the way elections are played out, the notion of accountability, there are all different ways to produce accountability. the amazing things about the founders when they constructed the constitution was they thought this through carefully each branch has a different balance. long terms the election by state legislatures. we have lots of options. no one is arguing but that's

not to say therefore you have to go all the way to the other extreme. via the point with you because i get this pushback also is congress, are you serious? and nothing could be worse than congress can i do agree. we're spending $50 million ad buy foundation just to figure out how to improve the. the point is if that's a problem, then the solution is to fix of that. turn to lawmaking overtone oligarchy. i don't get that part of it. never do. >> fdr added tried to add more justices to the supreme court. would adding solve problems or create more problems? we're just having nine justices. we've had nine justices throughout the 20th century anyway. but there's nothing in the constitution that tells us how many justices congress should designate. we have the right size on the court? does it matter?

>> again when lincoln gets elected to increase the size of the court. they want him to have more say. when he gets assassinated, they shrink the court. when grant is elected to increase the court again. those kinds of mutilation. fdr was completely successful. he have to look at not in isolation but part as a package of pressure that you would have to be because people to the kinds of things that were being set in congress in the 1930s would be shouted down across the spectrum. and that's why there is some pushback. president obama makes this one will often comment about citizens united which is so tempted and he gets slammed by everybody left or right. how dare you criticize -- that is a long way. go back and read the congressional debate around the new deal and that's a robust

debate that doesn't exclude the possibility of judicial review but also doesn't assume the court having said over the meaning of the important provisions of the constitution. >> the question may be related. what with the court look like if senate confirmation was no longer required? required of course by the constitution but setting that aside. what about the blue sky idf is getting rid of senate confirmation, let the president -- >> it would look more like congress. >> if there was no senate confirmation required? i think we got to remember historically that in the 19th century, 20% of presidential nominations in the supreme court rejected by the senate. almost always on ideological grounds. in the 20th century, and even the center, confirmation battles over when it's in is of a different a little go party than the president.

virtually never with the senate reject the nomination of the president when the senate is the same political party as the president. it's when they are of different parties such a confirmation fights. inhibitor important check. i think it is completely appropriate remember when the senate rejected robert bork. think i different a lot would've been if not. it was rejected precisely because of his ideology. we can go back to others who rejected because of their ideology. one of the checks built into the system is senate confirmation. when the president and the senate are of different political parties. >> i think an interesting sort subset of that argument is what about expanding the nuclear option for supreme court nominations? the ideas you essentially need 60 votes to get a somewhat through for the supreme court but there's a strong argument that the constitution does for

majority will and maybe we shouldn't have that, maybe we should be in the same way that right now because of the deployment of nuclear option for court of appeals judges may be stood for the supreme court. i think it's maybe something possibility under the constitution and an interesting thing to think about. >> i think the supreme court retains the power it has no senate confirmation would change, or getting rid of senate confirmation would change all that much because it's a political controversy that happens outside. figuring provide your place in which to do this and others pressured but it's not like president would make the appointments and nobody would care or do anything about it. you would have largely the same debate unless something changed about the power on the court. >> on that one, harriet miers was briefly nominated and then the establishment rose up as one and said not over our dead bodies. so i think that is a real phenomenon. it's possible that the senate confirmation process itself

intimidate some people who might otherwise be attracted judges. obviously, governor mario cuomo was a gracious contender in the clinton administration. he did play hamlet for longtime. as possible the scrutiny that once objected to through the process does make some people say thanks, but no thanks. >> is it possible that the courts law is not enough power especially in enforcing its decisions? case in point. look in the court due to keep other alabama state officials are refusing to comply with the marriage equality provision? so the court cannot carry out its borders as we are reminded in history but should have some kind of enforcement power? >> in some ways i think enforcement power is the sort of believe in its legitimacy.

