have been going on longer than a year. all six of the cases we're currently working on in the country of tunisia have been active for longer than one year. that is not comforting information. we're happy and pleased with the opportunity to print that kind of information and to give that perspective and that picture to other parents and to the committee as you try and get a real perspective on whether or not these countries are complying. but that remains a depressing picture. and that remains a depressing picture even in the month since the goldman act has been passed. so i'm hopeful and i'm optimistic, but the active cases remain the way they are. >> as you all know the next shoe to drop will be on the sanctions portion vis-a-vis the 42 nations which ought to be 23. japan has to be on that list. and they are very serious repercussions which i hope the

administration will use as a that toolbox. we will hopefully hear from the ambassador in july as to how that is going so we don't get a designation without commensurate sanctions so that the countries know we mean business. there are two other areas i've worked on very closely, trafficking and -- and very often, we have seen a lack of enforcement of sanctions when it comes to other human rights abuses. so this ought -- you know hopefully is an opening for the administration to say, if you use the toolbox right if you say we mean business, sanctions will be deployed and the quickest way to get those listed is to obviously, resolve the cases in a way and return is the ultimate resolution of the case. let me just ask you, finally to what extent any of you might want to speak to this, do you believe that corruption abroad

in terms of judicial system judges, a foreign ministry that might not be susceptible corruption, we know corruption is a huge problem in many countries. it's a bad problem here in the united states. what would you say to that? has that caused some of this? >> to some extent i will try to answer your question. to some extent, i would defer to the individual parents of faced and so i wouldn't presume to speak to each situation. as relates to this hearing one of the most useful pieces of information contained in previous compliance reports has been detailed descriptions of the performance problems in countries that are concerned for noncomply noncompliance. when previous reports listed concerns for instance about judicial performance, there was significant detail provided for

a country that has not been spoken about today, but a country such as costa rica when there were in past compliance reports detailed descriptions of the problems that the united states noticed in the application of the treaty's principles in their court when considering hague convention cases. they remain noted, i believe in the current report as do numerous other countries. however, to some extent some of the details and the level of depth and what lid to those designations does not exist in the current report. as i look at this as a useful tool to educate and make everyone aware of not just existing problems, but how to prevent this it's important to make sure that the level of depth and the level of detail remains. >> i think your point is extremely well taken. on page 30 of the report, it has countries demonstrating patterns of noncompliance and there's an a, b c, d, e with foreign central authority prrchbls judicial performance, law

enforcement performance and of course persistence failure of nonconvention countries to works with the states authorities to resolve abductioncations. then when you turn the next page, it has brazil, understand why. that point needs to break out so we know and so that they know so there's real transparency about what is the depth of the problem. more is more here and we need more. this is -- i mean, you've got to keep referring back to say what is e? it shouldn't be that way. so thank you for that. that's a good insight. >> i think in japan, we have a -- i would not describe it actually, as corruption. i would just say that there is -- the fix is in. the law just doesn't allow for this to happen. and the courts aren't changing it. there is a problem with

following rule of law, even within japan itself. >> but i think what you pointed out, even with the supreme justice of the supreme court in japan, we need to become a tailwind behind the performers in japan so if we put a zero for unresolved cases who are we really helping there? one is it's inaccurate. and we're taking the wind out of their sails, actually. when the chief justice was saying that, he was speaking to the family court judges in this country and saying, look, you've got to get with it and actually follow the laws. there are some laws that could be used to the books. in japan. and the lawmakers have put things in there like article 766 has been reformed somewhat to help visitation. the parental rights thing hasn't changed. but the courts themselves are not cooperating. and when you have this kind of intrinssy and this kind of cultural recalls trans, it is an

official problem that we have. and by calling out japan with its problem for what it is and saying to our friend our come patriots over there, saying look, you have a problem with your system. it is violating human rights. let's not do that. i don't think we're hurting japan. we're helping japan and we're helping japanese children at the same time who deserve those same human rights. >> thank you for the question. i would echo that statement. i'm not sure it would be corruption. the descriptive word i would use, but there is certainly an issue in tunisia with rule of law when you have tunisian presidents visiting with u.s. senators and declaring to them that there is no final judgment

