Dr. Timothy Hoyt and Dr. Liz Clark Hold a Media Roundtable to Present the Calendar Year 2023 DOD Annual Suicide Report and Efforts to Address and Prevent Suicide Across the Department of Defense

View Online Dr. Timothy Hoyt and Dr. Liz Clark Hold a Media Roundtable to Present the Calendar Year 2023 DOD Annual Suicide Report and Efforts to Address and Prevent Suicide Across the Department of Defense Nov. 14, 2024 MS. JADE FULCE:  Good morning, everyone. Thank you so much for joining us today. We're going to start with Major General Ryder. Sir, I'm going to turn it over to you. MAJ. GEN. PAT RYDER:  Thanks very much, Jade, and good morning, everyone. Maj. Gen. Pat Ryder, Pentagon Press Secretary. And just want to say right up front, thank you for joining us today to discuss an important topic, DOD's annual report on suicide in the military for calendar year 2023. Our speakers today will be Dr. Timothy Hoyt, the Deputy Director of the Office of Force Resiliency for the Undersecretary of Defense for Personnel and Readiness and Dr. Elizabeth Clark, Director of the Defense Suicide Prevention Office. Today's briefing is on the record, and I would ask that you keep your questions to the topic of the annual report. I'm going to turn the floor over to our speakers here in just a moment, but I'd like to emphasize up front the department's continuing commitment to taking care of our people. Since his first day in office, the health, safety and well-being of our military community has been one of Secretary Austin's top priorities. As you've heard him say many times before, we owe it to our service members and our military families to provide the best possible care to identify risk factors and spot warning signs and to eliminate stigmas around seeking help. And when it comes to suicide, one loss to suicide is one too many. As you'll hear from our speakers today, the department remains focused on long-term sustained initiatives to prevent suicide. In 2023, Secretary Austin approved a comprehensive campaign plan with five lines of efforts and enabling tasks to guide and strengthen the department's suicide prevention strategy. Notably, the plan includes 83 key enabling actions adopted and modified from the approved Suicide Prevention Response and Independent Review Committee recommendations. Subsequently, the department has been urgently focused on implementing all 83 recommendations and moving out urgently to implement these key reforms. In 2024, The department completed 20 of the SPRIRC recommendations, and in fiscal year 2025, with the support of congress, the department will make an unprecedented investment in suicide prevention. Now while some progress has been made, Secretary Austin has been clear that there is still much work to do and that we won't let up. The Department will continue our efforts to improve the delivery of mental health care, bolster suicide prevention training, and educate our service members and their families about lethal means safety. And with that, I will turn it over to Dr. Hoyt for his opening comments, followed by Dr. Clark. Dr. Hoyt, over to you, sir. DR. TIMOTHY HOYT:  Thank you, General Ryder, and we appreciate everyone being here as we roll out our annual suicide report covering service member deaths that occurred in calendar year 2023 and family member deaths that occurred in calendar year 2022. As was stated, this is all part of our commitment to our people that's been emphasized throughout by the secretary and really a commitment also to transparency. I think the DOD is unique in putting forward our report card on how we are doing on this area and making sure that we remain accountable for our efforts in the suicide prevention space. As we go through all of these things — rates, counts, trends, numbers — I don't want us to get lost in the information there and lose sight of the fact that each death by suicide is a tragedy. That these are individual service members and family members whom we have lost to this scourge of suicide. And we want to not lose sight of how important that is at the individual level. So, even though we might say something like a not statistically significant increase, we really do view every single one of these cases as a significant event that warrants our time and attention in continuing to prevent suicide and redouble our efforts in this space. So, in terms of the specific numbers, we did tragically lose 523 service members to suicide in calendar year 2023. Numerically that was somewhat higher than the 493 that we lost in 2022. Although that increase in terms of the rate and the count for the active component was not a statistically significant increase. For the reserve component, we similarly saw that slight increase but then slightly lower in the National Guard. So, really what we want to look at here is the long-term trend. So, between 2011 and 2023, there's a slight increasing long-term trend in suicide rates in the active component, whereas for the reserve and the National Guard, that trend line is somewhat flatter, neither increasing or decreasing as a statistically significant trend. All of these rates were very similar to rates for the US population when accounting for age and sex differences, so that our rates are directly in line with really an increasing rate for the entire US population that's been over the last decade as well. We are not immune to the factors that drive suicide throughout the