Paragraph six of main article reads:  “Quality data
collection and analysis are critical components behind effective prevention
efforts. The Department made great strides over the last 12 months on gathering
critical information to understand the complexity of factors leading to suicide
and ways to prevent such tragedies from occurring within our communities. Data
collected by the DoD Suicide Event Report (DoDSER) tell us that we must continue
to educate our population and build programs, as there continue to be multiple
opportunities to intervene. For example, we are learning that 30% of individuals
who died by suicide communicated their potential self harm; 49% had been
seen in a medical/support clinic/program within 30 days of suicide; and
26% sought broadly defined mental health resources.”

Paragraph 34 of main
article reads:  “In recent years, antidepressant medications,
particularly the use of Selective Serotonin Reuptake Inhibitors (SSRIs) have
been closely evaluated for the increased risk of suicide-related behaviors in
adolescents and young adults associated with their use. In recognition

of this risk, the FDA’s requires a “black box” warning in the product labeling
of all antidepressant medications that advises clinicians to closely monitor any
worsening in depression, emergence of suicidal thinking or behavior, or unusual
changes in behavior, such as sleeplessness, agitation, or withdrawal from social
situations. Close monitoring is especially important during the first four weeks
of treatment. The FDA also recognizes that depression and other psychiatric
disorders are themselves associated with increased risks for
suicide.”

http://www.pennlive.com/newsflash/index.ssf?/base/national-15/12670299869190.xml&storylist=health

Link Between Medication And Veteran Suicide

2/24/2010, 10:27 a.m. EST
The Associated Press

(AP) ­ xfdte MEDICATION-AND-SUICIDE sked

TESTIMONY February
24, 2010 LOREE K. SUTTON, M.D. DIRECTOR U.S. DEPARTMENT OF DEFENSE HOUSE
VETERANS AFFAIRS LINK BETWEEN MEDICATION AND VETERAN SUICIDE Roll Call, Inc.
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of the content.Statement of Loree K. Sutton, M.D. Director, Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injury Special Assistant
to the Assistant Secretary of Defense for Health Affairs U.S. Department of

Defense

February 24, 2010

Introduction

Chairman Filner, Mr.
Buyer, distinguished Members of the Committee; thank you for the opportunity to
appear here today to talk to you about the Department of Defense‘s (DoD) efforts
to reduce the number of suicides across our force.

On behalf of DoD, I
want to take this opportunity to thank you for your continued, strong support
and demonstrated commitment to our service members, veterans, and their
families.

Over the last nine years, a new era of combat emerged, where
counterinsurgency and asymmetric warfare are the norm. This shift continues to
place a great amount of strain on our most important resource, our service
members. Despite the operational challenges facing them and their families, they
remain incredibly resilient, motivated, and well-trained. The Department
recognizes the need to provide the resources and programs necessary to maintain
their resilience and motivation. Our core messages tell our service members and
their families that they are not alone; treatment works; the earlier the
intervention the better; and reaching out is an act of courage and
strength.

The Department also recognizes that the total number and rate

of suicides continue to rise and this is of deep concern at all leadership
levels. Today, I will share with the Committee our current efforts to reduce the
number of suicides across the Force, and the role of medication and
suicides.

Suicide has a multitude of causes, and no simple solution.
There are many potential areas for intervention, and it is difficult to pinpoint
the best approach because each suicide is unique. Recognizing this, DoD is
tackling the challenge using a multi- pronged strategy involving comprehensive
prevention education, research, and outreach. We believe in fostering a holistic
approach to treatment, leveraging primary care for early recognition and
intervention, and when needed, providing innovative specialty care. The areas of

focus to reduce risk include: (1) conducting data collection and analysis to
detect contributing risk factors; (2) facilitating partnerships across DoD,
federal agencies, and civilian organizations to increase collaboration and
communication; (3) reducing stigma and increasing access to resources to provide
needed care; and (4) using research to close gaps and identify best practices.
Data Surveillance

Quality data collection and analysis are critical
components behind effective prevention efforts. The Department made great
strides over the last 12 months on gathering critical information to understand
the complexity of factors leading to suicide and ways to prevent such tragedies
from occurring within our communities. Data collected by the DoD Suicide Event
Report (DoDSER) tell us that we must continue to educate our population and
build programs, as there continue to be multiple opportunities to intervene. For
example, we are learning that 30% of individuals who died by suicide
communicated their potential self harm; 49% had been seen in a medical/support
clinic/program within 30 days of suicide; and 26% sought broadly defined mental
health resources.