in an abduction case where the supreme court of tunisia has made a ruling declaring that the best interest is served there to repeatedly, through various members of their administration up to the newly elected president to respond to any request by government officials to say that there is a final judgment. it's absurd. what is your rule of law? you just instilled a knew constitution that directly upholds your supreme court in its rulings. and then you turn around in the face of those and say, well we don't have a ruling. we don't have a final judgment. well if your supreme court is not final judgment then what is? permanently, i applaud the tee tunisian judiciary for following

international law and upholding its legal obligations in the face of what is very obviously an interest of society to protect its citizens because they see my children as tunisians and they do not see them as individual they do not see them as children who deserve the familyhood of both a mother and a father. they see them as symbols of their national -- national symbols. my children are tunisian. they're american as well. their home of residence is the united states. the tunisian courts have ruled. the american courts have ruled. it's simply time that those judgments be enforced and i don't know if you call that corruption. i certainly call it a problem. >> i can there's a lot of commonality that is hard for us to define whether we face

corruption or not. you know, for example, laws that have no clear guidelines so that from one judge to the next, these under the same set of circumstances, you would get different rulings. the fact that even after, for example, in india there's been a very progressive thought in the -- in 2006, one of the reports said india should make changes to their sole custody law soes that joint cut is allowed. fortunately on the latter there has been some movement within indian parliament. they have placed a rule change. it's still probably going the take some years to implement. but i think the change is going on. i think the main challenge that we face is both cultural and attitude appropriate to that i think. so it might not be an overt sort

of decision to harm somebody, but it's the lack of or the ignorance in the issue. probably is what's hurting us. >> if you have anything else you'd like to say, i'd like to give you all the last word or we'll just conclude. but the trafficking protection act, the t.i.p. report which i wrote in the year 2000 requires this mammoth study in a country which you know so well which breaks out prevention prosecution and protection, trying to combat section and labor trafficking. every country has a box of recommendations and then there's a tier system, one, two, three and watch list. if you're a tier three country, you're a violator in the issue of human trafficking and you get sanctioned. this didn't start out as this thick book but it quickly became that data calls going out to our embassyies in the

goldman act, we make clear that we want somebody in every embassy working this issue. we want a seriousness of implementation for you and for your kids. my hope is that, again correctioning the deficiencies, and we will appear to secretary curry who i think is a very reasonable man and he'll hear that appeal and hopefully will take it to heart and make sure that on japan and on india where there are no unresolved cases, according to this we have an unresolved case, too, from both of those countries sitting right here. we'll look to fix it and to get it right for accuracy. and, again good, for the courts, how important it is for current cases, you know, before judges that this report be correct so that they make informed decisions about the vulnerabilities of someone perhaps going abroad with their

kid, with their child. >> am happy to speak to that just yesterday, wednesday of this week i was on the phone and speaking to a family court in the state of washington had to the litigants and attorneys requiring that case and describe in answering questions related to the risks of production ash dukz to a abduction to a particular country. the information that we have firsthand, the next and the most important and the most comprehensive source i have to point to is the information that comes from the u.s. state department. and i value that information and i value the completeness of that information. and i do know there are 14 states plus the district of columbia that have adopted laws that encourage or require family judges to receive information about whether or not a country is a signatory, but more

importantly, whether or not they are living up to the terms of that treaty and that is built right in. that is a factor for that court to consider when deciding whether or not to allow visitation or relocation. so i know firsthand and our sister knows first hand that there are interested parties, there are government entities, parents, advocates who are desperate for this information and would love as much information as can be provided. we do our best to provide what limited input we can and we share that with the subcommit but that's where i'll leave it. that information is important. whether or not it's comforting or paints a happy picture, it's still important. >> yesterday, an individual contacted me about the report and knew that i was testifying here today and he wanted me to mention his case which is very much on point.