US, and our service members face, in addition to those, a number of unique military challenges. In terms of the mechanism of injury, firearms are still the leading mechanism of injury in these suicide deaths and including for both service members and family members. And then looking at our family member data, there were fewer family member deaths by suicide in 2022 versus 2021. Numerically 146 versus 165. Those numbers are lagged by one year because we're dependent on the National Death Index for being able to count those. And similarly, that long-term trend line is gradually increasing over the same time. As General Ryder mentioned, we are in the midst of this comprehensive campaign plan announced by the secretary last year that encompasses these five lines of effort. We are working hard to foster a supportive environment for our service members, wherein they have greater predictability of their schedules, wherein we've promoted leadership that really focuses on strengthening the support to service members and their families. We have worked to improve the delivery of mental health care, including recruitment and retaining our behavioral health providers, and working to increase appointment availability by revising MTF staffing models. We have worked to address stigma and other barriers to care through a greater investment in nonmedical counseling as well as telehealth services for our service members and their family members. And in terms of what's going to be the most noticeable here, we are doubling down on our revisions to suicide prevention training. We're modernizing that training and creating better tools for leaders to facilitate these difficult discussions with their service members. The fifth line of effort then, we're continuing to promote this culture of lethal means safety, incentivizing secure firearm storage and really promoting safety across the installation, and particularly in our barracks and dorms to make sure that we are securely storing firearms when we're off duty and in our homes. Taking all that into account then, we'll dive into more of the data here and I'll turn things over to Dr. Liz Clark from the Defense Suicide Prevention Office. DR. LIZ CLARK:  Thank you. How the slides will be run through is I will first provide key data on active component service members. I'll then look at the reserve component. We'll then move into the family member and then we'll talk about the department's efforts moving forward. As a reminder, when we publish the annual report, we assess changes and analyze the data in suicide rates using three different measures. First, we look at the recent year changes as preliminary insights but not as trends. Second, we analyze the trend between 2011 and 2023 to see if the rates are increasing, decreasing or staying the same. And then third, we compare to the US population after adjusting for age and sex differences. So, for the short term in 2023, more active component service members died by suicide at a rate of 28.2 and a count of 363 compared to 2022 when the rate was 25.1 and the count was 331. This is an increase of 32 deaths. This represents a rate increase of 12 percent from 2022. Still this increase is not statistically significant, meaning it's likely due to a chance or normal variation. While I know 12 percent may seem like a large change, reaching statistical significance requires changes in multiple factors which are less visible and relatively small populations with relatively small event counts. And statistical significance does not depend solely on the magnitude of change. Rather, it depends on a combination of factors like sample or population size, variability and the threshold of significance. We also analyze the trends within the components for the longer periods of time to see if the rates are increasing, decreasing or staying the same. These longer-term analyzes are the most robust — more robust than the year-to-year comparisons. And for the longer term, we continue to see a gradual, statistically significant increase in the active component suicide rates from 2011 to 2023. This tells us that it's most likely a real change. Stated differently, there is a low likelihood that this change is due to natural variation or chance. When comparing to the US population, active component suicide rates were similar in most years after accounting for age and sex differences between 2011 and 2022, with the exception in 2020 when the active component rate had a statistically significant higher rate. The CDC has not published final data for 2023, so this comparison is through calendar year 2022. With the annual data, we also examine suicide risk for each demographic group relative to the population average for each component. Similar to previous years, service members who died by suicide were largely young, enlisted males under the age of 30. This group accounted for 61 percent of suicide deaths in the active component. This is consistent with previous years and the overall demographic profile of the total force. Female service members appear to be at lower risk compared to active component population average. This is consistent with females having a lower suicide rate when compared to a population that is largely male. We then look at demographics and health and life stressors reported for suicide deaths overall: 5 percent identified as gay, lesbian or bisexual; 12 percent experienced abuse before the age