DR. GAYLE IWAMASA, NATIONAL DIRECTOR FOR INPATIENT MENTAL HEALTH IN THE DEPARTMENT OF VETERAN'S AFFAIRS: Good afternoon everybody. My name is Dr. Gayle Iwamasa. I am the National Director for Inpatient Mental Health in the Department of Veteran's Affairs and I have had the honor and privilege of leading the Suicide Prevention and Response Independent Review Committee. We're very excited this afternoon to be sharing with you a high-level summary of our report, which as you heard from Nicole will be released shortly. We have prepared for you all a very brief slide deck and so we will present that to you at first and then take questions. Before we do that, I would like the folks in the room to introduce themselves as well.
DR. BECKY BLAIS, PROFESSOR OF PSYCHOLOGY AT ARIZONA STATE UNIVERSITY: My name is Dr. Becky Blais a professor at Arizona State University and a licensed clinical psychologist.
DR. JERRY REED, NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION: Good morning, I'm Dr. Jerry Reed, a retired Federal service employee and also retired -- excuse me, a Navy veteran, a member of the committee and a social worker by profession.
DR. CRAIG BRYAN, CLINICAL PSYCHOLOGIST AND PROFESSOR OF PSYCHIATRY AT THE OHIO STATE UNIVERSITY: My name is Dr. Craig Bryan. I'm a clinical psychologist and a professor of psychiatry at the Ohio State University and am an Air Force veteran as well.
DR. RAJEEV RAMCHAND, CO-DIRECTOR OF THE RAND-EPSTEIN FAMILY VETERAN‘S POLICY RESEARCH INSTITUTE: Hi everyone my name is Rajeev Ramchand. I'm an epidemiologist. I work at the Rand Corporation where I co-direct the Rand-Epstein Family Veteran's Policy Research Institute.
DR. IWAMASA: And rounding out the committee, unfortunately folks who are not able to be in the room with us, but as you heard or equally important. Dr. General Nadia West, the 44th Surgeon General of the Army, Retired Chief Master Sergeant of the Air Force Kaleth O. Wright, and Mrs. Kathy Robertson, Reverend Carl Trost, and Dr. Stephanie Gamble. It's been our honor and privilege to work on this and address suicide prevention. We will go ahead and get started the slides. We, you'll note, in the slides that, and the report that we utilize the National Strategy for Suicide Prevention and have organized our recommendations into the four pillars of this public health model that you see on the screen. To get started and, sort of set the stage for our recommendations, I'm going to turn it over to Dr. Bryan to talk about a gardening metaphor which we use.
DR. BYRAN: Yes. So this is Craig Bryan and on slide three we found it helpful to begin this conversation by providing a useful frame to understand how we approach the recommendations outlined in the report. And this idea of the garden metaphor is that if we were to plant crops or flowers, and wanted them to thrive and to be productive, we would not only need to focus on the plants themselves but also the environment. We would need to water the soil, fertilize it, make sure there's ample sunlight, address pests and disease processes and remove those as quickly as possible. And so by addressing the environment and the context surrounding the plants, those are all critical elements of ensuring that the garden will thrive, and so in many ways we've used this metaphor to help us think about military personnel and military leaders and the organization itself as gardeners of people. And if we want to effectively prevent suicide, it's not just focusing on service members themselves, but it's also ensuring that the conditions within which service members live and work are suitable to encourage them to thrive, to allow them to have a good quality of life as well. And so I'll turn it back over to Dr. Iwamasa now.
DR. IWAMASA: Thanks Dr. Bryan. So on slides four, this provides a summary of the various sources of information that we use in addition to the extensive subject matter expertise. Those on the committee, we received briefings from all of the services and the department. We reviewed all of the policies and programs related to suicide prevention. We reviewed internal and external reports related to suicide prevention as well as we heard from subject matter experts and researchers. We also, as you can see on the screen, engaged in a number of site visits where we met with service members of all ranks, and we met with service members from all services as well and this includes going OCONUS. We visited three installations in Alaska and we also went to Korea as well. So we utilized a large amount of information to develop our recommendations. Next slide please.
