on organization of CRC 

program 

4 

Each Medical 

Center will have 

a Mental Health 

Clinic with adequate staffing to 

meet the mental 

health needs of 

veterans. 

Each VISN will develop a planning 

initiative to address service gaps in 

outpatient mental health care identified by the MHSP model. Analysis 

and Network plan to address issues 

(with at least a 30% gap closure by 

COB FY07) must be submitted to 

MHSHG and AASC by 10/04. Markets with positive gaps over 16,000 

(actual CARES) stops in FY07 

MHSP model need to be addressed. 

This is the same market level gap 

used in the original CARES model. 

Each VA facility that currently does 

not have one will have a PTSD clinical team or PTSD specialists or a 

plan to secure these services. The 

role of these clinicians is to serve 

the facility MHC and CBOC based 

OPC services and also to provide 

consultative or clinical support to 

acute inpatient units for patients 

with PTSD. 

Ongoing, with 

all VAMCs have 

PTSD clinical 

teams or specialists. Adequacy of 

staffing is assessed through 

measures of access, intensity, 

and quality of 

care 

2 

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AA Rec. # Mental Health 

Strategies Initiatives 

Expand PTSD outpatient services in 

VISNs with gaps as identified in the 

PTSD subgroup report. Twelve 

VISNs, 3, 4, 5, 8, 9, 10, 11, 12, 15, 

19, 22 and 23 are identified as having PTSD care gaps in the P.L. 108– 

170 solicitation and will be considered the first priority for new PCT 

development. In addition, other 

VISNs especially those with significant Global War on Terrorism troop 

returnees (2, 6, 16, 17 and 21) will 

also receive priority in expanding 

new PCTs. 

Each VAMC has 

a PTSD clinical 

team or specialist 

1 

Medical Centers 

will have adequate beds and 

staffing to meet 

the needs of the 

local veteran populations for acute 

inpatient psychiatric services. 

Each VISN which has a market(s) 

with a MHSP projected service gap 

in inpatient mental health both for 

FY’02 and for FY’07 that exceeds 

7,300 bed days of care at the market 

level must submit a plan to close 

that gap by FY’07 with phased in increments of a minimum of 10% per 

year. Those markets that exceed a 

7,300 BDOC gap either for FY’02 or 

for FY’07 will assess and report if a 

plan is needed. Reports should be 

submitted to the AASC no later than 

10/1/04. 

Planning is in 

progress 

3 

Expand clinical 

monitoring systems to include 

Work Restoration 

services. 

Explore development of a Work Restoration Information Management 

System (WRIMS) for use in each 

VAMC and CBOC (using the CMIS 

of VISNs 1 as a model), to ensure 

that each veteran is offered the 

choice in participating in work restoration services; Increase Work 

Restoration services until all veterans in VAMCs and CBOCs have 

equal access to work skills training 

and development; Implement the 

Evidence-Based practice of Supported Employment into all Work 

Restoration programs; Add work restoration to Illness Mgt Training of 

unemployed patients who are participating in programs transferring 

from LT custodial care to rehabilitation in the community; Add work 

restoration training to MHICMs and 

other community support teams. 

The Uniform 

MH Services 

Package includes a strategy for broader 

implementation 

of CWT and SE 

3 

Meet the needs of 

SMI veterans for 

residential rehabilitation services. 

General psychiatry PRRTP (residential care) services increase at the 

VISN level by FY’07 based on the 

MHSP Model projection. VISNs that 

have a gap of 15 or more PRRTP 

beds should develop a plan to reduce 

the gap by at least 30% by FY07, 

phased in annually with a minimum 

of 10% improvement each year. The 

plan to be developed by 10/1/04 and 

reviewed by the Action Agenda 

Steering Committee. 

The Uniform 

MH Services 

Package includes a strategy for making 

residential care 

services available to those 

who need them 

3 

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AA Rec. # Mental Health 

Strategies Initiatives 

Meet the needs of 

veterans with 

substance abuse 

for residential rehabilitation services. 

SARRTP (residential care) services 

increase at the market level by 

FY’07 based on the MHSP Model 

projection. Market areas that have a 

gap of 15 or more SARRTP beds, 

after taking into account bed section 

86, DOM/SA, develop a plan to reduce the gap by at least 30% by 

FY07. The plan to be developed by 

10/1/04 and reviewed by the Action 

Agenda Steering Committee. 

The Uniform 

MH Services 

Package includes a strategy for making 

residential care 

services available to those 

who need them 

3 

Meet the needs of 

veterans with 

PTSD for residential rehabilitation 

services. 

1. PRRP (residential care) services 

to be increased at the VISN level by 

FY07 based on the MHSP Model 

projection. VISN areas that have a 

gap of 5,475 or more PRRP beds 

(taking into account Dom PTSD program beds as equivalents) will develop a plan to correct the gap. The 

plan to be developed by 10/1/04 and 

reviewed by the Action Agenda 

Steering Committee. Preliminary 

analyses indicates that VISNs 4, 6, 

9, 16 and 22 would develop plans. 

The Uniform 

MH Services 

Package includes a strategy for making 

residential care 

services available to those 

who need them 

3 

Allocate additional resources 

for enhanced outpatient treatment 

of all Mental Illness Chemical 

Abuse (MICA) 

patients. These 

treatments must 

consist of appropriate integration 

of substance 

abuse and mental 

health treatment 

services. 

Proposed that VHA adopt the standards outlined in the integrated treatment of patients contained in the 

MICA Task Force report (January 

2004) at each facility with a substantial population of individuals 

who meet the definitions for MICA. 

Ongoing. Standards adopted in 

SA operating 

plan, FY 2005. 

Resources allocated in FY 

2005/06/07 

1 

Expand Opiate 

Agonist Treatment (OAT) in 

urban centers 

with high prevalence of heroin 

use and large 

CARES-projected 

gaps in VA methadone treatment. 

Open OAT clinics at Phoenix, AZ; 

Denver, CO; Tampa, FL; Orlando, 

FL; Salt Lake City, UT. 

The Uniform 

MH Services 

Package includes a strategy for making 

buprenorphine 

prescribing 

available at all 

VAMCs 

3 

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AA Rec. # Mental Health 

Strategies Initiatives 

Ensure effective 

utilization of the 

continuum of 

long term inpatient mental 

health care. 

1. Authorize a joint review and refinement by Mental Health, Geriatrics and Extended Care, and the 

SMI Committee, of the 1996 VHA 

Program Guide 1103.22 ‘‘Integrated 

Psychogeriatric Patient Care’’; by 2/ 

2005. 2. Promulgate throughout VA 

the algorithm for functional decisions on level of nursing and mental 

health care for older veterans needed (presented in full report of the 

Older Adult subgroup) over the next 

year (and then ongoing), as a recommendation by the Secretary for 

decisionmaking in each VISN. This 

will be done in conjunction with ongoing efforts in Geriatrics and Extended Care to develop a broad new, 

compassionate model of nursing 

home care for Veterans. 3. All nursing home care facilities will have 

staff educated in and competent to 

care for patients with both functional and behavioral health problems. In some circumstances, specialized units such as dementia 

units, or psychogeriatric units may 

be necessary to meet local needs. 

In planning. 

Programs are 

being at NHCUs 

in each VISN to 

place mental 

health staff who 

can ensure that 

recommendaton 

#3 is accomplished: educating staff in 

competent care 

for patients with 

both functional 

and behavioral 

health problems 

3 

Ensure adequate 

day treatment facilities for SMI 

veterans. 

VISNs without Day Treatment (or 

equivalent) capacity should add it at 

the most appropriate facility, based 

on size and access considerations. 

The Uniform 

MH Services 

Package includes a strategy for making 

psychosocial rehabilitation 

available at all 

VAMCs. Day 

treatment with 

a PSR orientation already implemented in 

most VISNs 

3 

Facilities serving over 1,000 veterans in the psychosis registry without a Day Treatment (or equivalent) 

facility should add one with appropriate staffing and education. Peer 

Specialists should be used whenever 

feasible. 

Included in the 

Uniform MH 

Services Package 

3 

Existing Day Treatment programs 

with waiting lists will provide resources to eliminate them. 

Enhancements 

in day treatment 

are included in 

the Uniform MH 

Services Package 

3 

President’s New Freedom Commission Goal 2. Mental health care is consumer and family driven. 

Commission Recommendation 2.1. Develop an individualized plan of 

care for every adult with a serious mental illness and child with a serious 

emotional disturbance. 

Develop a performance measure based on percentage of Seriously Mentally Ill 

(SMI) patients whose family members have been contacted to participate in developing an individualized plan of care. A. Create data capture mechanism for family 

contacts that include implementation of a clinic stop code for family work and a 

family education/counseling field on encounter forms. 

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AA Rec. # Mental Health 

Strategies Initiatives 

2.1.9 A Initiatives 1–5 Ensure that 

every mental 

health patient 

has an individualized treatment 

plan that includes family involvement in 

treatment plan 

and process. 

Operationalize Family Education 

clinic stop code and encounter form 

procedure code in FY–05; Implement 

(VISN 10 pilot) Family Involvement 

Performance Measure nationwide in 

FY–05. 

Planning is underway to evaluate how to capture family involvement in 

care 

3 

The FPE/FE Task Force of MH 

QUERI outlined the following in 

FY–05: Develop policy directive on 

Family Involvement/Education to include issues of confidentiality and 

expectation that the care plan for all 

patients with schizophrenia establish at least one family contact or 

document the reason for its absence. 

In planning 3 

Expand seamless 

transition efforts 

to fully cover veterans with mental health diagnoses. 

1. Assign Transition case managers 

to focus on mental health programs, 

based on caseload to WRAMC, 

Brooke etc. where the bulk of the 

mental health MEBs and PEBs are 

conducted; 2. Develop case management program for all DoD ‘‘complex 

care’’ patients coming into VHA 

health care system; 3. Include VHA 

social worker/case manager and patient family in transition planning 

for DoD personnel with mental 

health problems who will be 

transitioning to VHA health care 

system, with a special focus on pain 

management; 4. Improve transition 

planning, referral/placement and information exchange for patients with 

mental illness coming into VHA 

health care system; 5. Improve outcomes for patients eligible for VA 

services and/or benefits thru use of 

recovery approach to provision of 

services. 

Care management programs 

focus on seriously injured 

2 

1. Assign Transition Social Workers 

to focus on mental health including: 

2. Survey all MTFs to determine the 

need for social workers focused on 

mental health programs; 3. Ensure 

that Points of Contact at VISN and 

local treatment systems have appropriate knowledge about mental 

health programs and capabilities; 4. 

Have transition social workers followup on referrals at three and six 

months to ensure effective program 

placement; Identify VACO point(s) of 

contact for problem resolution. 

Care management programs 

focus on seriously injured 

2 

Mental health assessments are an 

integral part of 

all exams of separating military 

service personnel. 

1. Every military man and woman 

meet individually with a mental 

health professional as part of the 

post-deployment and separation 

exams. 2. An MOU needs to be developed with DoD to spell out authority, responsibility, accountability, and funding for the necessary clinical capacity to be assured. 

Ongoing. VA has 

worked with 

DoD to support 

PDHRAs 

2 

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Commission Recommendation 2.2. Involve consumers and families fully 

in orienting the mental health system toward recovery. 

Involve veteran consumers and families in educating staff/veterans/family members on recovery. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.2.10 Initiatives 1–2 Seek stakeholder 

input into mental 

health programming related to 

recovery. 

For VHA staff educational efforts, 

MHSHG will ensure that stakeholders are included in planning 

educational programs related to recovery. 

Ongoing 1 

Assess barriers and explore implementation of Vocational Rehab and 

education for DoD patients with 

mental health problems while they 

await their MEBs or PEBs. 

Need further 

guidance on collaborations between VBA and 

MH 

4 

Implement administrative incentives that facilitate work with veteran’s families. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.2.11 / 

2.2.12 Initiatives 1–3 

Reduce barriers 

to working with 

families. 

Implement (VISN 10 pilot) Family 

Involvement Performance Measure, 

including developing stop codes and 

other incentives for tracking workload. MHSHG and Mental Health 

QUERI will review results of VISN 

10 performance measure pilot prior 

to advocating for national performance measure. 

In planning 3 

Implement Family Education in 

every Network through partnership 

with NAMI (Family to Family Program). 

MOU is in concurrence 3 

Offer Family-to-Family Education in 

partnership with NAMI in every 

Network. Partner every facility, outpatient clinic and CBOC with corresponding county NAMI Affiliate, 

or other comparable Family Education program where FFEP is not 

offered and/or there is an already 

existing Family Education program; 

FY–06: Implement FPE in pilot Networks; Implement FPE/FE utilizing 

technology in pilot Networks; Work: 

Insure Family Education addresses 

issues regarding Work Restoration. 

In planning 3 

Educate staff. A. Begin process of educating staff with a satellite broadcast introducing the current evidence base for the recovery based model of treatment. B. Develop programs for staff use on family psycho-education. C. Educate staff on clinical 

benefits and effective approaches to working with families, including issues of older 

couples and intergenerational families. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.2.13 A, B, 

C Initiatives 1–3 

Educate staff on 

the evidence 

based recovery 

model of treatment. 

MHSHG will work with EES to develop an educational program, including a satellite broadcast, for 

staff regarding the recovery model of 

treatment including issues of older 

veterans, female veterans and other 

special emphasis groups. 

Ongoing 1 

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AA Rec. # Mental Health 

Strategies Initiatives 

Train staff on QUERI FPE via EES 

Broadcast and develop FPE Tool Kit; 

Disseminate FPE Task Force Tool 

Kit (planned) which will include 

working with diverse families to include older couples and intergenerational families. 

FPE is being 

disseminated 

through with 

multiple supports 

2 

Develop programs for staff use on 

family psycho-education at the VA 

Palo Alto MIRECC and NCPTSD 

(VAPAHCS is the educational site 

for the National Centers for PTSD). 

A number of 

centers are involved in training 

2 

Include veteran consumers and family members in facility mental health councils. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.2.14 Initiatives 1–3 Establish facility 

mental health 

council that include consumer 

membership. 

All facility Mental Health Services 

will report to MHSHG about membership composition of the facility 

mental health council. 

Additional guidance is required 4 

All facility mental health councils 

will have at least one veteran consumer and one family member as 

standing members of the facility 

mental health council. 

Additional guidance is required 4 

To provide guidance to the field, 

VACO to develop and issue a Directive promoting the establishment of 

consumer/advocate liaison councils 

at both VISN and facility levels by 

2nd Qtr FY’05. Such a Directive to 

include language about the communication chain to maximize the effectiveness of the council. 

Additional guidance is required 4 

Commission Recommendation 2.3. Align relevant Federal programs to 

improve access and accountability for mental health services. 

Develop Peer Support Program as an adjunct to mental health services. A. Explore models of peer support certification (e.g. those developed by Georgia). B. Determine whether a directive on Peer Support is advisable. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.3.15 A, B 

Initiatives 

1–5 

Partner with 

other Federal 

agencies to develop peer support programs. 

Pilot State Peer Specialist Certification projects (such as Georgia/ 

South Carolina, Hawaii, etc); Peer 

Support: FY–05: Issue national Information Letter to promote paid 

Peer-led services programming, (directly or through contract with community providers) as an adjunct to 

traditional mental health services at 

all facilities serving veterans with 

serious mental illness. FY–06: Issue 

national directive with detailed procedural guidance. 

A strategy for 

developing peer 

support is included within 

the Uniform MH 

Services Package 

3 

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AA Rec. # Mental Health 

Strategies Initiatives 

Establish partnership with 

SAMHSA and continue participation 

in Federal partners workgroup at 

VACO level. Establish nationwide 

method for reimbursing peer support. Add Work Restoration to Peer 

Counseling and Vets Helping Vets 

programs. Oversight of this effort to 

be conducted by the AASC. 

Requires additional guidance 4 

Develop a partnership between the 

MHSHG and RCS to develop model 

systems for consumer and family 

driven services with VHA and to create a national Program of Excellence 

in Peer Counseling Services within 

VHA. 

Requires additional guidance 4 

VISN 1 MIRECC will develop a 

‘‘How To’’ manual on developing a 

Peer Support program. 

Manuals for psychosocial rehabilitation, including peer 

support, are 

under development 

3 

Transition planning and referral/ 

placement for 

OEF and OIF returnees 

Explore early transfer of patients 

with mental health problems to the 

VA treatment system and the use of 

VA health care providers to conduct 

MEBs and PEBs. 

Plans for DoD 

VA partnerships 

are being developed 

3 

Initiate a national Recovery and Rehabilitation Task Force to develop a ‘‘How To’’ 

manual on developing a Peer Support Program. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.3.16 Provide support 

for the development of a Peer 

Support Program. 

VISN 1 MIRECC will facilitate the 

following efforts: 1. Family Support/ 

education—Implement family education program in each VISN; educate staff; appoint family POC within each facility. 2. Veteran Advisory 

Councils/peer support. 3. Change 

VHA culture to recovery oriented 

service delivery. Reference AA Recommendation 5.3.61. 

In planning, 

with reassignment to OMHS 

3 

Develop task oriented veteran-consumer councils in each facility. A. Insure consumer council has communication mechanism to facility leadership. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.3.17 A combined with 

2.3.14 

Develop paid positions for veterans) within the facility/network to work with Mental Health leadership in developing Peer to Peer Programs. 

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AA Rec. # Mental Health 

Strategies Initiatives 

2.3.18 Initiatives 1–3 Utilize veterans 

in the provision 

of mental health 

care. Reference 

AA Recommendation 5.3.61. 

Hire or identify existing staff as a 

permanent veteran mental health 

consumer in the MHSHG and in 

each Network to work with Mental 

Health leadership in developing 

Peer Programming and to represent 

the consumer perspective in other 

mental health planning/management 

initiatives and to serve as peer/MH 

para professional. 

In planning 3 

Pilot Certified Peer Specialists in selected VISNs (suggest VISNs 7 and 

20) Pilot Peer Bridgers in selected 

VISNs (suggest VISNs 2 and 3); 

Modify current State Certified Peer 

Specialists training to tailor for VHA 

implementation nationwide. 

A strategy for 

broad implementation of peer 

support services 

is included in 

the Uniform MH 

Services Package 

3 

Issue national directive on Peer programs; Establish Network performance monitor to require a formal 

Peer Support Program at each facility serving greater than 2,500 veterans with SMI; FY–06: Establish a 

clinic stop code for Peer-Led Groups, 

and a Peer Provider category on encounter forms. 

A strategy for 

broad implementation of peer 

support services 

is included in 

the Uniform MH 

Services Package 

3 

Hire veterans as Peer / Mental Health Para Professionals. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.3.19 See 2.3.18 and 

5.3.61. 

FY 06. Establish network performance monitor to require a formal 

paid peer support program at each 

facility serving greater than 2,500 

veterans with SMI. FY 07. Expand 

that monitor to include facilities 

with more than 1,200 veterans with 

SMI. 

A strategy for 

broad implementation of peer 

support services 

is included in 

the Uniform MH 

Services Package 

3 

Issue a national directive to facility leadership on the creation of local Peer Support programs. A. Identify a facility coordinator for the development of peer programs. B. Develop a progressive performance measure that addresses incremental 

steps to the implementation of a facility Peer Support program. C. Create data capture mechanisms for peer support and peer training that include implementation of 

clinic stop codes and modification of encounter forms to include fields for peer support as well as peer training. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.3.20 A, B, 

C 

See 2.3.18 and 

5.3.61 

Make housing with support more available for those veterans who are homeless 

or at risk for homelessness, particularly older veterans and those veterans who are 

new to the system. 

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AA Rec. # Mental Health 

Strategies Initiatives 

2.3.21 Initiatives 1–6 Provide additional homeless 

housing. 

Task HSR&D with creating a Management Consultation Project to develop a demand model for residential services at all facilities. The 

needs of older veterans and veterans 

new to the system will addressed in 

this model. 

DOMS have 

been moved 

within OMHS. 

Projecting need 

is the responsibility of OPP 

2 

Work with HUD to maintain current 

capacity and create new capacity in 

the HUD/ VASH. 

Ongoing 1 

Continue support of joint VA/HUD/ 

HHS collaborative initiative in 

chronic homelessness. 

Ongoing 1 

Expand grant and per diem and 

domiciliary care programs. 

Ongoing 1 

Develop programs focused on prevention of homelessness and unemployment for DoD patients with 

mental health problems (Legislative 

authority may be required). 

For planning 

with DoD COE 

3 

Make underutilized space at VA facilities available for community organizations to provide programs. For program by 

program evaluation 

3 

Work with state, local and community partners to increase opportunities for veterans to participate in supported employment programs. Support legislation to increase VA’s authority to form partnerships to provide supported employment opportunities for veterans. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.3.22 Initiatives 1–3 Increase opportunities for veterans to participate in supportive employment. Partner with Department of Labor 

(DOL) to develop Work Restoration 

services that promote entrepreneurship and private enterprise; Develop 

contract with Department of Defense 

(DoD) to expand the CWT Veterans 

Construction Team (VCT) to assist 

veterans in restoring lost construction skills; Develop policy and procedures for utilization of non-appropriated CWT Special Therapeutics 

Rehabilitation Activities Fund 

(STRAF) to contract with state, local 

and community partners to provide 

job development and coaches for 

Supported Employment services; Increase outreach by providing CWT, 

IT, CWT/TR programs in shelters for 

homeless veterans. 

Specific elements require 

reevaluation 

4 

Improve outcomes for patients eligible for VA services and/or benefits 

thru use of recovery approach to provision of services. 

Additional guidance is required 

about recommendation 

related to benefits 

4 

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AA Rec. # Mental Health 

Strategies Initiatives 

MHSHG to create a RFP for the development of new or expanded CWT/ 

TR programs and that they be provided with $500,000 annually to 

support these programs. This alternative centralized funding mechanism would be established and supported to sustain the provision of 

residential rehabilitation in the 

CWT/TR program for SMI veterans 

until authority is restored for use of 

non-appropriated dollars. 

Evaluations of 

CWT funding 

are in progress. 

3 

Commission Recommendation 2.4. Create a comprehensive State Mental 

Health Plan 

Ensure that VISNs participate in State Mental Health Plan development. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.4.23 Initiatives 1–3 All VISNs will actively participate 

in the development of their 

State mental 

health plans. 

Participate in President’s 10 Year 

Plan to End Chronic Homelessness. 

Ongoing 1 

FY–05/06: Partner with state-funded 

Consumer-run services to provide 

supports for housing, employment 

and other community services to veterans. 

The state service liaison program needs updating. 3 

VISNs will work with their state(s) 

and The National Association of 

State Mental Health Program Directors to develop strategic plans and 

processes for collaboration of the delivery of mental health service. The 

VISNs submit their proposals to 

10N and the MHSHG for consideration. 

The state service liaison program needs updating. 3 

Encourage development of state plans that provide supported housing, employment and other community services to veterans. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.5.24 collapsed with 

2.2.23 

Commission Recommendation 2.5. Protect and enhance the rights of 

people with mental illnesses. 

Identify a family point of contact within each facility to coordinate services, education and liaison with National Alliance for the Mentally Ill. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.5.25 Ensure facility 

coordination with 

NAMI. 

MHSHG will initiate a Task Force 

including representatives from the 

Mental Health QUERI FPE/FE Task 

Force, and charge it with developing 

a process for implementing FE. 

AN MOU with 

NAMI is in concurrence 

2 

Assist with development of an Advanced Directive for every veteran with serious 

mental illness who desires one. Advanced Directives can designate power of attorney 

at times the veteran is deemed not competent to make decisions for him/herself. 

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AA Rec. # Mental Health 

Strategies Initiatives 

2.5.26 Across the age 

span, there will 

be no disparity 

between mental 

health and medical health of veterans in completing a mental 

health and a 

medical advanced 

directive. 

Develop and disseminate to the 

VISNs a mental health advanced directive policy. This policy will address the following issues: Across 

the age span, there will be no disparity between mental health and 

physical health in completing a medical advance directive. When data on 

advanced directive compliance are 

reviewed by facility, rates of completion for veterans with and without 

SMI will be compared. If rates are 

not equivalent, training for staff described under Goal 1 (re. destigmatization) should be repeated for relevant staff, with an emphasis on the 

rights and abilities of veterans with 

SMI and veterans of all ages to state 

their advanced directive wishes. 

OMHS is collaborating with 

Ethics on MH 

advance directives 

3 

Partner with academic institutions that have a commitment to the understanding 

and development of psychosocial rehabilitation (e.g. Robert Wood Johnson Foundation). 

AA Rec. # Mental Health 

Strategies Initiatives 

2.5.27 Initiatives 1–3 Provide psychosocial rehabilitation expertise to 

VHA staff. 

Create working group to expand 

partnerships by participating in research and training activities. 

Ongoing 1 

Identify current partnerships 

through a survey of MIRECCs, PSR 

fellowship programs, Mental Health 

QUERI, and field clinicians and researchers. 

Ongoing 1 

Partner with OAA to develop VHA 

psychosocial internships in association with universities and foundations. Increase linkages in Supported Education with state and regional colleges and training schools. 

Supported education must increase 

marketability in an ever-changing 

job market in which all employees 

rapidly become obsolete as technology continually transforms. 

OAA has established 7 psychosocial rehabilitation fellowship 

programs 

2 

Explore grants awarded to not for profit groups targeted at Peer Development and 

Education. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.5.28 Initiatives 1–2 Refer to 2.3.18 Peer: FY–05: Explore development of 

a VA Technical Assistance Center 

for Peer Support Services and/or develop grant/contractual arrangement 

with established technical assistance 

organizations. 

Ongoing. Technical Assistance 

for peer support 

is available from 

a number of centers 

2 

Part of the Special Needs Grant for 

Homeless Chronically Mentally Ill 

Veterans MHSHG is requiring nonprofit organizations that receive 

funding to develop ‘‘Vet-to-Vet’’ peer 

counseling model. Ten such programs are planned for funding. 

OMHS is developing a peer 

support program 

for homeless 

veterans 

2 

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Charge Veterans Benefits Administration (VBA)’s Vocational Rehabilitation Service with identifying and developing opportunities for training veteran/consumers as 

mental health service providers. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.5.29 Align VBA work 

restoration efforts 

with VHA work 

restoration efforts. 

Expand the partnership with VHA/ 

CWT Program to improve access and 

services to VR&E programs for veterans with mental illness by development of supported employment 

models that include veteran/consumers as employment specialists, 

job coaches, and other support roles. 

MHSHG will prepare memo to USB 

from USH with this proposal. 

Recommendations for partnership with VBA 

should be clarified 

4 

Strengthen and expand local partnerships with NAMI and with National Mental 

Health Association (NMHA) for consultation on the development of peer facilitated 

programs. 

AA Rec. # Mental Health 

Strategies Initiatives 

2.5.30 Refer to 2.5.25 

President’s New Freedom Commission Goal 3. Disparities in mental 

health services are eliminated. 

Commission Recommendation 3.1. Improve access to quality care that is 

culturally competent. 

Develop a culturally competent health care workforce A. Intensify efforts to improve the cultural diversity of health care staff and seek to recruit professional staff 

that better reflect the veteran enrollee population. B. Institute health professional 

scholarship programs targeted to attract minority candidates. C. Provide incentives 

for university affiliates to send undergraduate and graduate health care professional 

trainees to VA health care sites with large minority populations. 

AA Rec. # Mental Health 

Strategies Initiatives 

3.1.31 A, B, 

C Initiatives 1–2 

Ensure that VHA 

workforce is culturally diverse in 

ethnicity, gender, 

and age. 

The Office of Academic Affiliations 

to develop and fund health professional scholarship programs targeted 

to attract minority candidates. 

To be reevaluated. OAA has 

been developing 

other training 

initiatives. 

4 

The Office of Academic Affiliations 

to develop incentives for university 

affiliates to send undergraduate and 

graduate health care professional 

trainees to VA health care sites with 

large minority populations. 