of 18; 28 communicated intent for self-harm to one or more of the following — mental health staff at 5 percent, talking to a friend at 10 percent, and then talking to a spouse or a partner at 11 percent. This data just reinforces the need to improve the delivery of mental health services and appropriate screening, as well as that continued vigilance of educational support across the military community for how best to respond to someone in crisis or with suicide ideation. When looking at suicide death and attempt characteristics in contextual data within the last year prior to the suicide death or attempt, similar to last year, intimate relationship problems and/or behavioral health diagnosis within a year of death were the most frequently reported health and life stressors at 44 percent and 42 percent respectively, noting here that these categories are not mutually exclusive. For those with a behavioral health diagnosis reported, possible diagnosis includes one or more of the following — again, they're not mutually exclusive: alcohol use disorder at 10 percent; depressive disorder at 19 percent; anxiety disorder at 18 percent; adjustment disorder at 21 percent; and PTSD at 7 percent. The department is actively working to create a culture where help seeking is a sign of strength. Our messaging reinforces that help seeking is something to be applauded and encouraged. As the SecDef mentions, mental health is health, period. Administrative, legal problems, workplace difficulties and financial difficulties continue to be stressors as in previous years. And we also saw that 2 percent experienced physical or sexual assault or harassment within the last year. Then other factors that are not highlighted here, but they are in the report, is that: 67 percent had a primary care encounter in the last 90 days prior to their suicide death; 34 percent had an outpatient mental health encounter; 8 percent were discharged from an inpatient mental health facility. And at the time of death: 18 percent were on psychotropic medication; 3 percent were perpetrators of physical or sexual assault or harassment within the last year; 6 percent experienced the death of a friend or a family member within the last year; and 15 percent had previous self-harm. And this continues to underscore the relevance and the importance of our comprehensive integrated approach to suicide prevention and primary prevention efforts as well as postvention response after a suicide death and/or a suicide attempt or related behavior. Now we're going to be focused in on the reserve component. Overall, when we look at the year-to-year comparisons compared to 2022, the rate for the reserves appears higher at 8 percent in 2023, while the rate for the National Guard appears lower at 5 percent. These changes were not statistically significant. For the reserves, the calendar year 2023 rate is 20.9 compared to last year at 19.4, which was an increase of almost 8 percent from 2022. For the National Guard, the rate is 21.2 compared to last year's rate at 22.2, a decrease of almost 5 percent. And with respect to the longer-term trends, the rates for the reserves remained stable from 2011 to 2023 and they were similar to rates in the US population. The National Guard rates similarly remained stable from 2011 to 2023 and were largely similar to the US population with the exception of 2012 and 2013 where the National Guard rates were significantly higher. Demographics of those who died by suicide in 2023 in the reserve of the National Guard resembled those of the active component, primarily its young, enlisted males. And firearm was the most common method of death for the reserves at 62 percent and the National Guard at 71 percent. Now we're going to look at data for military family members, meaning military spouses and dependents. By dependents, we mean dependent children up to age 23 and based on the Title 10 definition. We recognize that military service is an experience shared by families and not limited to only the service member. Unlike their civilian counterparts, military spouses and dependents experience many unique challenges and stressors and the department remains committed to helping families navigate these difficult times. And as a reminder, this data is for calendar year 2022 as military family member data lags one year behind service member data due to the CDC sourcing. And for the short term, fewer military family members died by suicide in 2022 than in the previous two years, representing a 9 percent decrease in the rate from 2021 and 19 fewer family members. Although this is not a statistically significant decrease, it is worth noting that the count and the rate both decreased. This decrease is primarily driven by a reduction in the number of military spouses who died by suicide. The suicide rate for military spouses in 2022 appears lower than in 2021. And then for dependents we saw the same number of deaths in 2022 as in 2021, resulting in unadjusted rates at 3.5 and 3.4 respectively. This change was not statistically significant. We then look at the longer term. This is the first year we've analyzed and published longer-term trends for our military family members. When looking at the rates from 2011 to 2022, there is a gradual statistically significant increase in the trend at a 1.25 increase. And when the long-term trend is examined for spouses and dependents separately, there is a statistically