"We lost a soldier yesterday," Maj. Gen. David Rubenstein, the Army's deputy surgeon general, told Sens. Ben Nelson (D-Neb.) and Lindsey Graham (R-S.C.) at a Capitol Hill hearing in March.

The general wasn't talking about the latest battlefield casualty from Iraq or Afghanistan.

Hearings in Washington too often sound like Kabuki dramas, scripted and ritualized, hinting that the real work goes on behind the scenes. Witnesses read from preprinted statements; legislators ask questions prepared in advance by their staffs.

But on this day Rubenstein ignored the script and went to the heart of the matter in testimony before the Senate Armed Services Subcommittee on Personnel—suicide prevention in the military services.

"This man received a traumatic brain injury in a motorcycle accident and had been in treatment for two years," he said. "He gave talks on the benefits of treatment. He saw his psychiatrist on Friday. He saw his primary care doctor on Monday morning and his nurse case manager on Monday afternoon. He was treated, he was compliant, but he killed himself."

Rubenstein was just one of seven generals and one admiral, including the second-highest-ranking officers in the four branches of the U.S. armed services, who testified to senators about the status of their suicide-prevention programs.

Suicide has not left high-ranking officers untouched either.

"Every naval officer of my generation remembers where he was when he heard about Mike Boorda's suicide," recounted Adm. Patrick Walsh, vice chief of naval operations. Adm. Michael Boorda killed himself in 1996 when news reports said he was wearing a medal he was not entitled to wear.

"The reality is, we're dealing with a tired and stressed force," said Army Vice Chief of Staff Gen. Peter Chiarelli.

Two-thirds of the 140 Army soldiers who committed suicide in 2008 (a rate of 20.2 per 100,000) were currently or formerly deployed to the two Middle-East war zones, which contributed to their stress and anxiety, he said. The present era of "persistent engagement" with its 15-month deployments and the stress they cause was not likely to end soon, so the Army had to do what it could to mitigate that stress.

Suicide rates in other services have gone up too, but not as much as those in the Army. The rate for 2008 was 20.2 per 100,000.

Gen. James Amos, assistant Marine Corps commandant, told the Senate panel that the Marine Corps saw the number of suicides rise in recent years from 25 in 2006 to 41 in 2008 (the latter statistic indicating a rate of 19 per 100,000).

"These increases are unacceptable," said Amos. "The tragic loss of a Marine to suicide is deeply felt by all those who are left behind."

The Air Force instituted its own suicide-prevention program in 1996 and saw rates fall, although rates rose again slightly in 2008 (to 11.5 per 100,000) over the previous 10-year average, said Gen. William Fraser III, Air Force vice chief of staff.

All of the armed services have instituted suicide-prevention programs. The Army, for example, instituted the "Ask, Care, Escort" program to overcome the stigma surrounding seeking mental health care among soldiers. It required unit commanders to conduct two to four hours of training for all soldiers and civilian employees between February 15 and March 15. The Air Force has its "Wingman" program, in which airmen are trained to watch out for each other. The Navy and Marines have their "Operational Stress Control" program to try to prevent suicides.

However, none of the service vice chiefs who testified was satisfied with the status and success of his branch's existing prevention efforts.

Asked what else could be done, they all said that additional mental health clinicians of every variety would be a first step, although they have all recruited several hundred new personnel in the last few years. Persuading social workers, psychologists, and psychiatrists to enlist in the uniformed services is the most preferable strategy, because they can be sent wherever the troops go, but some of the newly hired mental health clinicians have come on board as civilian employees or as contractors, whom the Pentagon does not send to war zones.

Improved continuity would help too. Physicians or other health professionals currently leave their posts at military hospitals when they are assigned to a unit in the field, but then return to their home bases afterward, leaving the troops to start over with another set of health care providers, said Chiarelli.

The Marines have begun embedding mental health professionals in combat units while they train in the United States before deployment, said Amos. The same clinicians stay with the unit during service in Iraq or Afghanistan and return home with it following deployment. That process was designed to build familiarity and trust between the clinicians and the Marines and thus lessen their reticence to seek help.

Overcoming soldiers' reluctance to seek help, however, requires more than a roster of programs, said Chiarelli. "We need to change the culture of our Army."

Or as Rubenstein put it, "Stigma is not a problem between the soldier and the health care provider but between the solider and the leadership."

Walsh agreed: "The challenge is to get people to the point where they don't fear they'll be hurt or stigmatized by asking for help."

Stigma is a "toxic, unacceptable workplace hazard," said Brig. Gen. Loree Sutton, an APA member and director of the Department of Defense's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. "[The department is] committed to transforming its culture by emphasizing that seeking treatment is an act of courage and strength."

In concluding his testimony, Chiarelli said he will be briefed on every suicide in the Army this year. The first round, covering 15 events, was" one of the most intense two hours of my life," he told the senators.

Prepared statements and an archived Webcast of the hearing are posted at<http://armed-services.senate.gov/e_witnesslist.cfm?id=3722>.▪