Requires additional guidance 4 

Request that the Office of Research and Development (ORD) support research on 

minority mental health treatment. A. Identify areas of research specifically needed 

to close the gap in providing mental health care for minority veterans. 

AA Rec. # Mental Health 

Strategies Initiatives 

3.1.32A Conduct research 

to assess and 

remedy potential 

disparities in 

treatment for minorities, including ethnicity, 

gender, age. 

SOTA conference with HSR&D and 

HSR&D COE on minorities will review existing portfolio and develop 

solicitations as appropriate for research on minority mental health 

treatment. The research will cover 

psychobiology of ethnicity, service/ 

treatment disparities, and health related characteristics of other special 

emphasis groups. 

VISN 4 HSR&D 

COE focuses on 

health disparities including 

MH disparities 

2 

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Collaborate in national interagency efforts to address minority issues, staff training needs, and assessment instruments, etc 

AA Rec. # Mental Health 

Strategies Initiatives 

3.1.33 Initiatives 1–3 Ensure that there 

are effective 

interagency relationships to address minority 

issues, staff 

training needs, 

and assessment 

instruments, etc. 

MHSHG will designate a liaison to 

other Federal agencies to collaborate 

with their efforts in this area. 

Ongoing. Federal Partners on 

MH focuses on a 

broad array of 

issues 

1 

MHSHG will explore options to collaborate with HHS minority offices 

in this area. 

Ongoing. Topic 

covered as part 

of Federal Partners work group 

2 

VA will initiate collaboration with 

National Federal Partners’ work 

group in this area. 

Ongoing. Topic 

covered as part 

of Federal Partners work group 

1 

Incorporate a cultural competence strategy in the VHA Strategic Plan. 

AA Rec. # Mental Health 

Strategies Initiatives 

3.1.34 Initiatives 1–2 Ensure that all 

VHA staff are 

culturally competent 

By January of 2005, the MHSHG to 

establish a Cultural Competency 

Task Force to focus on clinician education and health care services. Representation to be from VACO and 

the field as well as MIRECCs, 

QUERI and EES. This Task Force to 

provide an action plan to be implemented by end of FY2006 and to include an evaluation component to 

assess effectiveness of the implementation in improving cultural 

competency. Refer to 3.1.31 and 

3.1.37. 

Task Force developed and has 

produced an implementation 

plan that has 

been approved 

in PCS. It will 

be implemented 

as part of the 

Universal MH 

Services 

3 

Convene a work group to review literature and track the implementation of the recommendations of the 

Commission’s Cultural Competence 

Subcommittee, the Surgeon General’s Report on Mental Health, Minority Supplement, and evaluate the 

effectiveness of VA’s cultural competence training program. 

To be evaluated 

as part of the 

implementation 

of the Uniform 

MH Services 

Package 

3 

Fund EES to develop and implement comprehensive, cultural competence training, including a module on aging, for all VA employees. 

AA Rec. # Mental Health 

Strategies Initiatives 

3.1.35 Refer to 1.2.7 

Develop a knowledge management system to disseminate timely, program specific 

education that will keep staff continuously apprised of new information on best 

practices and research related to racial and ethnic differences in care needs and 

interventions. 

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AA Rec. # Mental Health 

Strategies Initiatives 

3.1.36 Initiatives 1–3 Enhance the current information 

dissemination 

system to speed 

the dissemination 

of information on 

research findings 

and best clinical 

and management 

practices 

throughout the 

VHA mental 

health community. 

MHSHG to urge VHA to develop information systems such as data 

warehouses and associated tools 

that allow real-time access to clinical data, and to encourage training 

of managers and providers in use of 

these tools as well as sharing of best 

practices. 

Planning and 

preparation 

3 

Develop web-based educational programs on best practices and research related to racial and ethnic 

differences in care needs and interventions. 

ORD is developing a major 

program on personalized medicine 

2 

Develop a registry of best practices 

similar to SAMHSA’s National Registry of Effective Programs. 

Ongoing MH enhancements and 

the evolving 

Uniform MH 

Services Package disseminate 

evidence-based 

practices 

2 

Partner with Indian Health Service (IHS) to improve access to culturally competent mental health and substance abuse care for American Indian and Native 

Alaskan veterans. 

AA Rec. # Mental Health 

Strategies Initiatives 

3.1.37 Initiatives 1–2 Partner with IHS 

to improve access 

to the full continuum of MH 

care for Native 

Americans and 

Alaskan Indians. 

VHA will designate a VA liaison to 

work with IHS to promote this collaboration; specialty groups will be 

included in the planning. 

Ongoing operations 1 

OAA will review and disseminate 

the cultural competence education 

pilot in VISN 1 MIRECC. Refer to 

3.1.31 and 3.1.34. 

Requires reevaluation 4 

Commission Recommendation 3.2. Improve access to quality care in 

rural and geographically remote areas. 

Identify national, state and local partners who are focused on improving health 

care in rural America. VHA is a stakeholder in any process involving rural health 

care and should request to participate in national initiatives and activities. This 

should include any actions taken on the part of the Department of Health and 

Human Services (HHS) to establish a State rural health initiative, especially those 

involving National Institute of Mental Health (NIMH), Health Resources and Services Administration (HRSA), IHS or the Substance Abuse and Mental Health Services Administration (SAMHSA). 

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AA Rec. # Mental Health 

Strategies Initiatives 

3.2.38 Initiatives 1–2 Collaborate with 

other agencies in 

delivering quality 

health care to 

veterans in rural 

areas. 

VHA to have a designated liaison 

from the MHSHG to focus on rural 

mental health care issues and participate in the activities of HHS, 

NIMH, IHS, HRSA, SAMHSA. 

Rural issues are 

being addressed 

through multiple mechanisms within 

VHA 

3 

VA liaisons will advocate inclusion 

of veterans located in rural areas in 

all state MH plans. 

Liaison between 

VA and state 

MH systems is 

being strengthened 

3 

VHA should pursue a wide range of options for providing rural mental health 

care; particular attention should be paid to the needs of older veterans living in 

rural areas. VHA should examine existing and planned community access sites to 

ensure that they have mental health access that meet veteran’s needs. Options for 

providing mental health services include but are not limited to on site staffing, telemental health, use of mid level providers, partnerships with State agencies, and fee 

for services with local private providers. 

AA Rec. # Mental Health 

Strategies Initiatives 

3.2.39 Initiatives 1–5 Ensure that veterans in rural 

areas have access 

to quality mental 

health care. 

Develop internet-based services to 

facilitate Peer Support services for 

veterans. 

Requires reevaluation 4 

Case management models in rural 

areas where MHICM is not feasible/ 

practical will be developed by 

NEPEC. 

Ongoing operations 1 

Design and launch a major demonstration project on telehealth addiction and mental health services 

for veterans, including recently separated military personnel, living in 

remote and rural areas. 

Telemental 

health is being 

expanded and 

enhanced 

3 

VHA to examine existing and 

planned community access sites to 

ensure that they have mental health 

access that meets the veteran needs 

in those areas. Mental health providers to be available in all CBOCs, 

and they will provide training using 

the psychoeducational modules described in the various recommendations above. Tele-mental health options, as described in later recommendations, will be widely available for use of older adults, PTSD, 

women, SA, etc. 

A strategy for 

delivering MH 

in rural areas is 

included in the 

Uniform MH 

Services Package 

3 

MHSHG will collaborate with 

SAMHSA’s Registry of Effective Programs to establish a parallel mechanism to have a VHA registry of best 

practices/demonstration programs 

including, for example, telemedicine 

programs and practices in remote 

areas and best practices for rural 

communities. 

VA is in ongoing 

dialogue with 

SAMHSA about 

providing MH 

services in rural 

areas 

2 

VHA should request participation in SAMHSA efforts to identify and disseminate 

best practices to the rural community. 

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AA Rec. # Mental Health 

Strategies Initiatives 

3.2.40 collapsed 3.2.39 

There are no items for Commission recommendations 4.1 and 4.2, as these 

deal with children & schools. 

President’s New Freedom Commission Goal 4. Early mental health 

screening, assessment, and referral to services are common practice. 

Commission Recommendation 4.3. Screen for co-occurring mental and 

substance use disorders and link with integrated treatment strategies. 

Ensure that every clinician knows that mental health and substance use disorders 

can and do co-occur with other disorders that they assess and treat. 

AA Rec. # Mental Health 

Strategies Initiatives 

4.3.41 Initiatives 1–3 Implement a 

broad range, selfadministered 

screening for 

mental health 

disorders. The 

screening will be 

conducted annually throughout 

the veteran’s lifespan by the veteran’s primary 

care team or 

identified care 

manager. 

HSR&D will evaluate current instruments and pilot a proposed mental health screening instrument. Processes for 

screening, followup, and monitoring of outcomes for MH 

conditions are 

being developed 

2 

Provide education 

to primary care 

providers regarding mental health 

disease management and to mental health providers regarding 

common medical 

conditions found 

in psychiatric patients. 

Require 8 hours annually of CMEs 

on mental health for primary care 

providers and on medical health for 

mental health providers. Recommend increasing medicine residency training program requirements for mental health electives 

and/or training. 

MH training for 

primary care 

providers is 

being provided 

through the Integrated Care 

programs 

2 

Improve diagnosis and treatment of mental 

health disorders 

among returning 

service personnel 

with serious 

physical injuries. 

Provide outreach to active duty, especially those with life altering injuries, and recently deactivated military personnel and their families to 

make them aware of VHA and VBA 

programs and eligibility requirements for persons with mental 

health problems. Develop partnership between the MHSHG and RCS 

to lead VHA outreach to special populations; 1. Partner with DoD MTFs 

to screen all patients for mental 

health and substance abuse problems; 2. Expand use of clinical reminder currently used to screen for 

mental health and substance abuse 

in OIF and OEF veterans to all new 

patients coming into the VA health 

care system. 

Programs for 

seamless transition and outreach are operational 

1 

Ensure that screening and evaluation for these disorders are part of accepted clinical practice for every health care provider. 

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AA Rec. # Mental Health 

Strategies Initiatives 

4.3.42 collapsed with 

4.3.41 

Ensure that diagnosis of a mental health or substance abuse disorder results in 

an automatic screen for the other disorder as a routine clinical practice. 

AA Rec. # Mental Health 

Strategies Initiatives 

4.3.43 See above 4.3.41 

Require cross training in the two areas including the acquisition of a minimum 

number of CME/CEU credits in the assessment and treatment of the two disorders 

for mental health and substance abuse service providers and non-specialists in these 

areas. 

AA Rec. # Mental Health 

Strategies Initiatives 

4.3.44 Initiatives 1–2 Mental health 

and substance 

abuse providers 

will be competent 

in assessment 

and treatment for 

both mental 

health and substance abuse disorders and these 

competencies will 

be documented. 

MICA Task Force is working on specific recommendations on mandatory 

CMEs. 

Plans for meeting the needs of 

patients with 

Dual Diagnoses 

are included in 

the Uniform MH 

Services Package 

2 

Link with SAMHSA Co-occurring 

Disorders Project to develop educational program. 

Resource enhancements, 

education, and 

strategic planning are in 

progress. VA is 

in dialogue with 

SAMHSA over 

many issues 

2 

Commission Recommendation 4.4. Screen for mental disorders in primary health care, across the lifespan, and connect to treatment and supports. 

Require annual screening for mental health and substance abuse disorders across 

the life span by the veteran’s primary care team or other providers responsible for 

the veteran’s VA health care. A. Pilot test the clinical reminder developed for veterans from Operation Iraqi Freedom for use as a screen in primary care and specialty care clinics for all recently deployed individuals. B. Evaluate whether early 

screening and treatment can prevent chronic mental and multi-system illnesses. 

AA Rec. # Mental Health 

Strategies Initiatives 

4.4.45 A, B Require annual 

screening for 

Mental Health 

and Substance 

Abuse Disorders 

across the lifespan by the veterans’ primary 

care provider. 

Work with MHSHG and MIRECCs 

to develop and test a comprehensive 

tool for annual screening. 

Annual screening for MH conditions is in 

place 

1 

Evaluate the dual diagnosis/co-occurring VA programs to identify best practices 

and to determine which programs were most effective. Fund research to develop a 

valid screen for suicide risk and prevention. 

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AA Rec. # Mental Health 

Strategies Initiatives 

4.4.46 Initiatives 1–4 Suicide prevention. Endorsement and implementation of 

the National Strategy for Suicide 

Prevention (2001) and the Institute 

of Medicine’s report, Reducing Suicide: A National Imperative (2002). 

Ongoing 1 

Develop methods for tracking veterans with risk factors for suicide 

and systems for appropriate referral 

of such patients to specialty mental 

health care. 

Ongoing 1 

EES in conjunction with MHSHG 

develop mandatory education programs for VA health care providers 

about suicide risks and ways to address these risks. Incorporate best 

practices for suicide prevention. 

Mechanisms to 

document mandatory training 

are being developed 

3 

Recommend support for new 

MIRECC with focus on suicide prevention, in collaboration in other 

MIRECCs working in this area. 

VISN 19 

MIRECC and 

Canandaigua 

COE are operational 

1 

Increase collaboration with VBA to provide the full range of supports and services 

that are needed by patients with mental health, substance abuse and co-occurring 

disorders. 

AA Rec. # Mental Health 

Strategies Initiatives 

4.4.47 Initiatives 1–2 Eliminate the 

disincentives in 

the work restoration program for 

veterans. 

MHSHG will evaluate and address 

these disincentives. Link VA work 

restoration program to Supported 

Employment in the Veterans Benefits Administration (VBA) that focuses on competitive work, rapid job 

search, coupled with job coaching, 

and training veteran/consumers as 

mental health service providers. 

MHSHG will prepare memo to USB 

from USH with this proposal. 

There have been 

a legal opinion 

that comp and 

pension are fully 

protected while 

veterans participate in CWT for 

voc rehab. 

1 

Increase collaboration with VBA. Recommend that VARO Benefits 

Counselors annually assess all veterans in the G&PD programs to determine eligibility for benefits. 

MHSHG will prepare memo to USB 

from USH with this proposal. 

G&PD liaisons 

evaluate veterans clinically 

to identify those 

who may be eligible for additional benefits. 

2 

Work with Residency Review Committees to encourage incorporation of mental 

health modules into all residency programs. 

AA Rec. # Mental Health 

Strategies Initiatives 

4.4.48 Incorporate mental health education and training into residency 

programs. 

The Coordination Council for education program, ‘‘Mental Health for 

Primary Care Providers,’’ described 

in Action Agenda recommendation 

5.3.65, will work through VHA clinical services & OAA to promote inclusion of a mental health module in 

all residency training programs. The 

Council will also work with professional organizations to include such 

a module as a requirement by Residency Review Committees. 

Integration of 

MH and Primary Care, and 

introduction of 

MH into other 

medical care settings lay the 

groundwork for 

residency training. 

3 

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Contract with the Institute of Medicine for a literature review to determine effective prevention strategies for mental illness in combat veterans, with and without 

physical injury. Recommendations should also include an agenda for needed research. 

AA Rec. # Mental Health 

Strategies Initiatives 

4.4.49 Determine effective prevention 

strategies for 

mental illness in 

combat veterans 

with/without 

physical injuries. 

VHA will contract with IOM, and 

other pertinent agencies, for literature review after consultation 

with specialty groups. 

Research on 

early intervention or prevention of PTSD is 

included within 

the activities of 

NCPTSD, 

MIRECC, other 

VA COEs and 

the DoD COE. 

Contracting 

with IOM may 

not be necessary 

3 

President’s New Freedom Commission Goal 5. Excellent mental health 

care is delivered and research is accelerated. 

Commission Recommendation 5.1. Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses. 

Convene an Evidence Based Practices (EBP) Steering Committee to focus on recovery and rehabilitation. Representatives from NIMH and SAMHSA should be invited to participate as committee members. The Mental Health Strategic Health 

Care Group (MHSHG) should be staffed to coordinate and manage this activity. This 

steering Committee continuously review advances published in the scientific literature and A. Identify new research that is needed; B. Identify research results 

that are ready for demonstration projects or pilot testing, and C. Identify models 

that can be disseminated as EBP or best practices. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.1.50 A, B, 

C 

Initiatives 

1–5.

Emphasize recovery and rehabilitation in mental 

health care. 

MHSHG will propose a structure 

and resources to facilitate recovery, 

including supporting the work of the 

EBP Steering Committee. 

Ongoing. Recovery coordinators 

have been appointed in each 

VAMHC 

2 

1. Establish a joint DoD/VA ‘‘Center 

of Excellence’’ focused on traumatic 

brain injury and other life altering 

injuries; 2. Develop longitudinal 

tracking system for veterans from 

OIF and OEF; 3. Evaluate the effectiveness of the mental health transition program. 

Ongoing 1 

Pilot and research State Peer Specialist certification programs; Pilot 

partnership with NY Assoc of Psych 

Rehab Services to develop Peer 

Bridgers in VISNs 2 and/or 3. 

Peer support 

programs are in 

place and will be 

supported 

through the 

Uniform MH 

Services Package 

2 

Task the MIRECCs to review the 

role and function of Day Hospitals 

and Day Treatment Center to ensure adequate dissemination of recovery based care in the centers. 

Psychosocial Rehabilitation Centers have been 

developed, and 

will be disseminated throughout VAMCs 

2 

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AA Rec. # Mental Health 

Strategies Initiatives 

Identify recovery-oriented research 

across the age span that is ready to 

be tested for generalizability or developed into best practice models; 

Develop demonstration pilots to test 

implementation strategies prior to 

national program dissemination. 

Ongoing. All 

RFPs have emphasized use of 

PSR evidencebase as source of 

program proposals 

1 

Facilitate the work of the Steering Committee by tasking the MIRECCs to: A. 

Identify recovery-oriented research across the age span that is ready to be tested 

for generalizability or developed into best practice models. B. Develop demonstration 

pilots to test implementation strategies prior to national program dissemination. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.1.51 A, B Refer to 5.1.50 

Task the National Center for PTSD to develop a research agenda to close the gap 

in developing prevention and evidence based early interventions for acutely traumatized veterans. Research should have sufficient analytic power to identify racial and 

ethnic differences in response. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.1.52 Develop a research agenda to 

close the gap in 

developing prevention and evidence based early 

interventions for 

acutely traumatized veterans. 

Present suggestions to NCPTSD Scientific Advisory Board & ORD and 

jointly develop a plan to conduct targeted research. 

Ongoing activities of NCPTSD, 

MIRECC, other 

VA COEs and 

DoD COE 

1 

Emphasize and strengthen the VA mental health research portfolio focused on rehabilitation/recovery; A. Establish a Cooperative Study Program Center of Excellence in Mental Health. The Center(s) will issue Request for Proposals to conduct 

clinical trials and large-scale demonstration programs. B. Initiate an educational 

study to evaluate the impact of the Office of Academic Affiliations (OAA) Interdisciplinary Fellowship Program in Psychosocial Rehabilitation training program on 

shifting the emphasis of care from a traditional medical model to a recovery oriented 

model. C. Create a Mental Health Liaison position in ORD to develop the behavioral 

health research agenda and to assist with implementation. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.1.53 A, B, 

C 

Initiatives 

1–6.

Promote research 

related to rehabilitation and recovery. 

Convene a MHSHG/ORD workgroup 

to analyze the ORD mental health 

research portfolio and develop solicitations for clinical trials and largescale demonstration projects in the 

area of rehabilitation and recovery. 

ORD successfully manages 

mental health— 

and substance 

abuse—related 

projects within 

its current 

structures 

2 

Establish a Cooperative Study Program Center of Excellence in Mental 

Health. 

To be reevaluated 4 

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AA Rec. # Mental Health 

Strategies Initiatives 

Create a Mental Health Liaison position in ORD to monitor the mental 

health portfolio across research services, to coordinate development of 

solicitations for new research, and to 

coordinate mental health research 

initiatives across services. 

Ongoing 1 

Develop position description and 

hire a high-level scientific program 

manager to facilitate strategic planning for ORD mental health research, to monitor mental health 

portfolios in consultation with research leadership and investigators 

in the field, and to serve as a liaison 

to mental health leadership and the 

mental health community. 

To be reevaluated 4 

Establish a steering Committee of 

researchers and chief officers to advise on research efforts in this area. 

To be reevaluated 4 

Evaluate the 

interdisciplinary 

fellowship program in PSR to 

determine its impact in disseminating the rehabilitation/recovery model. 

Commission an evaluation of PSR 

fellowship programs to determine 

program impact on career trajectory, 

job duties (extent to which current 

position involves PSR), attitudes toward PSR and recovery, dissemination of PSR and recovery principles 

to other staff, and perceived barriers 

and facilitators to implementing 

PSR and recovery-oriented programs. 

The PSR program has recently been expanded to 7 

sites and a Hub 

site has been 

created to ensure national 

training consistency and evaluation. Evaluation 

of its impact is 

being planned 

3 

Commission Recommendation 5.2. Advance evidence-based practices 

using dissemination and demonstration projects and create a public-private partnership to guide their implementation. 

Develop a knowledge management system to disseminate almost real-time, program specific education that will keep staff continuously apprised of new information on best practices and research. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.2.54 Develop a knowledge management system to 

link research, 

guideline development and implementation, 

clinical tools, 

sharing of best 

practices, and 

real-time data 

analysis related 

to racial and ethnic differences in 

care needs and 

interventions in 

order to create 

continuous expansion of the 

evidence base 

and increased 

knowledge generated by a spirit 

of inquiry. 

See also 3.1.36 Prioritization 

from senior 

leadership will 

be needed to 

prioritize development of a MH 

real-time data 

analysis capability 

4 

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Implement an improved Clinical Practice Guideline (CPG) process to reduce the 

time between initiation of development and release of a CPG and ensure timely, 

periodic updates. Invite additional Federal partners to join the CPG effort. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.2.55 Initiatives 1–4 Ensure regular 

and timely updates of mental 

health CPGs. 

Establish a working group to monitor the literature and provide focused additions and revisions for expedited approval. Renew CPGs every 

3 years or sooner as indicated by the 

development of new treatment methodologies. 

Ongoing 1 

The National Clinical Practice 

Guidelines Council will have a member with expertise in evidence-based 

mental health care. 

Ongoing 1 

Expedite the approval of mental 

health CPGs, including updates. 

Once approved by MHSHG and the 

National Clinical Practice Guidelines Council, final approvals must 

be completed within 60 days. 

First CPG in 

MH since approval of the 

MHSP, on Major 

Depressive Disorder, is being 

developed. This 

item should be 

addressed upon 

approval of this 

CPG when completed. 

3 

Ensure that draft recommendations 

from the Medication Advisory Panel 

(MAP) are approved by the National 

Clinical Practice Guidelines Council 

to be consistent with CPGs. 

Ongoing 1 

Implement QUERI–MH current priorities & major projects including: A. Measure 

care gaps in depression & schizophrenia B. Develop Nat.Clin.Reminders key care 

processes for depression, schizophrenia, SA, & co-occurring disorders. C. Develop/implement evidence-based guidelines & perf measures across age span. D. Implement 

evidence-based antipsychotic practices in schizophrenia, promoting use of appropriate antipsychotic doses & newer atypical antipsychotics, and monitor important 

side effects. E. Implement evidence-based depression collaborative care model in primary care with particular attention to elderly; evaluate impact on quality/outcomes/ 

cost effectiveness. F. Convene group to review literature/track implementation of 

recommendations (Commission’s Cultural Competence Sub., Surgeon General’s Report on MH–Minority Supplement, & evaluate effectiveness of VA’s cultural competence trng. program. G. Prioritize interventions that assess applicability of existing family psychoeducation models to vets/families, & studies of interventions including advance directives, behavioral family management, intensive case management or assertive community treatment, and work restoration programs. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.2.56 A—G 

Initiatives 

1–11 

Promote implementation of research on evidence based practices. Put treatment initiation, engagement and continuation measures in 

official VA performance system. Implement benchmarked performance 

measures. 

Ongoing 1 

Appoint a representative from the 

MHSHG to the national CPG work 

group. 

Ongoing 1 

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AA Rec. # Mental Health 

Strategies Initiatives 

Collaborate with Mental Health 

QUERI to continue development of 

clinical tools and implementation 

strategies to improve medication 

management for schizophrenia and 

to implement a collaborative care 

approach. 

Multiple centers 

are contributing 

to the development of clinical 

tools 

2 

Support Mental Health QUERI, 

Substance Use Disorders QUERI, 

and MHSHG Informatics Section to 

develop and implement clinical practice tools. 

Multiple centers 

are contributing 

to the development of clinical 

tools 

2 

Support Mental Health QUERI initiatives to measure gaps in depression and schizophrenia care. Ongoing 1 

Support Mental Health QUERI and 

SMITREC in creating and analyzing 

national registries for psychosis and 

schizophrenia. Collaborate with 

Mental Health QUERI on development, testing, and implementation 

of outcomes monitoring. 

Ongoing 1 

Solicit new research and promote 

Mental Health QUERI implementation research efforts in management 

of individuals with depression or 

schizophrenia who have comorbid 

substance use disorders or medical 

disorders. 

Ongoing 1 

Prioritize the study and implementation of psychosocial and recoveryoriented interventions, including 

family psychoeducation, behavioral 

family management, intensive case 

management or assertive community 

treatment, work restoration programs, and peer support. 

Ongoing 1 

Collaborate with the Office of Quality and Performance in developing 

and implementing evidence-based 

guidelines and performance measures across the adult age span; Implement an evidence-based collaborative care model for depression in 

primary care settings with particular attention to the elderly, evaluating its impacts on quality and 

outcomes and measuring its cost effectiveness. 

Ongoing. Integrated care programs have been 

implemented in 

more than 100 

facilities 

2 

Solicit new research and promote 

Mental Health QUERI implementation research efforts in psychosocial 

rehabilitation and recovery. 

Ongoing. 1 

Implement the QUERI–Mental 

Health current priorities and major 

projects in EBPs. 

Evidence based 

practices from 

multiple sources 

have been incorporated in MH 

enhancements 

2 

Investigate strategies for sustaining treatment adherence and retention for individuals with major depressive disorder and schizophrenia; and strategies for increasing treatment engagement for patients who are not currently in treatment. 

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AA Rec. # Mental Health 

Strategies Initiatives 

5.2.57 Promote treatment adherence 

and retention for 

veterans with 

Major Depression 

and Schizophrenia. 

Continue to solicit new research in 

this area through Mental Health 

QUERI solicitation. 

Ongoing. Involving MIRECCs 

and other centers as well as 

QUERI 

2 

Commission Recommendation 5.3. Improve and expand the workforce 

providing evidence-based mental health services and supports. 

Work with the Senate and House Veterans Affairs Committees to enact the physician salary reform legislation to maintain our ability to recruit and retain a high 

quality psychiatrist workforce. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.58 VHA must have 

competent MDs, 

who are adequately reimbursed. 

A market survey of MD salaries to 

be performed in all markets, and the 

physician pay bill amended to reflect 

the results of the survey. 

MD pay has 

been increased 

1 

Implement legislation designating psychologists and social workers as Title 38 hybrid employees. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.59 Done 

Collaborate and affiliate with Historically Black Colleges and Universities 

(HBCUs) and Hispanic Association of Colleges and Universities (HACUs) to help us 

in developing diversity in our workforce and cultural competence among the providers. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.60 Expand diversity 

in the VHA workforce. 

Collaborate and affiliate with Historically Black Colleges and Universities (HBCUs) and Hispanic Association of Colleges and Universities 

(HACUs) to help us in developing diversity in our workforce and cultural 

competence among the providers. 

The previously (3.1.34) recommended Cultural Competency 

Task Force will be responsible for 

accomplishing this collaboration. 

There are multiple ongoing 

initiatives to increase diversity 

in the MH workforce 

2 

Train veterans who have recovered from mental illness in peer support, to develop 

a cadre of peer counselors. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.61 Initiatives 1–5 VHA will have 

veterans trained 

and competent as 

peer counselors. 