he prior to japan signing in the hague had been granted sole custody of his children with supervised visitation because there was a threat of an abduction. and now that japan has signed the hague, the other side is now petitioning to have that supervised visitation removed. in court. under the premise that japan is now a hague country and is compliance and, therefore, we don't have to worry about there any more. and very much to that point, if this report is not accurate and it says zero zero zero no problem, those children may well be ak abducted and may well be abducted with the judge's permission. because he or she will rely on this report saying hey, there's no problem and 90 days is actually not enough time to correct that for this individual.

now claim that japan has a flawless record in this area, when we all know that that is not the case. so it's very real. it's a very real concern and it's created a very real concern for this particular individual in texas, right now, who is worried that this report may have given the other side who may have me ferrous intentions to illegally abduct these kids right out from under us. >> that is also the case in the reports with tunisia. zero abduction cases, unresolved cases. did you want to speak today? >> i just -- you offered to have a closing statement. >> yes. >> so i'm going to take you up on that offer chairman. and thank you for that opportunity. i just want to reiterate that

ms. christiensen, in her testimony, asserted that the mission of oci is to assist children and families and to prevent its occurrence. the simple mission that does not mention recovery. my assumption is that the assistance to children and families involved means that they are offering the assistance for recovery. and yet, all that i heard in their testimony and all that i see through the compliance report is an interest in prevention. i stated in my testimony but want to restate that the convention is a powerful tool but it is not a tool that will result in the return of our already abducted children. while i advocate strongly for its use in future cases, i wish for it to be made crystal clear the record that as written it's a fair and powerful law that includes strong remedies which if applied will result in the return of our illegally retained abducted children abroad.

as request to this committee would ask that in the future you en sure that it is implemented with the spirit in which it was created. and, if necessary, it be updated with an explicit requirement of accountability for the total existing cases by country including newly reported cases and the total number of children involved in each case represented in future reports by state to congress. because our children count and they might be count.. it is so important that the state understands that they represent individuals and they must count. thank you. >> just to land on a couple of items on the recommendations that i had. i think while we are talking

about the report, for 30 years the hague convention has been in place. but we haven't had a consolidation of data sources. the department should expand and enhance the data gathering and tracking of abduction cases by leveraging sources such as the u.s. family courts, police department records the ncmec, fbi and other sources that they can then have a more consolidated reporting instead of waiting for the parent to report the case. one of the other recommendations i would like to highlight is in returning the children especially to the top destinations the department should consider deploying a permanent attache at the us mission who will be on -- will ensure the pending cases are being worked on in a fair and quick manner. the children actually come home is the bottom line.

and the 3rd request is with you and the rest of congress, to really take the leadership on this and make an amendment for a win-win situation for both the u.s. and india and really engage on them with this issue just like you would engage with them on any other extra toojic and economic issue. if you make it important, i am sure that it will be important for them, as well. >> i could just put on the congressional record one last request to be able to say that i love my children, isaac and rebecca and i will never stop fighting for the ability to be involved in their lives, and, and i look forward to the day that all of us can be reunited with them and thank thank you for your support and try to make that happen. >> thank you.

thank you all for your extraordinarily compelling testimony. i can assure you the subcommittee will be unceasing in our -- in my efforts. as you know, i learned the deficiencies and gaps in what you face on a day-to-day basis through david goldman's case. very good welfare and whereabouts but not much we can when came to policy in trying to effectuate the return of shawn his son. through that ordeal, i learned through him and through his son, and now through all of you, just how agonizing it is. and that's why we wrote the law. that's why we will be tenacious and making sure it is faithfully implemented. again, you are heros and i thank you for your leadership and thank you for the work you do. the hearing is adjourned.

on the next washington journal, a look at the debate over gun laws after the recent church shootings in charleston, south carolina. we are joined by a survivor of the virginia tech shooting and senior policy advocate for the organization every town for gun safety. also syndicated columnist ann coulter talks about her new book on immigration titled audios america. we'll take your kals and look for your comments on facebook and twitter beginning live at 7:00 a.m. eastern on c-span. epa carbon regulations are the focus of a senator environment subcommittee hearing on tuesday.