if that became further undermine and think it would be even harder for the court rulings to be accepted and followed. which is not to say we should criticize the court but i do think that is sort of the way when marbury was decided, it wasn't a given that the court ruling would be followed. and we have it today. i think it's it goes into one of my reasons for saying the court as an institution is not a failure. >> i think it doesn't need any more enforcement power because of his the lower courts to enforce these things. >> and essentially all of the department of defense have taken place, always have been a general assumption of we will enforce the judgment any particular case. so lincoln ignored dred scott in every the context but enforce the judgment in a particular case. i just had to follow the rule. it will force the debate back into politics and you get the

kind of public deliberation the constitution is designed to create so that we make a decision. >> here's a question that is really inside the court but maybe were strung out. should the circle be reform? it's a different justices pool their clerks to do the initial vetting of 8000 or so therefore petitions the coming every year and to make recommendations as to which are worth taking further or which will be subject to the default rule which is if nobody's interested they are just denied. so the cert pool came about in the 1970s and has been subject to various kinds of criticism ever since. does anybody think that cert pool isn't a problem that needs to be reformed because i think it is partially responsible for the smaller doctor. it used to be that every cert petition was read by nine law

clerk, any one of them could recommend cert. they didn't know the issues they're just as were interested in the now it is read by two law clerks, one for the cert pool and one for justice alito is not producing. i think it is a problem and from the worst perspective it would be better to have the petition read by nine people rather than to people. >> i assume this is still the case, certainly true years ago but there's a strong norm in favor of denying cert among supreme court clerks. the reason is if you goof off any case is granted and the court, the justices decide that was an improvident grant you're not a very popular person. nobody ever gets criticized for mistakenly recommending it is not a cert, and so that feeds into the problem. i think it is a serious problem although one would disappear when the clerks disappear.

[laughter] >> there were a bunch of justices not in that cert pool. a fair number of them would just read the question and would not look at all of the underlying petition. >> maybe this'll be our last question. you mentioned some dissatisfaction with the number and types of cases taken by the court. do you think this is an area where changes could be made such as a quota for cases for term? or having a third party entity have some say in which cases are granted a cert? that are variations of this, not the cord with a third party, the kind of cert court has been recommendations over the years kind of came up in the early 1980s when it seemed i went chief justice burger thought the court was drowning in work. it's maybe less salient today, but --

>> it is a fascinating chief justice roberts when he was come before joined the court, was interested in increasing the size of the docket and since you've become chief justice that is not happen. it's interesting to him talk all a bit more about why that is exactly. it's hard enough on the outside but i suspect if there were a quota, that the effect of that would be if it were much are they would take some of the cases they currently handled in a summary fashion and have a argument everything on those even the osha the justices would be incredibly irritated about having to have an hour of oral argument when they are ready to decide on the merits. i don't think the court is going to come a don't think i'm attracted to it. that seems odd.

>> the quarter deck consists of the court's calendar, that is to say, it's on the courts website and you see the calendar of days or argument on the bench and one thing they really hate and fear is a day on the calendar when they have no cases. that's happened and they're very unhappy when that happens. something we see a phenomenon for instance in january which is the last time to grant cases in the regular order that would better enable which is the last argument sitting of the term. it's a lot easier to get a case granted in january that it might be in november, whatever. so that's one kind of impetus and i once made the suggestion to some members of the court that if they were to be canceled the april arguments and then carried over the march, the cases granted that ordinary would be in april would be carried over until october and to just have much better flow of

cases and they wouldn't have this problem of having to expedite the briefing schedule in october in order to shoehorn cases onto the january calendar. and i was told yeah, we hear you but we can do that because the public would then think we weren't working hard enough. so should there be a third outside court, a third party that would inform them of the kinds of cases that ought to take and that they are not taking? >> i do think there's something interesting that can be learned from the lower courts in this regard. especially so in the petition there's a docket where you have a cases that have lawyers and then you have the pop-up doctor. it's rare for a case the nonpaid docket to be granted. that's partly because the justices -- i think there's

america, that if there is -- there some deeper supreme court what it would've taken the case pro bono and got in the case of that weight by reducing the lower courts you have panels that will look at some of these cases, especially if they're not going to be hard for argument might recommend a decision, and for the staff counsel for the court. i think that is something that is something to think about for the court when you have largely prisoner appeals that get overlooked because they are not written in a way that the court generally is used to sing. that might be one instance where having this sort of administrative body likely than some of the lower courts may be useful for the supreme court. >> you need to make a recommendation speak was right exactly. >> one thing that concerns me about that is the problem with the court and we haven't talked about, i think there's an increasing number of instances where the supreme court is issuing opinions without

briefing and oral argument based just on the petition for searcher and the opposition pressure sure i worry the proposal would make that more common and i think it's a terrible development division of there's an enormous difference one puts in petition versus the brief on the merits. the petition is all but convincing the court this is worth hearing, the split among the circuit, national and foreign. this isn't the right vehicle. and when the court is deciding the briefing on the merits and oral argument it's a big decision what we believe is necessary for judicial decision. there's been a lot more of that in the last few years and i am worried it could increase the for the speed and i think that's a good point and going back to larry's initial point about the lack of transparency. if there's one instance of a lack of transparency it is a per curiam opinion that is binding decisional judgment of the cert