Reference AA 

Recommendations 2.3.16, 

2.3.18, 2.3.19 and 

2.3.20. 

1. MH QUERI to develop an RFP in 

2005 for the assessment of the effectiveness of peer support. 2. MHSHG 

recommends the development of 

peer support programs consistent 

with the recovery model and would 

become Centers of Excellence to disseminate best practices. 

Peer support 

programs have 

been expanded. 

Evaluations are 

being planned 

2 

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AA Rec. # Mental Health 

Strategies Initiatives 

Pilot Peer Specialists and Peer 

Bridgers models in selected VISNs; 

FY–07: Develop VHA Peer Certification process and implement nationwide. 

Peer support 

programs have 

been expanded. 

A strategy for 

further expansion is included 

in the Uniform 

MH Services 

Package 

2 

Identify additional formal Peer-Specialist training programs (colleges, 

foundations, etc.) for targeted recruitment into paid Peer-Provider/ 

Specialist positions and for additional peer specialist training venues 

FY 07. 

The need for additional resources to support recruitment 

of certified peer 

specialists will 

be evaluated 

during the implementation of 

the Uniform MH 

Services Package 

3 

Work with SAMHSA’s Center for 

Mental Health Services and National Association of State Mental 

Health Directors to develop strategy 

for collaborative initiatives to improve veteran access to premier community-based, consumer-run services. 

To be reevaluated 4 

Issue national Information Letter 

promoting and providing broad guidance on the recruitment of peer professionals/para-professionals, and 

the development of paid Peer-led 

support services (directly or through 

contract with community providers) 

as an adjunct to traditional mental 

health services at all facilities serving veterans with serious mental illness. 

Included in the 

Uniform MH 

Services Package 

2 

Enhance clinical pastoral programs to connect to faith-based initiatives, and to 

add a spiritual dimension to the biopsychosocial framework, and thus reach the majority of veterans who are religiously committed. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.62 Initiatives 1–2 Spiritual assessment will be a 

routine part of 

mental health 

evaluation, and 

treatment provided according 

to the veteran’s 

preference. 

Establish MHSHG liaison to the National Chaplain Center to provide 

input into the Clinical Pastoral Education Program and other training 

programs. Include education about 

initial presentation and referral to 

enhance mental health outreach to 

veterans. MHSHG Liaison will also 

participate in activities of the National Chaplain Center Faith Based 

Initiative. 

Requires additional guidance 4 

Link the registry of mental health 

best practices to the Best Practices 

in Chaplaincy program. 

Requires additional guidance 4 

Extend Mental Health Liaison/Consultation to primary and specialty care to support and educate that workforce. 

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AA Rec. # Mental Health 

Strategies Initiatives 

5.3.63 Initiatives 1–2 Implement collaborative care 

models for MH 

care. 

Implement collaborative care models 

for depression care, etc. to promote 

the mental health liaison role and 

provide multi-modal education on 

mental health for non-mental health 

clinicians and staff. 

Ongoing 1 

Develop a mechanism to account for 

liaison and teaching time of mental 

health providers. 

Productivity 

workgroup has 

been empanelled 

3 

The MHSHG should enhance the Mental Health Leaders’ training and support 

the annual meetings of the VISN Mental Health Liaisons. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.64 Initiatives 1–8 Ensure highly 

competent Mental Health Leadership. 

Reestablish and enhance the Behavioral Health Leadership Training 

program. 

Ongoing 1 

Ensure effective 

organizational 

leadership in addressing the 

treatment of 

mental disorders. 

Develop options for effective mental 

health leadership that will further 

the goals of the PNFC on mental 

health incorporate this process into 

the ongoing patient care services review and add a mental health task 

force member to that committee for 

continuity. The Mental Health Chief 

Consultant will become a member of 

the NLB and Executive Committee 

by July/August 2004. 

Requires additional guidance 4 

Require that a mental health leader, 

representing care of veterans with 

mental disorders, be a member of 

the highest level decisionmaking 

body in every VISN. 

Ongoing 1 

Extend the mission of the Secretary’s Task Force for three years; 

request this task force submit a 

progress report to the Secretary by 

9/30/04. 

Completed. 1 

The PCS will provide quarterly reports to the task force on implementation of the recommendations. Resource needs and budget implications will be addressed in these reports. This information will be utilized in the preparation of the ELDA 

and FY 2006 budget. 

Completed. Such 

reports were 

sent during the 

time the Task 

Force was meeting. 

1 

Promote, expand, 

and support the 

annual ‘‘Best 

Practices in Network Mental 

Healthcare Systems’’ conference. 

Expand the size of the meeting to 

allow attendance of all VISN mental 

health leaders and at least one representative from each facility. 

Meeting structure was revised 

to be more inclusive 

2 

Each VISN must support the annual 

attendance of at least one VISN 

mental health leader or representative. VISN Directors, CMOs and 

QMOs will be invited. 

Meeting structure was revised 

to be more inclusive 

2 

Link ECF program and HPDM for 

preparation of future MH leaders. 

Ongoing 1 

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EES should develop a CME/CEU training program: ‘‘Mental Health for Primary 

Care Providers;’’ in coordination with the Mental Health, Geriatrics and Extended 

Care, and Acute Care Strategic Health Care Groups. These groups could be convened as Coordination Council to oversee development in this area. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.65 Initiatives 1–2 Develop CME/ 

CEU training 

program on mental health care in 

the primary care 

setting. 

Form a Coordination Council involving EES, MHSHG, Acute Care SHG, 

Geriatrics and Extended Care SHG, 

and Mental Health QUERI to oversee education program and plan implementation of collaborative care 

for depression. 

The Integrated 

Care program is 

ongoing 

2 

MHSHG and EES will develop training programs for mental health 

managers, providers, and staff. Programs will emphasize evidence base 

for collaborative care and recovery 

programs. 

The Integrated 

Care program is 

ongoing 

1 

Expand Office of Academic Affairs and the Mental Health Strategic Healthcare 

Group’s programs for training of interdisciplinary teams and collaborative care. The 

recovery orientation in these programs should be enhanced and expanded. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.3.66 Build on the 

model Psychosocial Rehabilitation Special 

(PSR) Fellowship 

program, expanding it to training 

at more than the 

fellowship level. 

Work with OAA to expand the PSR 

Fellowship Program to provide 

training in life span issues in recovery. The program will fund stipends 

for a wide variety of mental and 

physical health disciplines, provide 

training in sites with interprofessional recovery-oriented care, and 

include a didactic component on the 

recovery model and interprofessional 

collaboration in implementing the 

model. 

PSR fellowship 

has been expanded to 7 

sites. Other 

forms of training 

and career development are 

being evaluated 

1 

Commission Recommendation 5.4. Develop the knowledge base in four 

understudied areas: mental health disparities, long-term effects of medications, trauma and acute care. 

Enhance research programs and EBP related to treatment of minority veteran 

populations and cultural competence. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.4.67 Increase research 

that expands the 

evidence base related to ethnic 

variability in disease manifestations and treatment response; to 

inequities in access; and to disparities in evaluation and treatment. Conduct 

research on gaps 

in cultural competency and 

strategies to close 

gaps. 

Solicit research on variation in 

treatment response among ethnic 

groups to inform evidence-based 

guidelines; solicit research on disparities in access and availability of 

services, treatment practices, and 

outcomes. Solicit research on cultural competency, including descriptive studies and intervention research. 

ORD is implementing a major 

program in personalized medicine 

3 

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Enhance trauma research related to combat trauma, terrorism, and prevention of 

chronic PTSD after exposure to traumatic events. Screening, prevention, 

neurobiology, treatment and recovery should be priorities. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.4.68 Initiatives 1–2 Enhance trauma 

research. 

Engage NCPTSD, MIRECCs, ORD, 

DoD/ USUHS in these projects. Include minority & collaborative care 

issues. 

Ongoing 1 

Establish a joint DoD/VA ‘‘Center of 

Excellence’’ focused on traumatic 

brain injury and other life altering 

injuries; Develop longitudinal tracking system for veterans from OIF 

and OEF. Trauma research agenda 

to also include trauma related to 

MST. 

Ongoing 1 

Assess the effects of long-term medications: A. Task a Work Group consisting of 

the Pharmacy Benefits Management (PBM), Mental Health QUERI, Clozapine Center, and Serious Mental Illness Treatment Research and Evaluation Center 

(SMITREC) to perform a literature review, analyze the Clozapine and Psychosis 

Registries, and report their findings and recommended actions to the Office of Patient Care Services. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.4.69 Develop algorithm for use of 

atypical 

antipsychotics. 

MHSHG will take responsibility for 

organizing a work group that will 

utilize the National Consensus 

Guidelines to develop an algorithm 

for: use of atypical antipsychotics 

with consideration of medical complications and cost, including recommendations for changing therapy 

when medical complications develop; 

develop monitors for medical complications related to the use of the 

atypical antipsychotics; and education of primary care and mental 

health providers on the complications of atypical antipsychotics. 

A work group 

has recently 

been formed 

3 

Assess the VHA’s provision of Acute Mental Health Care: A. Develop and test a 

valid VA demand model for acute inpatient and outpatient mental health care. B. 

Develop a national electronic database to track veterans who request admission or 

transfer to a VA acute inpatient mental health facility but are denied admission because of unavailability of a hospital bed or inadequate staffing. 

AA Rec. # Mental Health 

Strategies Initiatives 

5.4.70 A, B See recommendation 1.2.8 

President’s New Freedom Commission Goal 6. Technology is used to access mental health care and information. 

Commission Recommendation 6.1. Use health technology and telehealth 

to improve access and coordination of mental health care, especially for 

Americans in remote areas or in underserved populations. 

Expand the charge to the VHA Telemental Health Field Work Group to coordinate 

the implementation of the 6.1 action agenda items, in conjunction with VISN leadership, VISN mental health clinicians, and VISN telemental health coordinators. 

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AA Rec. # Mental Health 

Strategies Initiatives 

6.1.71 Initiatives 1–2 Expand the 

charge to the 

VHA Telemental 

Health Field 

Work Group. 

The Telemental Health Field Work 

Group to continue to meet virtually 

or in person to coordinate the implementation of 6.1 action agenda 

items, in conjunction with VISN 

leadership, VISN mental health clinicians, and VISN telemental health 

coordinators. 

Ongoing. 1 

Expand telemental health to target 

homeless veterans. 

Homeless programs continue 

to be expanded 

through other 

mechanisms 

2 

Commission the VHA Telemental Health Work Group to perform a needs assessment for telemental health services. The needs assessment should focus on identification of underserved veteran populations, access to mental health services in 

CBOCs and Vet Centers, and provision of specialty mental health and substance 

abuse consultations in rural and remote areas. 

AA Rec. # Mental Health 

Strategies Initiatives 

6.1.72 Initiatives 1–5 Improve access 

through use of 

technology. 

Together, the Office of Care Coordination, the Mental Health Strategic 

Healthcare Group, VISN Leadership, and each VHA Telemental 

Health Field Work Group VISN representative will assure that the need 

for telemental health services are 

clearly determined, in conjunction 

with other mental health needs assessments already being undertaken 

by VISN mental health clinicians, 

VISN CBOC administrators, and 

VISN telemedicine coordinators. 

Ongoing 1 

Improve transition planning, referral/placement and information exchange for patients with mental illness coming into VHA health care 

system. 

Ongoing 1 

1. Ensure that all mental health 

programs within VHA, including 

RCS, have standardized systems of 

electronic technology to access information while maintaining confidentiality and informed consent; 2. Explore ‘‘at home’’ mental health care 

coordination for recently discharged 

veterans, especially those in rural 

areas or in areas where specialty 

care is limited. 

Ongoing 1 

Improve the electronic exchange of 

information from DoD to VA on patients awaiting MEBs and PEBs. 

Ongoing 1 

Include questions on screening tools 

for older veterans to determine difficulties with transportation or other 

resources that restrict ability to attend outpatient appointments; and 

to identify needs of caregivers for 

older veterans who are home bound 

due to medical problems and/or who 

have a dementing illness. 

Current planning 3 

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Based on the results of the needs assessment, each VISN should be tasked with 

the development of a telemental health implementation plan designed to improve 

access to mental health care within the VISN. A. Each VISN Telemental Health 

Plan should identify adequate equipment and staffing resources to assure that it 

can be successfully implemented. B. Implementation of VISN Telemental Health 

Plans should be assessed through such strategies as VHA performance measures/ 

monitors and official reports to VACO leadership on a regular basis. C. Formalize 

the registration of telemental health programs throughout VHA. 

AA Rec. # Mental Health 

Strategies Initiatives 

6.1.73 A, B, 

C 

Initiatives 

1–5.

Expand mental 

health telehealth 

care to all facilities, CBOCs, and 

Vet Centers. 

Each VISN will: submit a Telemental Health plan to Office of Care 

Coordination (OCC) by 6/30/05; Outcomes approved on National Performance Measures will be developed to assure implementation is 

successful; All Telemental Programs 

will be approved by OCC. 

Ongoing 1 

Action Agenda Steering Committee 

to appoint a group to review the 

data on pilot telemental health use 

and make recommendations on an 

outcomes monitoring system and 

feedback mechanism. 

Completed 1 

Together with the Office of Care Coordination, the Mental Health Strategic Healthcare Group and VISN 

Leadership, each VHA Telemental 

Health Field Work Group VISN representative will assure that their 

VISN Telemental Health Plans are 

viable, and that they identify adequate equipment and staffing resources to assure that it can be successfully implemented. 

Ongoing 1 

Together with the Office of Care Coordination, the Mental Health Strategic Healthcare Group and VISN 

Leadership the VHA Telemental 

Health Field Work Group will work 

to assure that implementation of the 

VISN Telemental Health Plans be 

assessed through accountability 

strategies such as official reports to 

VACO on a regular basis, and the 

establishment of applicable VHA 

performance measures/monitors. 

Mechanisms for 

accountability 

are being developed 

3 

Together with the Office of Care Coordination, the Mental Health Strategic health care Group and VISN 

Leadership, the VHA Telemental 

Health Field Work Group will extend its annual telemental health 

service inventory by formalizing the 

registration of telemental health 

programs throughout VHA. 

Ongoing 1 

Expand use of existing telemental health and telehome care technologies as well 

as develop new technologies, including : A. Identify mental health care coordination 

opportunities using in-home messaging devices, etc. B. Expand on the existing telemental health collaborations with VHA and the Readjustment Counseling Services. 

C. Identify existing sharing programs and evaluate telemental health opportunities 

with the DHHS, IHS, DoD. D. Develop and implement family psychoeducational 

video programs and telehome care family therapy programs. E. Increase telemental 

health consultation between mental health specialists at the medical centers and 

CBOC staff. F. Utilize telemental health technologies that make telemental health 

and telehome care accessible to the visually and hearing impaired. 

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AA Rec. # Mental Health 

Strategies Initiatives 

6.1.74 A–F 

Initiatives 

1–6 

Combine with 

6.1.73 

A. Together with the Office of Care 

Coordination (OCC), the Mental 

Health Strategic Healthcare Group 

(MHSHG) and VISN Leadership, the 

VHA Telemental Health Field Work 

Group will identify mental health 

care coordination opportunities 

using in-home messaging devices, 

mental illness management dialogues, interactive voice response 

programs, and other new technologies to bring mental health services to the patients’ homes, to halfway houses, to homeless shelters, 

and the state veterans homes. 

Home telemental health is 

currently being 

developed 

1 

Together with the Office of CC, the 

MHSHG and VISN Leadership, the 

VHA Telemental Health Field Work 

Group will expand on the existing 

telemental health collaborations 

with VHA and the Readjustment 

Counseling Services. 

To be reevaluated 4 

Together with the Office of CC, the 

MHSHG and VISN Leadership, the 

VHA Telemental Health Field Work 

Group will identify existing sharing 

programs and evaluate telemental 

health opportunities with the 

DHHS, IHS, DoD. 

Included in the 

activities of DoD 

COE 

3 

Together with the Office of CC, the 

MHSHG and VISN Leadership, the 

VHA Telemental Health Field Work 

Group will develop and implement 

family psychoeducational video programs and telehome care family 

therapy programs. 

Requires additional guidance 4 

Together with the Office of CC, the 

MHSHG and VISN Leadership, the 

VHA Telemental Health Field Work 

Group will increase telemental 

health consultation between mental 

health specialists at the medical centers and CBOC staff. 

Ongoing. 1 

Together with the Office of CC, the 

MHSHG and VISN Leadership and 

Office of Geriatrics and Extended 

Care, the VHA Telemental Health 

Field Work Group will utilize telemental health technologies that 

make telemental health and 

telehome care compliant with ADA. 

Ongoing. Attention continuously paid to 

ADA requirements. 

1 

Charge Northeast Program Evaluation Center (NEPEC), the MIRECCs, 

SMITREC and Health Services Research and Development (HSR&D) with providing 

outcomes monitoring and feedback regarding national, VISN, and individual facility 

telemental health and care coordination programs. 

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AA Rec. # Mental Health 

Strategies Initiatives 

6.1.75 Initiatives 1–2 Develop outcomes 

monitoring and 

feedback system. 

Together, the Office of CC, the 

MHSHG and VISN Leadership and 

the VHA Telemental Health Field 

Work Group to establish a plan to 

monitor outcomes of telemental 

health activities, utilizing existing 

mental health and VHA venues. 

In planning 3 

Charge workgroup with exploring 

outcome measures specifically related to older adults’ access and utilization. 

In planning 3 

Establish a full-time position for a VHA Telemental Health Coordinator. Provide 

adequate administrative staff and resources for necessary meetings and collaborations. 

AA Rec. # Mental Health 

Strategies Initiatives 

6.1.76 Provide full time 

coordination of 

telemental health 

care. 

The Office of CC and the MHSHG to 

facilitate adequate leadership and 

administrative staff resources necessary to successfully implement 

these action items. 

Ongoing 1 

Work with the HHS in the review recommended by the Commission of how best 

to deliver and finance telehealth services. 

AA Rec. # Mental Health 

Strategies Initiatives 

6.1.77 Initiatives 1–2 Optimize telehealth mental 

health delivery 

both in VA and 

the private sector. 

Work with HHS in the review recommended by the Commission of 

how best to deliver and finance telehealth services. 

Requires additional guidance 4 

Explore financial and other incentives to increase the use of telemental health. Ongoing. 1 

Develop and implement adequate means to accurately capture and reflect workload generated by telemental health and telehome care (stop codes, encounter forms, 

etc.). 

AA Rec. # Mental Health 

Strategies Initiatives 

6.1.78 Capture workload 

generated by telemental health 

services. 

Develop and implement adequate 

means to accurately capture and reflect workload generated by telemental health providers. Charge Office of Care Coordination with developing a system of secondary stop 

codes and guidelines for using correctly to capture data accurately. 

Ensure mental health review of 

plans to finalize and implement telemental health stop codes. 

Ongoing 1 

Commission Recommendation 6.2. Develop and implement integrated 

electronic health record and personal health information systems. 

Establish a Mental Health IT Work Group to enhance VHA’s electronic health 

record (VistA/CPRS and MHP/MHA) and personal health information systems 

(MyHealtheVet). This group should be charged with the responsibility of developing 

in more detail the other recommendations included under Action Agenda items 6.2. 

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AA Rec. # Mental Health 

Strategies Initiatives 

6.2.79 Initiatives 1–2 Establish a MH 

IT Work Group to 

work with IDMC 

and MHSHG. 

Charge this group with developing 

in more detail the other recommendations included under Action Agenda items 6.2. 

Requires additional guidance 4 

Develop electronic method to monitor community employment in the 

CWT supported employment program. Include NEPEC monitoring of 

Supported Employment. 

Ongoing 1 

VISTA/CPRS should be modified to provide optimal functionality for the care of 

veterans with serious mental illness. 

AA Rec. # Mental Health 

Strategies Initiatives 

6.2.80 Initiatives 1–2 Ensure that all 

mental health 

programs within 

VHA, including 

RCS, have standardized systems 

of electronic technology to access 

information while 

maintaining confidentiality and 

informed consent. 

Improve Transition planning, referral/placement and information exchange for patients with mental illness coming into VHA health care 

system. 

Ongoing 1 

Modify CPRS to include the identification of a Primary Mental Health 

Provider as well as Primary Care 

Provider. 

Requires additional guidance 4 

Develop a mental health treatment planning tool. VHA should consider build/buy 

options including the Commercial Off the Shelf (COTS) product currently being used 

at several facilities. The treatment planner should facilitate the participation of the 

patient and his/her family in the treatment planning process. The Mental Health 

IT Work Group should submit a formal request to the Informatics & Data Management Committee (IDMC) for the development of a treatment planner. 

AA Rec. # Mental Health 

Strategies Initiatives 

6.2.81 Develop a MH 

treatment planning tool. 

Mental Health IT Work Group will 

review treatment planner options including review of the planner developed in VISN 3. The treatment planner will facilitate the participation of 

the patient and his/her family in the 

treatment planning process. The 

Mental Health IT Work Group to 

submit a formal request to the 

Informatics & Data Management 

Committee (IDMC) for the development of a treatment planner. 

To be reevaluated 4 

Develop MyHealtheVet to better serve the needs of veterans with mental illnesses. A. Provide adequate resources to the Office of Information to ensure continuity and availability of the MyHealtheVet platform. B. Conduct a pilot test or a 

functional test of the use of mental health patient’s use of to assess possible implementation issues unique to this patient population. C. Fund development of a mental health portal as an addition to MyHealtheVet to better serve the needs of veterans with mental illness and their families. D. Develop criteria that veterans and 

their families could use to evaluate non-VHA mental health information sites (see 

http://helping.apa.org/dotcomsense/ for an example developed by the American Psychological Association). 

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AA Rec. # Mental Health 

Strategies Initiatives 

6.2.82 A, B, 

C, D 

Develop a MH 

component within 

MyHealtheVet. 

The MH IT Work Group will implement this Action Agenda recommendation. Some initial MH 

components for 

MyHealtheVet 

have been developed and are online. Additional 

MH components 

for 

MyHealtheVet 

are under development 

3 

A Comprehensive VHA Strategic Plan of Mental Health Services July 2004 

f 

Crosswalking between the U.S. National Strategy for Suicide Prevention, 

the VHA Comprehensive Mental Health Strategic Plan, and VHA’s Suicide 

Prevention Actions 

U.S. National Strategy for 

Suicide Prevention 

VHA Comprehensive MH 

Strategic Plan 

VHA Suicide Prevention Actions and Plans 

Endorse the National Strategy for 

Suicide Prevention (2001) and the 

Institute of Medicine’s report, ‘‘Reducing Suicide: A National Imperative’’ (2003). Implement their recommendations..

Promote awareness that suicide 

is a public health problem that is 

preventable 

Develop broad-based support for 

suicide prevention 

Develop and implement strategies to reduce the stigma associated with being a consumer of 

mental health, substance abuse 

and suicide prevention services 

Identify Mental Health an Employee Education Services (EES) 

focus area in 2005. All health care 

workers should understand that 

mental health is essential to overall 

health; reduce stigma by their 

interactions with veterans and 

their families; and understand the 

major suicide risk factors and the 

principles of suicide prevention 

Education and training activities 

including National Suicide Prevention Awareness Day and Operation 

Save; Ongoing public education and 

press releases, developing public 

service messages, publicizing hotline, collaborating with Federal 

partners 

Develop and implement suicide 

prevention programs 

Increase access to and community linkages with mental health 

and substance abuse services 

Develop and promote effective 

clinical and professional practices 

Develop a Suicide Prevention Program for VA patients, families, 

staff and the community. 

VHA has created a national system 

that includes: 1) Overall enhancement of mental health services; a) 

Enhanced access to care; b) Integration of mental health and primary care; c) transformation of the 

specialty mental health care system 

to focus on rehabilitation and recovery; d) Broad-based training in evidence-based Psychotherapy and 

pharmacotherapy; e) Outreach and 

clinical programs to support the engagement of OEF/OIF veterans; 2) 

Programs specifically addressing 

suicide prevention; a) Suicide Prevention Hotline; b) Suicide Prevention Coordinators in each Medical 

Center; c) Programs to identify 

high-risk patients and enhance 

their care; d) Training for all staff; 

e) Community outreach; and 3) Inclusion of suicide prevention activities in the uniform mental health 

services package that is under 

development; 

Promote evidence based strategies 

for suicide assessment and prevention, including emphasis on special 

emphasis groups. MHSHG will 

work with HSR&D, NEPEC, and 

SMITREC to develop and test an 

electronic suicide prevention database. Develop a national systematic 

program for suicide prevention. 

MHSHG develops a plan to educate 

all staff that interact with veterans, 

including clerks and telephone operators, about responding to crisis 

situations involving at-risk veterans. This would include suicide 

protocols for intake, telephone operators, and other first contact personnel 

Improve and expand surveillance 

systems 

Develop electronic suicide prevention database using institutional 

surveillance mechanisms that support population-based screening. 

SMITREC initiative based on information from the National Death 

Index; Evolving interactions with 

the CDC’s National Violent Death 

Reporting System; Validation and 

utilization of attempt reporting by 

the Suicide Prevention Coordinators; Exploration of interactions 

with state or county medical examiners 

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Crosswalking between the U.S. National Strategy for Suicide Prevention, 

the VHA Comprehensive Mental Health Strategic Plan, and VHA’s Suicide 

Prevention Actions—Continued 

U.S. National Strategy for 

Suicide Prevention 

VHA Comprehensive MH 

Strategic Plan 

VHA Suicide Prevention Actions and Plans 

Develop methods for tracking veterans with risk factors for suicide 

and systems for appropriate referral of such patients to specialty 

mental health care. 

A Category 2 flag, to be managed 

by the Suicide Prevention Coordinators is under development. It 

would serve to facilitate tracking 

and follow-up. 

Medical Centers establish contacts 

through the Chaplain Service with 

faith-based organizations and community resources to assist with culturally competent suicide prevention and other mental health issues 

at local and national levels. 

Deferred by VHA senior leadership 

Promote and support research on 

suicide and suicide prevention 

Fund research to develop a valid 

screen for suicide risk and prevention. 

ORD has been meeting with Federal partners to develop a research 

agenda; research at the VISN 19 

MIRECC and the Canandaigua 

COE is accelerating; nevertheless, 

developing a valid screen for suicide risk and prevention may prove 

elusive-instead, VA is pursuing a 

two stage process, screening for 

MH conditions and providing clinical evaluations for those identified 

as having these conditions. 

Implement training for recognition of at-risk behavior and delivery of effective treatment EES in conjunction with MHSHG 

develop mandatory education programs for V A health care providers 

about suicide risks and ways to address these risks. Incorporate best 

practices for suicide prevention. 

Ongoing training including Suicide 

Prevention Awareness Day, Operation Save, Facility-based activities 

organized by the suicide prevention 

coordinators; and other EES activities 

Recommend support for new 

MIRECC with focus on suicide prevention, in collaboration in other 

MIRECCs working in this area. 

Implementation of the VISN 19 

MIRECC and Canandaigua Center 

of Excellence as centers for research, demonstrations, training, 

and technical, assistance for the 

system as a whole 

Promote efforts to reduce access 

to lethal means and methods of 

self-harm 

Individualized interventions between providers and/or suicide prevention coordinators with high-risk 

patients and/or their families; VA 

policy for gun safety programs is 

under consideration 

Improve reporting and portrayals 

of suicidal behavior, mental illness, and substance abuse in the 

entertainment and news media.

Addressed through ongoing collaborations in the Federal partnership 

f 

on suicide preventions 

Information Provided by VA From Discussion with Secretary Peake during 

Post-Hearing Meeting 

In response to Dr. Rudd testimony of increased risk of suicide for wounded 

warriors. 

Discharge Plan, both mental health and wounded warriors (increased risk 

of suicide) need one. What do we do to ensure followup after discharge 

of both mental health patients as well as wounded warriors? 