members are looking at the impact of proposed rules on electricity costs for american businesses and communities. see it live 2:00 p.m. eastern here on c-span3. the new congressional directory is a handy guide to the 114th congress with color photos of every neither and house member, plus bioand contact information and twitter handles. also district maps a foldout map of congressional hill, the president's cabinet federal agencies and state governor. order your copy today. it's $13.95 plus shipping and handling through the c-span online store at c-span.org. in a news conference monday surrounded by south carolina lawmakers, governor nikki haley called for the removal of the confederal flag from the grounds of the statehouse. here is a look.

for many people in our state, the flag stands for traditions that are mobl traditions that are mobile. the hate-filled murderer who massacred our brothers and sister necessary charleston has a sick and twisted view of the flag. in month way does he respect the people in our state and revere it. those south carolinans view the flag as a symbol of respect moral and integrity, a way to honor the ancestors who came to the service of their state during time of conflict. that is not hate nor is it racism. at the same time, for many others in south carolina, the flag is a deeply offensive symbol of a brutally oppressive past. as a state, we can survive and,

indeed, we can thrive as we have done, while still being home to both of thoseviewpoints. we do not need to declare a winner and a loser here. we respect freedom of expression and for those who wish to show their respect for the flag on their private property no one will stand in your way. but the statehouse is different and the events of this past week call upon us to look at this in a different way. 15 years ago after much consentus debate south carolina came together to move the flag from atop the capitol dome. today, we are here in a moment of unity in our state without ill will to say it's time to move the flag from the capital grounds.

10 years after the end of the civil war the time has come. there will be some in our state who see this as a sad moment. i respect that. but know this. for good and for bad, whether it is on the statehouse grounds or in a museum, the flag will always be a part of the soil of south carolina. but this is a moment in which we can say that that flag while an integral part of our past, does not represent the future of our great state. the murderer, now locked up in charleston said he hoped his actions would start a rate war. we have the opportunity to show not only was he wrong, but just the opposite is happening.

my hope is that by removing a symbol that divides us, we could move forward as a state in armny and honor the nine blessed souls who are now in heaven. next, veteran's health administration officials testify about concerns over opioid medications and their possible links to veteran suicides. this hearing of the house veterans affair subcommittee on oversight and investigations is an hour and 40 minutes. good morning. this hearing will come to order. i want to welcome everyone to

today's hearing titled prescription mismanagement and the risk of veteran suicide. before beginning, i would like to ask unanimous consent the statement from the american legion be entered into the hearing record. no objection so ordered. this hearing will examine the relationship between veterans prescribed medications as a result of their mental health and the increased suicide rate among veterans. in a report issued in november of 2014, a hearing on veterans disorders it the extend they were prescribed medicine, the extent to which they were prescribed medications. the extent to which they were --

the extend to which they received proper care and whether va monitored that care and the information va requires vamcs to collect on veteran 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 guidelines. these treatments are vital and are designed to provide the maximum relief from the debilitating symptoms associated with mental health. it is imperative our veterans receive the proper care and

follow-up when receiving mental health care, especially when they are being prescribed various medications. what is also becoming clear is that va is receiving and reporting inaccurate and inconsistent data regarding veterans suicide. this severely impacts and limits the department's ability to accurately vault the suicide prevention efforts and identify trends in veterans' suicide. not only did the committee conduct a hearing in 2010 on this same issue, but since then there is countless media stories of veterans being overmedicated 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 and continuing today with regard to treatment of veterans with mental health. with mental health concerns adequate oversight treatment programs and more importantly, the actions taken to ensure veterans who are prescribed countless medications received proper follow-up. currently, va has approximately ten different programs dealing with prescription medications. 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 the va is throwing out a bunch of different ideas and programs hoping one of them will stick. and they can claim they 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 been made and cost veterans their lives? who will stand up and take responsibility for making a change? it is time to answers. it is time for change. with that, i yield the ranking member kuster for any opening remarks she may have. >> thank you, mr. chairman. good morning to the panel and 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 on veterans experiencing chronic pain are staggering. over 50% of all veterans enrolled and receiving care at va medical facilities experience 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 what can only be described as an opioid abuse epidemic. the centers for disease control and prevention has termed opioid abuse the worst drug addiction in the country's history killing more people than heroine and crack cocaine. in the issue of pain management and chronic addiction, many veterans who experience chronic pain also suffer from mental health disorders. therefore, it is vital that the va has in place the proper oversights mechanism to monitor the safe use of inn yoids for managing veterans' pain. i am particularly concerned about veterans at risk of self-medication and addiction being prescribed inn yoids for