As you can see we have a total of 127 recommendations in the report and you can see how many fit into each of the four pillars of the National Strategy for Suicide Prevention. We also, which you'll hear about momentarily, have 10 recommendations specific to, sort of, overarching issues in the military. You'll also see three color coded columns. That delineates a ranking of priority that the committee, sort of, wanted to communicate to the Department of Defense, that we think that these recommendations need to be addressed first and that's that first column in red, the high priority recommendations. There are 23 of those, followed by moderate and low priority recommendations, which nevertheless we believe are important in addressing suicide prevention.
We also want to emphasize that our report is in alignment with the White House strategies for reducing military and veteran suicide as well as the CDC's seven strategies for suicide prevention. As well as what you'll notice, is that many of our recommendations are likely recommendations you've all seen before from previous reports both internal and external to the Department of Defense. So we, in our report, have hopefully put together a pathway and strategy that's comprehensive for the department to follow. I will turn it over next to my colleague Dr. Jerry Reed.
DR. REED: Good afternoon. This is Dr. Reed. Despite considerable investment in suicide prevention strategies, DOD has shown an increasing trend over a 15 year period in suicide rates. What we determined when we went out to visit these installations from all branches of services, to include the National Guard, was there's a lot of variation and not much standardization in a lot of the work that's being done in suicide prevention across the world. So one of the recommendations we make in these overarching recommendations that, kind of, sums it up is it's important that we centralize responsibility for core suicide prevention activities at the DOD level. And the allow individual local innovation as appropriate moving forward, but at least the core responsibility, where possible, should be standardized so trending on suicide prevention, application of evidence-based practices, et cetera, are standardized across the department. So that whether you're sailor, a Marine, an airman or a soldier or a National Guardsman, you will benefit from the services available. I'll now be followed by Dr. Ramchand.
DR. RAMCHAND: First, by the way this is Dr. Ramchand, a member of the SPRIRC. The first pillar of our recommendations is healthy and empowered individuals, families and communities. What we learned during our site visits was that most of the service members we talked to, not only thought suicide prevention was important, but many were very passionate about it. They had friends who had died by suicide. They'd had family members, other service members that they knew who had died by suicide. So they wanted suicide prevention to be a priority, however they told us that the current approach across the DOD was more of a check the block approach. Suicide was not discussed frequently and it was during annual trainings or after the death of somebody.
The DOD requires annual trainings of service members, but what we have learned was that these trainings were often delivered in a way that is hard to believe that they are effective. There's a series of trainings over the course of days. Service members sat in an auditorium where the suicide prevention training was sandwiched between other trainings. It was a dark auditorium. Many of them were asleep. Many of them were on their phones. So it's hard to think that this is having an effect. So one of our recommendations, our high priority recommendations for this pillar, is to modernize that training, and what that means is paying attention to the content of the training, the mode in which the training is delivered, and the frequency in which service members get that training.
And to explore variability and how these are offered. So for example, a junior enlisted service members may need a training to focus on recognizing their own signs of distress, healthy habits, knowing what resources are available on the installation. A more senior leader on the other hand, might need some more education and training as to how to identify those at risk of suicide, how to help them, how to communicate with them, how to escort them to the resource that may help. That's our first pillar, and with that I'll turn it over to Dr. Bryan to talk about recommendations from our second pillar.
DR. BRYAN: So this is Dr. Bryan again, and on slide eight, you'll see the second area which focuses on clinical and community preventative services. This is actually the largest part of the report. It contains the most recommendations, and these really focus on institutional and organizational policies, practices and procedures that, in some cases, increase stress for service members or get in the way of effective protective strategies and interventions. And so I want to highlight just two example high priority recommendations, the first of which is we know that financial strain is one of the leading risk factors for suicide amongst military personnel. What we -- what we found in our site visits was that it was very common for service members to have problems being paid correctly and in a timely manner. Travel reimbursement processes were often confusing with high error rates and slow reimbursement systems, and so in many ways, a lot of at least one source of financial strain for many service members was the systems embedded within DOD itself.
And so we have a number of recommendations in the [report] to say that are targeted toward fixing problems that contribute to risk directly amongst the population. The next area of recommendation really focuses on a particular method that is commonly used for suicide and that's firearms. The bottom of slide eight you see several key statistics related to firearm suicide amongst military personnel. Around 2/3 of active duty suicides are a result of self-inflicted gunshot wound. When we look at the National Guard however, that percentage increases to nearly 80 percent. By comparison within the U.S. general public, only around 50 percent of suicides involve a firearm, and so firearms are much more often used and are a more central part of suicide within the military. Next slide.