Response: The Federal Recovery Coordinators (FRC) actively started working 

with discharge for patients January 28, 2008. FRCs develop Federal Individualized 

Recovery Plans (FIRPs) for servicemembers or veterans who have catastrophic 

wounds, illness and injuries, including mental health issues, which will require longitudinal care, coordination and oversight. Using the Federal Individual Recovery 

Plan, based on the input of clinical and non-clinical case managers as well as the 

patient and the family, the Federal Recovery Coordinator (FRC) will ensure that the 

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servicemember, veteran and family have access to and delivery of support programs 

and resources for family members and caregivers. 

Phase One of the FRC Program, scheduled to be completed in May 2008, targeted 

those catastrophically wounded, ill or injured arriving from theatre to the military 

treatment facility (MTF). Phase Two, which will begin immediately after Phase One, 

is complete, will expand the program’s scope to include those servicemembers and 

veterans who were discharged from an MTF prior to January 2008. 

At this time, FRCs are accepting servicemembers/veterans injured prior to January 2008 into the FRCP on a referral basis. As mentioned above, Phase Two will 

start in June 2008, and will expand the program’s scope to include those servicemembers and veterans who were discharged from an MTF prior to January 2008. 

Identification of this population will be conducted through a review of VA rehabilitation databases, to include spinal cord and blind rehabilitation, along with the 

polytrauma centers. In tandem, DoD will work through TRICARE in an effort to 

identify the same population for potential inclusion into the FRCP. Staffing support 

has been initiated to support this expansion effort. An additional registered nurse 

is being actively recruited to champion this effort along with additional FRCs whose 

geographic placement will be based on identified patient needs. 

Federal Recovery Coordinators are nurses and masters prepared social workers 

with experience in Mental Health issues and receive ongoing training which improves their ability to both identify and prioritize those servicemembers and veterans in need of mental health services and programs. Thus they will ensure that 

the clinical case manager addressed any mental health issues that the patient or 

family may have. 

As of May 13, the Combat Veteran Call Center has made 8,598 calls and has spoken to 2,953 veterans. The percentage of unique veterans spoken with on this initiative is 34.3%. 

————— 

Information Provided by VA From Discussion with Secretary Peake during 

Post-Hearing Meeting 

In response to Maris testimony. 

Reanalysis of data; pulling out base population, including veterans. 

Response: The National Violent Death Reporting System (NVDRS) database is 

owned by CDC. VA uses the information, however, we feel outreach efforts to make 

its use more prevalent should be initiated by CDC. 

To compare information of veterans using VHA health care services with all veterans and all Americans, VA uses information on all veterans’ suicides from the 

NVDRS. The NVDRS has been tracking suicides among veterans and others in an 

increasing number of States since 2003, in six States since 2003, in 13 since 2004, 

and in 16 since 2005. Only preliminary information is available for 2006. It is likely 

that the counts and rates presented for this year will increase as additional case 

reports are received. 

To give a view of suicide rates over time, the NVDRS document attached dated 

5–15–08 looks at NVDRS data for all veterans and compares it to information on 

VMA health care users and all Americans in separate tables for each grouping of 

NVDRS States. 

Calculations for VHA patients were based on causes of death from the National 

Death Index for veterans from the relevant States identified from clinical and administrative records. Figures for the general populations were derived from the 

CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS) site, 

again, for the relevant States. 

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The National Violent Death Reporting System (NVDRS) Update, 5–15–08 11am 

For VHA Patients in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia) 

FY03 FY04 FY05 

Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 

Males, 18–29 10,342 5 48.3 11,453 6 52.4 12,847 7 54.5 Males, 30–64 232,427 88 37.9 236,043 89 37.7 240,439 83 34.5 Males, 65+ 255,853 76 29.7 239,609 75 31.3 235,410 66 28.0 All Males 498,622 169 33.9 487,105 170 34.9 488,696 156 31.9 Females, 18–29 4,818 1 20.8 5,431 1 18.4 5,945 2 33.6 Females, 30–64 33,030 8 24.2 34,404 6 17.4 35,641 6 16.8 Females, 65+ 6,985 0 0.0 6,471 0 0.0 6,388 0 0.0 All Females 44,834 9 20.1 46,306 7 15.1 47,974 8 16.7 

For General U.S. Population in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)—Continued 

CY03 CY04 CY05 

Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 

Males, 18–29 2,882,507 520 18.0 2,940,762 498 16.9 2,979,291 524 17.6 Males, 30–64 8,478,693 1,676 19.8 8,554,240 1,730 20.2 8,626,030 1,697 19.7 Males, 65+ 1,829,120 512 28.0 1,853,752 491 26.5 1,885,066 489 25.9 All Males 13,190,320 2,708 20.5 13,348,754 2,719 20.4 13,490,387 2,710 20.1 

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For General U.S. Population in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia)—Continued 

CY03 CY04 CY05 

Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 

Females, 18–29 2,811,814 91 3.2 2,846,934 109 3.8 2,878,825 98 3.4 Females, 30–64 8,868,182 515 5.8 8,937,771 510 5.7 9,008,792 544 6.0 Females, 65+ 2,617,145 111 4.2 2,632,363 87 3.3 2,657,046 95 3.6 All Females 14,297,141 717 5.0 14,417,068 706 4.9 14,544,663 737 5.1 

For All Veterans in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia) 

CY03 CY04 CY05 CY06 Partial 

Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 

Males, 18–29 97,430 51 52.3 97,761 48 49.1 101,622 40 39.4 105,108 40 38.1 Males, 30–64 1,728,183 423 24.5 1,695,677 412 24.3 1,664,851 374 22.5 1,631,152 306 18.8 Males, 65+ 1,171,401 326 27.8 1,157,448 314 27.1 1,139,862 319 28.0 1,125,567 251 22.3 All Males 2,997,014 800 26.7 2,950,886 774 26.2 2,906,335 733 25.2 2,861,826 597 20.9 Females, 18–29 26,503 3 11.3 26,891 4 14.9 27,728 3 10.8 28,104 7 24.9 Females, 30–64 167,872 11 6.6 173,324 18 10.4 177,874 18 10.1 182,547 13 7.1 Females, 65+ 44,773 1 2.2 43,732 2 4.6 42,828 2 4.7 41,667 3 7.2 All Females 239,147 15 6.3 243,947 24 9.8 248,430 23 9.3 252,318 23 9.1 

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For VHA Patients in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, 

Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, 

Rhode Island, South Carolina, Virginia, Wisconsin) 

FY04 FY05 

Pop. Suicide 

Deaths 

Suicides 

/100,000 Pop. Suicide Deaths 

Suicides 

/100,000 

Males, 18–29 22,130 8 36.2 25,353 15 59.2 

Males, 30–64 494,213 202 40.9 510,042 180 35.3 

Males, 65+ 460,764 156 33.9 454,915 159 35.0 

All Males 977,106 366 37.5 990,311 354 35.7 

Females, 18–29 11,189 1 8.9 12,381 3 24.2 

Females, 30–64 70,609 9 12.7 73,261 12 16.4 

Females, 65+ 13,615 0 0.0 12,350 0 0.0 

All Females 95,414 10 10.5 97,991 15 15.3 

For the General U.S. Population in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, Wisconsin) 

CY04 CY05 

Pop. Suicide 

Deaths 

Suicides 

/100,000 Pop. Suicide Deaths 

Suicides 

/100,000 

Males, 18–29 5,759,748 1154 20.0 5,825,312 1117 19.2 

Males, 30–64 15,981,610 3647 22.8 16,172,388 3593 22.2 

Males, 65+ 3,371,832 971 28.8 3,439,314 1029 29.9 

All Males 25,113,190 5,772 23.0 25,437,014 5,739 22.6 

Females, 18–29 5,487,877 235 4.3 5,549,163 236 4.3 

Females, 30–64 16,507,912 1160 7.0 16,702,515 1133 6.8 

Females, 65+ 4,783,669 181 3.8 4,843,413 180 3.7 

All Females 26,779,458 1,576 5.9 27,095,091 1,549 5.7 

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For All Veterans in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, 

Rhode Island, South Carolina, Virginia, Wisconsin) 

CY04 CY05 CY06 Partial 

Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 Pop. Suicide Deaths Suicides /100,000 

Males, 18–29 190,949 100 52.4 198,183 88 44.4 204,917 89 43.4 Males, 30–64 3,311,746 889 26.8 3,261,900 833 25.5 3,206,111 750 23.4 Males, 65+ 2,111,452 592 28.0 2,086,273 674 32.3 2,066,921 491 23.8 All Males 5,614,146 1,581 28.2 5,546,357 1,595 28.8 5,477,950 1,330 24.3 Females, 18–29 51,664 9 17.4 53,454 9 16.8 54,207 9 16.6 Females, 30–64 333,660 39 11.7 342,846 37 10.8 352,071 30 8.5 Females, 65+ 75,115 2 2.7 73,945 3 4.1 72,625 4 5.5 All Females 460,438 50 10.9 470,245 49 10.4 478,902 43 9.0 

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For VHA Patients in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, 

Rhode Island, South Carolina, Utah, Virginia, Wisconsin) 

FY05 

Pop. Suicide Deaths Suicides /100,000 

Males, 18–29 31,966 17 53.2 

Males, 30–64 594,346 217 36.5 

Males, 65+ 524,948 189 36.0 

All Males 1,151,261 423 36.7 

Females, 18–29 15,988 4 25.0 

Females, 30–64 88,531 14 15.8 

Females, 65+ 14,293 0 0.0 

All Females 118,811 18 15.2 

For the General U.S. Population in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, 

Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, Wisconsin) 

CY05 

Pop. Suicide Deaths Suicides /100,000 

Males, 18–29 6,630,344 1,350 20.4 

Males, 30–64 18,026,867 4,196 23.3 

Males, 65+ 3,858,225 1,177 30.5 

All Males 28,515,436 6,723 23.6 

Females, 18–29 6,318,615 275 4.4 

Females, 30–64 18,602,682 1,309 7.0 

Females, 65+ 5,406,681 196 3.6 

All Females 30,327,978 1,780 5.9 

For All Veterans in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, 

Rhode Island, South Carolina, Utah, Virginia, Wisconsin) 

CY05 CY06 Partial 

Pop. Suicide 

Deaths 

Suicides 

/100,000 Pop. Suicide Deaths 

Suicides 

/100,000 

Males, 18–29 222,255 100 45.0 229,855 98 42.6 

Males, 30–64 3,636,370 931 25.6 3,575,055 842 23.6 

Males, 65+ 2,334,819 736 31.5 2,313,321 558 24.1 

All Males 6,193,443 1,767 28.5 6,118,231 1,498 24.5 

Females, 18–29 58,614 9 15.4 59,514 10 16.8 

Females, 30–64 376,875 43 11.4 387,015 34 8.8 

Females, 65+ 82,077 3 3.7 80,703 4 5.0 

All Females 517,566 55 10.6 527,232 48 9.1 

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For VHA Patients in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South 

Carolina, Virginia) 

FY03 FY04 FY05 

Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI 

Lower Upper Lower Upper Lower Upper 

Males, 18–29 48.3 15.7 112.8 52.4 19.2 114.0 54.5 21.9 112.3 Males, 30–64 37.9 30.4 46.6 37.7 30.3 46.4 34.5 27.5 42.8 Males, 65+ 29.7 23.4 37.2 31.3 24.6 39.2 28.0 21.7 35.7 All Males 33.9 29.0 39.4 34.9 29.9 40.6 31.9 27.1 37.3 Females, 18–29 20.8 0.5 115.6 18.4 0.5 102.6 33.6 4.1 121.5 Females, 30–64 24.2 10.5 47.7 17.4 6.4 38.0 16.8 6.2 36.6 Females, 65+ 0.0 0.0 52.8 0.0 0.0 57.0 0.0 0.0 57.7 All Females 20.1 9.2 38.1 15.1 6.1 31.1 16.7 7.2 32.9 

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For General U.S. Population in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia) 

CY03 CY04 CY05 

Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI 

Lower Upper Lower Upper Lower Upper 

Males, 18–29 18.0 16.5 20.3 16.9 15.5 18.5 17.6 15.9 19.8 Males, 30–64 19.8 18.8 20.7 20.2 19.3 21.2 19.7 18.7 20.6 Males, 65+ 28.0 25.6 30.5 26.5 24.2 28.9 25.9 23.7 28.3 All Males 20.5 19.8 21.3 20.4 19.6 21.1 20.1 19.3 20.8 Females, 18–29 3.2 2.6 4.0 3.8 3.1 4.6 3.4 2.8 4.1 Females, 30–64 5.8 5.3 6.3 5.7 5.2 6.2 6.0 5.5 6.6 Females, 65+ 4.2 3.5 5.1 3.3 2.6 4.1 3.6 2.9 4.4 All Females 5.0 4.6 5.4 4.9 4.5 5.3 5.1 4.7 5.4 

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For All Veterans in the 7 States with NVDRS data for CY2003 (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia) 

CY03 CY04 CY05 CY06 

Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI 

Lower Upper Lower Upper Lower Upper Lower Upper 

Males, 18–29 52.3 39.0 68.8 49.1 36.2 65.1 39.4 28.1 53.6 38.1 27.2 51.8 Males, 30–64 24.5 22.2 26.9 24.3 22.0 26.8 22.5 20.2 24.9 18.8 16.7 21.0 Males, 65+ 27.8 24.9 31.0 27.1 24.2 30.3 28.0 25.0 31.2 22.3 19.6 25.2 All Males 26.7 24.8 28.5 26.2 24.4 28.1 25.2 23.4 27.0 20.9 19.2 24.0 Females, 18–29 11.3 2.3 33.1 14.9 4.1 38.1 10.8 2.2 31.6 24.9 10.0 51.3 Females, 30–64 6.6 3.3 11.7 10.4 6.2 16.4 10.1 6.0 16.0 7.1 3.8 12.2 Females, 65+ 2.2 0.1 12.4 4.6 0.6 16.5 4.7 0.6 16.9 7.2 1.5 21.0 All Females 6.3 3.5 10.3 9.8 6.3 14.6 9.3 5.9 13.9 9.1 5.8 13.7 

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For VHA Patients in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, Wisconsin) 

FY04 FY05 

Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI 

Lower Upper Lower Upper 

Males, 18–29 36.2 15.6 71.2 59.2 33.1 97.6 

Males, 30–64 40.9 35.4 46.9 35.3 30.3 40.8 

Males, 65+ 33.9 28.8 39.6 35.0 29.7 40.8 

All Males 37.5 33.7 41.5 35.7 32.1 39.7 

Females, 18–29 8.9 0.2 49.8 24.2 5.0 70.8 

Females, 30–64 12.7 5.8 24.2 16.4 8.5 28.6 

Females, 65+ 0.0 0.0 27.1 0.0 0.0 29.9 

All Females 10.5 5.0 19.3 15.3 8.6 25.2 

For the General U.S. Population in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, 

Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, Rhode Island, 

South Carolina, Virginia, Wisconsin) 

CY04 CY05 

Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI 

Lower Upper Lower Upper 

Males, 18–29 20.0 18.9 21.2 19.2 18.1 20.3 

Males, 30–64 22.8 22.1 23.6 22.2 21.5 22.9 

Males, 65+ 28.8 27.0 30.6 29.9 28.1 31.7 

All Males 23.0 22.4 23.6 22.6 22.0 23.1 

Females, 18–29 4.3 3.8 4.9 4.3 3.7 4.8 

Females, 30–64 7.0 6.6 7.4 6.8 6.4 7.2 

Females, 65+ 3.8 3.3 4.4 3.7 3.2 4.3 

All Females 5.9 5.6 6.2 5.7 5.4 6.0 

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For All Veterans in the 13 States with NVDRS data for CY2004 (Alaska, Colorado, Georgia, Maryland, Massachusetts, New Jersey, North Carolina, Oklahoma, Oregon, 

Rhode Island, South Carolina, Virginia, Wisconsin) 

CY04 CY05 CY06 (Partial) 

Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI 

Lower Upper Lower Upper Lower Upper 

Males, 18–29 52.4 42.6 63.7 44.4 35.6 54.7 43.4 34.9 53.4 Males, 30–64 26.8 25.1 28.6 25.5 23.8 27.3 23.4 21.7 25.1 Males, 65+ 28.0 25.8 32.5 32.3 29.9 34.7 23.8 21.7 26.0 All Males 28.2 26.8 29.5 28.8 27.3 30.2 24.3 23.0 25.6 Females, 18–29 17.4 8.0 33.1 16.8 7.7 32.0 16.6 7.6 31.5 Females, 30–64 11.7 8.3 16.0 10.8 7.6 14.9 8.5 5.7 12.2 Females, 65+ 2.7 0.3 9.6 4.1 0.8 11.9 5.5 1.5 14.1 All Females 10.9 8.1 14.3 10.4 7.7 13.8 9.0 6.5 12.1 

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For VHA Patients in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, 

Rhode Island, South Carolina, Utah, Virginia, Wisconsin) 

FY05 

Suicides 

/100,000 

95% CI 

Lower Upper 

Males, 18–29 53.2 31.0 85.1 

Males, 30–64 36.5 31.8 41.7 

Males, 65+ 36.0 31.1 41.5 

All Males 36.7 33.3 40.4 

Females, 18–29 25.0 6.8 64.1 

Females, 30–64 15.8 8.6 26.5 

Females, 65+ 0.0 0.0 25.8 

All Females 15.2 9.0 23.9 

For the General U.S. Population in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, 

Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, Wisconsin) 

CY05 

Suicides 

/100,000 

95% CI 

Lower Upper 

Males, 18–29 20.4 19.3 21.4 

Males, 30–64 23.3 22.6 24.0 

Males, 65+ 30.5 28.8 32.2 

All Males 23.6 23.0 24.1 

Females, 18–29 4.4 3.9 4.9 

Females, 30–64 7.0 6.7 7.4 

Females, 65+ 3.6 3.1 4.2 

All Females 5.9 5.6 6.1 

For All Veterans in the 16 States with NVDRS data for CY2005 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, 

Rhode Island, South Carolina, Utah, Virginia, Wisconsin) 

CY05 CY06 (Partial) 

Suicides 

/100,000 

95% CI Suicides 

/100,000 

95% CI 

Lower Upper Lower Upper 

Males, 18–29 45.0 36.6 54.7 42.6 34.6 52.0 

Males, 30–64 25.6 24.0 27.2 23.6 22.0 25.1 

Males, 65+ 31.5 29.2 33.8 24.1 22.2 26.2 

All Males 28.5 27.2 29.9 24.5 23.2 25.7 

Females, 18–29 15.4 7.0 29.1 16.8 8.1 30.9 

Females, 30–64 11.4 8.3 15.4 8.8 6.1 12.3 

Females, 65+ 3.7 0.8 10.7 5.0 1.4 12.7 

All Females 

f 

10.6 8.0 13.8 9.1 6.7 12.1 

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Information Provided by VA From Discussion with Secretary Peake during 

Post-Hearing Meeting 

Cost of Call Center 

Response: Currently, the cost for the suicide hotline in FY 2008 is projected to be 

$2.6 million. However, the funding will increase if and when the calls require additional lines. 

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Detail of Program Expenses 

Specific Purpose Program: Suicide Hotline 

Estimated Expenses: FTEE Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Comments 

VA Personnel 37.50 $517,805 $647,760 $642,521 $652,384 $2,460,469 Contract Personnel (IPA, etc.) Contract Services & Misc. $118,456 $118,456 Supplies $1,050 $1,050 $1,050 $1,050 $4,200 Other $4,688 $4,688 $4,688 $4,688 $18,752 Travel $9,375 $9,375 $9,375 $9,375 $37,500 Equipment $5,463 $5,463 Total Expenditures: 37.50 $656,837 $662,873 $657,634 $667,497 $2,644,840 

VA Personnel 

(Name) 

Grade 

/Step Position (Title) FTEE Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total 

Function 

(Job 

Duties) 

Station To 

Receive 

Funding 

Station 

Number 

11 Social Worker 1.00 $16,833 $16,889 $16,909 $17,170 $67,801 528 528 09 Other Therapists 1.00 $19,403 $19,468 $19,492 $19,792 $78,155 528 528 06 Other Health Aides 1.00 $12,443 $12,484 $12,499 $12,692 $50,118 528 528 01 RN 1.00 $21,528 $21,600 $21,626 $21,959 $86,713 528 528 05 Other Health Aides 1.00 $7,803 $7,829 $7,838 $7,959 $31,429 528 528 11 Social Worker 1.00 $18,696 $18,759 $18,781 $19,070 $75,306 528 528 06 Other Health Aides 1.00 $12,918 $12,961 $12,977 $13,177 $52,033 528 528 09 Other Therapists 1.00 $14,954 $15,004 $15,022 $15,253 $60,233 528 528 11 Social Worker 1.00 $16,635 $16,690 $16,710 $16,967 $67,002 528 528 

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VA Personnel 

(Name) 

Grade 

/Step Position (Title) FTEE Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total 

Function 

(Job 

Duties) 

Station To 

Receive 

Funding 

Station 

Number 

11 Social Worker 1.00 $15,935 $15,988 $16,008 $16,254 $64,185 528 528 11 Social Worker 1.00 $17,917 $17,977 $17,999 $18,276 $72,169 528 528 02 RN 1.00 $7,386 $7,411 $7,420 $7,534 $29,751 528 528 06 Other Health Aides 1.00 $10,468 $10,503 $10,516 $10,678 $42,165 528 528 11 Social Worker 1.00 $19,156 $19,234 $19,243 $19,539 $77,172 528 528 01 RN 1.00 $19,749 $19,815 $19,839 $20,144 $79,547 528 528 11 Social Worker 1.00 $18,594 $18,656 $18,679 $18,966 $74,895 528 528 05 Nursing Aides 1.00 $9,376 $9,407 $9,419 $9,564 $37,766 528 528 11 Social Worker 1.00 $17,109 $17,166 $17,186 $17,451 $68,912 528 528 11 Social Worker 1.00 $17,268 $17,325 $17,346 $17,613 $69,552 528 528 09 Other Therapists 1.00 $15,826 $15,878 $15,898 $16,142 $63,744 528 528 

3 RN 1.00 $23,026 $23,103 $23,131 $23,486 $92,746 528 528 3 RN 1.00 $20,593 $20,662 $20,687 $21,005 $82,947 528 528 2 RN 1.00 $21,038 $21,108 $21,134 $21,459 $84,739 528 528 2 RN 1.00 $20,867 $20,936 $20,962 $21,284 $84,049 528 528 

11 Other Therapists 1.00 $15,510 $15,562 $15,581 $15,820 $62,473 528 528 11 Other Therapists 1.00 $15,164 $15,215 $15,233 $15,467 $61,079 528 528 

RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528 RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528 RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528 RECRUITMENT 02/11 RN or SW 1.00 $10,361 $19,058 $19,081 $19,375 $67,875 528 528 RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528 

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RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528 RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528 RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528 RECRUITMENT 02/11 RN or SW 1.00 $19,058 $19,081 $19,375 $57,514 528 528 RECRUITMENT 02/11 RN or SW 0.50 $9,529 $9,541 $9,688 $28,757 528 528 RECRUITMENT 11 Program Analyst 1.00 $10,591 $19,482 $19,505 $19,806 $69,384 528 528 RECRUITMENT 6 Program Support 

Asst. 

1.00 $6,440 $11,847 $11,861 $12,044 $42,192 528 528 

OT $23,135 $1,750 $1,750 $1,750 $28,385 528 528 Awards $10,000 $6,000 $16,000 528 528 

Sub Total: 37.50 $517,805 $647,760 $642,521 $652,384 $2,460,469 

Contract Personnel (IPA, etc.) 

Personnel Position FTEE Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Function 

Station To 

Receive 

Funding 

Station 

Number 

Sub Total: 

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Detail of Program Expenses 

Specific Purpose Program: Suicide Hotline—Continued 

Contract Services & Misc. 

Contract (Service 

provided) Contractor Needed Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total 

Reason for 

Service 

(Contract) 

Station To 

Receive 

Funding 

Station 

Number 

Accreditation $5,000 $5,000 528 528 Lifeline $111,456 $111,456 528 528 Advertising $2,000 $2,000 528 528 

Sub Total: $118,456 $118,456 

Note: Actual Services which are under a contract (copier maintenance, phone service, etc.). Any service provided by the local facility and charged to the program are listed under Supplies or Other. Also List in order of priority to your program. 

Supplies Purpose Needed Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Comments 

Station To 

Receive 

Funding 

Station 

Number 

Office supplies $1,050 $1,050 $1,050 $1,050 $4,200 528 528 

Sub Total: $1,050 $1,050 $1,050 $1,050 $4,200 

Note: Includes paper, pens, toner, etc. along with any additional supplies which are consumable and need to be replaced. Also List supplies in order of priority to your program. 

Other Purpose Needed Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Reason for expense Station To Receive Funding 

Education/tuition/registration $4,688 $4,688 $4,688 $4,688 $18,752 528 528 

Sub Total: $4,688 $4,688 $4,688 $4,688 $18,752 

Note: Any item not covered under contracts or supplies (not to include equipment which is covered below). Also List in order of priority to your program. 

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Detail of Program Expenses 

Specific Purpose Program: Suicide Hot Line—Continued 

Travel 

Personnel (Name) Traveling to Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total Reason for Trip Station To Receive Funding Station Number 

Employee travel $9,375 $9,375 $9,375 $9,375 $37,500 528 528 

Sub Total: $9,375 $9,375 $9,375 $9,375 $37,500 

Note: Please include as much detail on each separate trip and the personnel taking the trips as possible. Also List Travel in order of priority to your program. 

Equipment Purpose Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total 

Reason 

Equipment is 

needed 

Station To 

Receive 

Funding 

Station 

Number 

Filing cabinet $1,100 $1,100 528 528 Security System $4,363 $4,363 528 528 

Sub Total: $5,463 $5,463 

Note: Equipment consist of items which bear an actual VA property tag all other items go under ‘‘Supplies’’ or ‘‘Other’’. Also List Equipment in order of priority to your program. 

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1 Age based on age in 2005. Suicides, n=144, were identified among a cohort of 490,346 OEF/ 

OIF selected for mortality follow-up through 2005. 

POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD 

Committee on Veterans’ Affairs 

Washington, DC. 

May 21, 2008 

The Honorable James B. Peake, M.D. 

The Secretary Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Mr. Secretary: 

In reference to our Full Committee hearing on ‘‘The Truth About Veterans’ Suicides’’ on May 6, 2008, I would appreciate it if you could answer the enclosed hearing questions by the close of business on July 7, 2008. 

In an effort to reduce printing costs, the Committee on Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting 

changes for materials for all full committee and subcommittee hearings. Therefore, 

it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer. 

Due to the delay in receiving mail, please provide your response to Debbie Smith 

by fax your responses at 202–225–2034. If you have any questions, please call 202– 

225–9756. 

Sincerely, 

BOB FILNER 

Chairman 

CW:ds 

Questions for the Record 

The Honorable Bob Filner, Chairman 

House Committee on Veterans’ Affairs 

May 6, 2008 

The Truth about Veteran Suicides 

Question 1(a): In testimony before the Committee, the VA presented data regarding suicide rates for the general population and veteran users grouped into 

three cohorts: 18–29; 30–64; and, 65+. Please provide a detailed explanation to the 

Committee to explain why these particular age cohorts were chosen. 

Response: To ensure consistency with other Veterans Health Administration 

(VHA) data on suicides, age groups selected by the National Serious Mental Illness 

Treatment Research and Evaluation Center (SMITREC) were used. 

Question 1(b): Please provide the Committee with the data presented at the May 

6, 2008 hearing grouped by the following age cohorts: 20–24; 25–29; 30–34; 35–39; 

40–44; 45–49; 50–54; 55–59; 60–64; 65–69; 70–74; and, 75+. 