pain management. we know for multiple inspector general and gao reports that the va has struggled and i'm concerned that a potentially deadly mix of opioid use, mental health disorders and lack of oversight is contributing to our high rate of veteran suicide. the newest drug enforcement opioid medications creates an additional burden on veterans who have difficulty accessing care at va medical facilities, leaving some veterans to suffer from extreme pain and experience opioid withdraw symptoms when they're unable to schedule an appointment to refill. this hearing provides us with the opportunity to begin to seriously examine whether the benefits of managing veterans pain with opioid sess outweighed by the risks and side effects experienced by veterans and the

va health care system struggles to properly monitor opioid use. during this hearing i would 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 higher level of informed consent is needed to make sure they can manage. and whether the va is properly coordinating health prevention programs and mental health programs with monitoring opioid use. i'm also interested in alternative pain management and whether -- as i get to my comments later i'll talk about what's happening at the white water junction va in bringing down the rate of opioid prescriptions 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'd 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 in one moment. but i ask that the witnesses stand and raise their right hand. do you swear under a penalty of perjury your testimony you are about to provide is the truth, the whole truth and nothing but the truth? please be seated. i would like to recognize the honorable jeff miller, chairman of the full veteran affairs

committee. welcome, chairman miller. you have the floor. >> thank you, mr. chairman and ranking member ms. kuster and thank you subcommittee toult work you have been done over the last several years. if i might, instead of giving a typical opening statement, i want to ask ms. clancy a couple questions because i need to move on to another appointment. and i believe dr. clancy, that you have been made aware that i am going to be asking a couple of questions albeit a little bit out of order. i want to talk specifically about bradley stone. we know he was seen by his va psychiatrist a week prior to his commission of multiple murders and subsequently dying of suicide. he was on many, many prescription drugs and had alerted the va, as i understand it, to 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 or homicidal ideations. i would like to know how the va come to that conclusion when the veteran was okay -- and i say that in quotes -- 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 were they 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 veteran answered -- gave negative responses to those.

>> on the 24th of april of this year, i asked the department if it would confirm whether or not they had 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, has the va provided this committee with all of the files on bradley stone? >> i had been told that va had provided the committee with the files with some redactions and provided an in-camera review. the redactions were about social security numbers and some information that was about sensitive details about the living family members of bradley stone and offered to discuss that with the committee incamera. >> and again, as i have stated

in every single letter sent to the department requesting information, an in-camera review is not acceptable. that may be what you want to provide us, but that is not at all acceptable. and so, you know, the staff has informed you and the department that i was going to ask particular questions. again, i ask you has all of the information -- and -- and i would go back to -- i sent the secretary a letter on april 24th where i referred to ms. diana ruben's director of the regional office on april 22nd saying the philadelphia regional office provided everything related to mr. stone's file. her response was inequivocally, yes. i am taking from your comment today everything that she provided to the central office, the central office has now provided to this committee?

>> since i am under oath i am going to be very careful. i cannot speak for what diana ruben is telling you. i have been informed by our lawyers directly that we have provided this committee with all the records with the redactions that i mentioned before. again, social security numbers and some sensitive details about the living family members of mr. stone. >> okay. i want to, 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 file. and so with that, i would say that we have requested all of 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? >> i will take that back and i will verify what i have been told.

that we have given this committee everything except for redactions as i noted earlier. >> i can assure you it is not redacted. it is missing. completely missing. >> i will bring that message back. >> we also expect you to deliver the behavioral health autopsy unredacted by the end of the week and i have told va and i will reiterate it again an in-camera review is not acceptable and i ask will you commit that all the documents ta i have requested will be provided by the end of this week? >> 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 or deep dive of what happened when a veteran takes his or her own life, this is something we centralized so we can learn across the system what factors might have precipitated the

suicide, what could we have done differently or better and it nofrls 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. we think it will have a chilling effect on family 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, again the fact that we are the legislative branch and 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'll subpoena it if necessary. can i expect to have this information delivered by friday? >> i will take that back, mr. chairman.