And so you'll see here, are a handful of several recommendations that we made that are targeted towards easy access to firearms among service members who are especially at high risk for suicide. One of the messages that recurrently came up as we made site visits from military leaders, medical professionals, investigators, law enforcement personnel was that often times the -- how someone found out that a service member had purchased or acquired a firearm often, on base at a military exchange, was only after they had used it to kill themselves. And so this was a common refrain in our site visits was that the -- that military personnel wanted to encourage a culture of secure firearm storage and also to reduce convenient access to firearm acquisition, especially for those who are in acutely elevated distress. So I'll next turn it over to Dr. Blais.
DR. BLAIS: Thank you. This is Dr. Blais. Suicide can be prevented if service members have access to mental health support services, but what we found was that there was a large supply and demand and imbalance, and that when service members were getting into care, they might not be seen for their second visit for about six weeks. The providers on the ground told us that they weren't managing mental healthcare as they were managing crises. And so what we wanted to understand was what was making this so challenging to access. In addition to not having enough providers, we learned that many installations were facing hiring challenges, where when they opened up a job posting they would receive applications, and it would take about 365 days to hire a psychologist onsite. And by that time, the psychologist had moved on to another job, placing additional burdens and burnout onto those existing staff, so they would have to start the hiring process all over again.
We also saw that ancillary service providers who could provide support outside of mental health or behavioral health services, had a cultural sphere around the idea or when they would hear things related to suicide ideation or suicide attempts, and so they would stop providing care to those service members and send them over to behavior health, at which point there's a challenge getting these service members in. So we wanted to think creatively knowing that there is a national shortage of behavioral healthcare providers, about ways to address these issues, and so we've asked the secretary of Defense to understand and to work with relevant agencies to decrease the hiring time.
We've also suggested they create a billet for case managers who can work with behavioral health providers, so that they can provide care to individuals who are being seen. So that they're having sessions with providers who can be trained in evidence-based care to provide that care in between those sessions that can be taking up to about six weeks. We've also requested that the Secretary of Defense look into increasing the Tri-Care Reimbursement so that service members can see providers on the outside if they can't be seen in a timely manner. I'll turn it over to Dr. Ramchand to talk about surveillance and research.
DR. RAMCHAND: Hey, this is Rajeev Ramchand again. Our last pillar of recommendations regards surveillance, research and evaluation. In many ways the DOD collects a lot of data but there -- there are places where data is needed where it's not being collected. We learned on our site visits and through our briefings a number of pilot programs, or policies that are created or enacted to prevent suicide, but there's very-- there's frequently little evaluation that's being done to identify which programs are working, to them communicate those programs to that other installations or service branches can learn about the successes of programs. But also to identify programs where there's need for improvement or for programs to be sunset because they're not effective. So we have a recommendation, a strong recommendation, in this pillar, 7.2, to enhance these program evaluation efforts and continuously monitor how these policies, programs and pilots are impacting suicides or -- or proxy outcomes. So that we can learn from them and distill the best practices throughout the Department of Defense. I'll turn it back over to our lead, Dr. Iwamasa.
DR. IWAMASA: Thank you Dr. Ramchand and on the next slide, sort of, coming full circle we feel like our report provides a comprehensive pathway for the Department of Defense to really create an environment, so that service members cannot just survive but also thrive and sustain the military. So that ends our formal presentation and now we'd like to open it up to discussion.
STAFF: OK. So, I'm going to go ahead. This is Commander Schwegman again. I'm going to start down the list of folks who asked for questions. Travis, please unmute yourself and feel free to ask your question.
Q: Hey, thank you so much for doing this. I wanted to ask two questions regarding the section on firearms, and my first question is about this NDAA Section 1057 I think it is. It suggests a repealing and replacing that law. Can you explain what that law does and what you're proposing to replace it with? And my second question is about the waiting periods for purchasing firearms and ammunition, I'm just trying to understand what the current system is. Is it your understanding that state law governs that at this point on military bases, or generally there is no waiting period to buy a firearm at a base exchange? Thank you.
STAFF: Thank you for those questions. We're going to turn it over to Dr. Bryan to respond.