Response: The table below provides: Number of Suicides by Age Group Among 

Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans Compared to U.S. General Population 1

Age Groups Observed # 

Suicides 

Expected # Of 

Suicides 2

Standardized 

Mortality 

Rate 3

95% confidence 

interval 4

20–24 38 23.6 1.61 1.14–2.21 

25–29 37 32.7 1.13 0.80–1.56 

30–34 19 15.1 1.26 0.76–1.97 

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Age Groups Observed # 

Suicides 

Expected # Of 

Suicides 2

Standardized 

Mortality 

Rate 3

95% confidence 

interval 4

35–39 18 14.8 1.21 0.72–1.92 

40–44 14 18.7 0.75 0.41–1.26 

45–49 5 10.6 0.47 0.15–1.10 

50–54 7 5.2 1.34 0.54–2.75 

55–59 6 3.5 1.72 0.63–3.74 

60–64 0 — — — 

65–69 0 — — — 

70–74 0 — — — 

75-+ 0 — — — 

A2 Expected based on U.S. general population. 

A3 Standardized Mortality Ratio (SMR) is the ratio of observed to expected with adjustment for race, sex, 

age, and calendar year period. 

A4 95 percent confidence interval (C.I.). 

There were no OEF/OIF veteran suicides in the age groups older than 55–59, therefore expected numbers 

and SMRs were not presented. 

Question 2: On December 12, 2007, the Committee held a hearing entitled ‘‘Stopping Suicides: Mental Health Challenges within the U.S. Department of Veterans 

Affairs.’’ Please provide to the Committee a detailed explanation of the specific steps 

and actions undertaken by the VA to improve mental health care and services since 

December 13, 2007. Please exclude any steps and actions that the VA had planned 

to undertake prior to December 12, 2007. 

Response: Since December 13, 2007, the following actions were initiated to improve mental health care: 

• Expansion of the suicide prevention coordinator staffing into teams is underway, with increased access in community based outpatient clinics (CBOC) • Expansion of mental health staff • Expansion of sites of care—CBOCs • Expansion of veteran centers • Collaborating with the Defense Center of Excellence (DCoE) on mental health 

and traumatic brain injury (TBI) by providing a Deputy Center Director and a 

mental health subject matter expert • Funding to expand VA’s substance use disorder outpatient intensive care programs by adding 28 new sites and a substance use disorder care specialist to 

every post traumatic stress disorder (PTSD) team or specialty program if one 

doesn’t already exist 

Question 3(a): An Associated Press article dated April 15, 2008, entitled ‘‘Dallas 

Veterans’ Hospital Shutters Psych Ward after Fourth Patient Suicide of Year’’ states 

that ‘‘[t]he fourth suicide this year among mentally ill patients treated at the Dallas 

VA Medical Center has led the hospital to close its psychiatric ward to new patients, 

and investigators from the national Veterans Affairs office are expected to arrive 

next week to assess safety.’’ Please provide the Committee with the results of this 

investigation to date. If the results of this investigation have not been finalized, 

please provide the preliminary findings and recommendations of these investigators. 

Response: The Medical Inspector Final Report #2008–D–654 dated May 20, 2008 

(Quality of Care Review, Veterans Affairs Medical Center (VAMC) Dallas, Texas, 

Veterans Integrated Service Network 17) is attached. 

[The Medical Inspector Final Report #2008–D–654 dated May 20, 2008, entitled 

‘‘Quality of Care Review, Veterans Affairs Medical Center (VAMC) Dallas, Texas, 

Veterans Integrated Service Network 17,’’ will be retained in the Committee files.] 

Question 3(b): Please provide the Committee with a detailed explanation regarding the VA’s plans to address this situation. 

Response: On April 5, 2008, the Dallas VAMC, formally known as the Department of Veterans Affairs (VA) North Texas Health Care System (VANTHCS), temporarily stopped admitting new patients to the two inpatient psychiatry units (a 22- 

bed unit located on 3 South and a 29-bed unit located on 3 North) following two 

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mained on the units until completion of their course of treatment to ensure continuity of care. The temporary stand down was put in place to allow adequate time 

for a thorough review of mental health staffing and environment of care issues. 

On April 16–17, and April 22–23, 2008, the Office of Medical Inspector (OMI) and 

the Office of Mental Health, respectively, visited the Dallas VAMC to evaluate the 

mental health program. The OMI and Office of Mental Health teams made several 

recommendations for safety improvements, including environment of care enhancements, staffing/program enhancements, and organizational/cultural changes needed 

to enhance patient safety. The Dallas VAMC leadership embraced these recommendations and has implemented an action plan successfully correcting all deficiencies. 

On May 8, 2008, Veterans Integrated Service Network (VISN) 17 responded to Office of Mental Health’s recommendations with a detailed action plan. All items on 

the list were either completed or closed out in compliance and confirmed with the 

Deputy Chief of Mental Health prior to re-opening the inpatient units. VISN 17 also 

consulted with the National Center for Patient Safety (NCPS). NCPS determined 

that the Dallas VAMC’s plan for enhanced safety checks and increased staffing on 

the units should mitigate the risk of suicide. 

On May 19, 2008, following renovations, the 3 South inpatient unit was reopened. New admissions were capped to two per day, with exceptions for patients 

hospitalized under the order of protected custody. While the unit was closed to new 

admission, patients were assessed in the emergency department and outpatient clinics and transferred for inpatient hospitalization as needed to the Waco VAMC and 

local psychiatric hospitals. A social worker coordinated admissions and discharges 

to ensure continuity of care. Mental health staff was proactive in providing information to the receiving facilities and remained in communication with the facilities 

throughout the hospitalization. 

Over the past 6 months, Dallas VAMC has invested $250,000 in the inpatient 

units to provide upgrades to the environment of care to decrease suicide risks. An 

additional $250,000 has been spent on furniture to also reduce suicide risk. These 

improvements included the following: replacing windows and door hardware, clipping ceiling tiles in bedrooms, installing camera systems in hallway, changing bathrooms fixtures, enclosing plumbing and electrical wiring, and removing tall furniture and nightstands. Continuous improvements and modifications are being 

made to the environment of care. 

The Dallas VAMC is actively recruiting permanent additional staff and reorganizing the Mental Health Department. Education for all existing and new staff hired 

on integrating principles of psychosocial recovery and suicide prevention is being 

conducted and will continue. The Dallas VAMC regularly consults the Office of Mental Health in preparation for the reopening of 3 North. The tentative opening date 

for 3 North is fiscal year (FY) 2009. Outsourcing of services will discontinue once 

the unit is re-opened and fully staffed. 

Question 3(c): Please provide the current level of mental health care services at 

the Dallas facility 

Response: The chart below provides the current level of mental health services 

at the Dallas facility. 

Question 3(d): What is the expected level of services at the Dallas facility in one 

year? 

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VA North Texas Health Care System (Dallas) 

Mental Health Services 

• Inpatient acute care 

• Intensive outpatient 

group therapies 

• Alcohol/drug recovery 

counseling 

• Anger management 

• Evaluation and treatment of PTSD 

• Geriatric psychiatry 

• Memory problems 

• Homeless domiciliary 

• Compensated work 

therapy (CWT) 

• Community residential care program 

(CRCP) 

• Programs to help exoffenders reintegrate 

back into society 

• Assisted housing veterans 

• Health care for homeless veterans 

• Outreach for homeless 

veterans 

• Special programs for 

women veterans suffering from trauma 

• Support groups for 

wives of veterans with 

PTSD 

• Day treatment 

• Suicide prevention coordinators (Dallas/ 

Bonham/Fort Worth) 

• Recovery services that 

help promote veteran 

empowerment, development of life and work 

skills, supportive family 

and social networks and 

improved problem solving 

• Trauma team (military 

sexual trauma, PTSD) 

Response: In FY 2009, the Dallas VAMC will provide the full spectrum of mental 

health services as indicated in the chart above including the reopening of 3 North. 

Question 3(e): What is the length of time the VA plans to outsource these services to other VA facilities in North Texas, Waco, and Temple? 

Response: The inpatient mental health services will continue to be outsourced 

in FY 2009 until the renovations of the 29-bed unit is on 3 North and the 22-bed 

unit on 3 South are complete and the facilities are in full compliance with national 

patient safety measures. 

Question 4(a): A Dallas Morning News article dated January 18, 2005, entitled 

‘‘Dallas VA Hospital is Nation’s Worst’’ states that the ‘‘Dallas veterans hospital is 

so dirty, dangerous, and poorly managed, Federal investigators have found that it 

ranks as the worst such medical center in the country.’’ Please provide the Committee with information regarding the current ranking of the Dallas facility. 

Response: In May 2008, VA Office of Quality and Performance issued a second 

quarter FY 2008 Facility Aggregated Report ranking Dallas 123 out of 139. 

Question 4(b): Please provide the Committee with a detailed explanation of the 

specific steps undertaken by the VA since 2005 to improve the Dallas VA Medical 

Center. 

Response: Since 2005, the Dallas VAMC has taken steps to improve the organization. The graph below shows the total budget, staffing and equipment purchases 

from 2005 through 2008. Since 2005, the total budget increased by 21 percent, staffing increased by 10 percent and equipment purchase expenditures were 145 percent. 

VANTHCS 

Operational Budget** FY 2005 FY 2006 FY 2007 FY 2008 

Medical $408,470,538.30 $461,669,051.57 $484,666,641.06 $530,439,213.09 

Administration $ 54,860,479.67 $ 50,051,586.51 $ 57,226,061.12 $ 42,143,425.62 

Facility $ 50,477,600.71 $ 56,877,468.86 $ 64,230,384.76 $ 49,410,582.70 

Total $513,808,618.68 $568,598,106.94 $606,123,086.94 $621,993,221.41 

**Includes general purpose/specific purpose/Consolidated Mail Out Pharmacy 

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Since 2005, the Dallas VAMC has improved its infrastructure and its ability to 

provide high quality of care. Its capital budget has increased by 30 percent since 

2005. Below is a detailed list of its minor and non-recurring Maintenance (NRM) 

projects and capital funding for VA North Texas Health Care System. 

FY 2005—FY 2008 Minor Projects: 

FY Approved Facility Project Title Total Project 

Cost 

2005 Dallas Patient Privacy/UFAS Deficiencies, Ph 8 $2,200,000 

2005 Dallas Relocate Geropsychiatry $6,050,000 

2006 Dallas Transitional Care Unit $3,630,000 

2007 Dallas MRI Addition for Research $6,299,000 

2008 Dallas Upgrade Mental Health Ph 2 $6,984,475 

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FY 2005—FY 2008 Non-Recurring Maintenance (NRM) Projects: 

FY 2005 

Facility Project Title Total $ Obligated 

Dallas Correct Electrical Panel Deficiencies $ 219,565.00 

Dallas SCI Vocational Rehab $ 69,000.00 

Dallas Dallas Pharmacy Clean Room Renovation $ 33,000.00 

Dallas Bldg. #1 & #2 Connection Corridor Renovation $ 60,000.00 

Dallas Clinical Admission Renovation $ 44,610.00 

Dallas Mental Health Offices $ 35,000.00 

Dallas Modular Bldgs. 5/6 Installation $ 325,000.00 

Dallas Increase Provider/Patient Care Space $ 125,000.00 

Dallas GU Renovation $ 65,000.00 

Dallas CWT Modular Bldg. Site Utilities $ 187,603.00 

Dallas Replace PRV Stations $ 261,784.00 

Dallas Sump Pump Replacement $ 170,000.00 

Dallas Install Elevator Monitoring System $ 168,083.00 

Dallas EP/Cath Renovation $ 150,000.00 

Dallas Dallas Roof Repairs $ 164,850.00 

Dallas HVAC Campus Upgrade $ 81,180.00 

Dallas Asbestos Abatement $ 174,938.00 

Dallas Renovate Canteen BSMT, Ph. II $ 50,000.00 

Dallas Plan For Improvement (PFI) $ 168,196.00 

Dallas Correct Fire Alarm/Sprinkler Def. $ 571,113.00 

Dallas ER Nursing Triage $ 15,000.00 

Dallas Duct Cleaning $ 423,300.00 

Dallas HVAC Campus Upgrade $ 81,180.00 

Dallas FY05 Facility Lump Sum $ 293,364.00 

Total $ 3,936,766.00 

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FY 2006 

Facility Project Title Total $ Obligated 

Dallas HVAC Campus Upgrade $ 2,037,620.00 

Dallas Pneumatic Tube Installation $ 74,149.00 

Dallas B–1/B–12 Electrical Deficiencies $ 242,062.00 

Dallas Mental Clinical Unit $ 439,400.00 

Dallas Diabetes/Women’s Clinic $ 236,330.00 

Dallas 5A Telemetry $ 65,049.00 

Dallas Bldg. 2, Chaplain Corridor $ 86,652.00 

Dallas Dental Renovation $ 61,199.00 

Dallas QM Renovation $ 70,866.00 

Dallas Correct Steam Condensate $ 82,873.00 

Dallas Dallas Roof Repairs $ 29,506.00 

Dallas HVAC Campus Upgrade $ 2,057,620.00 

Dallas Replace Dallas UGST $ 146,000.00 

Dallas Correct HVAC Def. Phase III $ 172,043.00 

Dallas Asbestos Abatement $ 140,221.00 

Dallas Renovate Canteen BSMT, Ph. III $ 85,769.00 

Dallas USP 797 Dallas Pharmacy Clean Room $ 29,207.00 

Dallas Plan For Improvement (PFI) $ 79,000.00 

Dallas Correct Fire Alarm/Sprinkler Def. $ 47,609.00 

Dallas ER Nursing Triage $ 54,247.00 

Dallas Replace CPVC CA Sprinkler Piping $ 49,623.00 

Dallas Correct Steam Condensate $ 64,059.00 

Dallas Replace CPVC CA Sprinkler Piping $ 29,000.00 

Dallas FY06 Facility Lump Sum $ 335,273.00 

Total $ 6,715,377.00 

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FY 2007 

Facility Project Title Total $ Obligated 

Dallas Bonham Electrical Deficiency Corrections $ 43,475.00 

Dallas Bonham Fire Sprinkler $ 235,332.00 

Dallas Replace/Repair Ductwork Insulation $ 99,897.00 

Dallas Bonham Roof/Repair Replacements $ 219,979.00 

Dallas Repair Campus Asphalt Roadway and Sidewalks $ 161,339.00 

Dallas Correct Cooling Tower Deficiencies $ 68,932.00 

Dallas USP 797 Dallas Pharmacy Clean Room $ 218,000.00 

Dallas Polytrauma Program Renovation $ 218,824.00 

Dallas Brachytherapy $ 30,148.00 

Dallas 9th Floor Building #2 Call Center $ 83,504.00 

Dallas QM/PP #8 Domino Moves $ 124,070.00 

Dallas Remove Lithotripter Equipment $ 50,066.00 

Dallas Correct Steam Condensate $ 495,533.00 

Dallas Dallas Roof Repairs $ 229,462.00 

Dallas Correct HVAC Deficiencies, Bldg 2 $ 68,578.00 

Dallas Asbestos Abatement $ 85,513.00 

Dallas Plan For Improvement $ 200,894.00 

Dallas TCU Utilities Infrastructure $ 1,638,711.00 

Dallas Relocate Pharmacy Cache $ 30,500.00 

Dallas B.2 Steam and Condensate Return Upgrade $ 335,092.00 

Dallas Fuel Oil Tank Replacement Dallas/Bonham $ 114,848.00 

Dallas B.2 IT Upgrade $ 335,093.00 

Dallas B.2 Chill Water Upgrade $ 346,598.00 

Dallas 1.5T MRI SITE PREP $ 253,486.00 

Dallas Repair/Replace Campus Insulation $ 343,104.00 

Dallas Fisher House Site Preparation $ 397,407.00 

Dallas GI Recovery Expansion $ 143,303.00 

Dallas Radiology Renovation Phase I $ 3,000.00 

Dallas Human Resources (HR) Modular $ 471,651.00 

Dallas MAS Modular Building $ 471,651.00 

Dallas Mental Health Modular $ 383,124.00 

Dallas ASCO Upgrade Phase I $ 272,181.00 

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FY 2007 

Facility Project Title Total $ Obligated 

Dallas Additional NRM Mental Health Modular Bldg $ 448,608.00 

Dallas Correct Bldg 1 HVAC Deficiencies Phase 1 $ 70,513.00 

Dallas Correct Bldg 1 Electrical Deficiencies $ 47,131.00 

Dallas OR Vascular Equipment Site Prep. $ 49,790.00 

Dallas Dallas Roof Repairs, Bldg 2 $ 229,462.00 

Dallas Replace Chiller #2 $ 1,710,823.00 

Dallas Install Steam trap Monitoring System $ 46,418.00 

Dallas Power Factor Correction $ 16,300.00 

Dallas Building 1 Exterior Renovation Phase 1 $ 20,381.00 

Dallas Building 2 Exterior Renovation Phase 2 $ 67,734.00 

Dallas FY07 Facility Lump Sum $ 2,834,226.00 

Total $ 13,714,681.00 

FY 2008 

Facility Project Title Planned 

Design Cost 

Planned 

Construction 

Cost 

Dallas Install steam trap monitoring system $ 50,000 $ 200,000 

Dallas East Site Utilities $ 400,000 

Dallas Building 2 Exterior Renovation Ph.1 $ 45,000 $ 250,000 

Dallas Lot 27 Site Utilities $ 400,000 

Dallas Correct Steam Condensate Ph.2 $ 0 $ 500,000 

Dallas Replace deteriorated Bldg. 2 $ 60,000 $ 706,000 

Dallas SCI Pool Lift Upgrade $ 356,000 

Dallas Replace CPVC in Clinical Addition $ 100,000 $ 800,000 

Dallas Polytrauma Renovation $ 150,000 $ 1,350,000 

Dallas Window Repair/Replacement $ 70,000 $ 753,000 

Dallas Correct HVAC Deficiencies, Bldg 2 $ 65,000 $ 536,201 

Dallas Correct Bldg. 1 HVAC Deficiencies Ph1 $ 50,000 $ 450,000 

Dallas Correct Bldg. 1 Electrical Deficiencies $ 50,000 $ 412,500 

Dallas Replace Elevators Bldg. 1 $ 90,000 $ 900,000 

Dallas Chill water Replacement Upgrade* $ 60,000 

Dallas Bldg 43 Sprinkler Pipe Installation* $ 40,000 

Dallas Pharmacy Prescription Disp Area* $ 20,000 

Dallas Upgrade Dallas Campus Site work Phl* $ 90,000 

Dallas Replace Campus Fire Alarm System* $ 100,000 

Dallas Bldg 1 Replace FCU and Controls Ph.1 * $ 42,000 

Dallas Boiler Plant Repl* $ 200,000 

Total $1,282,000 $ 8,013,701 

* Only planned designed costs for FY 2008 

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FY 2007 and FY 2008 Emergency Supplemental: 

FY 2007 and FY 2008 Emergency Supplemental NRM 

Station Project Title/Description Total Cost 

Dallas Dallas Roof Repairs $ 816,000.00 

Dallas Correct B.2 HVAC Def $ 604,780.00 

Dallas Repair/Replace Campus Insulation $ 400,000.00 

Dallas Correct B.1 HVAC Def (Ph1) $ 520,514.00 

Dallas Correct B.1 Electrical Deficiencies $ 462,500.00 

Dallas Replace Chiller #2 $ 1,800,000.00 

Dallas Window Repair/Replace $ 753,000.00 

Dallas B.1 Exterior Renovation Ph.2 $ 450,000.00 

Dallas Replace Elevators B.1 $ 900,000.00 

Dallas Polytrauma Renovation $ 1,500,000.00 

Total $ 8,206,794.00 

VA North Texas Capital Budget for FY 2005–2008: 

VA North Texas Capital Budget 

FY 2005 Dallas VERA NRM Allocation $ 5,945,530.00 

FY 2005 Dallas Supplemental Appropriation for NRM $ 2,200,000.00 

Total $ 8,145,530.00 

FY 2006 Dallas VERA NRM Allocation $ 6,450,000.00 

FY 2007 Dallas VERA NRM Allocation $ 5,663,301.00 

FY 2007 Dallas Emergency Supplemental Allocation $ 2,581,985.71 

FY 2007 Dallas Energy Funds $ 700,000.00 

FY 2007 Dallas Mental Health (Modular Building) $ 831,732.00 

Total $ 9,777,018.71 

FY 2008 Dallas VERA NRM Allocation $ 3,137,240.00 

FY 2008 Dallas Supplemental Add-on Allocation $ 2,400,000.00 

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VA North Texas Capital Budget—Continued 

FY 2008 Dallas Mental Health Allocation $ 10,000.00 

FY 2007/2008 Dallas Emergency Supplemental Allocation $ 5,001,701.00 

Total $ 10,548,941.00 

Total Capital Funding $ 34,921,489.71 

The Dallas VAMC is a complexity Level I facility, providing tertiary care services 

to over 102,000 unique patients, which makes it VA’s 3rd largest health care system 

in terms of number of unique patients treated. The Dallas VAMC is a teaching hospital, providing a full range of patient care services with state-of-the-art technology 

as well as advanced education and research. Through its strategic partnership with 

University of Texas Southwestern Medical Center and Baylor College of Dentistry, 

Dallas VAMC helped train more than 740 medical residents and eight dental residents in FY 2007. The Dallas VAMC has affiliation agreements with over 100 agencies and institutions, providing training to approximately 2,000 students. 

Question 4(c): Please provide the Committee with a list including the names of 

the director and the senior leadership of the Dallas VA Medical Center during 2004 

and 2005, and if still employed by the VA, their current titles and responsibilities. 

Response: In 2004, Dallas VAMC leadership consisted of the following: 

Medical Center Director: Alan G. Harper, retired March 2005. 

Associate Director: William E. Cox, transferred to Clarksburg VAMC as Director, 

January 2005. He currently has full delegated line authority and responsibility for 

executive level management of the Clarksburg VAMC and its community outpatient 

clinics. 

Assistant Director: Daniel K. Heers, retired April 2005. 

Chief of Staff: Robert Cronin, reassigned to staff physician, Medical Services in 

March 2005. He currently treats patients in the Nephrology Clinic and on the inpatient wards for kidney diseases. 

Chief Nurse: Burlean Huff was the Acting Executive Nurse for Dallas from January 2005 to September 2005 until recruitment of Associate Director of Nursing. He 

retired December 2007. This position converted into the Associate Director of Nursing. 

In 2005, Dallas VAMC leadership consisted of the following: 

Medical Center Director: Betty Bolin Brown transferred to Employee Education 

System in Shreveport, LA on April 2007. She is the Executive Scholar for the Employee Education System. 

Current Medical Center Director: Joseph M. Dalpiaz, effective May 2007 has full 

delegated line authority and responsibility for executive level management of the 

VA North Texas Health Care System (VANTHCS). 

Associate Director: Jeff Milligan, Associate Director, effective September 2005, has 

the responsibility for the direction, evaluation and control of all administrative activities in the medical center. 

Assistant Director: Daniel K. Heers, retired April 2005. Eric D. Jacobsen, Assistant Director effective December 2005 his responsibilities include direction of human 

resources and information resources management, logistics, facilities and health 

care environment management and health services administration. 

Chief of Staff: Robert Cronin, Chief of Staff since January 2005, and reassigned 

in March 2005 to Staff Physician, Medical Service where he is responsible for treating patients in the Nephrology Clinic and on the inpatient wards for kidney diseases. John Sum-Ping, MD, Acting Chief of Staff effective 2005 through November 

2006. Dr. Sum-Ping is currently Chief, Anesthesiology and Pain Management Service at VANTHCS and manages all of the anesthesiology and pain management operations at VANTHCS. Clark R. Gregg effective November 2006 is the current Chief 

of Staff responsible for managing clinical operations. 

Associate Director of Patient Care Services: Sandra Y. Griffin, effective September 

2005 is the current Associate Director for Nursing Service having oversight for the 

daily clinical and administrative operations of the Nursing Service. 

Question 5: The email sent on March 20, 2008, by a VA employee at the Temple 

Texas VAMC, suggested that diagnoses of ‘‘adjustment disorder’’ be given instead 

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of diagnoses of PTSD. Please provide the Committee with the number of adjustment 

disorder diagnoses and PTSD diagnoses by facility since 2001. 

Response: The attached spread sheet provides data related to adjustment disorder diagnoses and PTSD diagnosis by facility, separately for each year from 2001 

through 2008. 

Question 6(a): Recently, CBS News reported that a VA team leader in Texas 

suggested mental health professionals should diagnose patients with ‘‘adjustment 

disorder’’ rather than post-traumatic stress disorder in order to save time and 

money treating veterans. Secretary Peake has characterized this email as ‘‘inappropriate.’’ An email by Dr. Katz dated February 13, 2008, entitled ‘‘Not for the CBS 

News Interview Request’’ has also been characterized as inappropriate. Please provide to the Committee the training materials provided to VA employees regarding 

proper electronic mail behavior. 

Response: Email training is provided annually to VA employees and contractors 

through the VA cyber security awareness training program. VA annual cyber security awareness training is mandatory for all VA employees, contractors, students, 

and volunteers. This requirement is specified in law through the Federal Information Security Management Act (FISMA) of 2002 and the Office of Management and 

Budget (OMB) Circular A–130, Appendix III. VA-wide compliance statistics are reported each year in accordance FISMA and to OMB. VA employees can access the 

Cyber Security Awareness Course on the VA Intranet. Attached is the course script 

for the VA National Rules of Behavior. 

[The Course Script entitled, ‘‘VA National Rules of Behavior,’’ Developed by the 

U.S. Department of Veterans Affairs, Office of Information and Technology, Cyber 

Security Service, and the Presentation entitled, ‘‘VHA Privacy Policy Training, FY 

2008,’’ will be retained in the Committee files.] 

Question 6(b): Please provide the Committee with the training materials provided to VA employees regarding what constitutes appropriate behavior and accountability or individual actions, especially with regards to electronic mail. 

Response: The VA Rules of Behavior document that each VA employee is required to sign prior to gaining access to VA IT systems outlines the proper use of 

VA email. Attached is a copy of the Rules of Behavior document. 

Question 6(c): Please provide the Committee with the number of disciplinary actions, including the reason for the disciplinary action, undertaken by the VA since 

2002 involving electronic mail or in response to individual actions that the VA has 

determined to be inappropriate. 

Response: The Department does not track reasons for disciplinary actions. 

Question 7(a): It has been clearly demonstrated that the Department of Defense 

and VA must work together to address issues that face departments, such as suicide, mental health and substance abuse treatment. Given such demonstrated need: 

Please provide the Committee with a detailed list of specific programs being developed by both departments to jointly address these issues. 

Response: VA and the Department of Defense (DoD) have collaborations on the 

following: 

• VA and DoD produced joint Clinical Practice Guidelines (CPG) on major depressive disorder (MDD), PTSD, and substance use disorders since the first MDD 

CPG in 1996. 

• VA and DoD collaborated on the creation of the mental health questions in the 

post deployment health re-assessment (PDHRA). The questions on PTSD, for 

example, are identical to those used as the standard PTSD screen administered 

to all veterans and are part of VA’s OEF/OIF automated screening tool. 

• DoD participated with VA and other entities in developing a plan for improving 

PTSD clinical research methodology subsequent to the recent Institute of Medicine (IOM) report on PTSD treatments. 

• VA and DoD are collaborating on the activities of the Defense Center of Excellence (DCoE) for psychological health and TBI. A VA clinician is the new Deputy Director of the DCoE. VA will collaborate on future DCoE research. 

Question 7(b): Please provide the Committee with a detailed explanation of the 

individual or joint efforts by both departments to collect data on suicides or to do 

a comprehensive study on suicides. If there have not been any efforts, please explain 

the lack of such efforts. 

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Response: There is an effort underway across Federal agencies, including VA, 

DoD, Substance Abuse and Mental Health Services Administration, Center for Disease Control, and the National Institutes of Health to examine suicide prevention 

efforts across systems. A panel of experts has been assembled to advise a Blue Ribbon Work Group on Suicide Prevention in the Veteran Population (Work Group) 

who will examine current knowledge as well as gaps in knowledge regarding suicide 

prevention. The Work Group is meeting in mid-June with a final report due 15 days 

following the meeting. New joint efforts to collect data on suicides based on the recommendations of the Work Group will be developed from these deliberations. 