Historically, the Services used unique suicide
surveillance systems. In January 2008, the National Center for Telehealth and
Technology (T2), a Defense Centers of Excellence (DCoE) component center,
launched the DoDSER Annual Report. The DoDSER Annual Report was developed to
standardize data collection and reporting. Pulling data from all branches of the
military, it captures over 250 data-points per suicide with details, summaries,
and analyses of a wide range of potential contributing factors. DoDSER Annual
Report data include specific demographics, suicide event details, treatment, and
military history, among others. The variables are designed to map directly to
the Centers for Disease Control and Prevention’s National Violent Death
Reporting System to support direct comparisons between military and civilian
populations.

By standardizing data and reporting,
DoD tracks and analyzes suicide data and contributing risk factors proactively
to inform and improve future prevention, intervention, and treatment services.
The DoDSER Annual Report is revised annually based on input from the Services.
The data facilitate the review and evaluation of the effectiveness of suicide
prevention initiatives and their execution over time. DoDSER represents the
strides DoD has taken to better understand what some of the
underlying factors are for suicide. The Department uses this tool to inform
current efforts and initiatives.

According to the Armed Forces
Medical Examiner System (AFMES), in January 2010 there were 24 confirmed

suicides, all in Regular Components within the DoD. In calendar year 2009, AFMES
reported that there were 312 confirmed suicides, with 286 confirmed in Regular
Components and 26 confirmed in the Reserve Components. Demographic risk factors
include: male, Caucasian, E-1 to E-4, younger than 25 years old, GED or less
than high school education, divorced, and in the Active Duty Component. Other
factors associated with suicide, which are consistent with data from civilian
populations, are: substance abuse, relationship issues, and legal,
administrative (Article 15), and financial problems. Although the impact of
deployment is still under investigation, a majority of suicides do not occur in
the theaters of operation. 16% of suicides occurred in Iraq or Afghanistan.
Despite the knowledge gained and data collected, it is important to resist
oversimplifying or generalizing statistics. Each suicide is as different as a
person is unique.

According to AFMES, there were 26 confirmed suicides in
calendar year 2009 among the Reserve Components, which include all Active Guard
and Reserves. Due to the unique nature of their service, there are challenges
associated with capturing all suicide completions, preparatory behavior and self
harm without intent to die among National Guard and Reserve populations when
they are not on active or activated status. To address this issue, DoD is
examining ways to utilize information gathered from existing tracking and
reporting systems including, but not limited to, insurance and benefit data. The
DoD continues to support National Guard and Reserve populations through numerous
initiatives to increase outreach, care, and resources on all fronts.

The
numbers also tell us that prevention is not enough, as 36% of military suicides

had a history of a mental disorder. The integrated efforts of prevention,
intervention, and treatment are essential to DoD’s approach to tackle the
challenge of suicide.

Facilitating Partnerships

Continued
collaboration with the Department of Veterans Affairs (VA) and other federal,
private, and academic organizations is a key part of DoD’s overall
strategy.

Conferences serve as dissemination and outreach platforms by
providing local and regional coordinators with innovative ideas to implement
within their communities and providing DoD and VA with the opportunity to gather
feedback on communities’ needs. The annual DoD/VA Suicide Prevention Conference
provides such a forum. With over 900 attendees, the 2010 conference shared
practical applications, results from research and pilot studies, guidance from
senior DoD and VA leaders on the way forward, and testimonies emphasizing the
importance of seeking help.

We work closely with our partners at the VA
to ensure that the transition out of service and into VA care is seamless and
that service members, veterans, and families receive the care they deserve. The
DCoE coordinates information and resources with VA’s National Suicide Prevention
Lifeline (1-800-273-TALK), and National Resource Directory. As part of this
partnership, DCoE worked with VA and the Substance Abuse and Mental Health
Services Administration (SAMHSA) in December of 2009 to modify the introductory
message on the Lifeline, so that callers are instructed to press “1” if they
are a United States military veteran or Active Duty Service Member (ADSM) or are
calling about one. This expansion increases the scope of services that are
available to ADSMs who may be in crisis.