DR. BRYAN: This is Craig Bryan. So regarding the first question around the recommendation to repeal the prior NDAA provision. In short, there was a -- there was a provision embedded within one of the NDAA's approximately 10 years ago that expressly prohibited the Secretary of Defense and military leaders from maintaining records of which service members lawfully acquired, owned, possessed, used firearms. The attention behind that original provision as we understand it was to protect the 2nd Amendment civil liberties of service members. What we found, however, was that unfortunately this provision and unintended consequence is that it actually really handcuffed many military leaders from being able to know who was at elevated risk and to properly assess the safety of their subordinates and personnel.
For me personally, I was really struck by how often we heard stories from military leaders, seniors NCOs saying, in essence, ‘I'm not allowed to ask and sort of keep track of who are my most vulnerable and highest risk service members.' And as a result, when we lose service members in our units to firearm suicide, there's often this sense of we could have done more. We could have gotten involved. We could have helped them to secure and lock-up their firearms more safely, which could have potentially prevented those suicides. And so the recommendation here to repeal that is in essence to allow military leaders to be able to more effectively take safety precautions to potentially save the lives of service members.
In essence to allow them to maintain some of those records, so that when they know a service member's in crisis or they're going through a rough patch in their life, they can do a more proper risk assessment and provide more targeted and effective interventions. Your second question was about waiting periods and, sort of, what the current system is, based on what we learned and we discovered this information when we were doing our site visits. Many of us would actually go to basic exchanges. And we went to speak the firearm vendors and dealers there and ask a lot of questions about, you know, what are the processes that someone has to follow in order to purchase a firearm here on base. In an essence what it came down to is that it -- they typically followed whatever the state or jurisdictional practices and laws were, wherever that installation was located.
And so we know that there's a lot of variability across the states related to minimum purchase age, requirements for locking of firearms, things like that, and there's also variability around waiting periods.
There's a very strong scientific basis showing that waiting periods, even as short as seven days significantly reduce suicide rates. And so our recommendations specific to that really was to, in essence, have the DOD follow the science and start implementing some of those waiting periods for firearms on base.
Q: Thanks. That was very good. If I could just follow-up, obviously this -- the firearm issue is very politically charged. So I wanted to ask very simply, is the commission saying that the easy availability of firearms on -- at base exchanges is part of the -- the cause of this problem with suicides?
DR. BRYAN: Yes, what we found and what we learned and over the past year was that a significant percentage of on base suicides involve firearms purchased on base at military exchanges. And so, yes, our recommendation here, the motive behind this really is to, in essence, slow down access to firearms to that -- slow down access to firearms so that people can, in essence, survive periods of high risk. And the -- the final thing I'll say about this is that, you know, when we look at the science of suicide prevention, there's arguably only one thing that all researchers agree on and that one thing is that taking steps to slow down convenient access to highly lethal methods, like firearms is the single most effective strategy for saving lives.
STAFF: Great. Meghann, you're up.
Q: Great. So I wanted to ask about a couple of the top recommendations here. The first one about modernizing and reforming the promotion system. You know, what are your suggestions for what that would look like, and also as far as centralizing responsibility, kind of, standardizing DOD programs? What in the course of these site visits and talking to leaders did you find any hurdles or any trepidation about moving all of that up to the top and having it, you know, sort of trickle down from there and what that might change about any effectiveness that -- that does exist already?
DR. IWAMASA: Thank you so much for your question. I will turn that over to Dr. Blais.
DR. BLAIS: This is Dr. Blais. Yes, one of the things that we heard and saw at each installation that people were promoted based on their ability to successfully carry out the mission. So there was great mission readiness but one of the things that we understood to be true at the same time, was that they wouldn't necessarily be great at leading people. And so people who were in charge, might not necessarily know how to deal with that service member who is experiencing a myriad of age appropriate issues that were increasing their risk for suicide. So what we've asked them to do is to look over the promotion system and to change how its allocated so that it's not simply measured based on their merit within mission readiness. And there are a few programs that are already in place that can help model this and serve as an infrastructure.