>> thank you very much. also, i would also like to add on a positive note, i was in cincinnati yesterday. i was in dayton the day before. i want to thank you for the good job that we see being done at the facilities there. there has been a great change in dayton in specifics and i enjoyed the opportunity to spend a couple 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. i would hope some of the good things specifically at cincinnati would be shared throughout vha and the rest of the department. thank you very much. >> if i might for one second, mr. chairman, first, thank you very much for that. i know how hard those people work. cincinnati is actually the hub of expertise in intensive care for our system. so they actually provide remote assistance to --

>> i had a chance to view it. >> it is great. thank you very much. >> mr. chairman one quick point, dr. clancy. the va has turned over behavioral health autopsies to this committee before. and so ranking member kuster. >> yeah. i just wanted to say for the record as a health care attorney who has worked in this area for quite a long period of time in the realm of quality assurance and what the purpose this type of quality assurance is about when you go back and look it's intended for physicians in the medical team to grow and learn from these experiences. and i just want to -- i'm concerned at the impression that might be left with veterans and their families particularly the family members that have been through the trauma of a suicide that this information would be treated confidentially because these hearings, as we know are

televised. this is a very public setting. and 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 around 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 is 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 as to if you believe there are documents that have not been provided. that's a separate matter. but i know that under our statutes in the state

confidential information in this quality assurance process is confidential and it's not to be shared. and the purpose of that is so that people will come forward. >> mr. chairman. >> thank you very much. i appreciated the expertise you bring to the committee and 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 and 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. i remind you that we are a federal body, not a state body. we are bound by the united states constitution of which we are given oversight of the xrve branch. and we are not bound by hippa laws and other information to receive that information for us to be able to do our oversight in this. and this is not political. again, we are trying to get to the bottom of a very tragic event. we are trying to partner with the va, as well. and right now, they are not being as open as they should be. there are documents that are clearly missing from the file. documents that i believe are [ expletive ] documents and would put va 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 is what we're trying to get at at this point. but, again i thank every member of this subcommittee for the job that you have been doing. and look forward to continuing the good work. thank you, ms. kuster. >> thank you, mr. chairman. i ask all other members wave their opening remarks as per the committee's cuts tom. hearing no objection, so ordered. i would like to introduce our panel with that. on the panel, we have dr. carolyn clancy. interim undersecretary for health for the department of veterans affairs. michael valintino, chief consultant pharmacy services veteran's health administration. dr. herald cutter and randall

william son, director of gao's health care team and dr. jacqueline maffucci research director. dr. clancy, you are now recognized for five minutes. >> good morning, chairman coffman, ranking member, and members of the committee. thank you for the opportunity to discuss the overuse of medication medication. one of the most important priorities at the va is keeping veterans from harm at all times. i am deeply saddened by the tragic outcome involving a veterans veterans. to families here or watching woo who have lost a loved one i want to express my sorrow and regret for your loss. i appreciate your sharing your

experiences with us and we will honor your loved ones by learning from those experiences xwrfing care for veterans in the future. we acknowledge up front that we have more work to do to reduce opioid use meet the increasing demands for mental health and prevent suicides and we have taken significant actions to improve these areas in order to better serve veterans. as ranking member kuster said, chronic pain is a national problem affecting a third of the nation's adults population and half of veterans from recent conflicts. as a result, a number of veterans and americans rely on opioids for pain control. they can be effective for a while until the side effects become quite worrisome and often missed with other drugs they can have additional adverse unintended effects. we have adapted 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 a veteran is taking visible at the network facility and most recently at the individual clinician level. starting this july 1, we will be expanding on a very successful pilot of 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 effective use of medications, it also -- this approach also works with clinicians to have the difficult conversations with veterans to help them try other alternatives for pain management and so forth. i think it is important to note that many of the veterans we serve come to us as they're trigging from military service on opioids and other medications.