significant increase in dependency rates and no increasing or decreasing trend for spouses. When we then compare it to the US population, between 2011 and 2022, after accounting for age and sex differences, the family member population, so combining military spouses and dependents, rate was similar to the US population with the exception of 2013, 2019 and 2020, when the family member rate was statistically higher. When we look at military spouses alone, there were no statistically significant differences noted between military spouses in the US population rates from 2011 to 2022. Dependents on the other hand experienced higher rates than the US population in the years 2013, 2015, 2018, 2019 and 2020. These longer-term trends for dependents appear to largely mirror that of US adolescents and young adult population. The CDC finds that suicide rates for these groups have been increasing over the past decade. Still the department recognizes that, for several years, military dependents had higher suicide rates than our civilian counterparts in the US population. The department is actively promoting mental health services to the whole of the military family to support dependents who may be struggling with stressors. I'll now speak to the efforts that the department is implementing as part of our public health approach to suicide prevention. Here we discuss the five lines of effort central to the DOD suicide prevention strategy, as well as highlight select accomplishments and examples of key enabling actions through the Suicide Prevention Response, Independent Review Committee recommendations. The five lines of effort are: fostering a supportive environment; improving the delivery of mental health care; addressing stigma and other barriers to care; revising and modernizing suicide prevention training; and promoting a culture of lethal means safety. I'll provide a couple of examples of efforts within each of these lines of effort and there are additional examples and SPRIRC accomplishments in the full report. For the first one, for fostering a supportive environment, the department has conducted a year-long media campaign called Joining Your Fight: Connect to Protect that raises awareness of suicide prevention resources with a focus on connection, collaboration and hope. And through our on-site installation evaluation, or our OSIEs, we continue to evaluate progress and implementing a comprehensive approach to reducing violent and harmful behaviors. In 2023, we completed over 30 site visits to installations. Across the department we've hired over 1,000 integrated primary prevention workforce with a goal of hiring 2,500 by the end of 2028. And some specific examples of SPRIRC enabling actions include — we've improved the work schedule predictability in after-hours communications with commanders and service members. We've also actioned retention incentives and bonuses to retain that key talent as well as improving the assignment processes. For improving the delivery of mental health care, the department has implemented the Brandon Act, which allows service members to self-initiate referrals for health care without declaring the reason to their commanding officer that helps reduce stigma to seek care. Some specific examples of SPRIRC enabling actions include: recruiting and retaining more behavioral health providers; regularly updating Tricare provider information available to service members and their families to improve that coordination of care; increasing appointment availability by revising mental health staffing models; expanding mental health services in primary care settings; expanding accessible options, especially telehealth services, to reduce barriers for accessing mental health care. To address stigma and other barriers to care through the Real Warriors campaign, the department is working to enhance collaboration between the clinical and non-clinical efforts to strengthen suicide prevention messaging, reduce stigma and then encourage those health seeking behaviors. We've collaborated with Department of Defense Education Activity, or DoDEA to develop resources to support military families and children when a military family member dies by suicide. And some specific examples of SPRIRC enabling actions include expanding evidence informed support options such as our non-medical counseling with our military family life counselors as well as financial readiness counselors. For revising and modernizing suicide prevention training, the department initiated an environmental scan of the current state of suicide prevention and response training across the military services as well as the nation and internationally with looking at what other federal agencies, universities and colleges, non-governmental organizations and other countries are doing in training for suicide prevention and response. This past July, the VA and the DOD co-hosted the biennial Suicide Prevention Conference in Portland, Oregon. We had over 2,300 participants and the only national conference dedicated to military and veteran suicide prevention. In some specific examples of SPORIRC enabling actions under this line of effort include creating a comprehensive postvention system to ensure that any service member who experiences suicide loss in their unit receives support. We have provided service leaders with tools to facilitate difficult conversations such as leadership focused postvention training, as