list, which is problematic for exactly the reason that you said stephen the problem is it is a summary judgment by publisher point. >> without having noticed the parties to the case is a poor decision on the merits as opposed to just decision whether to take it. i think we doing to stop him and asked to remind people that is reception down the street on the corner of 16th of blocks out there in the direction of the white house at the afl-cio headquarters beginning at 6:30 p.m. please have your convention in equity for admission. and with that i thank think everybody for your attention, and thank the panelists. [applause]

[inaudible conversations] >> the new congressional directory is a handy guide to the 114th congress with color photos of every senator and house member, plus bio and contact information in twitter handle. also district maps, a foldout map of capitol hill and delicate congressional committees the president's cabinet, federal agencies and state governors. order your copy today, it is $13.95 for shipping and handling for the c-span online store at c-span.org. >> coming up next a house hearing on suicide risks among veterans.

>> officials recently testified before the house veterans affairs subcommittee on oversight of the suicide risks among veterans and the heavy reliance on prescribed medication. this is one hour 40 minutes. >> good morning. this hearing will come to order. i want to welcome everyone to today's hearing entitled prescription mismanagement and the risk of veterans suicide. before we begin i would like to ask unanimous consent that a statement from the american legion be entered into the hearing record. hearing no objection so order. this thing will examine the relationship between veterans

prescribed medication and the result of their mental health and increased suicide rate among veterans. in a report issued in november 2014, which included in part evidence uncovered by the oni subcommittee gao examined va said that on veterans with major depressive disorder including the extent to which they were prescribed medication. the extent to which, the extent of which they receive proper care and whether the a monitored that care, and information va requires, the agency to collect on veterans suicide. it is now clear that va is not even aware of the population of veterans with major depressive disorder due to inappropriate coding by va physicians. as a result va cannot determine

if veterans are receiving care consistent with the clinical practice guideline. these guidelines are crucial to the treatment of mental disorders as they are designed to provide the maximum relief from the debilitating symptoms associated with mental health. it is imperative that our veterans receive the proper care and follow-up when receiving mental-health care especially when they are being prescribed various medications. what has also become clear is that va is receiving and reporting inaccurate and inconsistent data regarding veteran suicides. is severely impact and thus the department of building to

accurately evaluate suicide prevention efforts and identify trends in veteran suicides. not only did the committee conduct a hearing in 2010 on this same issue but since then there have been countless media stories of veterans being overmedicated or expressing adverse drug reaction and not receiving the proper care. the proper follow-up or the proper monitoring and the all too common result of suicide. one story told of a veteran who went into a hospital seeking care, but after being quote-unquote lost in the system, ended up dying by suicide right in the facility. we will also hear other similarly tragic stories today that highlight the tremendous problems occurring within va for

years, continued today, with regard to treatment of veterans with mental health. with mental health concerns adequate treatment programs and more importantly, the actions taken to ensure veterans were prescribed countless medications receive proper follow-up. currently va has approximately 10 different programs dealing with prescription medication and suicide prevention issues. but it does not appear that any of these programs interact with one another. no one is talking to anyone else. how can we ensure that the veterans are getting the proper care, the proper follow-up, and the proper advice if the right hand doesn't know what the left hand is doing? i think it is more appropriate to say based on the statistics

from the gao report and in numerous media stories that va is just throwing out a bunch of different ideas and programs hoping one of them will stick, and they can claim to have solved the problem. this is unacceptable. we need to know exactly what va is doing to change this pattern and what is it doing to improve protection of veterans? what is a real way forward? who will be held accountable for mistakes that have already been made and have caused veterans their lives? who will stand up and take responsibility for making the change? it is time for answers. it is time for change. with that by now you've to ranking member kuster for any opening remarks she may have.