Another joint effort between VA and DoD is collaboration on the development of 

a joint Web site for suicide prevention. The goal of building such a site is to provide 

linkage with multiple resources appropriate for servicemembers, veterans, and their 

families. 

In addition, the Center of Excellence at Canandaigua and the Serious Mental Illness Treatment Research and Evaluation Center (SMITREC) at Ann Arbor are 

planning a study to use population based data on suicide and suicide attempts to 

develop real time tracking systems of suicidal behavior for veterans in VA. 

The Center of Excellence at Canandaigua is planning a study of the reliability of 

the suicide behavior template data, which includes data on suicide attempts and 

completions reported by the suicide prevention coordinators. Reliability will be established through the use of vignettes that present a series of diverse scenarios of 

veterans in psychological or emotional distress. A rating scale based on consensus 

from a consortium of Center of Excellence experts will be developed in order to define an appropriate assessment of the veteran depicted in each scenario. These vignettes will be rated by the suicide prevention coordinators. This will allow us to 

examine both the inter-rater reliability and reliability with the expert consensus response. 

The Center of Excellence at Canandaigua, in collaboration with SMITREC at Ann 

Arbor, will also conduct a study to establish concurrent validity of the Suicide Behavior Template using administrative and clinical data. This collaborative study will 

include establishing the predictive validity of the reported measures of suicidal behavior using repeat attempts or death from suicide. 

The Center of Excellence at Canandaigua and the SMITREC at Ann Arbor, Michigan are planning a study of the data from VA’s 24-hour suicide crisis line to determine if there are new, emergent veteran populations at risk for suicidal behaviors. 

Both younger veterans and veterans in rural or underserved areas will be evaluated 

as part of this study as to mental health care needs of both groups that VA should 

address. 

Question 8(a): VHA testified before the Subcommittee on Health on January 17, 

2008, regarding Mr. Boswell’s bill H.R. 4204, the ‘‘Veterans Suicide Study Act.’’ The 

testimony given was very critical of the bill as far as what the bill would accomplish 

as written. Specifically, VHA stated that ‘‘[w]e do not believe the study required by 

this bill would generate information that would further our understanding of how 

to effectively screen and treat veterans who may be at risk of suicide. It would 

merely provide us with the rates for this cohort of veterans. VA has studied suicide 

rates for multiple cohorts of veterans and, through such efforts, has already identified the major clinical risk factors for suicide’’. VHA also stated that this bill, as 

drafted, would not afford VA the flexibility needed to develop a thorough and useful 

study. Is this still the position of the VA? 

Response: We do not believe the study required by this bill would generate information that would further our understanding of how to effectively screen and treat 

veterans who may be at risk of suicide. It would merely provide us with the rates 

for this cohort of veterans. VA has studied suicide rates for multiple cohorts of veterans and has already identified the major clinical risk factors for suicide. In fact, 

we recently completed such a study for OEF/OIF veterans. Using the data generated 

from those studies, we have developed protocols and processes to mitigate those 

risk-factors. For these reasons, we do not support section 103. 

Further, certain requirements mandated by the bill make its implementation not 

feasible. As now drafted, it would not afford VA the flexibility needed to develop a 

thorough and useful study. To design and carry out a study that is best designed 

to provide usable information to address the issue of veteran suicide rates, we believe the Secretary should determine the organization(s) with which the Department 

should coordinate the study. For instance, the Center for Disease Control (CDC) 

studies suicide rates among the general population, while VA’s role has been to validate the information compiled by CDC. 

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Additionally the 180-day timeframe is not realistic, as there is currently a 2-year 

time lag in the information released by CDC on suicide rates. We estimate the cost 

of this bill to be $1,580,006 in FY 2008 and $2,078,667 over a 10-year period. 

Question 8(b): Is VA developing a large scale study on the OEF/OIF veteran population to track suicides? 

Response: VHA’s Environmental Epidemiology Service is conducting a large 

scale study of suicides among OEF/OIF veterans. Study results are expected within 

the next 6 months. 

Question 8(c): Does VA believe this needs to be done? If not, why not? 

Response: VA believes this study should be conducted. 

Question 9(a): In a July 2005 briefing by the Veterans Health Administration 

on ‘‘Modeling and Strategic Planning for Mental Health and Substance Abuse Services’’ slide 14, entitled ‘‘Negative Gaps,’’ states that: VISNs will not address gaps 

where the FY 2013 or 2013 forecast demand is less than the FY 2003 actual demand 

with one exception 

—In those markets in which enrollment is projected to decline for the FY 2003 

actual demand by more than 10% in FY 2013 and/or by more than 20% in FY 

2023, the VISN should develop plans to reduce services in line with the projected 

declines in demand. 

Does this accurately reflect the current policy of the VHA? If not, when was this 

policy changed and for what reasons? 

Response: Since the 2005 presentation, our planning process for mental health 

and substance abuse services has significantly evolved with the creation of the VHA 

Comprehensive Mental Health Strategic Plan (MHSP), which was signed as policy 

by the Secretary in November 2005. The plan calls for expansion and enhancement 

of mental health services to fill gaps in mental health care, and to use the best practices in care that will offer the greatest likelihood of decreasing mental health symptoms and improving overall functioning and well-being of veterans with mental 

health problems. There is no current policy that would fit the information as described in this query. 

Question 9(b): What is the current strategic plan of the VHA regarding mental 

health and substance abuse, especially with regards to planning for future infrastructure and employment needs? Has this planning changed since 2005? 

Response: The MHSP of 2005 is the current strategic plan of VA regarding mental health and substance abuse services. It provides guidance for infrastructure and 

employment needs, along with many other elements of enhanced mental health 

care. The MHSP continues to be implemented aggressively, with collaboration 

across many offices in VHA to guide that process, including the Office of Mental 

Health Services, working within Patient Care Services (PCS) and involving many 

other offices within PCS; the Office of the Assistant Deputy Under Secretary for 

Health for Policy and Planning; and the Office of the Deputy Under Secretary for 

Health for Operations and Management. 

Additional guidance for implementation of the MHSP is under development. A VA 

handbook on Uniform Mental Health Services outlines services available to all veterans seeking or identified as needing mental health care. This handbook is an outgrowth of our extensive experience in implementing enhanced mental health services and reflects the MHSP. The handbook delineates the essential components of 

the mental health program that are to be implemented nationally, to ensure that 

all enrolled veterans, wherever they obtain care, have access to needed mental 

health services. It also specifies those services that must be accessible through each 

VAMC and each CBOC, and delineates that services must be made available 

through collaborative fee basis and contract relationships for veterans who are not 

close enough to receive care directly from VA facilities. By establishing the requirements of what services must be available to each veteran, no matter where in VHA 

they receive care VHA is ensuring a patient-centric uniform mental health services 

package to meet the care needs for each veteran. 

Question 10(a): The recent RAND report, ‘‘Invisible Wounds of War,’’ defined 

‘‘minimally adequate exposure to psychotherapy’’ (as part of the definition for minimally adequate care) in the following manner: 

Minimally adequate exposure to psychotherapy. was defined as having had at 

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utes. Criteria for minimally adequate courses of treatment were adapted from the 

National Comorbidity Study Replication (Wang et al., 2005). Does the VA agree 

with this definition? Why or why not? 

Response: This definition is not a sufficient representation of adequate treatment 

and is limited in a number of significant respects, as follows: 

• This definition is very broad and could include a wide variety of 

psychotherapies that have not been empirically established or shown to be effective, such as supportive counseling or other talk therapies that do not focus on 

promoting changes in thinking, behavior, or emotional functioning in a sustained way, as other psychotherapies have been demonstrated to do. Significantly, the above definition was initially developed by Wang et al. (2005) for 

measuring patterns of services, not for evaluating or establishing standards of 

care. Moreover, the references cited for the authors’ definition were to practice 

guidelines that specifically recommend established evidence-based psychotherapies, such as cognitive-behavioral therapy (CBT). 

• In addition to including psychotherapeutic interventions that have not been scientifically established, the definition could also include case management, counseling, and other similar interventions that are not standard treatments for the 

core symptoms of PTSD, depression, and other mental health conditions. 

• The definition of what may be considered adequate psychotherapeutic treatment 

is inconsistent with widely accepted practice guidelines for psychotherapy. This 

includes guidelines established by the American Psychiatric Association and the 

Agency for Health Care Policy and Research, as well as the VA/ DoD Clinical 

Practice Guidelines for PTSD and depression. These guidelines recommend the 

delivery of evidence-based psychotherapies, such as CBT for depressive and 

anxiety disorders, and cognitive processing therapy (CPT) and prolonged exposure (PE) therapy for PTSD. Both CPT and PE are highly recommended in the 

VA/DoD Clinical Practice Guidelines, indicating that the intervention is always 

indicated and acceptable. This was affirmed by a recent report on evidencebased treatments for PTSD by the Institute of Medicine. These practice guidelines also generally recommend 12–16 sessions of 50–90 minutes each, as opposed to the standard of eight 30-minute sessions included in the definition in 

the RAND report. 

Psychotherapies identified as ‘‘evidence-based,’’ including CBT, CPT, and PE, are 

psychotherapies that have been shown in randomized clinical trials to be more effective than other forms of psychotherapy, such as supportive counseling. Evidencebased psychotherapies are structured with established protocols and have manuals 

to help guide the treatment process. They also have the benefit of being time-limited. Moreover, evidence-based psychotherapies typically provide long-term benefits 

and have thus been found to be cost-effective. 

Data on mental health care delivery in VA indicate that psychotherapy, particularly individual psychotherapy, is provided at levels of frequency and intensity well 

below those recommended in practice guidelines. Evidence-based psychotherapy appears to be especially under-used. Unfortunately, psychotherapy codes in medical 

records do not indicate the specific type of psychotherapy provided, so precise data 

on the delivery of evidence-based psychotherapies in VA is unknown. However, a recent survey of VA program leaders found that lack of implementation of evidencebased psychological treatments was due, in large part, to limited knowledge and 

skills and lack of administrative support (Willenbring et al., 2004). 

VA has recently developed several national initiatives to train VA mental health 

providers in the delivery of a number of evidence-based psychotherapies for a variety of mental health conditions, including CPT and PE for PTSD, CBT for depression and anxiety, and social skills training for serious mental illnesses. CPT was 

the first funded initiative, initially funded in early FY 2007. In May 2008, VA began 

the training rollout for all mental health professionals. 

Question 10(b): On average, over the last 5 years, how many visits with a psychiatrist, psychologist or counselor could a veteran expect over the course of one 

year, and what is the average length of each visit? 

Response: The following table provides summary data of veterans who received 

mental health services in an outpatient mental health program from FY 2003 

through FY 2007: 

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Veterans with a MH Dx* seen as an Outpatient by Fiscal Year 

FY 

Veterans with a MH 

Dx Seen by 

MH Provider 

Total Outpatient 

Encounters with MH 

Provider for 

Veterans with 

MH Dx 

Avg Number of 

Outpatient 

Encounters with 

MH Provider for 

Veterans Seen by 

MH Provider 

FY03 708,882 7,345,328 10.4 

FY04 771,235 7,514,644 9.7 

FY05 831,890 7,914,211 9.5 

FY06 878,246 8,489,263 9.7 

FY07 944,969 9,387,070 9.9 

*Outpatient Diagnoses 290.x-319.x excluding Tobacco Use 305.1x 

Data provided by VSSC on June 23, 2008 using VA Outpatient Workload and Enrollment Data. Fee data not included. Veterans Only. 

The duration and intensity of treatment varies depending on the acuity level of 

the veteran. Typically in the early stages of recovery veterans are seen more frequently for both medication management and psychotherapy. As the veteran progresses and becomes more stable, the frequency and duration of treatment decreases. The duration of medication management sessions range from 15—60 minutes. Most psychotherapy sessions are 60 minutes but they also can be 30 minute 

brief treatment sessions, or they may be up to 90 minutes for some sessions of PE 

therapy for PTSD. Group therapy sessions tend to be 60 minutes. 

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ATTACHMENT TO QUESTION 5 

VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01 

(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis) 

Uniques with 

PTSD and/or 

Adj Disorder 

Uniques with 

PTSD 

Dx 

Uniques with PTSD 

Dx Only (w/o Adj 

Disorder Dx) 

Uniques with 

Adj Disorders 

Dx 

Uniques with Adj 

Disorders Dx Only 

(w/o PTSD Dx) 

Uniques with PTSD 

Dx and Adj 

Disorder Dx 

N % of Total N % of Total N % of Total N % of Total N % of Total 

VHA 257,332 193,954 75.4% 180,006 70.0% 77,326 30.0% 63,378 24.6% 13,948 5.4% (V01) (402) Togus, ME 2,494 2,132 85.5% 1,978 79.3% 516 20.7% 362 14.5% 154 6.2% (V01) (405) White River Junction, VT 1,426 1,114 78.1% 1,055 74.0% 371 26.0% 312 21.9% 59 4.1% (V01) (518) Bedford, MA 1,155 917 79.4% 829 71.8% 326 28.2% 238 20.6% 88 7.6% (V01) (523) VA Boston HCS, MA 6,655 4,435 66.6% 3,957 59.5% 2,698 40.5% 2,220 33.4% 478 7.2% (V01) (608) Manchester, NH 1,206 1,013 84.0% 964 79.9% 242 20.1% 193 16.0% 49 4.1% (V01) (631) Northampton, MA 1,442 1,236 85.7% 1,183 82.0% 259 18.0% 206 14.3% 53 3.7% (V01) (650) Providence, RI 1,952 1,729 88.6% 1,687 86.4% 265 13.6% 223 11.4% 42 2.2% (V01) (689) VA Connecticut HCS, CT 2,444 2,062 84.4% 1,983 81.1% 461 18.9% 382 15.6% 79 3.2% (V02) (528) Albany, NY 2,535 1,951 77.0% 1,730 68.2% 805 31.8% 584 23.0% 221 8.7% (V02) (528) Bath, NY 852 648 76.1% 595 69.8% 257 30.2% 204 23.9% 53 6.2% (V02) (528) Buffalo, NY 2,396 1,648 68.8% 1,532 63.9% 864 36.1% 748 31.2% 116 4.8% (V02) (528) Canandaigua, NY 1,227 995 81.1% 946 77.1% 281 22.9% 232 18.9% 49 4.0% (V02) (528) Syracuse, NY 1,698 1,209 71.2% 1,112 65.5% 586 34.5% 489 28.8% 97 5.7% (V03) (526) Bronx, NY 1,090 850 78.0% 812 74.5% 278 25.5% 240 22.0% 38 3.5% (V03) (561) New Jersey HCS, NJ 3,344 2,848 85.2% 2,739 81.9% 605 18.1% 496 14.8% 109 3.3% 

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(V03) (620) VA Hudson Valley HCS, NY 1,536 1,369 89.1% 1,213 79.0% 323 21.0% 167 10.9% 156 10.2% (V03) (630) New York Harbor HCS, NY 4,879 3,327 68.2% 2,959 60.6% 1,920 39.4% 1,552 31.8% 368 7.5% (V03) (632) Northport, NY 1,794 1,375 76.6% 1,281 71.4% 513 28.6% 419 23.4% 94 5.2% (V04) (460) Wilmington, DE 988 717 72.6% 664 67.2% 324 32.8% 271 27.4% 53 5.4% (V04) (503) Altoona, PA 503 329 65.4% 313 62.2% 190 37.8% 174 34.6% 16 3.2% (V04) (529) Butler, PA 407 249 61.2% 236 58.0% 171 42.0% 158 38.8% 13 3.2% (V04) (540) Clarksburg, WV 1,652 1,452 87.9% 1,342 81.2% 310 18.8% 200 12.1% 110 6.7% (V04) (542) Coatesville, PA 2,735 1,655 60.5% 1,444 52.8% 1,291 47.2% 1,080 39.5% 211 7.7% (V04) (562) Erie, PA 513 354 69.0% 324 63.2% 189 36.8% 159 31.0% 30 5.8% (V04) (595) Lebanon, PA 1,540 1,000 64.9% 891 57.9% 649 42.1% 540 35.1% 109 7.1% (V04) (642) Philadelphia, PA 2,996 2,711 90.5% 2,604 86.9% 392 13.1% 285 9.5% 107 3.6% (V04) (646) Pittsburgh, PA 2,337 1,985 84.9% 1,863 79.7% 474 20.3% 352 15.1% 122 5.2% (V04) (693) Wilkes-Barre, PA 1,628 1,120 68.8% 1,063 65.3% 565 34.7% 508 31.2% 57 3.5% (V05) (512) Baltimore HCS, MD 2,925 1,651 56.4% 1,436 49.1% 1,489 50.9% 1,274 43.6% 215 7.4% (V05) (613) Martinsburg, WV 1,972 1,476 74.8% 1,320 66.9% 652 33.1% 496 25.2% 156 7.9% (V05) (688) Washington, DC 2,226 1,905 85.6% 1,765 79.3% 461 20.7% 321 14.4% 140 6.3% (V06) (517) Beckley, WV 961 765 79.6% 733 76.3% 228 23.7% 196 20.4% 32 3.3% (V06) (558) Durham, NC 2,411 2,105 87.3% 2,027 84.1% 384 15.9% 306 12.7% 78 3.2% (V06) (565) Fayetteville, NC 1,246 1,041 83.5% 1,011 81.1% 235 18.9% 205 16.5% 30 2.4% (V06) (590) Hampton, VA 1,703 1,500 88.1% 1,441 84.6% 262 15.4% 203 11.9% 59 3.5% (V06) (637) Asheville, NC 1,680 1,482 88.2% 1,397 83.2% 283 16.8% 198 11.8% 85 5.1% (V06) (652) Richmond, VA 1,321 948 71.8% 890 67.4% 431 32.6% 373 28.2% 58 4.4% (V06) (658) Salem, VA 1,521 1,282 84.3% 1,210 79.6% 311 20.4% 239 15.7% 72 4.7% 

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VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01—Continued 

(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis) 

Uniques with 

PTSD and/or 

Adj Disorder 

Uniques with 

PTSD 

Dx 

Uniques with PTSD 

Dx Only (w/o Adj 

Disorder Dx) 

Uniques with 

Adj Disorders 

Dx 

Uniques with Adj 

Disorders Dx Only 

(w/o PTSD Dx) 

Uniques with PTSD 

Dx and Adj 

Disorder Dx 

N % of Total N % of Total N % of Total N % of Total N % of Total 

(V06) (659) Salisbury, NC 2,696 2,090 77.5% 1,964 72.8% 732 27.2% 606 22.5% 126 4.7% (V07) (508) Decatur, GA 2,895 2,700 93.3% 2,616 90.4% 279 9.6% 195 6.7% 84 2.9% (V07) (509) Augusta, GA 1,856 1,606 86.5% 1,562 84.2% 294 15.8% 250 13.5% 44 2.4% (V07) (521) Birmingham, AL 2,310 2,001 86.6% 1,864 80.7% 446 19.3% 309 13.4% 137 5.9% (V07) (534) Charleston, SC 1,403 1,166 83.1% 1,131 80.6% 272 19.4% 237 16.9% 35 2.5% (V07) (544) Columbia, SC 3,707 2,611 70.4% 2,302 62.1% 1,405 37.9% 1,096 29.6% 309 8.3% (V07) (557) Dublin, GA 1,456 1,276 87.6% 1,163 79.9% 293 20.1% 180 12.4% 113 7.8% (V07) (619) Montgomery-West, AL 2,046 1,773 86.7% 1,695 82.8% 351 17.2% 273 13.3% 78 3.8% (V07) (679) Tuscaloosa, AL 1,814 1,718 94.7% 1,676 92.4% 138 7.6% 96 5.3% 42 2.3% (V08) (516) Bay Pines, FL 4,285 2,950 68.8% 2,775 64.8% 1,510 35.2% 1,335 31.2% 175 4.1% (V08) (546) Miami, FL 3,024 2,051 67.8% 1,937 64.1% 1,087 35.9% 973 32.2% 114 3.8% (V08) (548) West Palm Beach, FL 2,191 1,652 75.4% 1,558 71.1% 633 28.9% 539 24.6% 94 4.3% (V08) (573) Gainesville, FL 4,897 3,470 70.9% 3,181 65.0% 1,716 35.0% 1,427 29.1% 289 5.9% (V08) (672) San Juan, PR 1,969 976 49.6% 929 47.2% 1,040 52.8% 993 50.4% 47 2.4% (V08) (673) Tampa, FL 6,006 3,791 63.1% 3,398 56.6% 2,608 43.4% 2,215 36.9% 393 6.5% (V09) (581) Huntington, WV 1,806 1,623 89.9% 1,594 88.3% 212 11.7% 183 10.1% 29 1.6% (V09) (596) Lexington, KY 1,788 1,482 82.9% 1,382 77.3% 406 22.7% 306 17.1% 100 5.6% 

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(V09) (603) Louisville, KY 1,857 1,017 54.8% 866 46.6% 991 53.4% 840 45.2% 151 8.1% (V09) (614) Memphis, TN 1,588 1,073 67.6% 935 58.9% 653 41.1% 515 32.4% 138 8.7% (V09) (621) Mountain Home, TN 2,154 1,658 77.0% 1,580 73.4% 574 26.6% 496 23.0% 78 3.6% (V09) (626) Middle Tennessee HCS, TN 3,466 2,656 76.6% 2,502 72.2% 964 27.8% 810 23.4% 154 4.4% (V10) (538) Chillicothe, OH 1,612 1,173 72.8% 1,031 64.0% 581 36.0% 439 27.2% 142 8.8% (V10) (539) Cincinnati, OH 2,006 1,586 79.1% 1,422 70.9% 584 29.1% 420 20.9% 164 8.2% (V10) (541) Cleveland—Wade Park, OH 4,347 2,752 63.3% 2,452 56.4% 1,895 43.6% 1,595 36.7% 300 6.9% (V10) (552) Dayton, OH 1,776 1,206 67.9% 1,087 61.2% 689 38.8% 570 32.1% 119 6.7% (V10) (757) Columbus, OH 937 601 64.1% 565 60.3% 372 39.7% 336 35.9% 36 3.8% (V11) (506) Ann Arbor, MI 885 689 77.9% 659 74.5% 226 25.5% 196 22.1% 30 3.4% (V11) (515) Battle Creek, MI 1,983 1,506 75.9% 1,371 69.1% 612 30.9% 477 24.1% 135 6.8% (V11) (550) Danville, IL 2,108 960 45.5% 837 39.7% 1,271 60.3% 1,148 54.5% 123 5.8% (V11) (553) Detroit, MI 1,225 738 60.2% 661 54.0% 564 46.0% 487 39.8% 77 6.3% (V11) (583) Indianapolis, IN 1,247 751 60.2% 667 53.5% 580 46.5% 496 39.8% 84 6.7% (V11) (610) Northern Indiana HCS, IN 981 675 68.8% 651 66.4% 330 33.6% 306 31.2% 24 2.4% (V11) (655) Saginaw, MI 723 526 72.8% 491 67.9% 232 32.1% 197 27.2% 35 4.8% (V12) (537) Jesse Brown VAMC (Chicago), IL 2,938 1,750 59.6% 1,589 54.1% 1,349 45.9% 1,188 40.4% 161 5.5% (V12) (556) North Chicago, IL 1,300 872 67.1% 759 58.4% 541 41.6% 428 32.9% 113 8.7% (V12) (578) Hines, IL 1,219 858 70.4% 807 66.2% 412 33.8% 361 29.6% 51 4.2% (V12) (585) Iron Mountain, MI 388 350 90.2% 344 88.7% 44 11.3% 38 9.8% 6 1.5% (V12) (607) Madison, VVI 863 702 81.3% 668 77.4% 195 22.6% 161 18.7% 34 3.9% (V12) (676) Tomah, VVI 917 815 88.9% 786 85.7% 131 14.3% 102 11.1% 29 3.2% 

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VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01—Continued 

(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis) 

Uniques with 

PTSD and/or 

Adj Disorder 

Uniques with 

PTSD 

Dx 

Uniques with PTSD 

Dx Only (w/o Adj 

Disorder Dx) 

Uniques with 

Adj Disorders 

Dx 

Uniques with Adj 

Disorders Dx Only 

(w/o PTSD Dx) 

Uniques with PTSD 

Dx and Adj 

Disorder Dx 

N % of Total N % of Total N % of Total N % of Total N % of Total 

(V12) (695) Milwaukee, WI 1,756 1,267 72.2% 1,121 63.8% 635 36.2% 489 27.8% 146 8.3% (V15) (589) Columbia, MO 1,025 805 78.5% 755 73.7% 270 26.3% 220 21.5% 50 4.9% (V15) (589) Eastern KS HCS, KS 2,510 1,795 71.5% 1,473 58.7% 1,037 41.3% 715 28.5% 322 12.8% (V15) (589) Kansas City, MO 1,804 1,161 64.4% 1,026 56.9% 778 43.1% 643 35.6% 135 7.5% (V15) (589) Wichita, KS 880 752 85.5% 730 83.0% 150 17.0% 128 14.5% 22 2.5% (V15) (657) Marion, IL 1,254 1,075 85.7% 1,047 83.5% 207 16.5% 179 14.3% 28 2.2% (V15) (657) Poplar Bluff, MO 1,074 858 79.9% 825 76.8% 249 23.2% 216 20.1% 33 3.1% (V15) (657) SI. Louis, MO 2,074 1,374 66.2% 1,307 63.0% 767 37.0% 700 33.8% 67 3.2% (V16) (502) Alexandria, LA 775 628 81.0% 592 76.4% 183 23.6% 147 19.0% 36 4.6% (V16) (520) Biloxi, MS 3,776 2,812 74.5% 2,599 68.8% 1,177 31.2% 964 25.5% 213 5.6% (V16) (564) Fayetteville, AR 1,693 1,474 87.1% 1,384 81.7% 309 18.3% 219 12.9% 90 5.3% (V16) (580) Houston, TX 2,524 2,187 86.6% 2,114 83.8% 410 16.2% 337 13.4% 73 2.9% (V16) (586) Jackson, MS 1,120 810 72.3% 786 70.2% 334 29.8% 310 27.7% 24 2.1% (V16) (598) Little Rock, AR 3,549 2,279 64.2% 2,032 57.3% 1,517 42.7% 1,270 35.8% 247 7.0% (V16) (623) Muskogee, OK 1,784 1,547 86.7% 1,515 84.9% 269 15.1% 237 13.3% 32 1.8% (V16) (629) New Orleans, LA 2,961 2,774 93.7% 2,743 92.6% 218 7.4% 187 6.3% 31 1.0% (V16) (635) Oklahoma City, OK 2,619 2,055 78.5% 1,904 72.7% 715 27.3% 564 21.5% 151 5.8% 

