Tragic Trends: Suicide Prevention Among Veterans
Chairman Takano, Ranking Member Roe, and distinguished members of the Committee on Veterans' Affairs, on behalf of National Commander Brett Reistad and the nearly two million members of The American Legion, we thank you for the opportunity to testify on this deeply troubling issue of the growing number of suicides amongst the veteran community, and on how to prevent such tragedies. As the largest patriotic service organization in the United States with a myriad of programs supporting veterans, The American Legion appreciates the leadership of this committee in focusing on this critical issue.
The latest data on veteran suicide shows more than 6,000 veterans have died by suicide every year from 2008 to 2016, and in 2016, the suicide rate was 1.5 times greater for veterans than non-veteran adults.[1] Veteran Suicide is a national issue and far exceeds the ability of any one organization to handle alone. The American Legion stands behind the Department of Veterans Affairs (VA) in its efforts to collaborate with partners and communities nationwide.
On April 24, 2019, National Commander Brett Reistad teamed up with Dr. Keita Franklin, VA's Executive Director of Suicide Prevention, and penned a letter[2] emailed to nearly 850,000 American Legion members, family, and friends, to let them know that we are working together to adopt a public health approach to suicide prevention. The public health approach looks beyond the individual to involve peers, family members and the community in preventing suicide. Preventing veteran suicide is a top priority for VA, but they need help from dedicated partners to reach veterans outside the VA health-care system. The letter provided links to VA's National Strategy for Preventing Veteran Suicide, a toolkit that includes a guide to online suicide prevention resources, and a resource locator for contacting local VA Suicide Prevention Coordinators.
The best available information and practices should be used to support all veterans, whether or not they are engaging with VA.[3] According to the VA National Suicide Data Report 2005–2016, there are approximately 20 million veterans in the United States. Of these 20 million, only 30 percent receive services from the Veteran Health Administration (VHA).
In April of 2019, three suicides were reported at VA facilities within the span of five days. In February, the Washington Post reported that 19 suicides took place on VA campuses from October 2017 to November 2018, seven of them in parking lots. The American Legion remains deeply concerned by the substantial number of servicemembers and veterans who die by suicide, and is committed to finding solutions to help end this crisis.
One contributing factor to the increase in suicide on VA campuses may be traced to staffing shortages experienced by VA hospitals and clinics. Data released in February 15, 2019, as mandated by the VA Mission Act, reported 48,985 employment vacancies in VA. This number increased by nearly 4,000 since last reported in August 2018.[4] The high rate of employee turnover, insufficient recruitment, retention, and relocation budget, and a drawn-out hiring processes attributes to shortages in VA personnel. These factors inherently lend themselves to overworked staff, poor patient experiences, and lower quality of care.
Another area of concern is the number of potentially harmful medications like benzodiazepines and opioids currently prescribed to veterans. VA has made progress in improving opioid safety through its Opioid Safety Initiative (OIS) and state prescription drug monitoring programs (PDMP); however, room for improvement exists. A study conducted by the VA's Office of Inspector General found several factors that may have contributed to inconsistent adherence to key opioid risk mitigation strategies. These inconsistencies include: the absence of a pain champion (a primary care position required by VHA that can help providers adhere to opioid risk mitigation strategies), limited access to academic detailing, and inconsistent reviews of veteran medical records to ensure provider adherence to these strategies.[5]
Monitoring opioid prescriptions given to veterans using programs outside VA is critical to reducing the risk of veteran overdoses. The Government Accountability Office also found patients who receive opioid prescriptions from non-VA clinical settings are especially at risk. This is due to conflicting guidelines of VA facilities and non-VA facilities as it relates to opioid prescribing and monitoring. Moreover, that risk is exacerbated when information about opioid prescriptions is not shared between VA and non-VA providers.[6]
We must consider these facts as we try and understand the tragic trend of veteran suicides on the VA facilities, and work to increase the quality of mental health services provided by VA.