Collaborative care is an example

of an immediate solution that DoD is aggressively implementing. According to
DoDSER data, 36 percent of completed suicides had a history of a mental health
condition. Providing mental health services in conjunction with primary care is
an important part of our prevention strategy because early detection and
intervention is a key to preventing suicide behaviors. Each Service is
developing collaborative care models based on recommendations from a National
Institute of Mental Health (NIMH) study. The DCoE collaborates with the Services
to integrate the best practices from these models to develop consistent
standards across DoD. DCoE is currently implementing a controlled trial study at
six sites and 18 clinics of collaborative primary care to inform future
efforts.

In August 2009, the DoD Suicide Prevention Task Force was
established under the purview of the Defense Health Board. The goal of the task
force is to provide recommendations to legislative and administrative bodies on
suicide prevention within the military.

The Department recognizes the
importance of eliminating the toxic threat of stigma by transforming its culture
from reactionary to a more proactive environment by engaging leadership to
encourage transparency, accountability, candor, and respect. The DoD is
promoting awareness among leaders and urging them to lead by example in matters
related to health and well-being. In addition, changes in policies and messages
to all levels help create a safe culture to seek help. One significant change
was the revision of question 21 on the questionnaire for security clearances on
whether a service member has sought mental or behavioral help in the past year.
DoD believes that service members should not have to deny themselves the care
they need and deserve out of fear of repercussions. Our efforts to combat stigma
will continue alongside our efforts to provide the best prevention, intervention
and treatment options.

Additionally, DoD is undergoing a cultural
transformation to push care closer to the service members and their families. An
emphasis on early intervention for antecedent issues such as post- traumatic
stress, depression, and substance abuse can help address needs before they
develop into bigger issues that could contribute to suicides. This population
based approach enables DoD to engage multiple audiences including peers,
families, units, and communities to support suicide prevention, risk reduction,
and overall health promotion. The Services also have programs to address needs
before they develop into issues that must be addressed in a specialty care
setting.

DCoE helps combat stigma through the Real Warriors Campaign, a
public education initiative that reinforces the notion that reaching out is a
sign of strength. Under the theme of “Real Warriors, Real Battles, Real
Strengths,” this effort provides concrete examples of service members who sought
care for psychological health issues and are maintaining a successful military
career. While primarily focused on stigma, the Real Warriors Campaign is
actively engaged in the fight against military suicide in a number of

ways:

The website prominently displays the National Suicide Prevention
Lifeline on every page;-Two video profiles of service members involved in the
campaign openly discuss their struggles with suicidal ideation from a position
of strength and optimism having reached out for care that is working; and-The
site allows service members, veterans, families and health professionals to
confidentially reach out to health consultants around the clock through the Real
Warriors Live Chat feature or by calling the DCoE Outreach Center.

The
Campaign’s message boards include numerous posts from service members who share
their coping strategies for dealing with suicidal ideation. The site includes
content that focuses on suicide prevention and substance abuse. Short,
documentary-style videos illustrate the resilience exhibited by service members,
their families, and caregivers.

Since the Real Warriors Campaign launched
in May 2009, the website, www.realwarriors.net,
saw more than 45,500 unique visitors from 127 countries, with more than 69,128
visits and 450,000 page views. The DoD believes that stigma can be defeated by
encouraging and supporting service members to reach out when help is
needed.

critical component of DoD’s strategy is advancing research. As
part of DoD’s research portfolio, the RAND Center for Military Health Policy
Research is reviewing and cataloguing suicide prevention programs across the
Services with recommendations for enhancements of current programs. The results
will be released March 2010 and disseminated to inform future program
development.

A pilot study that showed promise in the civilian sector is
the Caring Letters Program. In a randomized clinical trial, sending brief
letters of concern and reminders of treatment to patients admitted for suicide
attempt, ideation, or for a psychiatric condition was shown to dramatically
reduce the risk of death by suicide. In an effort to determine the applicability
to military populations, the National Center for TeleHealth and Technology (T2)
is piloting a program at Ft Lewis, Washington. The goals of the Caring Letters
Pilot are to (1) test the feasibility of expanding the program to other military
treatment facilities, (2) collect preliminary outcome data, and (3) evaluate the
method of letter transmittal (email vs. postal mail). Since its inception in
July 2009, 81 letters have been sent. Efforts are currently underway to plan a
multi-site randomized control trial.

