Continue to Combat Suicide Among Troops and Veterans

The Clay Hunt SAV Act, signed into law on February 12, 2015, puts into motion three critical policies to help end veteran suicide by increasing access to mental health care, better meeting the growing demand for mental health care providers, and boosting the accountability of Department of Veterans Affairs’ (VA) mental health and suicide prevention programs. Even with this progress, the fight against this silent killer has only begun. It will take the full force of our nation to combat the crisis of suicide among troops and veterans.

The VA estimates that 20 veterans die from suicide each day, and the Department of Defense (DoD) reports that 434 service members (active and reserve components) died by suicide in 2014. Despite increased efforts to combat suicide among troops and veterans, we are still missing the fundamentals of a high-quality, timely mental health care system. The Clay Hunt SAV Act was a first step in addressing this challenge, but there is still more to be done

Troops and veterans deserve immediate access to the best mental health care in the world, yet more than 70 percent of IAVA’s surveyed members indicate they did not believe that troops and veterans are getting the care they need. Common barriers to care—like lack of access to providers, inconvenient appointment availability and limited access to evidence-based treatments—make getting help difficult. Additionally, the stigma of seeking mental health care continues to be an obstacle for many veterans.

Among survey respondents who self-report a mental health injury but have not sought help, the main reason for not seeking care are concerns over how their loved ones and peers will perceive them and concerns that it might affect their career. Significantly more work is needed to eliminate the barriers and stigma that prevent many from seeking the care they need.

The high number of suicides among troops and veterans demands a proactive approach to support troops and veterans in crisis. When veterans and service members seek care, they cannot be met with ever-changing providers or unresponsive programs. No troop or veteran can be allowed to fall through the cracks between programs and services—or between the DoD and the VA.

To streamline available resources, IAVA has maintained a close partnership with the Veterans Crisis Line, consistently connecting veterans in need with its lifesaving services. Our Rapid Response Referral Program, which has supported more than 5,000 veterans since launching in December 2012, provides veterans with one-on-one transition navigation support, including connecting them to both government and non-government mental health resources. Government funding, support and partnerships with innovative programs like this must be expanded.

The year 2014 will hopefully prove itself to be a turning point in our fight to end veteran suicide. What began as IAVA’s Campaign to Combat Suicide grew to a national movement to combat suicide among troops and veterans. As the Clay Hunt SAV Act is implemented this year, lasting change will come with sustained focus and a national, multi-sector effort building on the momentum of 2014.

1.1: Improve Access to Quality Mental Health Care
1.2: Grow the Supply of Mental Health Providers to Meet the Growing Demand
1.3: Improve the Quality of Mental Health Care
1.4: Better Identify and Support Troops and Veterans in Crisis
1.5: Streamline Mental Health Care for Troops and Veterans
1.6: Engage All Americans in Combating Suicide

1.1: Improve Access to Quality Mental Health Care

Every veteran and service member should have access to low cost, high-quality mental health care. Today, all veterans of Iraq or Afghanistan are eligible from the Department of Veterans Affairs (VA) health care for five years following their deployments. But for many veterans, this is not enough time. Mental health injuries often manifest years after service when the five-year window has closed and, as a result, many veterans are left without care.

Other veterans are ineligible for services because of their discharge status. Between 2001 and 2010, an estimated 30,000 service members were potentially improperly discharged from the military with a “personality disorder,” leaving them ineligible for VA mental health support. 10 Even now, some veterans are discharged because of disciplinary problems that can be attributed to mental health injuries. The Department of Defense (DoD) must review procedures to ensure veterans in need are not left without access to benefits and services because of a mental health problem resulting from their service.

National Guard members and reservists often struggle to gain access to mental health services. Unlike their peers who return to military bases, they’re at particularly high risk because they transition from active duty status into communities that often have few resources to support them. Yet, existing programs aren’t being fully funded and many programs that serve others in the military community, like Vet Centers, are not available to them.

IAVA Recommendations:
I. Extend special combat veteran eligibility for VA health care from five years to 15 years after leaving active duty.

II. Conduct a comprehensive audit of previous personality disorder (Chapter 5–13) discharges by the DoD in order to certify that service members suffering from service-connected psychological or neurological injuries were not improperly discharged.

III. Fully fund the embedded behavioral health provider program for National Guard and Reserve units.

IV. Evaluate Vet Center utilization and patient outcome, conduct a gap analysis nationally and expand this model of care to fill those gaps in communities across the nation.

V. Clarify the existing mental health parity regulations for Managed Care Organizations and Alternative Benefit plans.

VI.Review and alter DoD procedures to prevent discharges for disciplinary or administrative issues that are the result of a mental health injury.

