Apr 28, 2019
Statement of
Carlos Fuentes, Director
National Legislative Service
Veterans of Foreign Wars of the United States
For the Record
United States House of Representatives
Committee on Veterans’ Affairs
With Respect To
“Tragic Trends: Suicide Prevention Among Veterans”
WASHINGTON, D.C.
Chairman Takano, Ranking Member Roe, and members of the committee, on behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW) and its Auxiliary, thank you for the opportunity to provide recommendations on suicide prevention.
Eliminating suicide among our nation’s veterans continues to be a top priority for the VFW. The most recent analysis of veteran suicide data from 2016 found suicide has remained fairly consistent within the veteran community in recent years. An average of 20 veterans and service members die by suicide every day. While this number must be reduced to zero, it is worth noting that the number of veterans who die by suicide has remained consistent in recent years, while non-veteran suicides have continued to increase.
Congress must ensure sufficient resources are available and used for effective Department of Veterans Affairs (VA) suicide prevention efforts, including to identify veterans at increased risk of suicide, adopt new interventions, and effectively treat those with previous suicide attempts. Programs such as the Veterans Crisis Line, the placement of suicide prevention coordinators at all VA medical centers and large outpatient facilities, integration of behavioral health into primary care, and joint campaigns between the Department of Defense and VA must continue to be improved and expanded. The VFW also supports the recent executive order to establish the Veteran Wellness, Empowerment, and Suicide Prevention Task Force to coordinate suicide prevention efforts at the national and local levels, and expanding efforts with community partners like the VFW.
The Government Accountability Office has identified several key barriers that deter veterans from seeking mental health care. These include stigma, lack of understanding or awareness of the potential for improvement, lack of child care or transportation, and work or family commitments. Early intervention and timely access to mental health care can greatly improve quality of life, promote recovery, prevent suicide, obviate long-term health consequences, and minimize the disabling effects of mental illness.
The VFW is proud to have partnered with VA, and community and corporate partners to raise awareness of mental health conditions, foster community engagement, improve research and provide intervention for those affected by invisible injuries and emotional stress through the VFW Mental Wellness Campaign. Since Fall 2016, nearly 300 VFW posts around the world and 13,000 volunteers have successfully reached 25,000 people in the past three “Day to Change Direction” events, hosted in partnership with Give an Hour’s Campaign to Change Direction.
The focus of the VFW’s Mental Wellness Campaign is to teach veterans and caregivers how to identify when they or their loved ones are experiencing the signs of emotional suffering –– personality change, agitation, being withdrawn, poor self-care, and hopelessness. In an effort to destigmatize mental health, participants are informed that mental health conditions such as post-traumatic stress disorder (PTSD) are common reactions to abnormal experiences.
The goal is to also reduce the number of veterans who die by suicide each day without having made contact with VA health care services. Research indicates that veterans who do not use VA for their health care are at an increased risk of suicide. This comes as no surprise to the VFW, as our members have continuously informed us that they prefer VA health care because of the high-quality and veteran-centric care VA provides. To better assist all veterans, veterans service organizations, VA, and Congress must know more about the two-thirds of veterans who die by suicide each day without any contact with VA. The VFW urges VA to analyze the demographics, illnesses, socioeconomic status, and military discharges of the 14 veterans and service members who die by suicide every day and do not use VA health care. There are questions that need to be answered in order to properly address this epidemic. Did those 14 use private sector care? Were they eligible to use VA? Were they among the many who were discharged without due process for untreated or undiagnosed mental health disorders? Were they discharged for unjust and undiagnosed personality disorders due to transgenderism or during the era of “Don’t Ask, Don’t Tell? Have they used other VA benefits such as the GI Bill?
However, VA must stand ready to assist veterans who take the bold step of seeking assistance when they are suffering from suicidal ideation. Over the past decade, the VA Office of Mental Health Services has developed a comprehensive set of services to treat the approximately 1.7 million veterans who received VA mental health services in fiscal year (FY) 2018, which is a significant increase from the 927,000 veterans who received such care in FY 2006. Since 2016, VA has strived to provide same day access to veterans who need urgent and emergent health care. While this and other suicide prevention initiatives have resulted in VA saving the lives of veterans in crisis, it must do more to ensure veterans who need help receive it.
It is unconscionable for veterans who experiencing mental health care crises to be turned away. For example, the VFW was informed of a veteran who presented to a VA mental health clinic with suicidal thoughts and asked to be seen immediately because she feared she would take her own life. The front desk clerk informed her that she could not be seen immediately because she had just completed a mental health care appointment the previous day and the next available appointment was in a week. Luckily, the veteran was able to cope with her crisis without VA assistance, and is alive and well.
Too many veterans have died because VA has turned them away in their time of need or failed to identify the seriousness of their health conditions. For example, it is unacceptable for a veteran who is in a VA waiting room to complete suicide without someone noticing the veteran needed immediate assistance. VFW commends VA for looking into ways to protect its employees and patients at VA medical facilities. However, enhanced safety procedures at VA medical facilities will not address the underlying problem. VA employees have become desensitized to veterans with mental health concerns. I have personally witnessed a VA employee disregard a veteran as “just another crazy veteran.” Such mentality must stop. VA must train its employees to identify and assist veterans in crisis. VA must also encourage its employees to take action when they identify a veteran in crisis, without fear of reprisal.
Another reason VA is required to turn veterans away is eligibility for VA health care. The VFW lauds Congress and VA for recent action to expand VA mental health care services to recently discharged veterans and veterans with Other Than Honorable discharges. VA also has the ability to treat any veteran who is not eligible for VA care through its humanitarian care authority under section 1784 of title 38, United States Code (U.S.C.). However, VA is required to charge veterans the full cost of urgent or emergent mental health care. It is understandable for VA to bill other health insurance for such care, but VA must not be required to place an undue burden on veterans who have survived a mental health crisis, particularly because financial instability is often a contributing factor to mental health crises.