Many programs are currently in place
to raise awareness among service members, train civilian providers supporting
our service members and communities, and increase leadership involvement in
behavioral health efforts. The programs are on all levels, from the national
level down into local communities. These initiatives, including programs that
provide face-to-face support or online support, demonstrate DoD’s multi-pronged
approach and commitment to ensuring service members and families have access to
the best resources. Some examples of these efforts are detailed
below:

Each Service has its own suicide prevention initiatives tailored
to its culture. In November 2007, DoD established the DCoE to offer a central
coordinating point for activities related to psychological health concerns and
traumatic brain injuries. DCoE focuses on the full continuum of care and
prevention to enhance coordination among the Services, federal agencies, and
civilian organizations. DCoE works to identify best practices and disseminate
practical resources to affected communities. In this effort, emphasis is placed
on building resilience, supporting recovery, and promoting reintegration to
ensure a comprehensive, multi-faceted, and proactive approach in promoting
health and wellbeing.

The Suicide Prevention and Risk Reduction Committee
(SPARRC), chaired by DCoE, provides a forum for inter-Service and VA partnership
and coordination. Members include Suicide Prevention Program Managers from the
Services and representatives from the National Guard Bureau, Reserve Affairs,
VA, Office of Armed Forces Medical Examiner, T2, Substance Abuse and Mental
Health Services Administration, and others. This committee is the main venue for
ensuring collaboration and consistency in system-wide communication related to
suicide, risk reduction policy initiatives, and suicide surveillance metrics
across the military. A SPARRC website is currently in development to serve as a
“clearinghouse” for suicide prevention information, contacts, innovative
approaches, and tools.

Additionally, the DCoE Outreach Center coordinates
with Military OneSource, accessible by phone at 1-800-342-9647. Licensed mental
health consultants are available to listen, answer questions, and refer callers
to a wide range of services 24 hours a day, seven days a week, 365 days a year.
Military OneSource provides services on a range of other topics including
education, relocation, and parenting.

Another DoD program that encourages
seeking care is inTransition, which provides a bridge of support for service
members while they are transitioning between health care systems or providers.
The program assigns credentialed “Supercoaches” on a one-on-one basis to service
members in transition. These “Supercoaches” provide support, encouragement, and
promote continued use of behavioral health services.

In an effort to
increase access to resources and align with modern communication platforms, DoD
is harnessing technology and social media tools. Afterdeployment.org, an
interactive website developed by T2, provides service members and families
behavioral health information using an anonymous platform. This mental wellness
resource is designed to help service members and families manage the challenges
faced after a deployment. In addition, Afterdeployment.org launched a series of

free podcasts, available on iTunes, discussing a variety of mental health issues
affecting service members and families. Since the rollout in August 2008,
Afterdeployment.org has seen 86,083 visits to its website. Afterdeployment.org
is currently developing both a mobile version of the site and a mobile
application. The portability will allow access to resources regardless of
location.

Telebehavioral health refers to use of telecommunications and
information technology for clinical and non-clinical behavioral health care
services. Telebehavioral health may include the use of videoconferencing,
web-based cameras, email and telephone. T2 is exploring ways to supply timely
telebehavioral health services to service members in theater and during health
screenings immediately upon return to the continental United States. The use of

technology provides service members and their families access to psychological
health care even in the most extreme and/or remote circumstances. Medication and
Suicide Risk

The Department supports the use of psychopharmacological
treatments as a key component of mental health care. Scientific evidence over
the past several decades points to the role of medications in limiting the
severity and duration of illness as well as for preventing relapses and
recurrences. These findings have been translated into recommendations for
clinicians in the VA-DoD Clinical Practice Guidelines for Major Depressive
Disorder, Post-Traumatic Stress Disorder, Psychoses and Substance Use Disorder.
These guidelines are updated periodically as required to reflect the most
current knowledge concerning each of these conditions. Recognizing that all

medications carry potential risks as well as benefits, clinicians must exercise
their judgment in applying these guidelines and determining the most effective
use of medications, other therapies which include Cognitive Behavioral Therapy,
Cognitive Processing Therapy and/or Prolonged Exposure treatment, or a
combination of medication and therapy. Therapy must be monitored, with careful
attention to diagnosis, dosing, clinical response and potential adverse
events.

In recent years, antidepressant medications, particularly the use
of Selective Serotonin Reuptake Inhibitors (SSRIs) have been closely evaluated
for the increased risk of suicide-related behaviors in adolescents and young
adults associated with their use. In recognition of this risk, the FDA’s
requires a “black box” warning in the product labeling of all antidepressant

medications that advises clinicians to closely monitor any worsening in
depression, emergence of suicidal thinking or behavior, or unusual changes in
behavior, such as sleeplessness, agitation, or withdrawal from social
situations. Close monitoring is especially important during the first four weeks
of treatment. The FDA also recognizes that depression and other psychiatric
disorders are themselves associated with increased risks for
suicide.