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(V16) (667) Shreveport, LA 2,205 1,294 58.7% 1,108 50.2% 1,097 49.8% 911 41.3% 186 8.4% (V17) (549) Dallas, TX 4,653 3,197 68.7% 2,953 63.5% 1,700 36.5% 1,456 31.3% 244 5.2% (V17) (671) San Antonio, TX 4,448 3,612 81.2% 3,383 76.1% 1,065 23.9% 836 18.8% 229 5.1% (V17) (674) Temple, TX 2,885 2,433 84.3% 2,356 81.7% 529 18.3% 452 15.7% 77 2.7% (V18) (501) Albuquerque, NM 4,263 3,169 74.3% 2,909 68.2% 1,354 31.8% 1,094 25.7% 260 6.1% (V18) (504) Amarillo, TX 832 707 85.0% 696 83.7% 136 16.3% 125 15.0% 11 1.3% (V18) (519) Big Spring, TX 527 486 92.2% 479 90.9% 48 9.1% 41 7.8% 7 1.3% (V18) (644) Phoenix, AZ 3,789 2,552 67.4% 2,302 60.8% 1,487 39.2% 1,237 32.6% 250 6.6% (V18) (649) Northern Arizona HCS 1,220 716 58.7% 601 49.3% 619 50.7% 504 41.3% 115 9.4% (V18) (678) Tucson, AZ 1,825 1,282 70.2% 1,233 67.6% 592 32.4% 543 29.8% 49 2.7% (V18) (756) EI Paso, TX 1,179 953 80.8% 898 76.2% 281 23.8% 226 19.2% 55 4.7% (V19) (436) Fort Harrison, MT 1,085 921 84.9% 895 82.5% 190 17.5% 164 15.1% 26 2.4% (V19) (442) Cheyenne, WY 688 561 81.5% 546 79.4% 142 20.6% 127 18.5% 15 2.2% (V19) (554) Denver, CO 3,536 3,076 87.0% 2,919 82.6% 617 17.4% 460 13.0% 157 4.4% (V19) (575) Grand Junction, CO 773 421 54.5% 347 44.9% 426 55.1% 352 45.5% 74 9.6% (V19) (660) Salt Lake City, UT 1,621 1,424 87.8% 1,365 84.2% 256 15.8% 197 12.2% 59 3.6% (V19) (666) Sheridan, WY 543 447 82.3% 414 76.2% 129 23.8% 96 17.7% 33 6.1% (V20) (463) Anchorage, AK 684 538 78.7% 522 76.3% 162 23.7% 146 21.3% 16 2.3% (V20) (531) Boise, ID 1,065 1,027 96.4% 1,022 96.0% 43 4.0% 38 3.6% 5 0.5% (V20) (648) Portland, OR 4,225 3,604 85.3% 3,357 79.5% 868 20.5% 621 14.7% 247 5.8% (V20) (653) Roseburg, OR 1,851 1,592 86.0% 1,525 82.4% 326 17.6% 259 14.0% 67 3.6% (V20) (663) VA Puget Sound, WA 6,081 5,465 89.9% 5,221 85.9% 860 14.1% 616 10.1% 244 4.0% 

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VA Uniques with a Record Diagnosis of PTSD and/or Adjustment Disorder in FY01—Continued 

(includes inpatient and outpatient services provided within VA with a primary or secondary diagnosis) 

Uniques with 

PTSD and/or 

Adj Disorder 

Uniques with 

PTSD 

Dx 

Uniques with PTSD 

Dx Only (w/o Adj 

Disorder Dx) 

Uniques with 

Adj Disorders 

Dx 

Uniques with Adj 

Disorders Dx Only 

(w/o PTSD Dx) 

Uniques with PTSD 

Dx and Adj 

Disorder Dx 

N % of Total N % of Total N % of Total N % of Total N % of Total 

(V20) (668) Spokane, WA 1,281 1,132 88.4% 1,099 85.8% 182 14.2% 149 11.6% 33 2.6% (V20) (687) Walla Walla, WA 903 698 77.3% 631 69.9% 272 30.1% 205 22.7% 67 7.4% (V20) (692) White City, OR 812 749 92.2% 730 89.9% 82 10.1% 63 7.8% 19 2.3% (V21) (358) Manila, PI 192 189 98.4% 187 97.4% 5 2.6% 3 1.6% 2 1.0% (V21) (459) Honolulu, HI 1,515 1,331 87.9% 1,221 80.6% 294 19.4% 184 12.1% 110 7.3% (V21) (570) Fresno, CA 1,366 894 65.4% 812 59.4% 554 40.6% 472 34.6% 82 6.0% (V21) (612) N. California, CA 4,272 3,706 86.8% 3,481 81.5% 791 18.5% 566 13.2% 225 5.3% (V21) (640) Palo Alto, CA 3,247 2,580 79.5% 2,319 71.4% 928 28.6% 667 20.5% 261 8.0% (V21) (654) Reno, NV 1,114 728 65.4% 670 60.1% 444 39.9% 386 34.6% 58 5.2% (V21) (662) San Francisco, CA 2,592 2,014 77.7% 1,874 72.3% 718 27.7% 578 22.3% 140 5.4% (V22) (593) Las Vegas, NV 2,206 1,504 68.2% 1,350 61.2% 856 38.8% 702 31.8% 154 7.0% (V22) (600) Long Beach, CA 1,599 857 53.6% 762 47.7% 837 52.3% 742 46.4% 95 5.9% (V22) (605) Lorna Linda, CA 2,146 1,912 89.1% 1,837 85.6% 309 14.4% 234 10.9% 75 3.5% (V22) (664) San Diego, CA 2,050 1,846 90.0% 1,815 88.5% 235 11.5% 204 10.0% 31 1.5% (V22) (691) West Los Angeles, CA 5,877 3,940 67.0% 3,407 58.0% 2,470 42.0% 1,937 33.0% 533 9.1% (V23) (437) Fargo, ND 434 341 78.6% 332 76.5% 102 23.5% 93 21.4% 9 2.1% (V23) (438) Sioux Falls, SD 632 462 73.1% 445 70.4% 187 29.6% 170 26.9% 17 2.7% 

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(V23) (568) Black Hills HCS, SD 1,007 718 71.3% 650 64.5% 357 35.5% 289 28.7% 68 6.8% (V23) (618) Minneapolis, MN 2,415 1,806 74.8% 1,727 71.5% 688 28.5% 609 25.2% 79 3.3% (V23) (636) Central Iowa, IA 1,026 551 53.7% 468 45.6% 558 54.4% 475 46.3% 83 8.1% (V23) (636) Iowa City, IA 1,057 662 62.6% 629 59.5% 428 40.5% 395 37.4% 33 3.1% (V23) (636) Nebraska-W Iowa, NE 1,322 979 74.1% 949 71.8% 373 28.2% 343 25.9% 30 2.3% (V23) (656) St. Cloud, MN 1,616 1,339 82.9% 1,213 75.1% 403 24.9% 277 17.1% 126 7.8% 

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ATTACHMENT TO QUESTION 6(B) 

September 18, 2007 VA Handbook 6500 

Appendix G 

Department of Veterans Affairs (VA) National Rules of Behavior 

1. Background 

a. Section 5723(b)(12) of title 38, United States Code, requires the Assistant 

Secretary for Information and Technology to establish ‘‘VA National Rules 

of Behavior for appropriate use and protection of the information which is 

used to support Department’s missions and functions.’’ The Office of Management and Budget (OMB) Circular A–130, Appendix III, paragraph 

3(a(2)(a) requires that all Federal agencies promulgate rules of behavior 

that ‘‘clearly delineate responsibilities and expected behavior of all individuals with access’’ to the agencies’ information and information systems, as 

well as state clearly the ‘‘consequences of behavior not consistent’’ with the 

rules of behavior. The National Rules of Behavior that begin on page 

G–3, are required to be used throughout the VA. b. Congress and OMB require the promulgation of national rules of behavior 

for two reasons. First, Congress and OMB recognize that knowledgeable 

users are the foundation of a successful security program. Users must understand that taking personal responsibility for the security of their computer and the VA data that it contains or that may be accessed through it, 

as well as the security and protection of VA information in any form (e.g. 

digital, paper), are essential aspects of their job. Second, individuals must 

be held accountable for their use of VA information and information systems. 

c. VA must achieve the Gold Standard in data security which requires that VA 

information and information system users protect VA information and information systems, especially the personal data of veterans, their family members, and employees. Users must maintain a heightened and constant 

awareness of their responsibilities regarding the protection of VA information. The Golden Rule with respect to this aspect of an employee’s job is to 

treat the personal information of others the same as they would their own. 

d. Since written guidance cannot cover every contingency, personnel are asked 

to go beyond the stated rules, using ‘‘due diligence’’ and highest ethical 

standards to guide their actions. Personnel must understand that these 

rules are based on Federal laws, regulations, and VA Directives. 

2. Coverage 

a. The attached VA National Rules of Behavior must be signed annually by all 

VA employees who are provided access to VA information or VA information 

systems. The term VA employees includes all individuals who are employees 

under title 5 or title 38, United States Code, as well as individuals whom 

the Department considers employees such as volunteers, without compensation employees, and students and other trainees. Directions for signing the 

rules of behavior by other individuals who have access to VA information 

or information systems, such as contractor employees, will be addressed in 

subsequent policy. VA employees must initial and date each page of the copy 

of the VA National Rules of Behavior; they must also provide the information requested on the last page, sign and date it. 

b. The VA National Rules of Behavior address notice and consent issues identified by the Department of Justice and other sources. It also serves to clarify 

the roles of management and system administrators, and serves to provide 

notice of what is considered acceptable use of all VA information and information systems, VA sensitive information, and behavior of VA users. 

c. The VA National Rules of Behavior use the phrase ‘‘VA sensitive information’’. This phrase is defined in VA Directive 6500, paragraph 5q. This definition covers all information as defined in 38 USC 5727(19), and in 38 USC 

5727(23). The phrase ‘‘VA sensitive information’’ as used in the attached VA 

National Rules of Behavior means: 

All Department data, on any storage media or in any form or format, 

which requires protection due to the risk of harm that could result from 

inadvertent or deliberate disclosure, alteration, or destruction of the information. The term includes information whose improper use or disclosure could adversely affect the ability of an agency to accomplish its 

mission, proprietary information, records about individuals requiring 

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protection under various confidentiality provisions such as the Privacy 

Act and the HIPAA Privacy Rule, and information that can be withheld 

under the Freedom of Information Act. Examples of VA sensitive information include the following: individually identifiable medical, benefits, 

and personnel information, financial, budgetary, research, quality assurance, confidential commercial, critical infrastructure, investigatory, 

and law enforcement information, information that is confidential and 

privileged in litigation such as information protected by the deliberative 

process privilege, attorney work-product privilege, and the attorney-client privilege, and other information which, if released, could result in 

violation of law or harm or unfairness to any individual or group, or 

could adversely affect the national interest or the conduct of Federal 

programs. 

d. The phrase ‘‘VA sensitive information’’ includes information entrusted to the 

Department. 

3. Rules of Behavior 

a. Immediately following this section is the VA approved National Rules of Behavior that all employees (as discussed in paragraph 2a of Appendix G) who 

are provided access to VA information and VA information systems are required to sign in order to obtain access to VA information and information 

systems. 

Department of Veterans Affairs (VA) National Rules of Behavior 

I understand, accept, and agree to the following terms and conditions that apply 

to my access to, and use of, information, including VA sensitive information, or information systems of the U.S. Department of Veterans Affairs. 

1. GENERAL RULES OF BEHAVIOR 

a. I understand that when I use any government information system, I have 

NO expectation of Privacy in VA records that I create or in my activities 

while accessing or using such information system. 

b. I understand that authorized VA personnel may review my conduct or actions concerning VA information and information systems, and take appropriate action. Authorized VA personnel include my supervisory chain of command as well as VA system administrators and Information Security Officers (ISOs). Appropriate action may include monitoring, recording, copying, 

inspecting, restricting access, blocking, tracking, and disclosing information 

to authorized Office of Inspector General (OIG), VA, and law enforcement 

personnel. 

c. I understand that the following actions are prohibited: unauthorized access, 

unauthorized uploading, unauthorized downloading, unauthorized changing, 

unauthorized circumventing, or unauthorized deleting information on VA 

systems, modifying VA systems, unauthorized denying or granting access to 

VA systems, using VA resources for unauthorized use on VA systems, or 

otherwise misusing VA systems or resources. I also understand that attempting to engage in any of these unauthorized actions is also prohibited. 

d. I understand that such unauthorized attempts or acts may result in disciplinary or other adverse action, as well as criminal, civil, and/or administrative 

penalties. Depending on the severity of the violation, disciplinary or adverse 

action consequences may include: suspension of access privileges, reprimand, suspension from work, demotion, or removal. Theft, conversion, or 

unauthorized disposal or destruction of Federal property or information may 

also result in criminal sanctions. 

e. I understand that I have a responsibility to report suspected or identified 

information security incidents (security and privacy) to my Operating Unit’s 

Information Security Officer (ISO), Privacy Officer (PO), and my supervisor 

as appropriate. 

f. I understand that I have a duty to report information about actual or possible criminal violations involving VA programs, operations, facilities, contracts or information systems to my supervisor, any management official or 

directly to the OIG, including reporting to the OIG Hotline. I also understand that I have a duty to immediately report to the OIG any possible 

criminal matters involving felonies, including crimes involving information 

systems. 

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g. I understand that the VA National Rules of Behavior do not and should not 

be relied upon to create any other right or benefit, substantive or procedural, enforceable by law, by a party to litigation with the United States 

Government. 

h. I understand that the VA National Rules of Behavior do not supersede any 

local policies that provide higher levels of protection to VA’s information or 

information systems. The VA National Rules of Behavior provide the minimal rules with which individual users must comply. 

i. I understand that if I refuse to sign this VA National Rules of Behavior as required by VA policy, I will be denied access to VA information and information systems. Any refusal to sign the VA National Rules of Behavior may have an adverse impact on my employment with the Department. 

2. SPECIFIC RULES OF BEHAVIOR 

a. I will follow established procedures for requesting access to any VA computer system and for notification to the VA supervisor and the ISO when 

the access is no longer needed. 

b. I will follow established VA information security and privacy policies and 

procedures. 

c. I will use only devices, systems, software, and data which I am authorized 

to use, including complying with any software licensing or copyright restrictions. This includes downloads of software offered as free trials, shareware 

or public domain. 

d. I will only use my access for authorized and official duties, and to only access data that is needed in the fulfillment of my duties except as provided 

for in VA Directive 6001, Limited Personal Use of Government Office Equipment Including Information Technology. I also agree that I will not engage 

in any activities prohibited as stated in section 2c of VA Directive 6001. 

e. I will secure VA sensitive information in all areas (at work and remotely) 

and in any form (e.g. digital, paper etc.), to include mobile media and devices that contain sensitive information, and I will follow the mandate that 

all VA sensitive information must be in a protected environment at all times 

or it must be encrypted (using FIPS 140–2 approved encryption). If clarification is needed whether or not an environment is adequately protected, I will 

follow the guidance of the local Chief Information Officer (CIO). 

f. I will properly dispose of VA sensitive information, either in hardcopy, 

softcopy or electronic format, in accordance with VA policy and procedures. 

g. I will not attempt to override, circumvent or disable operational, technical, 

or management security controls unless expressly directed to do so in writing by authorized VA staff. 

h. I will not attempt to alter the security configuration of government equipment unless authorized. This includes operational, technical, or management security controls. 

i. I will protect my verify codes and passwords from unauthorized use and disclosure and ensure I utilize only passwords that meet the VA minimum requirements for the systems that I am authorized to use and are contained 

in Appendix F of VA Handbook 6500. 

j. I will not store any passwords/verify codes in any type of script file or cache 

on VA systems. 

k. I will ensure that I log off or lock any computer or console before walking 

away and will not allow another user to access that computer or console 

while I am logged on to it. 

l. I will not misrepresent, obscure, suppress, or replace a user’s identity on the 

Internet or any VA electronic communication system. 

m. I will not auto-forward e-mail messages to addresses outside the VA network. 

n. I will comply with any directions from my supervisors, VA system administrators and information security officers concerning my access to, and use 

of, VA information and information systems or matters covered by these 

Rules. 

o. I will ensure that any devices that I use to transmit, access, and store VA 

sensitive information outside of a VA protected environment will use FIPS 

140–2 approved encryption (the translation of data into a form that is unintelligible without a deciphering mechanism). This includes laptops, thumb 

drives, and other removable storage devices and storage media (CDs, DVDs, 

etc.). 

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p. I will obtain the approval of appropriate management officials before releasing VA information for public dissemination. 

q. I will not host, set up, administer, or operate any type of Internet server 

on any VA network or attempt to connect any personal equipment to a VA 

network unless explicitly authorized in writing by my local CIO and I will 

ensure that all such activity is in compliance with Federal and VA policies. 

r. I will not attempt to probe computer systems to exploit system controls or 

access VA sensitive data for any reason other than in the performance of 

official duties. Authorized penetration testing must be approved in writing 

by the VA CIO. 

s. I will protect Government property from theft, loss, destruction, or misuse. 

I will follow VA policies and procedures for handling Federal Government 

IT equipment and will sign for items provided to me for my exclusive use 

and return them when no longer required for VA activities. 

t. I will only use virus protection software, anti-spyware, and firewall/intrusion detection software authorized by the VA on VA equipment or on computer systems that are connected to any VA network. 

u. If authorized, by waiver, to use my own personal equipment, I must use VA 

approved virus protection software, anti-spyware, and firewall/intrusion detection software and ensure the software is configured to meet VA configuration requirements. My local CIO will confirm that the system meets VA 

configuration requirements prior to connection to VA’s network. 

v. I will never swap or surrender VA hard drives or other storage devices to 

anyone other than an authorized OI&T employee at the time of system 

problems. 

w. I will not disable or degrade software programs used by the VA that install 

security software updates to VA computer equipment, to computer equipment used to connect to VA information systems, or to create, store or use 

VA information. 

x. I agree to allow examination by authorized OI&T personnel of any personal 

IT device [Other Equipment (OE)] that I have been granted permission to 

use, whether remotely or in any setting to access VA information or information systems or to create, store or use VA information. 

y. I agree to have all equipment scanned by the appropriate facility IT Operations Service prior to connecting to the VA network if the equipment has 

not been connected to the VA network for a period of more than three 

weeks. 

z. I will complete mandatory periodic security and privacy awareness training 

within designated timeframes, and complete any additional required training for the particular systems to which I require access. 

aa. I understand that if I must sign a non-VA entity’s Rules of Behavior to obtain access to information or information systems controlled by that non-VA 

entity, I still must comply with my responsibilities under the VA National 

Rules of Behavior when accessing or using VA information or information 

systems. However, those Rules of Behavior apply to my access to or use of 

the non-VA entity’s information and information systems as a VA user. 

bb. I understand that remote access is allowed from other Federal government 

computers and systems to VA information systems, subject to the terms of 

VA and the host Federal agency’s policies. 

cc. I agree that I will directly connect to the VA network whenever possible. 

If a direct connection to the VA network is not possible, then I will use VAapproved remote access software and services. I must use VA-provided IT 

equipment for remote access when possible. I may be permitted to use nonVA IT equipment [Other Equipment (OE)] only if a VA–CIO-approved waiver has been issued and the equipment is configured to follow all VA security 

policies and requirements. I agree that VA OI&T officials may examine such 

devices, including an OE device operating under an approved waiver, at any 

time for proper configuration and unauthorized storage of VA sensitive information. 

dd. I agree that I will not have both a VA network connection and any kind of 

non-VA network connection (including a modem or phone line or wireless 

network card, etc.) physically connected to any computer at the same time 

unless the dual connection is explicitly authorized in writing by my local 

CIO. 

ee. I agree that I will not allow VA sensitive information to reside on non-VA 

systems or devices unless specifically designated and approved in advance 

by the appropriate VA official (supervisor), and a waiver has been issued by 

the VA’s CIO. I agree that I will not access, transmit or store remotely any 

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VA sensitive information that is not encrypted using VA approved 

encryption. 

ff. I will obtain my VA supervisor’s authorization, in writing, prior to transporting, transmitting, accessing, and using VA sensitive information outside 

of VA’s protected environment. 

gg. I will ensure that VA sensitive information, in any format, and devices, systems and/or software that contain such information or that I use to access 

VA sensitive information or information systems are adequately secured in 

remote locations, e.g., at home and during travel, and agree to periodic VA 

inspections of the devices, systems or software from which I conduct access 

from remote locations. I agree that if I work from a remote location pursuant to an approved telework agreement with VA sensitive information that 

authorized OI&T personnel may periodically inspect the remote location for 

compliance with required security requirements. 

hh. I will protect sensitive information from unauthorized disclosure, use, modification, or destruction, including using encryption products approved and 

provided by the VA to protect sensitive data. 

ii. I will not store or transport any VA sensitive information on any portable 

storage media or device unless it is encrypted using VA approved 

encryption. 

jj. I will use VA-provided encryption to encrypt any e-mail, including attachments to the e-mail, that contains VA sensitive information before sending 

the e-mail. I will not send any e-mail that contains VA sensitive information 

in an unencrypted form. VA sensitive information includes personally identifiable information and protected health information. 

kk. I may be required to acknowledge or sign additional specific or unique rules 

of behavior in order to access or use specific VA systems. I understand that 

those specific rules of behavior may include, but are not limited to, restrictions or prohibitions on limited personal use, special requirements for access 

or use of the data in that system, special requirements for the devices used 

to access that specific system, or special restrictions on interconnections between that system and other IT resources or systems. 

3. Acknowledgement and Acceptance 

a. I acknowledge that I have received a copy of these Rules of Behavior. 

b. I understand, accept and agree to comply with all terms and conditions of 

these Rules of Behavior. 

—————————————————— 

[Print or type your full name] 

—————————————————— 

Signature

—————————————————— 

Date 

—————————————————— 

Office Phone 

—————————————————— 

Position Title

————— 

Questions for the Record 

The Honorable Stephanie Herseth Sandlin 

Question 1: What can the VA do to address the health care needs of Guard and 

Reserve members, who account for more than half of all veterans who took their 

own lives after returning from Iraq or Afghanistan? 

Response: In order to ensure that Operation Enduring Freedom/Operation Iraqi 

Freedom (OEF/OIF) combat veterans receive high quality health care and coordinated Department of Veterans Affairs (VA) services and benefits as they transition 

from the Department of Defense (DoD) to VA, VA and the National Guard developed 

a creative partnership. Late in 2005, following the signing of a memorandum of uncprice-sewell on PROD1PC72 with HEARING

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derstanding (MOU) between the National Guard and VA, the National Guard hired 

54 (now 60) National Guard transition assistance advisors (TAA) to serve as VA/ 

National Guard liaisons in the field at the State level, assisting National Guard 

service members and their families in accessing VA benefits and services. In February 2006, the newly hired National Guard/VA TAAs were trained by VA staff 

about VA benefits and services at the Veterans Benefit Administration (VBA) Academy in Baltimore. The purpose of the training was to enhance the outreach skills 

of the TAAs by learning about VA benefits and services and to connect them with 

VA resources and staff members in the field at the VA medical centers (VAMC) and 

the regional offices (RO). This knowledge will assist them in helping Guard/Reserve 

members in obtaining VA benefits and services and address access issues in the 50 

States and 4 territories. Annual refresher training was held in January 2007 and 

2008 in conjunction with the National Guard Family Program Conference. The 

TAAs have been the critical link in facilitating access to VA by National Guard/Reserves in each of the 50 States and 4 territories (Puerto Rico, Virgin Islands, Guam 

and District of Columbia) and providing VA with critical information on numbers 

of returning troops, location, homecoming and reintegration events. TAAs also facilitate enrollment of returning troops into the Veterans Health Administration (VHA). 

The National Guard is presently expanding the TAA program with a goal of two 

TAAs for States with large number of deployed troops. The VHA OEF/OIF Outreach 

Office continues to collaboration with the 60 TAAs at monthly teleconferences, 

through quarterly newsletters, and monthly identification of success stories and best 

practices in the States. Outreach staff work with VA experts at annual training 

events to ensure they are updated on changes in VA services/benefits. TAAs facilitate the development and maintenance of State coalitions using the State Triad 

Leadership of the Adjutant General, State Director of Veterans Affairs (DVA) and 

VA to integrate and coordinate the delivery of VA services and benefits to Guard 

and Reservists in each State. Over 47 States have developed State MOUs through 

the Leadership Triad of the State Director DVA, Adjutant General and VA. These 

State partnerships are the foundation for State coalitions with participation by community and State organizations to address the coming home needs of the Guard and 

the Reserve members. 

In addition VA operates a system of over 200 community based counseling centers, known as Vet Centers, located near where veterans and their families reside. 

Vet Centers are staffed by small multi-disciplinary teams of dedicated providers, 

many of which are combat veterans themselves, providing a broad range of counseling, outreach, and referral services to OEF/OIF veterans in order to help them 

readjustment to civilian life. Services include individual counseling, group counseling, marital and family counseling, bereavement counseling, medical referrals, assistance in applying for VA benefits, employment counseling, guidance and referral. 

alcohol/drug assessments, information and referral to community resources, military 

sexual trauma counseling and referral, outreach and community education. 

On May 2, 2008 VA began contacting nearly 570,000 OEF/OIF combat veterans 

to ensure they know about VA medical services and other benefits. The Department 

will reach out and touch every veteran of the war to let them know it is here for 

them. The first of those calls are going to an estimated 17,000 veterans who were 

sick or injured while serving in Iraq or Afghanistan. If any of these 17,000 veterans 

do not now have a care manager to work with them to ensure they get appropriate 

health care, VA will offer to appoint one for them. 

Question 2: What is the VA doing, and what should the VA be doing to address 

the unique mental health care needs of younger veterans? 

Response: VA has several resources to train staff to better understand the needs 

of younger veterans and their families. These resources include: 

• My HealtheVet. Younger veterans use the Internet to obtain information and 

communicate. We have developed mental health content for My HealtheVet and 

continue to expand that content. 

• VA also has clinical programs geared to returning veterans, many of whom are 

younger, such as: 

• Serving returning veterans mental health needs teams (SeRV–MH teams) 

to address issues of younger veterans and families in clinical care. Monthly 

conference calls are held for the SeRV–MH team and include discussion of 

various issues, such as non-traditional scheduling to meet the needs of 

working or school engaged patients, and care needs of younger families. 

• Additionally, as many younger veterans are married and may have young 

children. The new Housing and Urban Development/VA supported housing 

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(HUD/VASH) voucher program offers opportunities for housing of homeless 

veterans with families. 

• The Iraq Clinician War Guide, developed by the National Center for Post Traumatic Stress Disorder (NCPTSD) in collaboration with DoD in 2004, is posted 

on the NCPTSD Web site, as well as being used in VA training sessions across 

the country. • A national conference, Evolving Paradigms in Treating Combat Veterans. Was 

developed as a joint VA/ DoD training effort in 2007. • Conferences for Veterans Integrated Service Networks (VISN) 5 and 6 staff 

were held in 2006/2007 with a focus on Family Transition Meetings. Training 

to other VISNs is being planned. • Many younger veterans have families with young children, and reintegration 

into the family after deployment to a combat zone can be stressful for the veteran’s family. We have used the Sesame Street project, ‘‘Talk, Listen, Connect’’, 

to help families of servicemembers and veterans guide their children’s adjustment to a parent who returns form Iraq or Afghanistan. Copies of the video and 

accompanying materials are currently available at all VA facilities and we will 

be disseminating additional copies to staff system-wide to train them to use this 

valuable tool. 

Question 3: What should the VA be doing to address the mental health care 

needs of veterans, especially veterans in rural or underserved areas? 

Response: The Center of Excellence at Canandaigua and the Serious Mental Illness Treatment Research and Evaluation Center (SMITREC) at Ann Arbor, Michigan are planning a study of the data from VA’s 24-hour Suicide Crisis Line to determine if there are new, emergent veteran populations at risk for suicidal behaviors. 

Both younger veterans and veterans in rural or underserved areas will be evaluated 

as part of this study as to mental health care needs of both groups VA should address. 

VA also has increased availability of mental health services in community based 

outpatient clinics (CBOC) designed to bring care closer to the veterans. As of the 

end of the first quarter of fiscal 2008, 93 percent of CBOCs reported mental health 

visits. All 21 VISNS have some form of VA/State-community collaborations including telemental health or VA staff placements in community health or mental health 

centers; Tribal or Indian Health Service clinical sites. VA’s Office of Mental Health 

Services and Office of Rural Health are collaborating to improve access to services 

for veterans in remote areas, including an increased effort at telemental health capabilities. VA has authorized facilities to arrange for fee basis and contract services 

in situations where timely services cannot be provided by existing VA facilities. 

Questions for the Record 

The Honorable John J. Hall 

Question: When a veteran gets a prescription or has to order a refill there is no 

way for a doctor to expedite the delivery of the medication which can take 10 days. 

Someone needing an anti-depressant should be able to get that sent quickly by allowing the doctor to overnight the delivery. Why can’t his be done? 