Efforts of The American Legion to Reduce Veteran Suicide
In a national effort to reduce veteran suicide, The American Legion established a Suicide Prevention Program (SPP) on May 9, 2018. The program is charged with examining trends of veteran suicide as it relates to traumatic brain injury, posttraumatic stress disorder (PTSD), military sexual trauma (MST), and analyzing the best practices in veteran suicide prevention not currently used by the Department of Defense (DoD) or Department of Veterans Affairs (VA). The objective of the SPP is to then encourage the aforementioned government agencies to adopt best practices not already utilized.[7]
The American Legion's TBI/PTSD Committee met on January 24, 2019, during our annual Washington Conference, and in an effort to increase collaboration with partners and communities nationwide, the committee developed a Mental Health Survey. The survey is designed to collect data that will help The American Legion bring local resources related to TBI, PTSD, and Suicide Prevention to veterans and their families. The survey is scheduled for release in May during Mental Health Awareness Month. Information collected will include current suicide prevention training taken by participants and their perceived effectiveness of that training. This data will help The American Legion determine its current suicide prevention readiness and areas of potential improvement. Data will also be collected on treatment programs for TBI and PTSD, both inside and outside of VA. The information gathered on various forms of treatment experienced by participants will aid in the development of a consolidated list of available resources for veterans. Resources will be categorized by location and vetted to ensure the treatments are evidence based and beneficial for veterans.
Within the American Legion National Headquarters in Washington, D.C., our Executive Director of Government and Veterans Affairs, created a community service policy encouraging employees to get involved with their local communities and work together to save veterans' lives. The policy allows employees additional paid time off to volunteer (40 hours per year) with a suicide prevention program of their choice. This policy encourages good citizenship by supporting local organizations that offer meaningful opportunities for civic engagement in effort to prevent veteran suicide.
In an effort to raise awareness of veteran suicide, The American Legion's Veterans Affairs & Rehabilitation Headquarters Division published a white paper report titled, "Veteran Suicide." This report describes causes, risk factors, and protective factors of veteran suicide, as well as the American Legion's concerns and recommendations regarding this tragic national issue. Publications from The American Legion's TBI/PTSD Committee titled, "The War Within," and "The Road Home," highlight the Legion's research of Post-Traumatic Stress and Traumatic Brain Injury. TBI and PTSD are serious risk factors that put veterans at an increased risk of suicide. The information[HJL1] covered in these publications includes: the symptoms and risk factors of individuals dealing with PTSD and TBI; the treatments and testimonials of those on the road to recovery, and the Resolutions passed by The American Legion in an effort to ease the suffering of these veterans. The Suicide Prevention and Crisis Response Protocol is a toolkit developed by TBI/PTSD Committee to relay the recommendations of the Committee pertaining the veteran suicide and suicide prevention. Information on suicide prevention training, suicide prevention resources, and how to market information pertaining to suicide safely, can all be found in this toolkit.
The American Legion's efforts are also evident at our local posts. Legion Post 102 in Erie, Kansas 102 is partnering with their local elected officials as part of VA's Governor's and Mayor's Challenge to prevent suicide among servicemembers, veterans, and their families. They also recognized the need to help bridge the gap between local communities and VA services, and created position called the Suicide Prevention Officer (SPO). This officer will serve as a liaison to local services for veterans in their communities. The SPO will be trained in peer-to-peer training, have close connections with local mental health providers, police departments, first responders, EMT services, schools, primary health care providers, other veteran service originations, and VA programs.
The Florida Department Chaplain is developing training for ministers and clergy on the characteristics of veterans' trauma. In addition, Legionnaires in Florida created a 2.2-mile "ruck" walk, called Challenge 22, designed to raise awareness for veteran suicide. The event's motto, 22 Until Zero, was adopted in recognition of the number of veterans that die by suicide each day. The event raised $31,000 in 2017, and $33,000 in 2018. This year's event is scheduled to take place November 16, 2019, with a goal to raise $100,000 in support of local programs for veterans with PTSD including: PROJECT VetRelief, Kine9line, Warrior Beach Retreat, Veterans Counseling Veterans, Camaraderie Foundation, and Florida 4 Warriors.
Moving Suicide Prevention to a Public Health Model
The public health approach to preventing veteran suicide has four components as defined by the Center for Disease Control (CDC). These components include population approach, primary prevention, commitment to science, and multidisciplinary strategies.[8] The public health model uses a population approach to improve health on a large scale. A population approach means focusing on prevention approaches that impact groups or populations of people, as opposed to treatment of individuals.[9] The American Legion supports the population approach component of the public health model and understands that reducing veteran suicide will involve looking beyond individuals' suffering, to those willing to support them.