Accordingly, the Department uses multiple tools to address the
identified risk for antidepressant as well as other medications, as scientific
evidence reaches the threshold for action. These methods include dissemination
of safety alerts to clinicians, patient information sheets, pharmacy monitoring
for harmful combinations of prescribed medications, adherence to The Joint
Commission standards governing medication reconciliation, compliance with the
reporting of adverse events, increasingly sophisticated use pharmacotherapeutic
analysis as well as training and education programs in evidence-based modalities
reflecting the most current clinical practice guidelines.

The DoDSER data
base, while still maturing, provides an unprecedented repository of Service
suicide surveillance data that will continue to inform our efforts. Further, we
look forward to the payoff from continued research investments.

Way
Forward

Suicide is a problem that needs solutions now. DoD is focused on
rapidly translating best practices into applicable tools for service members and
families. At the same time, DoD continues to improve on collaborative
relationships across the Services and with national experts, collecting data,
and in research efforts that will accelerate improvements in current services
and programs as well as spur new innovations. In addition, DoD will also
continue to evolve and leverage our population-based system to push innovations
in prevention and care toward the service member and family.

DoD’s
current initiatives to address the challenges placed on service members and
their families are progressing, but we recognize that there is still much to be
done. In order to build on our current efforts and successfully shift to a model

of population-based care, we identified the following areas of additional
focus.

An issue of increasing concern is suicides of military family
members and how to support surviving families. At this point in time, DoD does
not track suicides of military family members. However, DoD recognizes the
importance of engaging and supporting this population, as their sacrifices
deserve our recognition. The DoD Suicide Prevention Task Force met this year
with surviving families at the Tragedy Assistance Program for Survivors (TAPS)
Seminar. The DoD Task Force will provide recommendations to the Secretary of

Defense and Congress. Efforts will be focused on increasing outreach to
families; providing families with more education and training to recognize the
signs of suicidal behavior and where to seek help; and supporting families after
a suicide event. In addition, for calendar year 2010, SPARRC partnered with TAPS
to form a sub-committee to identify additional needs of families and to
recommend concrete solutions.

Postvention, which refers to all activities
and response after a suicide event, is another area of growing attention. The
goals of postvention include: (1) promote healing, (2) reduce risk of contagion,
and (3) identify those at risk and connect them to help. Postvention is also
viewed as a form of prevention for survivors. This year, DoD will work with the
Services to promote consistent postvention protocols across
programs.

Connect/Frameworks Suicide Postvention Program is a civilian
program that utilizes evidenced supported protocols to promote an integrated
community based response to suicides. Postvention protocols and guidelines
include topics such as discussing cause and method of death; how to address
needs of families; memorial service activities; and media coverage and
messaging.

In addition to prevention, intervention, and treatment, DoD is
shifting attention to increasing resilience. DoD promotes a holistic approach
that optimizes the physical, psychological, and spiritual components of the
human condition. The DoD is also piloting resilience programs in military
settings to determine applicability and effectiveness within military
populations. While the impact of deployment on suicide is still under
investigation, it cannot be denied that an era of high operational tempo and
persistent conflict increases pressure on our warriors. A comprehensive approach
to enhancing resilience actively confronts the increasing stressors service
members face in this environment.

2010 will also provide DoD further
opportunities to demonstrate a public health model of prevention, by supporting
peer-to-peer programs in the Services and continuing to increase the number of

mental health providers in communities. DoD is actively engaged in hiring more
mental health providers and providing them with quality and continued training.
Conclusion

Through our united and concerted efforts, we can continue
making a change for the better. DoD recognizes the need to provide the resources
and programs necessary to maintain the resilience and motivation of our service
members and families. We will continue to emphasize education as we deliver our
core messages. “You are not alone; treatment works; the earlier the intervention
the better; and reaching out is an act of courage and strength.”

We are
devoted to this effort and will continue to work aggressively to prevent the
unnecessary loss of life.

With the Committee’s continued assistance and
support, we will ensure our brave men and women in uniform and their families
have access to the resources they require.

On behalf of the DoD, thank
you for the opportunity to highlight these vital issues. I look forward to your
questions.