Vets Suicide Hotline on the Hot Seat

A Blue Ribbon report and a hearing in a House subcommittee raised fresh questions about the sufficiency of the Department of Veterans Affairs (VA) response to suicides among veterans-especially those returning from Iraq and Afghanistan. A hearing in the House Veterans Affairs Subcommittee on Health on September 16 focused on a year-old veterans suicide hotline headquartered at the Canandaigua, NY, veterans medical center, home to the VA’s Mental Health Center of  Excellence.

A report a week earlier from The Blue Ribbon Work Group on Suicide Prevention in the Veteran Population, composed of military and academic psychiatrists and others, said the link between suicide prevention coordinators (SPCs) at each VA medical center and the veterans suicide prevention hotline “represents the most extensive national effort to connect suicide hotline callers with appropriate care.”

But the operation of that hotline came under fire at the hearing on September 16. Tyrone Ballesteros, office manager, National Veterans Foundation (NVF), criticized the quality of the interventions on the basis of phone calls that were made to the National Suicide Prevention Lifeline by NVF staff members. “The results were not satisfactory, at least not to the standards of our organization,” he said. “The primary advice given to our staff members was to refer callers to the closest VA medical facility and to advise them to ‘hang on’ until that facility could contact them. Our concern is the reluctance of the person advising the caller to address any immediate suicidal ideation and the lack of exploration of other means of giving the caller immediate assistance.”

The VA suicide hotline was established late last year. It is actually a subset of the National Suicide Prevention Lifeline. When someone calls 1-800-273-TALK, he or she is asked if he is
a veteran. If the answer is “yes,” he is asked to push 1 on the phone keypad and the call is connected to Canan-daigua, which has 6 lines in operation at all times.

Janet E. Kemp, RN, PhD, National Suicide Prevention coordinator at the VA who is stationed at Canandaigua, said that the 6 lines are manned by 35 responders who are social workers, mental health nurses, or certified counselors, and a couple of psychologists. “They all have extensive training,” she said, replying to Ballesteros’s criticism. The VA hotline fielded 32,854 calls from veterans or veterans’ family members in the past year. Calls from veterans led to 5980 referrals to SPCs, who are stationed at all the 133 veterans medical centers, for follow-up for the problems that led to the call. Those calls also led to 1628 rescues, meaning calls to police or ambulances for immediate responses for those judged to be at imminent risk. Kemp said the number of SPCs is being doubled.

Tom Berger, PhD, senior analyst for veterans benefits and mental health issues, Vietnam Veterans of America, questioned the value of the 1628 “rescues.” He said in some instances those rescues involved sending SWAT teams or police out to the home of a veteran who is “retraumatized.”

“That, in my opinion, is not a success story.” Berger noted that Memphis and Chicago have special crisis intervention teams within their police forces composed of ex-vets who respond to such emergencies and are trained to do so. “My version of success is that there is follow-up to find out if these people go into treatment and recovery programs, and how many people have completed treatment,” he stated.

Kerry Knox, MD, director of the VA Center of Excellence for Suicide Prevention, admits that it is too early to tell whether the hotline is helping reduce suicides among veterans. In an interview, she said, “the crisis line started over a year ago. Over the next year, we will begin planning to analyze the effects.”

Knox and Kemp both stated that the Blue Ribbon report essentially endorsed the VA’s current efforts to improve its suicide prevention program. “It is important to remember that their recommendations are things we are already doing,” said Kemp. “We are really pleased with their report.”

However, the report includes a laundry list of criticisms (albeit in muted tones) and suggestions, and it is not clear how much headway the VA is making on much of the reform agenda. Members of the Blue Ribbon Work Group on Suicide Prevention in the Veterans Population include Colonel Charles W. Hoge, MD, director of the division of psychiatry and behavior services at Walter Reed Army Institute of Research, and Colonel Robert Roy Ireland, MD, program director for mental health policy, Office of the Assistant Secretary of Defense for Health Affairs. The 2 academic psychiatrists on the panel are Eric D. Caine, MD, chair of the department of psychiatry at the University of Rochester, and Jan Fawcett, MD, professor of psychiatry at the University of New Mexico School of Medicine.

The Blue Ribbon report complained that the command-level emphasis on clozapine and lithium “does not appear to have a sufficient body of evidence” and lauded the introduction of SPCs at each VA medical center. But it added: “However, there is insufficient information on optimal staffing levels of SPCs.” The work group suggested that the SPCs may have too much on their plates to function effectively. Whether Congress ensures that the VA follows up on the Blue Ribbon report’s recommendations remains to be seen.