DR. RAMCHAND: This is Dr. Ramchand, with respect to the second point about the, kind of, the centralization of activities versus the diffusion and things that might be working on the ground. You know, I think our recommendations to -- to echo that was stated earlier by other-- my colleague Dr. Reed is there needs to be some type of standardization, just given that the military, there's such frequent moves. There's such frequent changes in service members that -- that consistency and that standardization becomes really important, but we also highlight in the report areas of successes, where -- that are -- that are local. So areas there is success at a local level, but rather than, kind of, refraining -- keeping that -- that successful program at that installation, what we're calling for is we think that that centralization or that organizational centrality can help diffuse those successful approaches across to other installations. So that other installations can benefit from them.
STAFF: OK. Lita?
Q: Hi, thanks. I wanted to get back to the gun control measures that you recommend. Number one, it's going -- the department should restrict the possession and storage of privately owned firearms in military barracks and dorms. Does that mean not allow it or just put restrictions on it? I just wanted clarification on that one and then, sort of, more broadly. How likely do you think any of these measures could be implemented considering what everyone realizes is the highly politicized nature of this issue? Thank you.
DR. IWAMASA: Thank you for those questions. We'll turn it to Dr. Bryan.
DR. BRYAN: Yes. So this is Dr. Bryan. I would say a couple of thoughts related to this. First off is, I want to say that I would argue that what the recommendations contain are not strategies for gun control, but they are strategies focused on enhancing safety. And a lot of the inspiration for many of the recommendations were actually pulled from other DOD policies and programs that are very safety focused. A great example that really actually was very helpful was to look at DOD policy surrounding requirements for service members to operate motorcycles, and so the DOD is very clear guidance around extra requirements for motorcycle safety, helmet use, things like that which go above and beyond, you know what a typical state might require for a -- for a drivers license. And so a lot of the recommendations, when you get a copy of the report, you'll see we referenced some of those other DOD policies and you'll see the language is very, very similar because of what we were hoping to do is really capture this, sort of, spirit, this commitment to a culture of safety.
And leverage that as, sort of, the platform for thinking at a very similar way about firearm availability while being able to balance, you know, the -- the absolute need to protect and also respect the civil liberties that are enshrined in our Constitution. Specific to, kind of, the issue of firearms in the barracks or in housing quarters on base, so as it stands right now the DOD does not actually have a standardized policy. They're different, sort of, references to rules and guidelines scattered across different DOD instructions and policies but there isn't really, sort of, a central like this the rule so to speak or this is the guidance. And so that inconsistency and sort of the rules around security and firearm availability processes across installations, we saw as another missed opportunity to promote safety and suicide prevention.
Research actually shows, pretty consistently that in the United States when we look at firearm owning households, when the owners of those firearms use locking devices, safes, gun locks, cable locks. You know, clamshells, you name it. As long as there's some kind of a safety locking system in place, that actually reduces the likelihood of someone living in that home, dying by suicide by 50 percent, and the benefit that lifesaving benefit, is really disproportionately effective by younger individuals, adolescents and young adults which is, sort of, the majority of the military suicides. And so, our hope is that through a standardize policy that reduces access to firearms in living quarters on base, we'll be able to leverage this very well scientifically supported concept that could potentially prevent a lot of suicides.
I think the last question you asked was regarding to likelihood of implementation. I think it was a good question. I mean, there's a part of me that says it's a little hard to answer, you know, I don't know how -- which of the recommendations will ultimately be implemented, what I can say is that the more of the recommendations that are implemented, the greater likelihood that we'll see a fairly quick and large reduction in suicide rates within the military. And so my hope is that all of the recommendations are implemented because I think that is the clearest path to success.
Q: Can I just clarify specifically does the recommendation restrict, like when you call for restrict the possession of guns or limit or not? Does that mean prohibit or does it just mean put with some other restrictions on it? That was I wasn't clear on. Sorry.
DR. BRYAN: Yes. So what we found was that in our research there was some installations that, in essence prohibit the possession and storage of firearms in barracks and dorms, and so we would say within barracks and dorms, we would want to, in essence, set up rules that say you cannot keep your personally owned firearms here but you can safely and securely store them in other places. And so we have other recommendations that would be tied to this saying that, in essence, the Department of Defense needs to provide options. If we're not going to allow people to store it in the dorms, then where are they going to store it? And so we need to make sure that those options are available and the good news that DOD policy has some provisions that it allows, for instance, people to store their personal firearms in armories on base. We learned that wasn't always the most attractive option to service members, and not surprisingly and so we make recommendations as well to perhaps find other ways that the DOD can encourage out of the home storage of firearms, or at least out of the barracks and out of the dorms storage.