an abrupt discontinuation is not possible or actually practical. but we have to continue to taper these doses. we have seen some successes and as you might expect those are the least amount of problems have tend pd to do better than those who are experiencing more severe pain. suicide among veterans is very complex and tragic. those of us who have lost a loved one to suicide know the deep and lasting pain. wee worked diligently with our scientific partners to understand suicide among the veterans receiving va care and among all veterans across the nation. we know the treatment works. we have identified many positive outcomes for veterans receiving our care. for example, the rate of repeat attempts at suicide among veterans who have attempted to take their own lives has

declined quite a bit for veterans enrolled in our system. between 1999 and 2010, the suicide rate among middle aged male veterans who use our system fell by 31%. at the same time, the suicide rate for middle aged men who are not veterans or who are veterans who don't use our 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 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 22 veterans die by suicide every day. what is less well known is 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 fearful about raising

mental health concerns because of concerns about stigma or privacy. suicide prevention efforts has to extend to veterans who may not seek assistance. and any veteran who needs help can come to any point of entry of care in our system and will be seen that day. we have increased targeted outreach efforts to veterans in communities throughout the country and made it easier for anyone to call the 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 won't have to hang up and call the line. you can just hit a number on the phone and that will directly transfer you. i really want to express my appreciation to the congress for the clay hunt act and its passage, which will expand our capabilities to help 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 we simply did not recognize how important a challenge mental health care is for all americans. at va, we have embraced the problems that veterans from returning conflict brought to us whether that is various mental health problems, post traumatic stress, traumatic brain injuries and so forth. and in doing so, we have had to blaze some trails. we have had to go ahead of what is going on in the rest of u.s. health care where utilization of mental health has been pretty dramatically curtailed or utilization controlled over the years. so that meant that we have 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, made significant gains, and seen the successes of treating mental health problems. but we have so much to do to dispel the stigma of mental health issues.

it wasn't that long ago that cancer inspired that whispering and people didn't talk about it out loud because of fears and misinformation. frankly, we hope with your help and the help of many partners that soon we'll be able to eliminate that fear and misinformation associated with seeking mental health care. and in the meantime, we're focusing on creating an atmosphere of trust and privacy. i want to close by saying we're committed to improving our existing programs, taking every available action to create new opportunities and most importantly, improving the quality of life for veterans. we are compassionately committed to serve those who have served. we are proud to have this honor and privilege and we're prepared to answer your questions and look forward to working with you until we get this right. thank you. >> thank you, dr. clancy. mr. williamson, you are recognized for five minutes. >> good morning, mr. chairman

and ranking member kuster. i am pleased to be here to discuss our november 2014 report on vha's effort to monitor major depressive disorder who were referred to as mdd who were prescribed one or more antidepressants. md does the a major risk factor among suicide for veterans. it is a particularly debilitating mental illness often associated with severe depression and reduced quality of life. i will discuss certain aspects of vha's suicide prevention program. specifically i will discuss the incidence of mdd among veterans treated by va the stens that va clinicians prescribe antidepressants to veterans with mdd and monitor antidepressant use and data vamcs are collecting and reporting on veteran suicides to inform vha's suicide prevention efforts. vha day showed about 10% of the

veterans receiving va health care were diagnosed with mdd. and 94% of those veterans with mdd were prescribed one or more antidepressants. however, the estimate of veterans with mdd may be low because, in reviewing a sample of medical records and selected vamcs, we found that vamcs does not always correctly report and record confirmed mdd diagnoses among veterans. as six vamcs, we reviewed a sample of veterans with mdd that were prescribed one or more antidepressants and found they did not always receive recommended care for three important recommendations in this clinical practice guideline referred to as cpg, that vha has established to guide its clinicians in treating mdd. for example, although the cpg recommends a veteran's depressive symptoms be assessed

using a standardized assessment tool at four to six weeks after initiation of antidepressant treatment, we found for 26 of the 30 veterans in our sample, the va clinicians did not use this assessment tool at all or use it within a specified time frame.+++