well as we've trained behavioral health clinicians and behavioral health technicians in evidence-based practices. And the last one promoting a culture of lethal means safety. We are continuing to collaborate with other federal agencies, particularly the VA and HHS and SAMHSA to promote a culture of lethal means safety. For example, together with our VA colleagues, we've published a fact sheet on firearm safety during a permanent change of station. The department continues to evaluate lethal means safety efforts in coordination with the military services. These include evaluation of outreach materials as well as secure storage programs. And some specific examples of SPRIRC enabling actions in this line of effort include, we are working with firearm retailers near military installations to provide discounted safe storage devices to our service members when they purchase a personally owned firearm. We're also in the process of working with the military exchanges to provide vouchers for service members who buy personally owned firearms at the exchanges and safe storage devices of their choice. We're also developing and implementing a multi-media public education campaign with the VA and have started the creative work to launch a campaign to promote firearm safe storage by service members and veterans. And with that, Dr. Hoyt, I turn it back over to you. DR. HOYT:  All right, thank you, Dr. Clark, and we really appreciate everything that DSPO is doing on a day-to-day basis to move forward all these initiatives and really implement Secretary Austin's vision for this long-term campaign plan to eliminate suicide in our military and family — and for their family members. So again, in the short term, our suicide rates for the active component and the reserve were higher in terms of numerical count in 2023 in the active component and the reserve compared to 2022 and slightly lower in the National Guard with our 2023 number compared to 2022. Again, those changes were not statistically significant. But looking at that long term trend since 2011, our suicide rates are on that gradual increase in the active component while remaining relatively stable for the reserves and National Guard. These rates have been very similar to the US population trends, highlighting the fact that throughout the entire United States we're taking on this sort of national problem of suicide risk. And in particular then amplified by military specific risk factors. In the short term, here again, there were fewer suicide deaths noted for family members, for spouses and dependents. But again, that long-term trend still shows that statistically significant increase over the long term. Now again, what are we doing about this? It gets back to our department's campaign plan across those five lines of effort in terms of addressing the stigma and other barriers to care, fostering a supportive environment, improving the delivery of mental health care, revising our suicide prevention training and promoting that culture of lethal means safety. With that, Jade, I think we'll turn it back to you to facilitate some questions. MS. FULCE:  Thank you, sir. We'll now open this up to questions. Please limit your question to one question and one follow up. I'm going to move to David Roza from AFA. Q:  Hey there, thanks for holding this. I appreciate it. So, my question has to do with the reported attempts by service. It seems to me that the Department of the Air Force and Space Force have a much higher number compared to the other services, despite not being the largest service out there on the active-duty side. Do you guys have any theories as to why there is that higher number on the Department of the Air Force side? Thank you. DR. HOYT:  Yeah, this is something that we've looked at in detail. And I think that we should not put too much interpretation on service level differences in the numbers of reported suicide attempts across the services, because there is service level variability in what gets reported in terms of those suicide attempts. Suicide attempt information is very noisy. We're looking across various sources of data including survey data, health record data. And so, I would kind of think of these as kind of a lower bound of identified suicide attempts, but I wouldn't make a direct service comparison there. There's just differing processes in each of the services by which those numbers are reported. Q:  Got it. Thank you. And just on the subject of attempts versus deaths, very basic question, but throughout the report counts and rates, those specifically refer to deaths, correct, not deaths and attempts? DR. HOYT:  Yes, typically when we're talking about the suicide rate, that is just the rate of death by suicide. MS. FULCE:  Thank you. Now on to Heather Mongillio, USNI News. Q:  Hi, thanks so much. Just to be blunt, it seems that the Department of Defense has been trying to do a number of different suicide preventions. Each of the services are doing suicide prevention, but the rates just keep going up. So, I guess what are some of the roadblocks preventing these efforts from working? What is working, what's not working? And what is the Department of Defense planning to do to really try to get a grasp on this problem? DR. HOYT:  Yeah, I think the most important thing here is that upcoming in the next fiscal year budget will be an unprecedented investment of funds in these initiatives. A lot of the