Q: Thanks so much. I have two, clarifying questions and a follow-up. The first is that, how you -- you were talking about the statistics in terms of firearm usage and -- and suicides, and I was wondering if that is biased or not biased, sorry, influenced by the percentage of men who kill themselves using firearms. I understand that men specifically use firearms while women tend to use other methods and then the -- the recommendation for the -- I think was age 25 was one of the recommendations. Can you explain why 25 was the age?
STAFF: I think we're losing you Heather….
Q: Yes. Can you hear me?
STAFF: We can hear you now. Can you repeat your second question?
Q: Sure. The second question was in one of the recommendations there was 25 as an age, I believe, for one of the things about owning guns and I was just wondering why you selected 25 for that (inaudible) -- DOD property raising the minimum age?
DR. IWAMASA: Yes. Thank you. Dr. Bryan will respond to those questions.
DR. BRYAN: So this is Dr. Bryan. So related to the first point you're making about the correlation between firearm -- or the use of firearms for suicide and male gender. Yes, that's part of the reason why we believe and the research would suggest that military personnel are so much more likely to die by firearms, is because the military, you know, it's approximately 85 percent male. And we know that as a whole, men are much more likely to use firearms, so there absolutely is a correlation. One thing that I think is -- is, kind of, interesting and relevant to this point is though is we know that military women are more likely to use firearms as well, and indeed when we compare military female service members to female civilians, part of the discrepancy, the higher rate amongst the military women is attributable to the fact that military women are much more likely to use firearms themselves. And so, so yes it is correlated to gender but there also is, I think, a -- a, sort of, broader issue within the military around firearm availability and ownership.
Regarding your question about [age recommendation of 25] that's a really great one, and so this was actually largely driven by DOD statistics themselves. And so what we did was we pulled suicide demographic information from the past decade to decade and a half and started looking at patterns and trends, and we looked at rates or the percentage of suicides that involve a firearm, we see this really interesting inflection point at around the age of 21. And so specifically when we look at 17, 18, 19 year old service members, only around 25 to maybe 30ish percent of the suicides involve a firearm. At the age of 21 however, the percentage of suicides that involve firearms jumps to about 50 percent, and by the age of 25 and thereafter. Once you hit 25, in essence, it's around 60 to 70 percent of all suicides involve a firearm, and so once we were looking at those data it was really striking that somewhere around the age or 21 is, sort of, this turning point where service members start using guns to kill themselves.
That is incidentally that corresponds to many laws for minimum purchase age of hand guns. So that's, kind of, the first piece of the puzzle is that around the age of 21, when you look at when are young people, when are people legally allowed to purchase firearms. That's when people start using guns to kill themselves. Then there's the second element which is just looking at the military population as a whole. We know that around half of all military suicides occur amongst 17 to 25 year old personnel, and so if we want to have a meaningful impact on suicide prevention, we would probably want to target that youngest age group, and here's this combination, this perfect storm of a lot of suicides are occurring amongst those under the age of 25, and the minimum purchase age seems to be a really important determinant of the use of firearms which is a highly lethal method of suicide. And so that was, sort of, the underlying motivation for setting or recommending a minimum purchase age of 25 on base, it was because that was, in essence, what the data were saying was probably the best age to recommend.
Q: Great. And then, just as a follow-up, so like this kind of research on firearms and suicide is not really anything new, maybe within the military context it is more new but just in general. So what do you think the buy in will be from the military community and Congress and leaders in terms of actually following through with these recommendations and doing something that's going to change, given the gun culture of the country?
DR. BRYAN: This is Dr. Bryan again. It's a great question and so I think to be frank, this is part of the reason why I was asked to be on the committee because this has been a growing part of my own research that I do. And so my background as a veteran, I deployed. I carried a firearm myself and we do a lot of work now with the military and with service members to talk about secure firearm storage. And one of the interesting things that I've run into over the past few years is that the military, I have found, military personnel are much more open to this than civilians, and my sense, I don't know for sure, but my sense is that so many of us who have served have lost friends to suicide.