>> thank you, mr. chairman. and good morning to our panel. thank you for being with us. this morning we are addressing a complex health care policy issue affecting veterans and over 100 million american adults. the statistics of veterans expensing chronic pain are staggering. over 50% of all veterans enrolled in receiving care at va medical facilities experience of chronic pain with over half a million veterans managing pain with prescribed opioids. as a nation and certainly in my district and throughout the northeast, we face a penalty described as an opioid abuse epidemic. the centers for disease control and prevention has turned opioid abuse the worst drug addiction epidemic in the country's history, killing more people than heroin and crack cocaine. in addition to the issue of pain

management and the problems of addictions, we must remember that many veterans who experience chronic pain also suffer from mental health disorders such as host of extras and traumatic brain injury. therefore, it is vital that the va has in place the proper oversight mechanisms to monitor the safe use of opioid for managing that paint diametrically concerned about veterans at risk of self-medication and addiction being prescribed opioids for pain management. we know from multiple inspector general and gao reports that the va has struggled to properly monitor prescribed opioids and the mental health of his patients. and i'm concerned a potentially deadly mix of hope you would use, mental health disorders and lack of oversight is contributing to our high rate of veterans suicide. the newest drug enforcement agency regulations that require veterans as a clinician monthly

for a refill of opioid pain medication creates an additional burden on veterans who have difficulty accessing care at va medical facilities. leaving some veterans to suffer from extreme pain and experienced opioid withdrawal symptoms when they're unable to schedule an appointment to refill. this hearing provides us with the opportunity to begin too seriously examine whether the benefits of managing veterans came -- paint with opioid is outweighed by the risk in side effects experienced by veterans and the va health care system struggle to properly monitor of opioid use. during this turn outward like to hear from our witnesses how we can better address safe and effective treatment of veterans while ensuring that care management is not forgotten. i would like to discuss whether a high level of informed consent is needed to ensure veterans and their families understand the risks and side effects before choosing to manage pain with

opioids, and whether they be properly coordinating mental health and suicide prevention programs with va medical facility clinicians and employees responsible for monitoring patient opioid use. i'm also interested in alternative pain management and whether, and as i get to my comments later i will talk about what's happening at the white river junction va, in bringing down the rate of opioid descriptions and how we can help get ourselves out of this problem, out of this cycle, and address the veterans to serve their needs without putting them and their families at risk. and, finally i would like to discuss what is being done to reduce long-term opioid use and treat the underlying conditions causing chronic pain so that veterans are able to live a better quality of life. thank you, mr. chairman, and i yield back the balance of my time.

>> thank you, ranking member kuster. i will introduce our witnesses and just one moment but asked that the witnesses stand and raise their right hand. [witnesses were sworn in] please be seated there at like to recognize the honorable jeff miller, chairman of the full veterans' affairs committee who hasn't joined us on the dais. welcome, chairman miller. you have the floor. >> thank you very much, mr. chairman. to the regular, thank you for the good work this subcommittee has been doing over the last several years. if i may, instead of giving a typical opening statement i want to ask ms. clancy a couple questions. because i need to move onto another appointment and i believe, dr. clancy, that you've

been made aware that i'm going to be asking a couple of questions, albeit all of it out of order. and i want to talk specifically about bradley stone, that we know that he was seen by his va psychiatrist a week prior to his commission of multiple murders and subsequently dying of suicide. he was on me many prescription drugs and had alerted va as i understand it the mental health and physical difficulties in the weeks leading up to the incident. but it appears that the va said he showed no signs of suicidal our homicidal ideation's. and i'd like to know how did it

come to that conclusion when the veteran was okay, ma and i say that in court, when he was reporting all of these feelings prior to the incident? >> in general people would come to that conclusion by asking the veteran a series of questions about whether having thoughts of harming themselves and so forth to get some assessment of suicide risk. so my conclusion, if the clinician said would be that the better answered, gave negative responses to that. >> okay. on the 24th of april of this year i asked the department it would confirm whether or not that they provided the full committee with all of the files related to bradley stone. to date i have not received a response. so again i ask you as a va provided this committee with all of the files on bradley stone?

>> i have been told that he had provided to the committee with the files with some reductions and had also provided him offered an in camera review. and the reductions were of a social security numbers and some information that was about sensitive details about the living family members of bradley stone, and again offered to discuss that with the committee in camera. >> and again as i've stated in every single letter that i sent to the department requesting information, and in camera review is not acceptable. that may be what you want to provide the that is not at all acceptable. and so, you know, the staff is informed you in the department that i was going to ask particular questions. so again i ask you as all of the information, and i would go back to, i sent the psychedelic

on april 24 where i referred to ms. diana reubens, director of the regional office on april 22 same that the philadelphia regional office had provided everything related to mr. stone filed, the response was unequivocally yes. and so i am taking from your comment today then everything that she provided to the central office from the central office has now provided to this committee. >> since i am under oath i'm going to be very careful. i can't speak for what diana reubens is telling you. i've been informed directly by our lawyers that we provided this committee with all the records with the reductions that i mentioned before. again, social security numbers and some sensitive details about the living family members of mr. stone. mr. stone. >> okay.