1.2: Grow the Supply of Mental Health Providers to Meet the Growing Demand

The number of mental health professionals dedicated to serving veterans and troops cannot keep pace with the demand for mental health services. Today, almost 30 percent of new veterans treated at the Department of Veterans Affairs (VA) have been diagnosed with Post-Traumatic Stress Disorder and 57 percent have some form of a mental health injury. If these trends are true for the entire veteran population, we will be profoundly unprepared to address this enormous demand for mental health services in and out of the VA.

The federal government, starting with the President, should continue to encourage the next generation of clinicians to pursue careers in mental health and expand the pipeline of qualified mental health providers to care for troops and veterans.

The VA is only bearing the brunt of a little more than half the demand. Only 60 percent of new veterans are enrolled with the VA, meaning many other veterans seek care through private or community services. The government should work closely with community partners to share best practices and ensure these local providers are equipped with the resources needed to care for veterans and their families. Private philanthropy must also respond.

IAVA Recommendations:
I. Ensure DoD and VA mental health care providers and appointment systems are available after traditional work hours.

II. Authorize federal or state grants to community-based nonprofits that provide mental health services and assistance.

III. Make permanent the funding of additional Graduate Medical Education slots established by the Veterans Choice and Accountability Act of 2014 beyond the five year window to ensure the added residencies do not disappear.

IV. Conduct a workforce analysis to project the future need for mental health providers at the VA and the DoD. Assessment should consider both services rendered and services requested.

V. Increase inpatient beds at VA health facilities to meet the demands of the veterans served at the local level, particularly for those who are traditionally underserved, such veterans with children or those with a history of alcohol dependency.

VI. Expand outreach to educate civilian mental health providers about TRICARE benefits.

VII. Develop, evaluate and partner with community-based peer-to-peer and support programs that promote community involvement, risk identification and response among veterans and their families.

VIII. Replace the statutory payment formula with a formula that accurately adjusts Medicare reimbursement rates with rising health care costs. Since TRICARE reimbursement rates are tied to Medicare reimbursement rates, the current formula discourages many providers from accepting TRICARE.

IX. Private philanthropy must also fund local and national non-profit mental health services and programs like IAVA’s RRRP.

1.3: Improve the Quality of Mental Health Care

Troops and veterans deserve high-quality mental health care staffed by highly trained professionals; however, veterans are concerned with the quality of the care currently available to them. Of the 73 percent of respondents to IAVA’s member survey who felt troops and veterans do not get the care they need for mental health injuries, half of those felt it was because they don’t have access to high quality services.

Providers must be trained to address the specific needs of veterans and their families. Departments of Veterans Affairs (VA) and Defense (DoD), along with other government and private entities must continue to invest in research to identify best practices in mental health care and suicide prevention. Existing and emerging research must then be widely disseminated to the DoD, the VA and private mental health care professionals. By providing best practices to service providers across the country, we can ensure that more veterans are getting specialized, quality care wherever they may seek it.

IAVA Recommendations:
I. Require all TRICARE providers be trained in the identification of PTSD.

II. Identify all programs within the DoD related to mental health and suicide prevention; develop clear metrics to assess their impact on mental health and suicide prevention programs.

III. Require the DoD to report annually about the impact of existing mental health programs. Reports should include how the program is improving the quality of life for veterans and their families.

IV. Ensure that personnel conducting the mandated person-to-person mental health screenings for all returning service members are trained to effectively identify hidden wounds.

V. Establish and fund a tool to allow for the dissemination and peer review of evidence-based practices for the outreach, engagement and treatment of invisible injuries. This tool should be focused on connecting members of the mental health community currently treating veterans and should be a resource to those who wish to start doing so.

VI. Establish and fund a visiting clinician program to allow for the identification of evidence-based practices, and fund an expert in the practice to train other clinicians.

VII. Establish a mechanism to better translate evidenced-based research into practice at the DoD and the VA.

1.4: Better Identify and Support Troops and Veterans in Crisis

Suicide prevention requires a proactive approach to identify veterans at risk of attempting suicide and to provide seamless care to these veterans. The act of suicide itself is a tragic symptom of a broad spectrum of factors, including relationship problems, mental health issues, and/or career and financial stressors. The earlier we identify that a service member or veteran is at risk, the more opportunities to address these challenges before he or she ever considers suicide. The Departments of Veterans Affairs (VA) and Defense (DoD) and private entities must continue to invest in research to identify risk factors and develop early intervention protocols.

IAVA Recommendations:
I. Train local first-responders in the best practices to identify, intervene and support a veteran in crisis.