And so many of those suicides involve firearms, that we recognize that there is a connection between the two, and over and over we heard over this past year, you know, I didn't see it coming. My friend seemed OK but they had a gun and they died. And so we have found -- or maybe I should say I have found that I think the military in many ways is the vanguard of this issue, because many of us are tired of our friends and loved ones dying and we recognize that we have to absolutely take on this issue straight away if we're going to bend the curve and save lives.
Q: Great. Thank you.
Q: Hi -- hi, one clarification and one question. As far as the recommended waiting period for ammunition purchases, is that only after the purchase or receipt of a gun or just in general? And then is there currently a minimum age for firearm purchases on -- on bases or does that vary from place to place like some of the other currently existing rules? Thank you.
STAFF: Thank you. Dr. Bryan.
DR. BRYAN: Yes, so Dr. Bryan again. The waiting period would basically be tied to the point of purchase. So let's say, if this recommendation were implemented and put in place. So let's say we were to go to a military exchange today and say I want to purchase this firearm. purchase, the transaction would occur and then, in essence, it would be next Friday, a week from now, if the seven day rule was instituted that, in essence, I could return to the base's exchange and then, at that time actually pick-up and go home with the firearm. And so that -- hopefully that kind of gets at what you're asking there and then, I believe the second one, the question was that about the minimum purchase age as well?
Q: Yes. Is that a -- does that just vary from jurisdiction to jurisdiction at this point? But also on the -- on the waiting period, I was asking about the ammunition specifically rather than the firearms, so if --
DR. BRYAN: Yes, so I mean I'm just taking notes so I don't forget the question again. So with ammunition, so the idea behind that was that again, its placing, sort of, slowing down the access to the different components required for someone to use a firearm to kill themselves. And so if we have a separate waiting period on ammunition, it provides just another strategy, to kind of, place some time and distance and space between the point of purchase, the transaction itself and the potential that someone is maybe making that purchase during a relatively acute episode of like heightened risk. And so that way, if someone and -- and the motivation behind this is again, we were hearing many, many instances of people walking into a base exchange, not only purchasing the firearms but also purchasing the ammunition at the same time and then walking out. And so its just another way to, kind of, separate the different pieces needed to, in essence, hopefully slow down some of those individuals.
Q: If it were implemented so there'd be the seven day waiting period for the firearm and then only after the receipt of the firearm, there'd be another four days before you could buy ammo or just a four day waiting period across the board?
DR. BRYAN: It would just be a four day waiting period across the board.
Q: OK. OK. That was I was wondering. Thanks.
DR. BRYAN: And then in terms of the minimum purchase age variability across states and jurisdictions, yes there is -- there is some variability. Right now if we look across, you know, the 50 states and, you know, the U.S. territories, its approximately, you know, a 50/50 split between 18 year old minimum purchase age and 21 year old minimum purchase age for handguns. The minimum purchase age in most states for long guns is typically around 18, handguns it's higher in many states. And so in those states that have the higher minimum purchase age, interestingly they have lower firearm suicide rates and lower suicide rates as a whole.
Q: Thank you.
STAFF: OK. That's my list of folks who asked us for questions. We probably have time for just one more question if anyone has one question who didn't get to ask questions.
Q: Hi, this is Ellen.
STAFF: Sure, go ahead.
Q: I noticed that in the slides you talk about eliminating the statutory limits on retention and incentive bonuses for behavioral health providers. Are you envisioning something like what the VA just got or do you just want, you know, broad abilities?
DR. IWAMASA: Dr. Bryan.
DR. BRYAN: Yes, so yes we did make the recommendation and one of the things that we learned over the past year was that Federal law currently restricts the DOD ability to make adjustments to professional pay and incentive pay, like bonuses for healthcare providers. This is actually in a report last year from DHA to Congress around this issue and by comparison the VA, which is a great, kind of, comparison point has a lot more flexibility in making adjustments to salaries and to bonuses, things like that, so they can do a more targeted job of hiring, recruiting and retaining behavioral health professionals. And so, in essence, that recommendation, yes was designed to say let's get rid of any legislative or law barriers that will allow DOD to better and more quickly, you know, incentivize the hiring and the retention of behavioral health providers.
STAFF: OK. You have a follow-up Ellen?
Q: No I don't. Thank you so much.