time where we've done initiatives during the past two decades, there's been insufficient investment in making sure that those have staying power, that we've got a long-term implementation of those programs. And then not necessarily making the investment in tracking whether or not those programs are working at both the micro and the macro level. And so, admittedly, yes, that long-term trend is gradually increasing, but I think there's so many of those societal factors that the SPRIRC recommendations have really given us a mechanism by which we can address as many of those potential risks as possible and make Investments in those spaces. Q:  Thank you. And to follow up, so one of the recommendations that the Department of Defense opted not to continue with was more limitations on firearms. Considering that the number one leading cause of suicide method tends to be firearms, is the Department of Defense reconsidering that, or is there anything that's going to continue to focus on more prevention when it comes to firearms? DR. HOYT:  I think the bulk of our efforts in our line of effort for promoting a culture of lethal means safety, get at secure storage of firearms, particularly giving service members more options for secure storage of their firearms, particularly in the home. And making sure that appropriate restrictions are in place such as not storing firearms in our barracks and dormitories. I realize that there were a lot of recommendations from the initial SPRIRC report getting at firearm purchases and all of those other sorts of factors. We feel that focusing on secure storage strikes a better balance between what might have been recommended and taking into account that firearms are the tools of military training. In many cases, we have a robust firearms culture in the military, and we can't go in opposition to that culture without taking it into account, without giving more options for the secure storage of particularly privately owned firearms. MS. FULCE:  OK, we're going to move to Leo Shane, Military Times. Q:  Yeah, thanks for doing this. To build off of Heather's question there — do you have any evidence that anything has worked in the last 12 years here? I mean, it seems like if you've got this continued increase in the long-term increase that you're not really seeing any results from the past efforts you've put in. I understand the more recent ones we won't see until later data. But I mean, are you receiving any indications that any of this emphasis, any of this talk, any of this work on stigma is producing any results? DR. HOYT:  I think that's a great question that gets at our investment in tracking whether or not programs are working. And I think that has been one of the weaknesses that was pointed out by the SPRIRC, that in many cases we may have had effective programs but weren't measuring whether or not they were having a substantial impact on the overall number. And so, going forward it's our commitment through these SPRIRC-enabling actions to really invest in tracking these efforts and finding those things that are the most effective. I think there have been limited scale studies looking at in particular safety planning and making sure that if a service member identifies as at risk that they're receiving a safety plan, that they know exactly whom to call during a moment of crisis. That has shown some very robust effects, including in service member samples. And a lot of our efforts on promoting that culture of lethal means safety have been informed by the research on the effectiveness of that strategy, to make sure that when a firearm is in the home that it is securely stored. That does correlate to a reduced overall likelihood of suicide death. We're really just looking at how do we do that at scale and how do we shift that culture to make sure that that is a priority for our service members. Q:  So, should we be reporting these new initiatives as a total reset after years of unsuccessful programs? DR. HOYT:  I think it's more about an unprecedented investment in making sure that we're doing things that work. And that's really our intent, is to make sure that that we're able to show that those programs have received sufficient support to really be implemented at scale. MS. FULCE:  Now to Matthew Adams, Stars and Stripes. Q:  Hi, Thanks. I wanted to follow up — Heather was mentioning that the department didn't decide to take up some specific gun recommendations by the commission that included longer waiting periods for purchase of firearms and ammunition and some other things. Is the department considering those? Because right now, since there is the increase — the long-term increase, is that even on the table? And I have a follow up afterward. DR. HOYT:  I'd say at this point we really are focusing on the 83 approved actions and taking robust steps to make sure that those are implemented first as a priority. We did get together, representatives throughout the department, to prioritize those recommendations and really focus on where we thought we could get the most value for our investments in these spaces. Clearly some of the SPRIRC recommendations were not assessed as feasible to implement at this point, but our focus right now is those approved recommendations as directed by Secretary Austin. Q:  OK, and my follow up is on the recommendations. 