i want, for the record mr. chairman and dr. clancy, i know for a fact that va has withheld hundreds of pages related to the bradley stone filed. and so with that i would say that we have requested all the documents every way we know how. so i will ask you one more time. can i expect the department to deliver the complete records by the end of this week's? >> i will take that back him and i will verify what i've been told that we've given this committee everything except for redactions as i noted earlier. >> okay. i can assure you it is not redacted. it is missing, completely missing. >> i will bring that message back. >> would also expect you to deliver the behavioral health autopsy unredacted by the end of the week, and i've told va and i will reiterate it again, and in camera review is not acceptable

and i asked, would you commit that all documents that i've requested will be provided by the end of this week's? >> the behavioral health autopsy is a unique feature of what we do at va health care for veterans. rather than having a private limited to the people at the facility, root cause analysis our deep dive of what happens when a veteran takes his or her own life this is something that we have centralized so that we can learn across the system what kinds of factors might have precipitated the suicide, what could we have done differently or better. and it also involves a conversation with the family members of that veteran. none of whom have been told that we would be thoughtfully sharing their details with members of the committee. and we think that they will have a chilling effect on coming members sharing sensitive details and are very very

uncomfortable with sharing the behavioral health autopsy. >> thank you very much for that educational opportunity. i refer to you begin the fact that we are the legislative branch. you are the executive branch. we have complete and constitutional oversight over the department, and unredacted information or anything that is done within your department that you choose to withhold we will subpoena it if necessary. cannotcan i expect to have this information delivered by friday? >> i will take that back mr. chairman. >> thank you very much. and also i would also like to add, on a positive note i was in cincinnati yesterday. i was in aden the day before. what you think you for the good job that we see being done at the facilities there. there's been a great change in dayton and specifics. and i've enjoyed the opportunity to spend a couple of hours with the people in cincinnati. we do focus on a lot of the

negative and the press likes to focus on that as well but i want to commend you on some of the great things. and i would hope some of the good things specifically at cincinnati would be shared throughout the a. j. -- vha and the rest of the department. thankthank you very much spent if i may for one second. first, thank you very much for the. i know how hard those people work. cincinnati is actually the hub of expertise in the intensive care for our system, so they actually provide remote assistance -- >> i had a chance to do it. >> it's great it really is. >> thank you very much. >> mr. chairman, one quick point, dr. clancy. the va has turned over behavioral health autopsy is to this committee before. and so ranking member kuster? >> i just wanted to say for the record, as a health care

attorney who is working is ever quite for quite a long period of time, in the realm of quality assurance and what the purpose of this type of quality assurance is about when you go back and look it's intended for physicians and medical team to grow and learn from these experiences. and i just want, i'm concerned that the impression that may be left with veterans and their families particularly the family members who have been through the trauma of a suicide that this information would be treated confidentially because these hearings as you are televised. it's a very public setting to i think we should get to the bottom but i don't want to do anything that would have a chilling effect on families that are sharing the most personal aspects. we already have such a strong stigma about mental health and about people seeking treatment and i would be extremely concerned if we left the impression today that we are in

some way digging into private affairs. if there's information about living family members that is not relevant, it could be extremely personal, and i guess i just don't understand why we couldn't do that in a private setting or in a redacted way. why this committee would be trying to determine, and i'm not speaking to a few places that are that have not been provided that's a separate matter, but i know that under our statues in the state, confidential information in this quality assurance process is confidential and it is not to be shared. and the purpose of that is so that people will come forward if so that's the only comment. >> i appreciate the expertise that you bring to this committee and to this subcommittee. you can rest assured, and i think you know, that what we are trying to do is to hold people

accountable. we are not trying to release any information that is personally identifiable. this is also a murder situation. it's a suicide which is very difficult, but a murder-suicide. and so i believe that while the va is going through and doing this at attempting to find out where things may have broken down, the fact is we have gotten this information before from other incidents. this one is particularly grievous because of the murders that took place. and i would remind you that we are a federal body not the state body to we are bound by the united states constitution of which we are given oversight of the executive branch and we are not bound by many of the laws, the hippa laws and other information they received