The VFW is working with a veteran who was rushed to a VA hospital during a mental health crisis caused by untreated bipolar disorder and depression. The veteran was admitted to the medical center’s inpatient mental health care clinic for two weeks, despite not being eligible for VA health care. VA saved his life, but now he has a $20,000 bill. His mental health crisis was exacerbated by unemployment and his inability to provide for his family. With proper treatment he has been able to return to work, but still lacks the resources to pay the VA bill. The VFW is working on having his bill waived, but he will never return to VA if he has another mental health crisis.
The fear of being turned down or billed for care should never prevent a veteran from seeking the urgent or emergent VA mental health care they need. Congress must amend section 1784 of title 38, U.S.C., to exempt those who have worn our nation’s uniform who receive urgent or emergent mental health care under VA’s humanitarian care authority from having to pay the full cost of such care.
The Office of Inspector General (OIG) report determining Veterans Health Administration (VHA) staffing shortages continues to list psychiatry clinics as having the most need, with the fourth being psychology. Out of 141 facilities surveyed, 98 had a shortage for psychiatrists and 58 had a shortage for psychologists. By not adequately staffing VA, the capacity to serve veterans and provide the necessary access to mental health care needed by so many veterans will continue to be limited. With the entire nation experiencing a critical shortage of mental health providers, such need cannot be sufficiently addressed by simply increasing use of community care. VA must utilize the tools it was given by the VA MISSION Act to hire more providers with enhanced recruitment and retention incentives, train more mental health providers with increased Graduate Medical Education opportunities, and maximize its current capacity with its anywhere to anywhere authority.
The VFW is proud to be part of the solution. Through Project Advancing Telehealth through Local Access Stations (ATLAS), the VFW has worked with VA and Philips to leverage VA’s anywhere to anywhere authority to expand telehealth options for veterans who live in rural areas. In this partnership, VA has identified highly rural areas where veterans must travel far distances to receive VA health care. The VFW identifies posts in those areas to serve as access points for VA health care. Once the post is modified to VA’s specifications, it is equipped with Philips-donated telehealth technology to provide veterans access to VA health care at a convenient veteran-centric location. More than 20 VFW posts have been identified as possible telehealth centers. The primary use for the first Project ATLAS site in Eureka, Montana, will be for mental health care. Veterans in Eureka are required to travel more than 70 miles to the nearest VA clinic for mental health care. Soon they will have the ability to receive VA health care closer to home.
VA is making concerted efforts to ensure it appropriately uses pharmaceutical treatments when providing mental health care. Under the Opioid Safety Initiative, VA has reduced the number of patients to whom it prescribes opioids by more than 22 percent. Prescribed use of opioids for chronic pain management has unfortunately led to addiction to these drugs for many veterans, as well as for many other Americans. VA uses evidence-based clinical guidelines to manage pharmacological treatment of PTSD and SUD to ensure better health outcomes. However, many veterans report being abruptly taken off opioids they have relied on for years to cope with their pain management, without receiving a proper treatment plan to transition them to alternative therapies. Doing so leads veterans to seek alternatives outside of VA or to self-medicate. VA must continue to expand research of non-traditional medical treatments, such as medical cannabis and other holistic approaches, for mental health care conditions.
In the past several years PTSD and traumatic brain injury (TBI) have been thrust into the forefront of the medical community and the general public in large part due to suicides and overmedication of veterans. Medical cannabis is currently legal in 33 states and the District of Columbia. This means veterans are able to legally obtain cannabis for medical purposes in more than half the country. For veterans who use medical cannabis and are also VA patients, they are doing this without the medical understanding or proper guidance from their coordinators of care at VA. This is not to say VA providers are opting to ignore this medical treatment, but that there is currently a lack of federal research and understanding of how medical marijuana may or may not treat certain illnesses and injuries, and the way it interacts with other drugs.
This is regardless of the fact that many states have conducted research for mental health, chronic pain, and oncology at the state level. States that have legalized medical cannabis have also seen a 15-35 percent decrease in opioid overdose and abuse. There is currently substantial evidence from a comprehensive study by the National Academy of Sciences and the National Academic Press that concludes cannabinoids are effective for treating chronic pain, chemotherapy-induced nausea and vomiting, sleep disturbances related to obstructive sleep apnea, multiple sclerosis spasticity symptoms, and fibromyalgia –– all of which are prevalent in the veteran population.
The VFW urges Congress to pass legislation to require VA to conduct a federally funded study with veteran participants for medical cannabis. This study should include participants who have been diagnosed with PTSD, chronic pain, and oncology issues.
The VFW has also long advocated for the expansion of VA’s peer support specialists program. VA peer support specialists are healthy and recovered individuals with mental health or co-occurring conditions who are trained and certified by VA standards to help other veterans with similar conditions and/or life situations. Veterans who obtain assistance from peer support specialists continuously sing their high praises. Peer-to-peer programs are also critically important for minorities, LGBT and women, or any group within the veteran community that is ostracized or misunderstood. This is instrumental in helping veterans avoid loneliness, which can lead to suicidality.
Aside from veterans receiving support from fellow veterans who have recovered from similar health conditions, and experiencing the bond and trust veterans share, peer support specialists also greatly assist in destigmatizing mental health conditions such as PTSD. For a veteran to become a peer support specialist, they must have actively gone through treatment, and be living a relatively healthy lifestyle. This allows veterans who may be struggling to see that their condition is treatable, manageable, and not something that has to negatively impact or control their lives.