II. Require the VA to develop mechanisms to share information across each department and establish standard procedures to ensure that every veteran identified as at risk for suicide is supported by all VA resources.

III. Continue to expand partnerships between the Veterans Crisis Line and external stakeholders to ensure veterans are aware of the crisis line and are effectively connected to its services.

IV. Ensure that VA primary care providers and their staff are trained in the assessment, management and triage of acute suicide risk patients.

V. Integrate VA and DoD suicide prevention efforts with local and state services, such as municipal 311 systems and community-based nonprofits, to ensure a seamless network of care and crisis intervention.

VI. Establish VA and DoD drug take-back programs at all medical facilities co-located with a pharmacy to limit the availability of unnecessary or leftover prescription medication.

VII. Fully implement the 19 new executive actions announced in 2014 to improve the mental health of service members, veterans and their families, which builds on the progress of the President’s 2012 (Mental Health) Executive Order.

1.5: Streamline Mental Health Care for Troops and Veterans

When veterans seek care for a mental health injury, services must be ready to immediately respond to their requests for treatment. Asking for help can be profoundly difficult and often requires tremendous courage. All too often, the families of those lost tell stories of disjointed services, moments when their loved one asked for help only to be met with overly complex bureaucracies, and ever-changing providers unable to administer the continuity of care needed. With proactive efforts that emphasize a holistic, long-term approach to mental health care, we can ensure veterans no longer slip through the cracks.

We must streamline the transfer of care between the Departments of Defense and Veterans Affairs. Today, if a service member attempts suicide while in the service, there are no mechanisms to ensure that he or she enrolls in care following separation from the military. Despite repeated promises to develop a fully interoperable electronic health record, the VA and DoD still struggle to share medical records, making coordinating long-term care for veterans even more difficult.

IAVA Recommendations:
I. Integrate mental health check-ups as a regular part of required physicals for preventative care.

II. Integrate basic skills for recognizing and treating mental health injuries into First Aid training for all service members.

III. Require VA and DoD mental health professionals treating clients to provide at least 30 days’ notice before leaving their positions.

IV. Implement the 2014 Executive Action to automatically enroll all service members leaving military service who are receiving care for mental health conditions in the Department’s inTransition program, through which trained mental health professionals help these individuals transition to a new care team in the VA.

V. Provide oversight by monitoring the progress and development of interoperable DoD and VA health records, including submitting regular DoD and VA progress reports to Congress. (Also listed in Section 3)

1.6: Involve All Americans in Combating Suicide

Communities in and out of the military are vital to combating suicide among troops and veterans to ensure veterans are supported in their efforts to seek care and in their transition home.

The stigma of seeking mental health care is a national problem, not just among veterans, and keeps many from trying to get help. According to IAVA’s member survey, an encouraging 77 percent of respondents sought care when it was suggested that they do so by a friend or family member. Still, for those who reported having a mental health injury and not seeking care, they identified the concern that a mental health diagnosis might affect their career as a primary reason for why they ultimately refused to seek professional care. Unfortunately, the stigma of seeking help is still very real, and to truly change this stigma, the entire American and military community must adopt mental health care as a routine aspect of maintaining a healthy lifestyle.

IAVA Recommendations:
I. Coordinate existing mental health awareness campaigns into one effort to remove the stigma of seeking help for combat stress injuries and to promote effective resources. This campaign should be well funded, research-tested and coordinated through the DoD, the VA, the White House, local governments and community-based partners.

II. Establish state and local public awareness campaigns that target veterans’ and family members’ mental health and reduce the stigma of seeking mental health care.

III. Develop, evaluate and partner with community-based peer-to-peer and support programs that promote community involvement, risk identification and response among veterans and their families.

IV. Decriminalize suicide attempts within the Uniform Code of Military Justice.

V. Emphasize throughout the chain of command the importance of mental health care, recognize and discipline accordingly those leaders who act as a barrier to care, and reward those who emphasize care among their service members.

VI. Distribute trigger locks when an individual registers a firearm with Military Police.

VII. Message firearm safety and safe storage through participation in a firearm safety campaign, such as the National Shooting Sports Foundation’s “Own it? Respect it. Secure it.” campaign.

VIII. Educate service members and veterans about the changes to the Questionnaire for National Security Positions security clearance form (SF86) regarding mental health history, which includes an exception if you have sought care for injuries related to military service.

IX. Integrate robust and effective mental health awareness and suicide prevention training into the military education systems.

How IAVA is making progress towards these goals?
Stephanie Mullen Statement of Record before the House Veterans Affairs Committee