information or us to be able to do our oversight in this, it is not a political. i didn't come we are trying to get to the bottom of a very tragic event, and we're trying to partner with the va as well. and right now they are not being as open as they should be. that our documents that are clearly missing from the file. documents i believe are damning documents and put it in a very negative light. i understand that but you can't remove those documents from the file just because it makes you look bad. and that's what we're trying to get at this point. but again i think every member of this subcommittee for the job that you have been doing, and look forward to continuing the good work. >> thank you, mr. chairman. i ask that all other all of the members

waved their opening remarks, ask for the committees custom, hear no objections so ordered. with that i would now like to introduce our panel. on the panel we have dr. carolyn clancy, interim undersecretary for health for the department of veterans affairs. mr. michael valentino chief consultant, pharmacy benefits management service, veterans health administration. dr. harold kudler chief consultant, mental health services, veterans health administration. esther randall williamson, director of gao's health care team, and doctor jacqueline maffucci research director for the iraq and afghanistan veterans of america. dr. clancy are now recognized for five minutes. >> good morning, mr. chairman

coffman, ranking member kuster mbs of the committee. thank you for the opportunity to discuss the overuse of medication and the provision of mental health care to veterans particularly for those at risk of suicide. one of our most important priorities at the agency keep our veterans patients free from harm at all times. i am deeply saddened by the tragic outcome involving a veteran. so the families here today are watching these hearings who have lost a loved one, i want to express my sorrow and regret for your loss. i appreciate you are sharing your experience is with us and we will honor your loved ones by learning from those experiences and improving care for veterans in the future. we acknowledge up front we have more work to do to reduce opioid use, meet the increasing demand for mental health care and prevent suicides and we've taken significant actions to improve these areas in order to better serve veterans. as ranking member kuster said chronic pain is a national

public health problem. it affects about a third of the nation's adult population and about half of veterans from recent conflict. as the result of a number of veterans and americans relying opioid pain control. and they can be effective for a while until the side effects become quite worrisome and often mixed with other drugs, they can have additional adverse unintended effects. as you noted, mr. chairman we've adopted a number of initiatives and tools to advance our goal of safe and effective pain management making data about rates and doses of opioids as well as the other medications the veteran is taking visible at the network facility, and most recently at the individual clinician level. starting july 1, we will be expanding on a very successful pilot of come an approach called academic detailing which

essentially consists of one on one coaching for every single clinician prescriber in our system. in addition to information about the effective use of medications this approach also works with clinicians to have a difficult conversation with veterans to help them try other alternatives for pain management and so forth. i think it's important to note that many of the veterans we serve come to us as their transition from military service on opioids and other medications, and abrupt discontinuation is not possible are actually practical but we have to continue to taper these a doses. we've seen some successes, and as you might expect those with the least amount of problems attended to do better than those who are experiencing more severe pain. suicide among veterans is very complex and tragic.

those of us who've lost a loved one to suicide know the deep and lasting pain. we have worked diligently with the scientific partners to understand suicide among those veterans receiving va care and among all veterans across the nation. we note that treatment works. we have identified many positive outcomes for veterans who are receiving our care. for example the rate of repeat attempts at suicide among veterans who attempted to take their own lives as it declined quite a bit for veterans enrolled in our system. between 1999-2010, the suicide rate among middle aged male veterans who use our system fell by 31%. at the same time that the suicide rate for middle aged men who are not veterans or who are veterans of the user system actually rose during that time period. the rate of suicide among women

veterans is higher than other women in the general public, but women veterans who use our system actually are less likely to die from suicide when compared to other women veterans. as you know, our research has allowed us to estimate that about 20 veterans die by suicide every day. was less well known is that 17 of those 22 do not receive treatment for care within the va system, and i worry that some of the 17 are actually seen in our system and are careful about raising mental health concerns because of concerns about stigma or privacy. suicide prevention efforts have to extend to veterans who may not seek assistance, and any veteran who needs help can come to any point of entry and care in our system and will be seen that day. we've also increased targeted outreach efforts to veterans in communities throughout the

country, we've made it easier for anyone to call of veterans crisis line. and in response to many suggestions from stakeholders in the very near future you'll be able to do that when you call one of our facilities directly. you and i have to hang up and call the wind. you can just do a number on the front and i went directly transfer you. i would want to express my appreciation for the congress for the clay hunt act in its passage which will expand our capabilities to the veterans, so thank you for that. the importance of mental health treatments, i don't think can be overstated. about 20 years ago in this country simply did not recognize how important a challenge mental health care is for all americans. fda we have embraced the problems that veterans and returning complex brought to us, whether that's there is mental health problems, post-traumatic stress, traumatic brain injury. and so forth. and in doing so we have had to place some trails. we have had to go ahead of what