20 of the 83 have been implemented at this time. What are going to be the next set that the department is looking to implement? What's the timetable? DR. HOYT:  In terms of timetable, once we've received the FY 2025 budget, I think some of our primary investments are making sure that our non-medical counseling systems are robustly implemented and that we've got good sustainability on those programs so that service members can confidentially access care during a moment of crisis. We've also seen ongoing investment in our partnership that Dr. Clark mentioned with the exchanges where service members then will be able to use vouchers to help purchase secure firearm storage mechanisms that are best for them and that best fit their personally owned firearms. And then also looking across in terms of taking care of people, really looking at improved predictability of the day-to-day schedule, how greater career predictability links directly to that day-to-day predictability as well for family members and improved career stabilization. I think those are some of the key areas where service members, boots on the ground, are going to start seeing that investment. And then next from there are our key investments in revising suicide prevention training. I think we've heard loud and clear the message from the front lines that previous suicide prevention training, whether slide decks or just videos that people watch without any facilitation were not working. We heard that and we're working very hard to make sure that it's much more dynamic, much more integrative and accounts for the concerns of the individual service members, meeting them where they are in our suicide prevention training. MS. FULCE:  Patricia Kime, Military.com. Q:  Yes, thanks for doing this. When you say unprecedented investment next year, what is the bottom-line dollar line on that? And do you have an estimate for how much, since 2012, the DOD and the services have paid overall for suicide prevention programs? DR. HOYT:  I don't have the long-term number right here at my fingertips, but the investment for next year, once we receive the FY 2025 budget, is projected to be around $250 million. Q:  OK, and any idea then compared with last year, how much that was? DR. TIMOTHY HOYT:  I can speak just to SPRIRC amounts, so specific to the SPRIRC –  recommendations and actions, we're looking at a difference of about $17 million that we invested in 2024 to get the SPRIRC recommendations started versus the projected amount, which is obviously much larger. Q:  OK, and my follow-up would be, you did have that VA suicide — VA, DOD suicide conference this year. How many have you had in the past dozen years of those? DR. CLARK:  I could take that one. So, it is a biennial conference, and we've had it every two years with the exception of this past year there was a three-year time period, but we've had it since I believe 2014. MS. FULCE:  And the last question we're taking is from Patty Nieberg, Task & Purpose. Q:  Hi, thank you for taking my question. So, going to the kind of outside stressors, for intimate partner stressors, the trend has been pretty common across the last few years. I'm wondering if you have an idea of whether that number is bigger because this is based on just self-reporting and folks knowing that they're reporting that they have those problems. DR. HOYT:  I mean, I think that our methodology in identifying relationship problems as a risk factor really is multifaceted, right, between survey data as well as the data we collect when doing a scrub of the risk factors in each suicide death individually. And so, I think relationship problems has been one of the biggest factors across all of these. And that's why we're investing in our line of effort with fostering a supportive environment to give families overall better predictability of their career stabilization options, when they're going to be seeing their service member at home versus not. Those factors I think, as well as in concert with Military OneSource and our military community and family office, those are really going to be a holistic approach to addressing suicide risk in our service members and their family members. Q:  And then if I could ask a follow up on the behavioral health outside stressor, is there anything you can say how that — how substance abuse, if that's kind of a big part of that? DR. HOYT:  I think substance abuse overall, one of our biggest concerns is obviously alcohol abuse. We know from several years of annual reporting that often alcohol use paired with inappropriate firearm use has substantially increased death in that very narrow window. And so, we're continuing to make investments in better education that accounts for improving safe alcohol use as well as safe firearm use. MS. FULCE:  I'm now turning this over to Major General Ryder. MAJ. GEN. RYDER:  Thank you, Jade. Well, ladies and gentlemen, to conclude, I just want to say thank you again for joining us today to discuss DOD's annual report on suicide and the proactive steps the department is taking to prevent suicide and to take care of our people. I also want to thank and express our appreciation to Dr. Hoyt and Dr. Clark for sharing their time and insights today on this very important topic. If you do have any follow-up questions or anything we didn't get to, please don't hesitate to reach out. We'll be happy to help. Thank you very much again for joining us and this concludes today's briefing.

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