Response: At the request of a Department of Veterans Affairs (VA) prescriber, 

VA medical center pharmacy staff will make urgently needed prescription medications available to patients within 24 hours of notification, using the most appropriate means available. This requirement applies to all points of service including 

community based outpatient clinics (CBOC). 

Current practice within VA system: Newly prescribed medications are available 

immediately through VA pharmacies or through non-VA contract pharmacies serving VA CBOCs. Refills for previously filled prescriptions are primarily available 

through VA’s consolidated mail outpatient pharmacies (CMOP), or alternately 

through VA medical center pharmacies. Current CMOP prescription refill processing 

times average 5 days after the refill is requested (1 day to send data to CMOP; 1.5 

days to fill the prescription; and 2.5 days to mail/ship the package to the patient). 

Current practice outside the VA system: VA has contracts with community pharmacies to provide urgently needed outpatient CBOC prescriptions, or to provide 

medications when the VA medical center does not offer 24/7 outpatient pharmacy 

services. VA’s current contract pharmacy prescription volume is approximately 

300,000 per year. 

Ongoing Emphasis: A VHA policy Directive intended to reemphasize VA’s practice 

of providing urgently needed outpatient medications in a timely manner has been 

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approved. The new Directive was distributed to the field in May 2008. Enclosed is 

a copy of Directive 2008–028, Access to Urgently Needed Outpatient Prescription 

Medications. 

VA/DoD Partnering: VA’s requirements have been included in the Department of 

Defense’s (DoD) TRICARE retail pharmacy network (TRx) which will allow VA to 

use DoD’s 50,000 retail pharmacies to fill urgently needed outpatient prescriptions 

if a VA pharmacy is not available. It is expected that VA will be able to begin using 

the TRx retail contract sometime in late 2009. 

Vet centers refer veterans to the local VA medical centers for medical care and 

follow up of prescriptions if needed. In the mental health mental status evaluation, 

any indicators of need for medical psychiatric or primary care are automatically referred to the medical center. If the veteran is on medications and have challenges 

in getting prescriptions filled, they are referred to the local VA medical center or 

CBOC. 

Department of Veterans Affairs VHA DIRECTIVE 2008–028 

Veterans Health Administration 

Washington, DC 20420 May 16, 2008 

ACCESS TO URGENTLY NEEDED OUTPATIENT PRESCRIPTION 

MEDICATIONS 

1. PURPOSE: This Veterans Health Administration (VHA) Directive defines expectations for access to urgently needed outpatient prescription medications. 

2. BACKGROUND: 

a. Urgently needed outpatient medications are medications that, in the clinical 

judgment of the prescriber, if not taken within 24 hours of determining the 

need of those medications have the potential to result in serious patient harm. 

b. Local restrictions on the use of overnight mail or package delivery service to 

deliver urgently needed outpatient prescription medications have the potential 

to cause unnecessary hospital visits, hospitalizations and patient harm. 

3. POLICY: It is VHA policy that at the request of a VA prescriber, VA medical 

center pharmacy staff will make urgently needed outpatient prescription medications available to patients within 24 hours of notification, using the most appropriate means available. This requirement applies to all points of service including 

Community Based Outpatient Clinics. 

4. ACTION: 

a. Facility Director. The facility Director, or designee, is responsible for ensuring 

written policies are established to address the timely delivery of urgently needed outpatient prescription medications. 

b. VA Prescriber. The VA prescriber must notify the pharmacy when a new prescription or refill is urgently needed due to a change in the patient’s clinical 

condition. NOTE: If the prescriber determines that medication is needed sooner 

than 24 hours, the prescriber needs to make arrangements for the patient to receive urgent medical care or instruct the patient to contact the local emergency 

medical care system. 

c. Chief of Pharmacy. The Chief of Pharmacy must contact the patient or the patient’s representative to determine the most appropriate means to make the 

prescription available and must take all necessary steps to make the prescription available. This may include: 

1. Making the prescription available at a VA pharmacy for pick up. 

2. Providing the prescription through a non-VA pharmacy under contract to 

VA. 

3. Mailing or shipping the medication overnight via commercial or government carrier. 

THIS VHA DIRECTIVE WILL EXPIRE MAY 31, 2013 

5. REFERENCES: None. 

6. FOLLOW-UP RESPONSIBILITY: The Pharmacy Benefits Management Services office (119) is responsible for the content of this Directive. Questions may be 

referred to (202) 4617326. 

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7. RESCISSIONS: None 

Michael J. Kussman, MD, MS, MACP 

Under Secretary for Health 

DISTRIBUTION: CO: E-mailed 5/19/08 

FLD: VISN, MA, DO, OC, OCRO, and 200—E-mailed 5/19/08 

Questions for the Record 

The Honorable Shelley Berkley 

Question 1: What are we doing to follow through with a veteran after it has been 

identified that they have a mental health issue to decrease their risk of committing 

suicide? 

Response: For veterans found to be at risk for suicide, the Veterans Health Administration (VHA) supplements basic mental health services with increased monitoring and intense treatment directed toward reducing suicidality, as well as the underlying mental health problem. For a veteran identified as having a mental health 

problem, the most basic approach to decreasing the risk of suicide is to provide appropriate, evidence-based treatment for the mental health problem. To ensure veterans’ mental health needs are addressed, VHA has been enhancing the mental 

health services it provides through substantial increases in the allocation of funds, 

and has hired almost 4,000 new mental health staff members over the past 3 years. 

Between 2005 and 2007, there was a 10.3-percent increase in uniques, and a 7.6- 

percent increase in encounters. 

Question 2: How much of the Joshua Omvig Suicide Prevention Act (aside from 

the establishment of the suicide hotline) has been initiated since its enactment in 

November 2007? 

Response: The Comprehensive Program for Suicide Prevention Among Veterans 

Report (Public Law 110–110) was submitted to Congress in February 2008 and is 

attached for your review. In the report we stated that we are able to monitor risk 

and needs and respond to them under existing legal authority. Since the report was 

released the Department of Veterans Affairs (VA) has the following updated information: 

Requirement: Designation of Suicide Prevention Counselors—To support the identification of patients at high risk, the suicide prevention coordinators have been collecting information from providers, other staff, and community contacts about veterans who have survived suicide attempts. In preliminary findings, we have identified approximately 1,000 attempts per month. To address the increased needs for 

these vulnerable veterans, VA has implemented standardized approaches to enhancing care while, at the same time, encouraging innovation and creativity. 

Further developments in process at this time include tests of the coordinators 

inter-rater reliability and its sensitivity in the identification of suicide attempts. 

Both will be necessary before the number of attempts (or reattempts) in a facility 

can be used as a measure for epidemiological or quality improvement purposes. 

Requirement: Hotline—From the time the veterans’ Hotline was established in 

July, 2007 until the end of May, 2008, we received 49,544 calls. From the start of 

2008 until the end of May we received 40,165 calls, with 16,436 confirmed as coming 

from veterans and 2,543 from family members or friends. These led to 3,240 referrals to the suicide prevention coordinators at VA facilities and 909 ‘‘rescues’’ requiring emergency services. 

Attached: Report to Congress on Comprehensive Program for Suicide Prevention 

Among Veterans 

————— 

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REPORT TO CONGRESS 

PUBLIC LAW 110–110 

COMPREHENSIVE PROGRAM FOR 

SUICIDE PREVENTION AMONG VETERANS 

Department of Veterans Affairs 

February 2008 

Report to Congress on VA’s Implementation of 38 U.S.C. § 1720F, ‘‘Joshua 

Omvig Veterans Suicide Prevention Act’’ 

Issue: Implementation of section 3(b)(1) of Public Law 110–110, the ‘‘Joshua 

Omvig Veterans Suicide Prevention Act,’’ requires the Department of Veterans Affairs (VA) to submit a report to Congress not later than 90 days after November 

5, 2007, on the Department’s implementation of its comprehensive suicide prevention program, as established by 38 U.S.C. § 1720F. 

Information on the status of the implementation of the VA comprehensive 

program for suicide prevention 

Requirement: Establishment—The Secretary shall develop and carry out a comprehensive program designed to reduce the incidence of suicide among veterans incorporating the components described in this section. 

VA Response: Recommendations for suicide prevention programs within VA were 

included in the 2004 VA Comprehensive Mental Health Strategic Plan. Implementation began shortly after the plan was approved and suicide prevention programs in 

VA medical centers were accelerated in spring 2006. Ongoing activities have been 

monitored by Office of Inspector General as documented in report number 06– 

03706–126 from May 10, 2007. 

Requirement: Staff Education—In carrying out the comprehensive program under 

this section, the Secretary shall provide for mandatory training for appropriate staff 

and contractors (including all medical personnel) of the Department who interact 

with veterans. This training shall cover information appropriate to the duties being 

performed by such staff and contractors. The training shall include information on— 

(1) recognizing risk factors for suicide; (2) proper protocols for responding to crisis 

situations involving veterans who may be at high risk for suicide; and (3) best practices for suicide prevention. 

VA Response: VA held its first Suicide Prevention Awareness Day for all VA medical centers in April 2007, which included a program that focused on recognizing 

risk factors for suicide, proper protocols for responding to crisis situations involving 

veterans who may be at high risk for suicide, and best practices for suicide prevention. It held its second Suicide Prevention Awareness Day in September 2007, and 

scheduled the event during National Suicide Prevention Week. The program consisted of required training for all staff on general principles of suicide prevention, 

and the use of specific new VA resources: the national VA Suicide Prevention Hotline and the Suicide Prevention Coordinators who are located at each VA medical 

center. VA Suicide Prevention Awareness Day is now an annual event held during 

Suicide Prevention Week each September. VA has also held several regional conferences on suicide prevention attended by mental health providers, primary care 

clinicians, administrators, and a wide range of other medical center staff members. 

Additional mandatory training initiatives are being developed for fiscal year (FY) 

2008, including a Web-based curriculum with associated written materials for all 

staff with patient contact. 

A major responsibility of Suicide Prevention Coordinators is coordination of local 

training in suicide prevention. This includes providing training for both providers 

and non-clinical staff with patient contact. Suicide Prevention Coordinators also provide special training to staff members who respond to telephone calls. Additional 

education and training includes outreach to the community, with a focus on ‘‘guide’’ 

training, designed for non-clinical staff who interact with veterans to help them better understand suicide risk and to assist veterans in accessing needed services. 

Requirement: Health Assessments of Veterans—In carrying out the comprehensive 

program, the Secretary shall direct that medical staff offer mental health in their 

overall health assessment when veterans seek medical care at a Department medical 

facility (including a center established under section 1712A of this title) and make 

referrals, at the request of the veteran concerned, to appropriate counseling and treatment programs for veterans who show signs or symptoms of mental health problems. 

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VA Response: VA policy for all new Operation Enduring Freedom/Operation Iraqi 

Freedom (OEF/OIF) veterans upon their initial visit to VA medical centers or clinics 

is to screen them for depression, Post-Traumatic Stress Disorder (PTSD), and problem drinking. Screening for depression and problem drinking is required on an annual basis for all veterans, and screening for PTSD is required annually for the first 

5 years after enrollment, and every 5 years afterward. Whenever veterans screen 

positive for one of these conditions, they must receive a followup clinical evaluation 

that considers both the condition(s) related to the positive screen, and the risk of 

suicide. When this process confirms the presence of a mental disorder or suicide 

risk, veterans must be offered mental health treatment. Whenever there is a referral or request for mental health services, veterans must receive an initial evaluation 

within 24 hours. When this evaluation identifies urgent need, treatment must be 

provided immediately; otherwise, veterans must receive a full diagnostic and treatment planning evaluation and the initiation of care within 2 weeks. 

Requirement: Designation of Suicide Prevention Counselors—In carrying out the 

comprehensive program, the Secretary shall designate a suicide prevention counselor 

at each Department medical facility other than centers established under section 

1712A of this title. Each counselor shall work with local emergency rooms, police departments, mental health organizations, and veterans service organizations to engage 

in outreach to veterans and improve the coordination of mental health care to veterans. VA Response: Each VA medical center is required to appoint a full-time Suicide 

Prevention Coordinator. The primary responsibility of the Suicide Prevention Coordinator is to support the identification of patients at high risk for suicide, and to 

ensure that their monitoring and care are intensified. Other responsibilities include 

training and education, both within VA and in the community. 

Requirement: Best Practices Research—In carrying out the comprehensive program, 

the Secretary shall provide for research on best practices for suicide prevention 

among veterans. Research shall be conducted under this subsection in consultation 

with the heads of the following entities: (1) The Department of Health and Human 

Services. (2) The National Institute of Mental Health. (3) The Substance Abuse and 

Mental Health Services Administration. (4) The Centers for Disease Control and Prevention. 

VA Response: The Mental Illness Research, Education and Clinical Center 

(MIRECC) at Denver, Colorado, and the Center of Excellence in Mental Health and 

PTSD at Canandaigua, New York, focus specifically on suicide prevention. Ongoing 

studies are addressing suicide risk factors, validation of suicide ideation screening 

instruments, structure/quality of mental health care and its relationship to suicide 

prevention, and risk factors for suicide as it relates to depression. Findings from two 

major studies were presented at the House Veterans’ Affairs Committee (HVAC) 

hearing on December 12, 2007. One, conducted by VA’s Office of Environmental Epidemiology, investigated the mortality and causes of death in returning OEF/OIF 

veterans. Another, conducted by VA’s Serious Mental Illness Research Education 

and Clinical Center, studied rates of suicide, risk factors, and their local variability 

in all of those receiving health care from VA. Research under development by the 

Center of Excellence at Canandaigua, includes clinical trials on the effectiveness of 

peer support for suicide prevention, and psychological autopsy studies involving 

linkages of VA medical centers with local coroners or medical examiners. 

VA plans to support several additional research programs and activities aimed at 

reducing and preventing suicide, including new research solicitations and a periodic 

update of a literature synthesis of best practices for suicide prevention. In January 

2008, a new research solicitation was initiated seeking studies to validate screening 

instruments and to identify successful strategies and interventions for suicide prevention. 

VA has convened a new targeted working group, the Interagency Working Group 

to Inform Research on Suicide Prevention, comprised of experts from the Department of Health and Human Services, National Institute on Mental Health, Substance Abuse and Mental Health Services Administration, Centers for Disease Control and Prevention, and the Department of Defense to assess the current state of 

knowledge and their respective relevant portfolios of research in order to provide 

recommendations on specific efforts that should be undertaken by VA. 

Requirement: Sexual Trauma Research—In carrying out the comprehensive program, the Secretary shall provide for research on mental health care for veterans who 

have experienced sexual trauma while in military service. The research design shall 

include consideration of veterans of a reserve component. 

VA Response: Ongoing research supported by the Office of Research and Development that is specific to sexual trauma includes studies examining sexual violence 

and gynecologic health; screening and treatment responses; risks, outcomes, and 

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services for women; and a longitudinal study of Military Sexual Trauma; and effects 

on PTSD and Health Behavior. These studies include a wide range of subjects, including National Guard and Reserve component veterans. Male veterans are also 

targeted in a study addressing sexual assault prevalence among Gulf War veterans 

suffering from PTSD. 

Requirement: 24-Hour Mental Health Care—In carrying out the comprehensive 

program, the Secretary shall provide for mental health care availability to veterans 

on a 24-hour basis. 

VA Response: VA policy requires 24/7 mental health coverage in all VA emergency 

departments and 24-hour urgent care centers. Twenty-four hour coverage for veterans who do not have ready access to these services is facility based and may include access to local or regional call centers, or to providers covering inpatient units. 

National coverage is available for all veterans through the Suicide Prevention Hotline. 

The Veterans Health Administration is developing a uniform policy that will require each medical center or clinic that does not have an emergency department or 

24/7 urgent care center to designate one or more nearby VA or community-based 

facilities to provide 24/7 emergency mental health coverage. Elements of the policy 

already approved ensure that: (1) providers and responders to telephone calls to the 

facility make veterans aware of coverage; (2) facilities develop contracts or memoranda of understanding with the designated emergency departments to facilitate 

bidirectional communication; and (3) contracts or memoranda of understanding to 

ensure that veterans receiving care in the designated facilities are transferred back 

to VA as soon as it is medically appropriate. Elements still under development include issues related to payment for emergency services and hospitalizations. 

Requirement: Hotline—In carrying out the comprehensive program, the Secretary 

may provide for a toll-free hotline for veterans to be staffed by appropriately trained 

mental health personnel and available at all times. 

VA Response: VA has partnered with the Substance Abuse and Mental Health 

Service Administration to include services for veterans in its Suicide Prevention 

Hotline program. When calls are made to the national toll-free Suicide Prevention 

Hotline, a message states that if the caller is a United States military veteran, or 

if the call pertains to a veteran, the caller should press ‘‘1.’’ With this action, the 

veteran or person calling is immediately connected to VA’s suicide prevention call 

center at Canandaigua, which is staffed by VA mental health professionals who 

have real-time access to veterans’ electronic medical records. 

Additionally, staff members at the Veterans Benefits Administration Call Center 

have received training on managing callers with warning signs of suicide. They immediately transfer these calls to the hotline call center. 

Requirement: Outreach and Education for Veterans and Families—In carrying out 

the comprehensive program, the Secretary shall provide for outreach to and education for veterans and the families of veterans, with special emphasis on providing 

information to veterans of Operation Iraqi Freedom and Operation Enduring Freedom and the families of such veterans. Education to promote mental health shall include information designed to—(1) remove the stigma associated with mental illness; 

(2) encourage veterans to seek treatment and assistance for mental illness; (3) promote skills for coping with mental illness; and (4) help families of veterans with— 

(A) understanding issues arising from the readjustment of veterans to civilian life; 

(B) identifying signs and symptoms of mental illness; and (C) encouraging veterans 

to seek assistance for mental illness. 

VA Response: Through its Readjustment Counseling Service (Vet Centers), VA has 

hired 100 OEF/OIF peer specialists to complement its existing peer outreach program to provide education and outreach to returning veterans. Staffs from Vet Centers attend each post-deployment health reassessment to provide information about 

the availability and effectiveness of VA services. This allows Vet Centers to facilitate counseling services. Vet Centers also provide extensive outreach services to National Guard and Reserve units, and to the community to provide education about 

readjustment and related mental health issues, and the availability of care. 

VA has funded over 90 OEF/OIF teams in mental health to provide further outreach and education in VA facilities, in National Guard and Reserve units, and in 

the communities. The messages they deliver are related to destigmatizing mental 

illness, increasing knowledge of the symptoms and warning signs of mental disorders, and ensuring that veterans and families are aware that effective, high-quality mental health treatment is readily available in VA facilities. 

Other sources of information for veterans and families include the Internet (e.g., 

www.ncptsd.va.gov, the National Center for PTSD’s Web site), and numerous media 

reports. 

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Requirement: Peer Support Counseling Program—(1) In carrying out the comprehensive program, the Secretary may establish and carry out a peer support counseling program, under which veterans shall be permitted to volunteer as peer counselors—(A) to assist other veterans with issues related to mental health and readjustment; and (B) to conduct outreach to veterans and the families of veterans. (2) In 

carrying out the peer support counseling program under this subsection, the Secretary shall provide adequate training for peer counselors. 

VA Response: VA provides a number of distinct types of peer counseling in a number of different contexts. 

Vet Centers have recently hired 100 returning veterans as OEF/OIF peer specialists to provide outreach, education, and counseling to returning veterans and their 

families. These OEF/OIF veterans complement the counseling and outreach services 

provided by an even larger number of ex-veterans who serve as staff members in 

Vet Centers. The services provided by Vet Centers are based on problem-focused, 

not diagnosis-focused, care for readjustment problems. Peer counseling is a key component of the overall program. Training for the OEF/OIF peers specialists is provided through the Vet Center program. 

VA’s homeless program established the Peer Housing Location Assistance Group 

(PHLAG) program as a 2-year pilot program started in late 2006, and is located at 

six VA medical centers. The program utilizes formerly homeless veterans trained as 

peer specialists to provide assistance to homeless veterans completing residential 

treatment programs. They also assist homeless veterans to locate community housing and make a successful transition to independent living. Veterans Integrated 

Service Network 5’s (VISN) MIRECC trained the peer specialists and is evaluating 

the outcome of the pilot program. 

VA’s specialty care programs include peer support services for patients with serious mental illness. Beginning in FY 2005, 123.5 Full-time Equivalent (FTE) peer 

support technicians have been funded from mental health enhancement funds in 47 

mental health programs across 27 states. Peer Support Technicians provide a variety of peer support services under the supervision of a mental health provider in 

homeless programs, therapeutic employment programs, residential programs, and 

day programs. Peer Support Technicians assist veterans in identifying personal recovery goals and in determining necessary steps to achieve their goals; teach problem solving techniques; assist and support skills training; and help veterans locate 

VA and community resources. Having availed themselves of mental health services, 

Peer Support Technicians share their own experiences and the skills, strengths, by 

serving as positive role models to other veterans working on their own recovery from 

serious mental illness. Several states offer certification as peer support specialists. 

VA facilities have developed training and continuing education for Peer Support 

Technicians utilizing both internal VA resources, as well as non-VA training entities. Peer support technicians and their supervisors obtain additional information 

and support from monthly conference calls. Two national face-to-face training meetings have been conducted on peer support and a third conference is planned for later 

in FY 2008. 

Requirement: Other Components—In carrying out the comprehensive program, the 

Secretary may provide for other actions to reduce the incidence of suicide among veterans that the Secretary considers appropriate. 

VA Response: VA’s comprehensive program for suicide prevention must be viewed 

as a dynamic activity that will evolve over time as new information becomes available on needs, opportunities, and best practices. The two Centers of Excellence with 

their capacity for research and technical assistance (Denver and Canandaigua), the 

ongoing studies on rates and risk factors being conducted by the Office of Environmental Epidemiology and the Serious Mental Illness Research Education and Clinical Center, the hotline call center, and the Suicide Prevention Coordinators at each 

medical center, constitute a core infrastructure to support the identification of 

needs, and the development of opportunities to allow enhancement of the program 

over time. 

To allow ongoing scanning of the clinical and scientific literature, as well as activities in the field, both within VA and in community-based programs, VA has appointed a Suicide Prevention Steering Committee cochaired by the Deputy Chief Patient Care Services Officer for Mental Health and the Director of the Center of Excellence at Canandaigua and with multidisciplinary staffing from relevant VA program offices. The steering committee has been charged with identifying opportunities for program development. Additional input from outside agencies comes from 

the Interagency Working Group to Inform Research on Suicide Prevention convened 

by VA’s Office of Research and Development, and from VA’s active participation in 

the workgroup on suicide prevention of the Federal Partnership on Mental Health. 

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Information on the time line and costs for complete implementation of 

the program within 2 years. 

VA’s comprehensive program on suicide prevention, as specified in the Joshua 

Omvig Veterans Suicide Prevention Act has been completely implemented. It is a 

dynamic program that will evolve over time in response to needs and opportunities. 

The basic structures and processes required by the Act have already been established and implemented. 

Expenditures for the suicide prevention program include $.97 million for the Hotline; $1.97 million for the Center of Excellence in Canandaigua; $2.20 million for 

the Mental Illness Research, Education and Clinical Center in Denver; $90,000 for 

the Serious Mental Illness Research, Education and Clinical Center for monitoring 

of suicide rates and risk factors; and $14.32 million for Suicide Prevention Coordinators. The expenditures for suicide prevention for FY 2008 will be more than $19.55 

million. 

A plan for additional programs and activities designed to reduce the occurrence of suicide among veterans. 

VA’s comprehensive program for suicide prevention must be viewed as a dynamic 

activity that will evolve over time as new information becomes available on needs, 

opportunities, and best practices. The two Centers of Excellence with their capacity 

for research and technical assistance (Denver and Canandaigua), the ongoing studies on rates and risk factors being conducted by the Office of Environmental Epidemiology and the Serious Mental Illness Research Education and Clinical Center, the 

hotline call center, and the suicide prevention coordinators at each medical center, 

constitute a core infrastructure to support the identification of needs, and the development of opportunities to allow enhancement of the program over time. 

VA also established a Suicide Prevention Steering Committee, convened the Interagency Working Group to Inform Research on Suicide Prevention, and participates 

in the workgroup on suicide prevention of the Federal Partnership on Mental 

Health, all to support the ongoing enhancement of its comprehensive program for 

suicide prevention. 

Recommendations for further legislation or administrative action that 

the Secretary considers appropriate to improve suicide prevention programs within the Department of Veterans Affairs. 

VA is able to monitor risk and needs and respond to them under existing legal 

authority. VA does not recommend further legislative action. 

f 

Committee on Veterans’ Affairs 

Washington, DC, 

May 21, 2008 

Michael Shepherd, M.D. 

Physician, Office of Healthcare Inspections 

Office of Inspector General 

U.S. Department of Veterans Affairs 

Washington, DC 20420 

Dear Michael: 

In reference to our Full Committee hearing on ‘‘The Truth About Veterans’ Suicides’’ on May 6, 2008, I would appreciate it if you could answer the enclosed hearing questions by the close of business on July 7, 2008. 

In an effort to reduce printing costs, the Committee on Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting 

changes for materials for all full committee and subcommittee hearings. Therefore, 

it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer. 

Due to the delay in receiving mail, please provide your response to Debbie Smith 

by fax your responses at 202–225–2034. If you have any questions, please call 202– 

225–9756. 

Sincerely, 

BOB FILNER 

Chairman 

CW:ds 

————— 

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U.S. Department of Veterans Affairs 

Washington, DC 

July 2, 2008 

The Honorable Bob Filner 

Chairman 

Committee on Veterans’ Affairs 

United States House of Representatives 

Washington, DC 20515 

Dear Mr. Chairman: 

This is in response to your May 21, 2008, letter to Dr. Michael Shepherd, Senior 

Physician, Office of Healthcare Inspections, Office of Inspector General, following 

the May 6, 2008, hearing on ‘‘The Truth About Veterans’ Suicides.’’ Enclosed is Dr. 

Shepherd’s answer to the additional hearing question. 

Thank you for your interest in the Department of Veterans Affairs. 

Sincerely, 

GEORGE J. OPFER 

Inspector General 

Enclosure 

————— 

Question from the Honorable Stephanie Herseth Sandlin 

For Michael Shepherd, M.D. 

Senior Physician, Office of Healthcare Inspections 

Office of Inspector General, U.S. Department of Veterans Affairs 

Before the Committee on Veterans’ Affairs 

United States House of Representatives Hearing 

‘‘The Truth about Veterans’ Suicides’’ 

May 6, 2008 

Question: In your written statement, you indicated that there are ongoing enhancements in the availability of mental health services at community-based outpatient clinics (CBOCs) that may help mitigate vocational and logistical challenges 

facing some veterans residing in more rural areas. What are the ‘‘ongoing enhancements’’ that are taking place at CBOCs? 

Answer: Because mental health conditions may require multiple modes of therapy and in some cases multiple weekly visits, treatment for veterans residing in 

rural areas is especially challenging. Traveling long distances to appointments can 

interfere with work and academic obligations which can diminish the ability and incentive for veterans to seek or stay involved in treatment programs. VA reports having taken the following steps to expand access to mental health care, which includes 

rural areas: 

• Increasing CBOC and Outreach Clinic Program sites over the past few years. 

Outreach clinics are ‘‘part-time’’ VA clinic or contract sites that do not have 

enough patient volume to sustain full-time hours. Mental health services are 

also available at outreach sites. 

• Planning to open 44 new CBOCs and 23 new Vet Centers over the next 2 years. 

• Expanding telemental health from use in 259 CBOCs in fiscal year 2007 to 295 

CBOCs in fiscal year 2008. 

• Changing the mission of the Veterans Integrated Service Network 16 Mental 

Illness, Research, Education, and Clinical Center to focus on improving access 

to evidenced-based mental health practices in rural and other underserved populations. 

While this indicates some increase in rural VHA mental health presence, the intent of my statement was to point out the need for continued progress in this important area. 

Æ 

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