is going on in the rest of the u.s. health care where utilization of mental health has been pretty dramatically curtailed, our utilization control over the years. so that meant we had to work with public and private science partners to build the basic science, the epidemiological data and population health expertise. we have learned a lot. we have made significant gains and sing the successes of treating mental health problems, but we have so much to do to dispel the stigma linked to mental health issues. it wasn't that long ago that cancer inspired that kind of whispering. people didn't talk about it out loud because of fears and misinformation. frankly, we help with your help and the help of many partners that soon we will be able to eliminate that fear and misinformation associate with seeking mental health care. and in the meantime we are focusing on creating an atmosphere of trust and privacy.

i want to just close by saying that we are committed to improving our existing programs, taking every available action to create new opportunities. and most important improving the quality of life for veterans. we are compassionately committed to serve those who served. we are proud to have this honor and privilege and we are prepared to answer your questions and look forward to working with you until we get this right. thank you. >> mr. williamson you are not recognized for five minutes. >> good morning, mr. chairman, and ranking member kuster. i am pleased to be here today to discuss our november 2014 report on vha's efforts to monitor veterans with major depressive disorder from refer to as mdd who were prescribed want a more antidepressant. mdd is a major risk factor for suicide among veterans. it is particularly debilitating mental illness often associated

with severe depression and reduced quality of life. also i will discuss certain aspects of vha suicide prevention program. specifically i will discuss the incidence of mdd among veterans treated by va, the extent that va clinicians prescribe antidepressants to veterans with mdd, and monitor antidepressant work, and data collecting and reporting on federal suicide to inform vha suicide attention after. vha data show about 10% of the veterans receiving vha health care were diagnosed with mdd come and 94% of those veterans with mdd were prescribed want a more antidepressants. however, the estimate of veterans with mdd may be low because in reviewing a sample of medical records collected at the agency we found the indices don't always correct report and

record confirmed indeed the diagnosis among veterans. at six the agencies would get a sample of veterans with mdd that were prescribed want a more antidepressants and found that they did not always receive recommended care for three important recommendations and the clinical practice guidelines referred to as cpg that vha has established to guide its clench in treating mdd. for example, although the cpg recommends that affects depressive symptoms bss, using standardized assessment tool at four to six weeks after initiation of antidepressant treatment, we found that for 26 of the 30 veterans in our sample va clinicians do not use his assessment to at all or use it with a specified time for it. while not mandatory for va in see clinicians fashion the agency clinicians it's based on

evidence-based data from clinical trials go research and other proven unreliable sources that are meant to enhance outcomes for veterans with mdd. moreover, vha does not have a process at any level to systematically monitor the extent that vamc clinicians dj'd from cpg recommendations. with little, if any, visibility over whether the care provided is consistent with the cpg, va is unable to ensure the deviations from recommended care are identified and evaluated, and what appropriate actions are taken to mitigate potential significant risks to veterans. finally, we found that demographic and clinical data in vamc's collect on veteran suicides to better inform vha suicide prevention program were often incomplete and inaccurate or for example as part of va's behavioral health autopsy program, which referred to as --

to collect data on federal suicide such as date of death, number of mental health visits and last be a contact. we've examined 63 reports and found about two-thirds of them contain inaccurate and incomplete affirmation. moreover, the situation is further exacerbated because the report prepared by the amcs are generally not reviewed at any level within vha for accuracy completeness or consistency. lack effective and complete bhap data limit opportunities to learn from past veterans suicide and of late diminish efforts to develop effective methods and approaches to enhance suicide prevention activities and reduce veteran suicides. va has made good progress in addressing the six recommendations to improve weaknesses we noted in our report. in a six months since the report

was issued, one recommendation has been fully implemented, and several others are very close to being fully implemented. more globally this work illustrates once again a continuing pattern of vha's noncompliance with its own policies and establish procedures, unclear guidance inaccurate data and poor oversight. these are among the same factors in the gao to include vha on a high risk lifted into va instills a culture throughout the organization that holds its staff and managers truly accountable for effectively perform their responsibilities operably overseeing outcomes, and achieving a recognized standard of excellence, vha will continue to fall short of providing the highest quality and cost effective care to our nation's veterans. this concludes my opening remarks. >> thank you mr. williamson, for your remarks. dr. maffucci judgment debtor