Using a population approach is a proactive strategy to increase suicide prevention readiness because it draws on the power of the collective, as opposed to the reactive strategy of focusing on the individual. The first line of defense in preventing veteran suicide is the veteran's primary social circle — close friends and family. Those individuals closest to the veteran are the most likely to notice small changes in mood and behavior. They are also best equipped to approach the veteran with concerns of suicide due to their established level of trust.
The primary prevention component of the public health model focuses on preventing suicidal behavior before it occurs and addresses a broad range of risk and protective factors.[10] The American Legion supports the primary prevention component of the public health model and recognizes the importance of addressing the risks of suicide before they become critical. Individuals with knowledge of suicidal warning signs and risk factors can help curve this alarming trend. Furthermore, individuals who identify at-risk veterans, must have available resources and tools to mitigate the risk of suicide.
The commitment to science component of the public health model is centered on scientifically increasing the understanding of suicide prevention and developing new and better solutions. The American Legion's support of this component of the public health model can be found in Resolution No. 160 which states, "…The American Legion urge Congress to provide oversight and funding to the Department of Veterans Affairs (VA) for innovative, evidence-based, complementary and alternative medicine (CAM) in treating various illnesses and disabilities." Treatments addressing the comorbidity of symptoms of PTSD, TBI, and suicide, are powerful protective factors contributing to suicide reduction.[11] The American Legion recognizes the only way to consolidate safe and effective treatments for the comorbidity of symptoms relating to PTSD, TBI, and suicide is to build upon evidence established by the scientific community.
The multidisciplinary strategies component of the public health model advocates for collaboration, bringing together many different perspectives to engineer solutions for diverse communities.[12] The American Legion supports this component of the public health model and has endeavored to collaborate with local communities in an effort to reduce veteran suicide.
The American Legion urges Congress to pass legislation to improve VA's tedious hiring process and increase VA's recruitment, retention and relocation budget. It will allow VA to retain quality mental health providers, incentivize exemplary performance, and increase employee morale. Improvements in these areas will lead to increased customer satisfaction and overall quality of care for veterans. The American Legion recommends state-level prescription drug monitoring program databases share data (Resolution No. 160: Resolved, The American Legion urges legislation that would improve pain management policies for the Department of Defense (DoD) and VA.). Implementing a strategy for state-level prescription drug monitoring programs to share data will reduce the unknowing prescription of risky drug combinations, and the overprescribing of potentially dangerous medication.
In closing, The American Legion appreciates the leadership of this committee and remains committed to eradicating veteran suicide. Further, The American Legion is committed to working with the Department of Veterans Affairs and this committee to ensure that America's veterans are provided with the highest level of support and healthcare. Chairman Takano, Ranking Member Roe, and distinguished members of this committee, The American Legion thanks this subcommittee for holding this important hearing and for the opportunity to explain the views of the nearly 2 million members of this organization. For additional information regarding this testimony, please contact Mr. Larry Lohmann, Senior Legislative Associate of The American Legion's Legislative Division at (202) 861-2700 or llohmann@legion.org
[1] The 2016 VA National Suicide Data Report
[2] https://www.legion.org/commander/245458/legion-va-team-approach-suicide-...
[3] National Strategy for Preventing Veteran Suicide 2018–2028
[4] VA Mission Act Section 505 Data released February 15, 2019
[5] Department of Veterans Affairs Office of Inspector General Report No. 17-01846-316
[6] GAO report 18-380
[7] Legion Resolution #20, 2018 Spring NEC
[8] Centers for Disease Control and Prevention, Enhanced Evaluation and Actionable Knowledge for Suicide Prevention Series. Suicide Prevention: A Public Health Issue (n.d.). Accessed March 2, 2018, at www.cdc.gov/violenceprevention/pdf/ASAP_Suicide_Issue2-a.pdf
[11] Resolution No. 160
[12] National Strategy for Preventing Veteran Suicide 2018–2028
[HJL1]I have added hyperlinks to "Veteran Suicide", "The War Within," "The Road Home," and "The Suicide Prevention and Crisis Response Protocol"
Legislative Center
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Using THOMAS Web site