sybarite? >> yesterday, and thank you. >> thank you. you are not recognized for five minutes. >> chairman coffman, ranking member kuster and distinguish numbers of of the subcommittee, on account of iraq and afghanistan veterans of america and our nearly 400,000 supporters, thank you for the opportunity to share our views and recommendations on prescription mentioned as a potential risk of veterans suicide. in 2014 iada launched its campaign to combat suicide. in february which we celebrate the signing of the clay hunt act into law. this was a first step on a long road to address the challenges of combat and suicide among our servicemembers and veterans. the issue that we had to talk about today is complex because it encompasses two topics. providing care for veterans seeking relief from chronic pain, mental injuries and other conditions, and recognizing the potential for misuse and abuse of these powerful drugs. while the strokes are extremely powerful they can also be

extremely effective for a veteran who is not bound relief elsewhere. 2011 report estimates chronic pain affects approximately 100 million american adults, and this number is going. going to give in the last 14 years of conflict and the very physical daily demands on our troops we've seen a similar trend among servicemembers and veterans. over 60% of the iraq and afghanistan veterans seeking va medical care seek care from ask your skeletal elements and this is the most common category for compensation. nearly 60% seek care for mental injury. within iada's uncommitted view -- one in five reported using prescription opioid medications, one in every using anti-anxiety our antidepressant medications. among this newest generation of veterans medical advances have allowed for higher survival rates from complex injuries but

this also increases the likelihood for lifelong impacts of nerve and skeletal damage. treatment of pain in these instances can be even more complex accounts cooccurrence with other conditions like depression, anxiety, ptsd or tbi may limit treatment options. for clinicians assessing pain and devising a management strategy can be very difficult as well, particularly given that knowledge in this field is still going. primary care physicians who see the bulk of patients with chronic pain report that they feel under prepared to treat these patients due to lack of training. this includes vha providers who were surveyed in 2013. adding to the challenge there are studies showing country to think and act to put individual at high risk of suicide. and yet we also know that prescription medications can result in strong addiction and provide a means for suicide victims. to be a report that over half of

not fill suicide events among veterans results from overdose or intentional poisoning. this highlights the challenges that clinicians face when treating patients with complex injuries and demonstrates the importance of comprehensive integrated pain management. wannabe has moved to newport investing in research on pain publishing an evidence-based clinical practice as evidence-based clinical practices guideline come into many opioid safety initiatives and introducing a set case pain management system, more remains to be done. with approximately 20 veterans dying by suicide every day and more attempting suicide, reducing instances of overmedication and limiting access to powerful prescription medications must be included in a apprehensive approach to addressing this issue. a recent study showed up while patients receiving opioid therapy are at an increased risk for attempting suicide following some of the clinical practice guidelines reduce it is

scientifically. they showed this is critical not only for these guidelines but full and limitation of the guidelines. the eighth 2009 directed on pain management which outlined a step care approach to paint expired in october 2014 while it expired in the own and the policy remains active updating this important policy has not been prioritized. we urge the va to prioritize this ample intimate it at all va facility. we would like to emphasize the importance of minimizing the risk of overdose and overmedication. last year an important change to dva regulations expanded authorization for drug drop off sites. this change could be a the ability to stand up to take back programs in the hospital, this is critical to limiting the possible misuse and abuse of powerful prescription drugs. yet, no action has been taken.

while the va is working to implement its participation in state prescription drug monitoring programs, full implementation remains to be seen come and we urge the va to prioritize this as well. too often we hear the stories of veterans who were prescribed what seems like an assortment of antipsychotic drugs and/or opioid with very little oversight or follow. and it would also their stories of veterans with enormous pain, and doctors who will not consider the request for stronger medications to manage this thing. these are tough challenges and we remain committed to working with the va and congress to address them. again thank you for the opportunity to offer our views on this important topic. we look forward to continue to work with each of you your staff and this committee in this critical year ahead. thank you for your time and attention. >> sankey, doctor. i deeply appreciate your

testimony. -- thank you doctor. fuson next? okay. our thanks to the witnesses. dr. clancy, according to ngo report, va deviated from recommending guidelines and most all of the 30 cases reviewed by not assessing antidepressant treatment properly. ..